GENERAL BACKGROUND
Adenocarcinoma of the prostate is a very common disease, affecting about 320,000 men in any given year. It is also a deadly disease. It can, without a doubt, be cured; it can often be controlled, but it will never resolve without active intervention. About 40,000 men die each year from prostate cancer, and the lifetime risk of a man developing prostate cancer approaches one in five.

The average age at diagnosis is 72 years; however, the availability of the blood test for prostate-specific antigen (PSA) has made it not only easier to assess responses to treatments and cure rates, but also to initially diagnose the disease.

From an epidemiological standpoint there are wide variations in the instance of prostate cancer throughout the world, with Scandinavian men experiencing the highest rates of prostate cancer and Asian men the lowest. Focusing on the United States, African-Americans living in urban areas appear to be predisposed to develop prostate cancer and also tend to present with more advanced disease than their cohorts.

The specific cause of prostate cancer is unknown. Most people are familiar with the very common condition of prostate enlargement known as benign prostatic hypertrophy (BPH). Studies have not revealed any causative link between BPH and prostate cancer. Other studies have investigated potential risk factors such as vasectomy, number of sexual partners, venereal disease, dietary fat, and cadmium intake.

Vitamins D and E have also been investigated and all the above have failed to demonstrate a uniformly conclusive link to development of prostate cancer. Exercise has been identified as a risk-reducing factor, while smoking has been implicated as a factor for increasing the relative risk for development of prostate cancer up to 1.9 x baseline. Smoking has also been associated with more extensive and aggressive disease. Genetic predispositions may also exist and are currently being investigated.

The natural history of prostate cancer is somewhat controversial. The disease in most cases has a relatively long natural history, and many patients with early stage, low-grade disease could have as low as a 10 percent risk of mortality from their disease at ten years. However, randomized trials are currently under way which are intended to allow us to assess the impact of early versus delayed treatment for patients with early, low-stage disease.

Inclusion of patients who are most likely to benefit from treatment as opposed to observation may be considered unethical by some physicians, and because of this concern the conclusions of such a study are likely to be biased against observation. At this point it is not clear if it is possible to design a "good study" to predict expected cure rates and provide more accurate assessments of the true extent of disease beyond the level within which we presently work.

DIAGNOSIS | Back to Top
Most men presenting with prostate cancer are asymptomatic and are noted upon routine prostate screening to have either an elevated PSA and/or an abnormality on digital rectal examination. Sometimes patients will have obstructive symptomatology and will see a urologist who will sometimes remove tissue to clear the blockage. Upon pathological review, samples of this tissue will usually reveal carcinoma of the prostate.

After prostate cancer is suspected by any of the above abnormalities (elevated PSA level, abnormal digital rectal examination, or suspicious pathologic results from a transurethral resection of a bladder obstruction) a tissue diagnosis must next be obtained. Typically, a urologist uses ultrasound guidance to search for hypoechoic areas within the prostate gland -- these being clinically suspicious -- and takes biopsies from these areas and sextant biopsies as well.

The pathologist is then able to give us extremely important information.First, he can tell us whether there is prostate cancer present. Secondly, if there is indeed prostate cancer present, (s)he will note and report the Gleason score of the tumor. The Gleason score is a histologic grading system with cells appearing most normal graded as 1 and those appear most abnormal, or dedifferentiated, as 5. A major and a minor histologic component are reported. The major component is reported first. For purposes of example, let's say it is a 4. The minor component is then reported and let's say again for example that it is a 3.

The total Gleason score then is 4+3=7. Higher Gleason scores reflect more aggressive or potentially aggressive disease, while lower Gleason scores conversely reflect less aggressive or potentially less aggressive disease. Management options and alternatives often begin with consideration of the patient's original PSA level and Gleason score.

TREATMENT | Back to Top
There are two gold standard, state-of-the art, curative treatments for prostate cancer.
There is 1) a surgical procedure known as a radical prostatectomy in which the prostate is removed by a urologic surgeon and 2) conformal radiation treatment, at its highest evolution delivered by intensity modulation. External beam radiation is sometimes supplemented by a boost of radioactive seeds.

Here at Carolina Regional Cancer Center we have specialized for several years in delivery of high-dose, high-energy conformal radiation treatment planned and delivered in three dimensions so as to encompass the prostate gland isovolumetrically with an extremely small and precise margin around the gland itself while sparing the surrounding normal tissues such as the bladder and the rectum from significant doses of radiation.

We have utilized the three-dimensional (3-D) capabilities of our equipment and staff since the equipment first obtained FDA approval about seven years ago.

SIDE EFFECTS | Back to Top
With the use of 3-D conformal treatment, we have been able to increase the radiation dose that we can deliver to the prostate while causing only mild, temporary irritative-type side effects such as mild diarrhea or increased urinary frequency in some patients, while many patients have no side effects at all.

While there is always a risk of more severe side effects such as those related to damage of the organs and tissues that the radiation beam is traveling through, they are extremely unlikely to happen and these are problems that for practical purposes are not seen on a daily basis. Notwithstanding this, we all must realize that such problems can occur.

IMRT EFFECTIVENESS IN TREATING PROSTATE CANCER
One of the best reports confirming the effectiveness of IMRT was published by The American Urological Association in the peer reviewed journal, The Journal of Urology. The article was titled HIGH-

DOSE RADIATION DELIVERED BY INTENSITY MODULATED CONFORMAL RADIOTHERAPY IMPROVES THE OUTCOME OF LOCALIZED PROSTATE CANCER.
This paper presented the results of a very large, very long study done at Memorial Sloan-Kettering Cancer Center in New York. The physician authors treated and followed 1,100 patients with early to locally advanced stage prostate cancer from October 1988 to December 1998.

All patients were treated with either 3-D conformal external beam radiation treatment or Intensity Modulated Radiation Therapy.
Results were measured at 5 years in terms of the PSA relapse-free survival rate and patients were grouped into favorable, intermediate, and unfavorable groups in terms of risk for recurrence. The radiation dose was the most important variable affecting the PSA relapse-free survival rate in each prognostic group. The higher the radiation dose, the higher the survival rate.

Treatment with IMRT significantly decreased the incidence of significant rectal toxicity in the patients getting high radiation doses. The degree of reduction was striking, a 7-fold reduction as compared to those patients treated to the same dose with 3-D conformal radiation treatment. The authors' conclusions indicated that sophisticated conformal radiotherapy techniques with high-dose, 3-D conformal and IMRT, improved the biochemical outcome (PSA results) in patients with all stages of prostate cancer -- favorable, intermediate, and unfavorable.

IMRT presents the further advantage of minimizing bladder and rectal toxicity and represents the treatment delivery approach with the most favorable risk to benefit ratio. The peer reviewed literature is becoming filled with articles such as the one outlined above.

PROSTATE SCREENING | Back to Top
Here at Carolina Regional Cancer Center, we encourage all men over age 50 to undergo yearly prostate screening, and if any abnormality is detected to maintain close contact with a urologist even if a definitive diagnosis is not obtained at the first intervention. Sometimes a significant amount of time -- 2-3 years or more -- can pass between the first PSA elevation and the ultimate diagnosis of prostate cancer. We then would suggest you carefully consider the reasonable treatment alternatives. Here at Carolina Regional Cancer Center we are happy to supply you with information by links, e-mails, faxes, telephone calls, etc., but suggest that before you make a firm decision you have a comprehensive consultation with one of our physicians. You will get his undivided attention, which all patients deserve. He can point out what is specifically unique, important, and unimportant in your case, as of course no two cases are identical.