Information for Newly Diagnosed Prostate Cancer Patients

Hello, I'm Dr. Vincent Laudone. The purpose of this short video is to provide some general information regarding prostate cancer to men who have been newly diagnosed with prostate cancer and will be seeing me in consultation. My hope is that this will offer a framework for a more detailed discussion regarding your specific situation.

That discussion will occur when we meet in person or have a telemedicine visit. I encourage you to watch this with your significant others, especially if they will be with you during your visit.

For most men with newly diagnosed prostate cancer, their cancer is most often found as a result of an elevated or increasing PSA, prostate-specific antigen blood test. The blood test is commonly obtained at the time of routine annual examination with a primary care physician or during a life insurance physical.

Nine out of ten men with newly diagnosed prostate cancer have no symptoms related to their prostate cancer. They feel normal and are usually quite surprised by the diagnosis.

The abnormal PSA blood test often leads to an MRI of the prostate and eventually a prostate biopsy. A definitive diagnosis of prostate cancer can only be made with a biopsy.

Men often ask, “What causes prostate cancer?” Unfortunately, we do not really know. For some men, there appears to be a genetic component. This could include a father, a brother, a grandfather, or an uncle with prostate cancer.

Prostate cancer can also be associated with other cancers in the family, such as breast, ovarian, pancreatic cancer, or melanoma. It is important to know your family history, and we will go over this with you.

When it comes to prostate cancer, not all prostate cancers are the same in every man. There are two specific things that we need to know about your cancer.

First, what is the extent of the cancer at this point in time in your situation? Secondly, how aggressive is your prostate cancer?

When it comes to the extent of the cancer, we look first at the biopsy. How many of the biopsy samples contain cancer? How much cancer was in each sample? Did the biopsy suggest the cancer was just in one part of your prostate or more widely found within the prostate?

Prostate cancer is often multifocal, meaning if it’s growing in one area of the prostate, there is a good chance it is growing in other areas of your prostate. It is not at all surprising to see it in multiple biopsy samples scattered around the prostate.

Furthermore, when it comes to determining the extent of the cancer, we look at the imaging studies that you have had. These might include an MRI of the prostate, a CT scan, a bone scan, or a PET scan, such as a PSMA PET scan.

On that imaging, we will look to see if the cancer is still contained inside the prostate or spread outside, and if outside, to what extent is it outside and where outside?

The MRI gives us a very good look at the prostate itself. The other types of scans show us the rest of the body.

Think of the prostate like an apple with a thin but tough skin that we call the capsule of the prostate. We look to see if the cancer has broken through that capsule into the tissue adjacent to the prostate.

We then also look at the lymph nodes and bones in the pelvis and throughout the rest of the body. Every type of cancer has a specific location where they tend to spread. For prostate cancer, that is lymph nodes and bones.

Now, the second thing we need to focus on is how aggressive is the prostate cancer that you have compared to all the other men with prostate cancers. For this, we determine the Gleason grade of the cancer.

This is a system for grading the aggressiveness of prostate cancer that was developed more than 50 years ago. It is still used today, because it is proven to be a very reliable measure of prostate cancer aggressiveness.

The determination of Gleason grade is made by the pathologist looking at the biopsy samples under a microscope and assigning a number. It is a visual assessment of the cancer.

Over the years, we have changed the system, so now the numbers go from 6 to 10, with 6 being the least aggressive prostate cancer and 10 being the most.

The Gleason grading system is made up of 2 numbers, such as 3 plus 3 equals 6 or 3 plus 4 equals 7. Both numbers are needed to make the final grade.

Folks are often confused and ask, “Why doesn't it go from 1 to 10?” Well, it used to when it was first developed, but in 2005, we changed the system, so now it only goes from 6 to 10.

We consider Gleason grade 6 to be low-grade prostate cancer, not very aggressive, 7 to be intermediate or moderately aggressive, and grades 8, 9, and 10 more aggressive.

In the last few years, we now have an additional way to measure aggressiveness. This is with a genomic or genetic profile of the cancer.

In this case, biopsy samples are sent to a company which does a limited genetic analysis of the cancer cells, looking for various genes that have to do with prostate cancer growth and development. These tests will characterize the cancer as either low, intermediate, or high risk, depending on the genomic profile.

So, at this point, we have talked about the extent of the cancer and the aggressiveness of your prostate cancer as two important factors that we need to focus on.

But before we can make any decisions regarding treatment, we also need to consider you, the patient: your age, medical conditions, prior surgery, level of fitness, and functional status. In particular, we focus on urinary and sexual functions, since both involve the prostate.

Once we have done that, we can look at what might be the best way to manage your cancer.

For some men with a low-volume, low-grade prostate cancer, this might mean no treatment, but instead a program of active surveillance. With active surveillance, instead of treating, we monitor the cancer closely and treat only if the cancer appears to be progressing.

For men with more aggressive prostate cancer, surgery, radiation, with or without hormonal therapy, which is also known as androgen deprivation therapy, may be appropriate.

Surgery and radiation are the most common treatments for men who are not candidates for active surveillance, but do need treatment.

Both surgery and radiation treat the entire prostate gland. With surgery, the whole prostate is removed. With radiation, the entire prostate is radiated.

The entire prostate is treated because, in the majority of cases, prostate cancer involves more than one area of the prostate.

In a smaller number of men, the cancer only involves one specific area of the prostate. For these men, focal therapy can be considered. Focal therapy is not done with surgery, nor with radiation, but instead by other means, such as high-intensity-focused ultrasound, cryotherapy, or electroporation.

For all treatments, there are pluses and minuses. There is no perfect treatment, and no one treatment is right for all.

In this video, I'm not going to go into detail regarding all of the various treatment options. I strongly suggest that patients consult with physicians who regularly perform these treatments to get a better understanding of exactly what is involved.

Since I am a surgeon, I will spend the last few minutes talking about surgery for prostate cancer. Like every treatment for prostate cancer, surgery has its pluses and its minuses.

With surgery, we are removing the entire prostate, along with the seminal vesicles that are on the back of the prostate, a little bit of the tissue around the prostate, and sometimes the lymph nodes that are near the prostate.

There are generally three advantages to removing the prostate in men with prostate cancer.

First, if the cancer is still contained in the prostate, the procedure usually results in a long-term cure, with or without the need for additional treatment.

Secondly, we learn more about the cancer, because all the tissue removed is examined by the pathologist, giving us additional information as to the nature and extent of your cancer.

And lastly, removing the prostate does not interfere with additional treatment later, should it be needed.

The operation itself typically takes three to four hours. Patients come in the hospital on the day of surgery and leave the next morning.

During surgery, a catheter is placed in the bladder to drain the urine. This catheter typically stays in for one week. During this week with the catheter, we encourage lots of walking and general activity. There is no need to stay indoors or in bed.

Once the catheter is removed, driving and light exercise can be resumed, but strenuous exercise is avoided for up to six weeks.

Treatment for prostate cancer can impact urinary and sexual function, because the prostate plays a role in both.

The prostate helps to hold back urine, working together with the muscles in the pelvis to do so. When the prostate is removed, these muscles must be strengthened to prevent leakage. Performing Kegel exercises before and after surgery will help minimize this leakage problem.

When it comes to sexual function, once the prostate and seminal vesicles are removed, no seminal fluid is present to be ejaculated during climax, but the sensations of orgasm remain. However, men interested in future childbearing should consider sperm banking prior to any treatment for prostate cancer.

Importantly, erections can be impacted by treatment for prostate cancer. This is because the nerves that are necessary for erections are attached to the sides of the prostate. With surgery, these nerves must be carefully peeled off the prostate prior to removing the prostate.

How well a man recovers erectile function after surgery depends on how good his erections were prior to surgery, his age, and most significantly, how extensive the cancer is.

We have a robust and multidisciplinary sexual medicine team dedicated to helping men recover their sexual function after any treatment.

Understanding the nuances of prostate cancer and the options for treatment can seem confusing or even overwhelming. Not to worry, this has been a general overview. We will get into the specifics of your situation during your consultation.

I encourage you to write down any questions you have so we can be sure to address them during your visit.

Thank you for watching.