Prostate Cancer

Questions and Answers


Q1. I’m 60 years old. I had routine lab work done and was found to have an elevated PSA. My doctor has suggested a prostate biopsy. Does this mean I have cancer?

A. First, PSA stands for “prostate-specific antigen”. PSA is a lab test, and is the most sensitive tumor marker yet discovered. In many cases PSA elevation is a warning sign of prostate cancer before the cancer is otherwise detectable, such as by a digital rectal exam (DRE or “finger wave”) or by the onset of urinary symptoms. The PSA range at which prostate biopsy is recommended has been lowered recently—it used to be >4.0 ng/ml (nanograms per milliliter)—however, many doctors now recommend biopsy for men with PSA >2.5 ng/ml/ml.

Q2. Can there be other causes for an increased PSA besides prostate cancer?

A. Yes, PSA can be elevated without cancer. If a person has an enlarged prostate gland, such as benign prostatic hyperplasia, or BPH, it is not uncommon to have a PSA mildly elevated out of the normal range. If a mildly elevated PSA, greater than 2.5 ng/ml but less than 10 ng/ml, is found but a person has an enlarged prostate too, another test, “Free PSA” or “PSA II” can be run to determine if a biopsy should be done. If the Free PSA is greater than 25% of the total PSA, and there are no other signs of cancer such as lumps in the gland, a prostate biopsy can be avoided. However, if the PSA is over 10, a biopsy should be done regardless.

Another circumstance in which PSA may be elevated is during a bout of prostatitis, an infection of the prostate gland. PSA is normally “leaked out” of the cells into the bloodstream, and infection increases the leakiness. More PSA is secreted into the blood, resulting in a false elevation. Infection can even lower the percent Free PSA, making both tests inaccurate. If prostatitis is suspected, the person should go on a course of antibiotics and then repeat the PSA. If the PSA has dropped below 2.5, generally nothing needs to be done. However, if the PSA remains elevated, a biopsy is in order.

Q3. Would you please tell me about the prostate biopsy?

A. To make a diagnosis of prostate cancer you need actual prostate tissue. Therefore a prostate biopsy is used to find prostate cancer. There are no lab tests that can conclusively diagnose cancer. While finger-directed biopsies were done in the past, almost all urologists now use an ultrasound probe inserted in the rectum to see the specific areas of the prostate to biopsy.

The prostate gland is shaped like an upside down pyramid, and the areas to be biopsied include the base, mid-gland and apex. Currently, most urologists take six to ten cores, and sometimes more, from the prostate, including 2 each from the base and mid-gland on the right and left (total of 8) and one each from the right and left apex (total of 2). If a person has had a prior biopsy that was suspicious or if the biopsy was negative but the PSA continues to elevate, an additional set of biopsies needs to be taken. In the case of re-biopsy for suspicion of cancer that is difficult to find, many more cores may be taken. It is not unusual to have 18, 20 or more cores obtained.

Q4. What does the prostate biopsy tell my doctor?

A.Once the cores are taken they are given to a pathologist for review. A pathologist is a doctor specially trained in examination of tissue to detect disease. He will determine whether or not prostate cancer is present, and if so, how aggressive the cancer appears. The Gleason score indicates the aggressiveness of prostate cancer.

Q5. What is the Gleason Score? What is its advantage in prostate cancer evaluation?

A. Donald Gleason, for whom this system is named, was a pathologist with the VA Urologic Research Group. Instead of looking at individual prostate cells to evaluate aggressiveness, he emphasized the overall ability of the cells to form glands like normal prostate tissue. Gleason proposed that the pathologist assign a “pattern score” based on gland forming ability. Pattern scores are rated 1-5. The two most common patterns the pathologist sees are assigned scores, and the scores are summed. Therefore a person has a possible Gleason Sum, or Gleason Score, ranging from 2-10.

For instance, if the most common pattern is Gleason 3 and there is no other pattern, the Gleason score would be 3+3=6. If the predominant pattern is 3 and the next most common pattern is 4, the tumor would be a Gleason 3+4-7. The presence of Gleason Pattern 4 indicates a more aggressive tumor with a higher likelihood of spread. Examples appear below.


 Q6. Does this mean some cancers more or less aggressive than others?

A. Yes. Less aggressive cancers are considered to be “low grade” and are assigned lower Gleason Scores, in the 2-4 range. These cancers have a greater tendency to stay put and not spread. Most cancers are diagnosed in the “moderately differentiated” group, Gleason Score 5-6, but frequently will show some higher grade components, such as Gleason Score 7 (3+4). The more disorganized the cancerous glands appear, the more aggressive the cancer and the higher grade they are. Cancers of the highest grades, Gleason 8-10, frequently have lost the ability to form glands at all, instead appearing as sheets of cells invading adjacent structures such as nerves and blood vessels. These high-grade cancers have a greater tendency to spread to other parts of the body in comparison to better-differentiated tumors of similar stage and PSA level.

In practice very few men have a Gleason Sum of 2, 3 or 4, and a few have Gleason 5 (2+3). The majority of men have a Gleason Sum 6 (3+3). Thirty percent of men will have a Gleason Sum of 7 or greater.

Q7. So if my biopsy is favorable, can I depend on the results?

A. Most likely, but not always. An important point to note is that the Gleason Score obtained at prostate biopsy does not always agree with the Gleason score actually found in the prostate at the time of Radical Prostatectomy (see treatment options). Because the biopsy needle may skim a tumor nodule rather than go right through it, in 30% of cases the biopsy Gleason Score is upgraded when the radical prostatectomy specimen is reviewed. For instance, researchers at Johns Hopkins found that in 30% of cases men who were thought to be Gleason 6 or less at biopsy were actually found to have Gleason 7 or greater cancer when the whole prostate was examined.  The uncertainty of what is actually in the prostate should be kept in mind when making decisions for prostate cancer treatment—any technique should be able to address higher-grade cancer as well as lower grades.

 Q8. My doctor said that he couldn’t feel anything in my prostate. And yet I still have cancer?

A.The digital rectal exam, or DRE, is the traditional way that prostate cancer is staged. Inserting a finger in the rectum, the doctor examines the prostate, feeling the size, consistency and whether there are any nodules present. If a suspicious nodule is found, note is taken of the size, whether it is present on both sides and whether it extends outside the prostate towards the apex (tip), laterally or into the seminal vesicles at the base of the gland.

Based on the DRE findings the prostate cancer is assigned a T, or Tumor, Stage. Most men are now diagnosed with T1c cancer, meaning a prostate cancer detected as a result of an elevated PSA test with no nodules felt in the prostate itself. In these cases, the PSA may have picked up the cancer before it has grown to a size that can be felt.  Or, because the doctor’s finger can only feel the cancer nodules in the back of the prostate that is accessible from the rectum, PSA may detect a cancer is located in the front part of the prostate that the doctor can’t feel.

Q9. What are the T-stage categories?

A. The tumor staging system is broken up into 4 general categories, or T-stages.  T1 represents tumors that can’t be felt by the doctor on DRE. T1a and T1b are cancers diagnosed following a “trans urethral resection of the prostate”, a TURP or roto-rooter operation. This was a common diagnosis before PSA was introduced into screening—a man would develop urinary obstructive symptoms, have a TURP to help his urination and be found to have prostate cancer which had grown so large as to obstruct the bladder.

T2 refers to tumors that can be felt but do not appear to extend outside the prostate capsule, e.g. are clinically organ-confined. T2a means that the tumor can be felt only on one side of the prostate and occupies less than one half of that side. T2b means the tumor is on one side but occupies more than half of that lobe. T2c refers to tumors that can be felt on both sides of the prostate.

T3 refers to tumors that, on DRE, have obviously spread outside the prostate. T3a means the tumor has extended outside towards the apex of the gland, T3b means it has spread out laterally, and T3c means it has spread into the seminal vesicles.

T4 prostate cancers are huge. They have extended not only outside the prostate capsule but have grown to involve the rectum, bladder or the walls of the pelvis.

Q10. Has PSA testing made a difference in the stage in which prostate cancer is detected?

A. Yes. Since the advent of PSA testing in 1987, the proportion of men diagnosed in the higher T-stages has fallen substantially. Now approximately 70% of all men diagnosed with prostate cancer have their cancer found by PSA elevation only, Stage T1c. The incidence of extracapsular spread has likewise declined. Most importantly, over the past several years the number of men dying of prostate cancer has declined by more than 25%, from a high of 41,800 in 1997 to 30,500 in 2005. It is believed by many researchers that the decline in prostate cancer deaths is due to the early detection of prostate cancer through PSA testing.

Q11. Should I have any other tests to see if the cancer is anywhere else?

A. If you have a low PSA, say less than 10, the Gleason score is 6 or less and the cancer is non-palpable, T1c, you may not need any further testing done. Bone scans, while sensitive, rarely find cancer in patients with these favorable presenting features. Fortunately, with routine PSA screening, more and more men are detected in this earliest stage.

Q12. If the cancer is worse than that, I should have a bone scan?

A. Yes. If the PSA is >10 and/or the Gleason Score 7 or higher, most physicians will order a bone scan, and perhaps a CT scan. If the PSA and Gleason Score are especially high, an operation called a lymph-node sampling is sometimes done prior to definitive treatment of the prostate to be sure that the cancer has not spread to the lymph glands.  If the cancer has spread to the lymph glands, most physicians will recommend hormonal therapy only, but sometimes also in conjunction with radiation therapy to the glands and prostate.


Q13. What are my options for treatment?

A.Once staging is completed, and if the patient is found to have clinically localized prostate cancer, he is counseled regarding his treatment options. These generally include Watchful Waiting, Radical Prostatectomy or Radiation Therapy. Because cryotherapy (freezing) and high-frequency ultrasound (HiFU) are still considered experimental by most clinicians, they will not be considered here.

Q14. Who is a candidate for Watchful Waiting?

A. Watchful waiting, or “expectant management”, is an option for men in whom it is felt the prostate cancer is either “insignificant” or so slow growing that it is unlikely to pose a threat to the patient’s health in his expected lifetime. Generally accepted criteria for watchful waiting require that a patient’s cancer show all the following features:
1. The cancer cannot be felt in the prostate. In other words, it is non-palpable cancer, Stage T1c;

2. Two or fewer needle cores are involved, and none involved with greater than 50% tumor;
3. The tumor is Gleason 6 or less;
4. The percent free PSA is 15% or greater.
5. Re-biopsy may be recommended every 12-18 months to monitor the aggressiveness of the cancer.


Q15. Is watchful waiting an option for any man with these characteristics?

A. Not really. Because biopsies don’t always tell the whole story, and cancer can be more extensive or of a higher grade than indicated by the biopsy results, most physicians will not recommend watchful waiting for younger men with many years ahead of them, regardless of favorable characteristics.

So watchful waiting is a better option for older men, usually at least in their late sixties.

Q16. Does treatment ever become necessary once a patient has chosen watchful waiting?

A. Yes, treatment may become necessary down the road, and it’s important that patients keep in touch with their doctors to ensure any changes that might indicate treatment are not overlooked. Watchful waiting is no good if treatment becomes necessary but is delayed or missed altogether.

Q17. How is the decision made to change to active therapy?

A. It is well known that the best opportunity for cure is when the PSA and tumor volume are at their lowest. So PSA should be monitored closely, at least every 6 months. Additionally, both the absolute PSA and the rate of PSA rise are predictors of prostate cancer curability. If the patient is otherwise healthy, serious consideration should be given to treatment should the PSA start to rise.
Gleason scores may worsen with time too, and there is always the risk that the initial biopsy may have under-sampled the actual tumor. Therefore, current recommendations include re-biopsy every 1-2 years. Should Gleason 7 or higher cancer be detected, treatment should be considered. It should be noted that repeat biopsies have been reported to be falsely negative up to one-third of the time; therefore a negative repeat biopsy should not be interpreted as “spontaneous cure” of prostate cancer.

Radical Prostatectomy: the surgical option

Are all radical prostatectomies performed the same way?

Not now. In the past the two most common types of radical prostatectomy procedures were the open radical retropubic prostatectomy and the trans-perineal prostatectomy. In the open RRP, an incision is made in the lower belly, the prostate exposed, removed, and the urethra and bladder re-attached. With the transperineal approach the man's legs are up in stirrups like a lady having a baby. An incision is made in the perineum (skin between scrotum and anus), the prostate identified and removed. The transperineal procedure is less common today, and many urologists are switching to laparoscopic or "robotic" types of retropubic prostatectomies.

Are the results of these types of Radical Prostatectomy procedures all the same?

It seems that the transperineal prostatectomy has a lower overall chance of potency preservation. None of the "retropubic" approaches, in other words, thruough the belly, whether open, laparoscopic or robotic, appear to have an advantage over one another in terms of either potency preservation or sex function.

The robotic and laparoscopic approaches may have an advantage in length of stay in the hospital and recovery time.

Who is a candidate for Radical Prostatectomy?

Radical prostatectomy can be a good treatment option for young men with low PSA, Gleason score of 6 or less and non-palpable cancer. In the hands of a skilled surgeon these men may have an excellent cure rate.

Q18. What about complications with Radical Surgery? I have heard that leakage and loss of sex function are almost universal.

A. Actually, radical prostatectomy techniques have improved greatly in recent years and now have a much-improved complication profile. Urinary leakage has been reduced, and the most common complication, impotence, now only occurs in young men around 50% of the time if both sex nerves can be preserved. However, if one or both sex nerves are removed, impotence is almost universal.

Q 19. Does age play a role in surgical complication rates?

A. Yes. All series seem to indicate that the older the patient, the higher the risk of incontinence and impotence. Additionally, men with higher PSA, Stage or Gleason scores who choose radical prostatectomy have a higher risk of extracapsular disease. These men may therefore end up with both radical prostatectomy and radiation therapy to control the disease. For many of these men, definitive radiation therapy may be a better option.

Radiation Therapy: Many options available

What are the types of radiation therapy that one can have for treatment of prostate cancer?

The type of radiation therapy a man should choose can be a confusing. Many different radiation therapy options are offered, including conventional external beam irradiation, intensity modulated radiation therapy (IMRT), proton beam irradiation, seed implants, whether permanent (iodine or palladium) or temporary (iridium), temporary or permanent seeds and external beam in combination with one another, or any of the above treatments in combination with hormonal therapy.

Q20. Why are there so many options?

A. These many radiation therapy strategies would not have emerged were there a consensus on how to treat prostate cancer and achieve high cure rates. Prostate cancer, while potentially curable with radiation therapy, requires high doses of radiation. However, because the prostate gland is nestled between the rectum and the bladder, targeting the prostate so that the cancer is cured and the risk of damage to the rectum or bladder is minimized requires great skill on the part of the radiation oncologist. Analysis of which treatments are effective also requires diligent and careful review of patients and their results. If radiation oncologists could agree how to measure success following treatment it would make comparison among treatments much easier.

Q21. That seems like a straightforward question. How could it be confusing?

A. Why this confusion exists is both easy and difficult to understand. With surgery, the prostate is removed and with it all possible sources of PSA. Therefore the PSA should fall to undetectable levels, most commonly stated as < 0.2 ng/ml within 6 weeks. If the PSA does not achieve this level or subsequently rises, the patient has persistence or recurrence of prostate cancer. Although very rarely PSA may become detectable because of some slight re-growth of benign tissue left behind, this is by far the exception.  Johns Hopkins researchers use a so-called “undetectable” PSA, < 0.2 ng/ml, the strictest criterion for cancer treatment success following radical prostatectomy.

However, with radiation therapy the prostate remains in the body. Radiation does not kill the prostate instantly. Rather, the cells die at different rates and over time, usually when they try to undergo cell division. Until then they can still carry out their normal cell functions, including the production of PSA. Because the PSA falls slowly over time as the prostate cells die, and may actually increase, or “bounce” for a brief period due to as yet unexplained factors, the slow rate of decline and PSA bounce can make interpretation difficult.

Q22. How was cure determined before PSA was available?

A. Before the PSA  test was developed and its role fully appreciated, radiation oncologists determined prostate cancer freedom just with a DRE. If no nodules were present, the patient was cancer free. When PSA became available and patients were diagnosed with cancer with no nodules at all, e.g. T1c cancer detected by PSA elevation only, the absurdity of checking for a nodule in a patient who never had one became quickly apparent. The next model considered men disease free if the PSA returned to a “normal” level, e.g. less than 4 ng/ml. With further follow-up it became apparent that many patients whose PSA levels declined to levels even as low as 1.5 ng/ml were still at substantial risk for recurrence. In 1996 papers appeared from groups in Boston and Atlanta examining whether the nadir PSA, that is the lowest PSA level achieved after radiotherapy treatment, could predict which patients had the best chance of cure following treatment. Investigators at Radiation Oncology of Atlanta were key authors on the Atlanta papers.

Q23. What did this research show?  

A. The findings of these papers were remarkably similar--yet totally different in outcome for the patients concerned. The paper from Boston reported on patients treated with external beam irradiation, while the paper from Atlanta reported patients treated with simultaneous irradiation, that is, a seed implant followed by conformal external beam radiotherapy. Both papers found similar results: Men who achieved a PSA nadir – the lowest level of PSA after treatment -- of 0.5 ng/ml or less had excellent cure rates of 90% or greater, while patients whose PSA did not go to such levels had much lower cure rates, with almost all men recurring if their PSA did not fall below 1 ng/ml.

Q24. So how low the PSA falls – the PSA nadir --  seems to have significance?

A. Yes. That two completely different radiotherapy techniques produced the same finding regarding the power of nadir PSA to predict cancer freedom is striking. What is more revealing, however, is that while men who achieved PSA nadir of 0.5 ng/ml or less went on to do well in both series, the proportion of men in the Boston series who actually achieved a low PSA nadir was only about 30%, whereas more than 90% of men in the Atlanta series achieved a PSA nadir of 0.5 ng/ml or less. So while the predictive value of PSA nadir was the same in both studies, the likelihood of cure was much higher in the Atlanta study, because many more men in the Atlanta study actually achieved the low PSA required for cure. To paraphrase he authors of the Boston study: “The goal of future radiotherapy efforts should be to get as many patients to undetectable PSA as possible.” We have since lowered our PSA nadir level for defining cure of prostate cancer to achievement and maintenance of nadir of 0.2 ng/ml or less for 10 or more years, the same as radical prostatectomy.  

Q25. That seems reasonable. Have all doctors adopted achievement and maintenance of an undetectable PSA nadir as the standard for radiation therapy?

A. Unfortunately, no.  Controversy continues in radiotherapy literature regarding how to evaluate the results of prostate cancer treatment. In 1997 a consensus panel convened by the American Society for Therapeutic Radiology and Oncology (ASTRO) proposed that disease-freedom be defined by three consecutive rises in PSA, with no reference to minimum follow-up or nadir PSA level. This definition has met with tremendous criticism both inside and outside the radiotherapy community, as it appears to grossly overstate cure rates. In fact, Dr Patrick Walsh of Johns Hopkins analyzed his results with the ASTRO definition, finding a difference of 13% at 10 years.

Q26. What were Dr Walsh’s cure rates using undetectable PSA  and then using the ASTRO definition?

A. In Dr Walsh’s series, ASTRO definition predicted 90% cancer freedom, while the strict definition of achievement and maintenance of undetectable PSA (nadir of 0.2 ng/ml or less) resulted in the more realistic cure rate of 77%.

Q27. Are there other problems with the ASTRO definition?

A. Dr Frank Vicini, of the William Beaumont Hospital, showed the impact of short follow-up on disease freedom calculated with the ASTRO definition—unless men are followed for a minimum of 5 or more years, the ASTRO definition will grossly overstate their cure rates.  

 Q28. Why is a strict definition of cure important?

A. When men choose a prostate cancer treatment there are many factors to consider, not only cure rates but also side effects including lifestyle changes brought about by treatment. Even if a cancer’s treatment causes major lifestyle changes—witness rectal cancer requiring a permanent colostomy, or lung cancer requiring removal of an entire lung—if that is the only route for cure people will take it and accept the consequences. By the same token, if prostate cancer killed folks rapidly but could only be cured with a procedure that caused incontinence and impotence in 100% of patients, patients would still likely accept these complications and be treated, because it would be the only way to save their lives.

However, that is not the case with prostate cancer. In most cases, prostate cancer is a disease process that takes years to play out, even if it is not cured initially. Radiation studies have traditionally evaluated older patients, many of whom may succumb to other illnesses before their cancers have had time to recur. If such a group of patients are then analyzed with the ASTRO definition, it may give a false impression of the cure rates of different radiotherapy approaches. Using such data to then tell a younger man that his cure rates are the same as those of radical prostatectomy is misleading. 

 Of note, several recent studies again confirm the Boston and Atlanta studies regarding the impact of PSA nadir on outcome.

Q29. Is there continuing research on how to best evaluate the results of therapy?

A.Yes, lots of papers appear in the literature looking into what PSA level –if any—should be used in determining cure of prostate cancer. Currently a “nadir plus two rises” definition seems to be gaining popularity. This definition does not use a strict nadir requirement, but may be more acceptable for patients treated with external beam irradiation alone. Nonetheless, other papers continue to emerge showing that regardless of which technique is used, the lower the PSA nadir achieved, the greater the likelihood of cure.

At ROA we use the strictest definition of success: achievement and maintenance of undetectable PSA, ≤ 0.2 ng/ml, for 10 or more years.


Q30. What is IMRT?

A. IMRT, or Intensity Modulated Radiation Therapy, is perhaps the most significant advance in radiation treatment in the last 30 years. Rather than the old-style “shotgun” type radiation, with beam shaping only around the outer edges of the field, IMRT breaks each beam into segments, allowing each “beamlet” to deliver a precise dose to a specific part of the target. When beams are modulated across the face of the entire beam, and multiple beam angles are used, minute gradations in dose to target (the prostate) and non-target (rectum, bladder) are possible. This has allowed for much more uniform dosing of the prostate with tighter dose limits on the bladder and rectum than have ever been possible.

Q31. Do you use IMRT?

A. Yes. To the best of our ability all of our patients are treated with IMRT.

Q32. Do you have an example of an IMRT plan versus a standard 3-D radiation plan?

A. Yes, here are two pictures of the same patient but planned with 3-D conformal treatment (top) or IMRT (bottom). It is easy to see how the coverage of the target, the prostate, is equally good between the two plans. But the dose lines on the top image, the 3-D plan, run deeply into the rectum. In contrast, with IMRT the dose to the rectum is much much lower. A lower dose to the rectum can mean a lower risk of complications. Until fairly recently this sort of “tailored dose” was impossible..

Treatment Plan 1

Treatment Plan 2

Q33. How much experience do you have with IMRT at Radiation Oncology of Atlanta?

A. Our physicians are among the most experienced with IMRT in the United States. In fact, we were the first to integrate IMRT into the follow-up radiation plan for men undergoing seed implant and followup external irradiation. Each facility where our prostate patients are treated are equipped with IMRT-capable linear accelerators.

Q34. Tell me about the your process of treatment with simultaneous irradiation. 

A. Simultaneous irradiation involves seed implant followed 3 weeks later with external beam irradiation. At ROA we use iodine-125 seeds, which are a bit smaller than a grain of rice, usually implanting between 90 and 120 seeds into the prostate.

Take me through a patient's typical "Day of Implant" experience. 

The implant procedure is as follows. The patient is admitted to the outpatient surgery department under the care of a urologist. The seed implant is a minor surgical procedure typically performed under general anesthesia, but spinal if necessary. No incisions are made. Anesthesia is given, and the patient’s legs are placed in stirrups. A catheter is placed in the bladder. The ultrasound probe is then inserted in the rectum, the prostate identified and mapped out. A needle guide is placed against the perineum and, watching directly with the ultrasound unit, needles are passed through the perineum (skin between the scrotum and the anus) and into the prostate. After confirming the needle arrangement, seeds are deposited as the needles are withdrawn. Typically bleeding is minimal except where the needles were inserted. After completion of the procedure the urologist performs a cystoscopy to be certain that there are no stray seeds or clots in the bladder requiring irrigation and removal. The patient is discharged either a few hours later or the following morning, based on the discretion of the admitting urologist.

Is the implant painful? Will I see any blood?

Since there is no cutting, only passing needles throught the skin into the prostate, the implant is usually painless, but some men may feel fullness where the needles were inserted. In addition, the scrotum usually turns black and blue temporarily.  Blood can be seen in the urine or semen for four to six weeks after implant.  Sexually active men may notice dark or rust-colored semen, and some may have a feeling of spasm at ejaculation. These side effects are normal and largely improve within four to six weeks after the implant.  

What kind of follow-up do you do to check the patient and prepare for the external beam treatment?

The patient comes to the hospital for a post-operative check and review of symptoms the next day. At that point a CT scan is performed to check the position of the seeds and their relationship to the urethra. The catheter is removed and the patient discharged.
Two weeks later the patient returns for a CT scan and treatment planning, with treatment scheduled to start about a week to 10 days later. In the case of patients traveling from out of town, they are seen in 3 weeks following the implant and the CT and treatment planning are done the same day.

When I start the external beam treatment, how long does it last? Do I have any symptoms?

Treatment lasts from 6-7 weeks, every day, Monday through Friday. Treatment takes about 15-20 minutes, but plan on being in the department for 45 minutes or so depending on how the schedule is proceeding.

Most men have few if any symptoms from the external beam part of the treatment. In fact, the side effects of SimART are typically no more than a seed implant alone.

Q35. What are the typical urinary side effects I can expect?

A. By the time prostate cancer is diagnosed, most men have some urinary symptoms simply related to aging and growth of the prostate. After implant, some men will perceive an upswing in urinary symptoms, or perhaps develop some urinary symptoms if they didn’t have any to start. These symptoms include frequency, urgency, dysuria (burning), increase in nighttime urination, slow stream and intermittency (stop and start) of urination.  The degree of symptoms varies from man to man and is affected by the level of symptoms he already have and the size of the prostate gland. 

Can these symptoms be treated?

Yes. most symptoms are easily controlled with medcines such as Flomax, Cardura, Uroxatral or Hytrin. The medicines relax the muscles that control urination. 

Does anyone ever need a catheter?

Rarely, but yes. Immediately following the prostate implant, about 5% of men may develop urinary obstruction and require a temporary catheter. Again, this likelihood depends on the prostate size and severity of symptoms before treatment.  A small fraction of men have prolonged urinary obstruction; about 1.5% have required a TURP (Roto-Rooter operation) for chronic obstruction.

Q36. What are the typical rectal side effects I can expect?

A. Rectal symptoms are most strongly influenced by a history of hemorrhoids.  Men who have a history of hemorrhoids, fissures, rectal bleeding, or other problems may find an increase in their symptoms during the six to seven weeks of external beam irradiation following implant.  Usually, rectal symptoms are usually the first to resolve after therapy, and only mildly bothersome, but sometimes require medication.  Diet change can help, especially the addition of fiber and elimination of acid foods.

Q37. Are there any long-term urinary or rectal side effects?

A. Long-term side effects are ones that may be seen 12-24 months after treatment.
While most men find that urinary symptoms begin to resolve by four to six months after treatment is completed, some may take longer to see improvement or have persistent symptoms. Men who have not had a prior TURP have about a 2% chance of developing urine leakage.  Urinary bleeding is rare except when taking aspirin. Some men will have prolonged burning with urination.  At about 18-24 months, about one in six men experience a return of urinary symptoms similar to what they had after the implant even if these symptoms had previously improved.. This second onset of symptoms is known as “post-irradiation prostatitis” (PIP), The exact cause of PIP is unknown, but is probably a cause similar to the PSA bounce.  If PIP occurs, the symptoms usually last for four to six months and then resolve on their own. Rarely, these symptoms will persist.  Medication may or may not be of benefit.
Urinary stricture, a scarring or tightening of the urethra, can occur in about 2% of patients. If a stricture develops, we recommend dilation only, which may need to be repeated. We do not recommend TURP except in exceptional circumstances. We recommend our patients call us first if a TURP is ever suggested.

You mentioned TURP. I had one years ago. Does that make a difference?

A TURP can mean more symptoms down the road. Men who have undergone prior TURP (Roto-Rooter operation) before or after implant have a greater risk of urinary problems than others.  About one-third of men who have had a TURP will develop some leakage of urine, usually associated with urgency. Of those with leakage, about half (1in 6 overall) will need a pad. The possibility of post treatment stricture or urinary symptoms is also be increased.

The most significant possible urinary complication is damage to the bladder requiring removal (cystectomy) and diversion. This risk is about one in 1000.

What about rectal problems? Can they persist?

Chronic rectal problems are rare.  Like PIP, rectal symptoms can be delayed, appearing 12-24 months after treatment. The most common symptom is a few drops of blood on the stool after a bowel movement, and is usually corrected with fiber, stool softeners and stopping aspirin.  Rarely patients will require cauterization. The most significant possible rectal complication is damage to the urethra or rectum resulting in a hole, called a fistula. A fistula requires a diverting colostomy, or bag, which may be permanent. This risk is very low, about 1 in 500.

Q38. What about sexual function?

A. Here, age can make a difference. The younger the patient, the more likely he is to keep good sex function. Still, some men will completely lose their erection and others may find the quality of the erection to be diminished. The likelihood of maintaining an erection sufficient for penetration by age group is: Age <60: 79%; Age 61-70: 67%; Age >70: 46%.  The risk of impotence is increased by a history of smoking, high blood pressure, diabetes or heart disease.  The ejaculate (semen) may decrease with time.  Whether this results in sterility is unknown.  If men want to father children in the future, we advise sperm banking prior to treatment.

Is there any risk of a second cancer following radiation therapy?  The literature is conflicting regarding the risk of second cancers as a result of radiation therapy to the prostate. Many studies show no increased risk of rectal cancer, but a few have shown a slightly increased risk.  Organs such as the bladder appear to show no increased risk.

Q39. What is your experience in treating men with prostate cancer?

A. Physicians at Radiation Oncology of Atlanta are among the most experienced in the United States, having performed thousands of implants. Our treatment results, as part of larger series, have been presented at major national and international meetings, and published in numerous peer-reviewed medical journals.

Q40. How do I become a patient at Radiation Oncology of Atlanta? 

Men who wish to find out more about Radiation Oncology of Atlanta should call our intake team at 404-303-3896. They will send you information about our practice and a series of forms to complete so that we can properly evaluate you. If you live in the Atlanta area, just schedule an appointment with one of our physicians. If you live outside a convenient driving distance, you may gather your records and send them in for review. A list of records required can be found here.

Please call Radiation Oncology of Atlanta at 404-705-9192, or contact us here if you have questions or want to schedule a consultation or follow-up appointment.