Located in Philadelphia, Pennsylvania, the Abramson Cancer Center was founded in 1973 and serves as the central body for planning, facilitating, and promoting cancer research, patient care, education, outreach and health information services for the University of Pennsylvania, including its School of Medicine and Health System. The Cancer Center includes 299 members representing 41 departments and eight schools who come together to create a highly interactive community that facilitates collaboration. Leading-edge cancer research, spanning basic, translational, clinical, and cancer control and population sciences research is stimulated through 11 disease specific (e.g., Breast, Melanoma, Hematologic Malignancies, Pediatric Cancers) and thematic-focused (e.g., Immunobiology, Tumor Biology, Tumor Virology, Radiation Biology, Cancer Control and Outcomes, Cancer Epidemiology and Risk Reduction) Research Programs, which are interdisciplinary and focused on pursuing intra- and interprogrammatic collaborations, and 14 Shared Resources that support innovative cancer research. The Cancer Center’s ability to develop and support strong interdisciplinary programs in cancer research is reflected in the steady growth of grant support (research and training) awarded to its members. Cancer Center members currently have research and training grant funding in the amount of $125 million in annual direct costs and $180 million in annual total costs. The Cancer Center ranks 5th nationally in NCI funding, and has been continuously funded by the NCI Centers’ Program since 1974.

The research base is complemented by a comprehensive, nationally recognized clinical cancer service that provides a full range of medical and supportive services to patients with all kinds of cancer. In addition to serving the tri-state region of Pennsylvania, New Jersey and Delaware, the Cancer Center serves as a leading cancer referral center for the eastern seaboard and beyond. This is reflected in the fact that Penn has the largest market share in the region, and is the dominant provider for multiple cancers, including urologic, lung, head and neck, GI, GYN, and hematologic malignancies/BMT. In light of the growth of the cancer clinical service, construction has started on a $247 million Center for Advanced Medicine, an ambulatory health care facility on the Penn health services campus. This facility will house all the ambulatory cancer programs of the Abramson Cancer Center, including disease specific clinics (e.g., breast and gynecologic cancer), as well as oncologic diagnostic testing and patient support services. A new radiation oncology department will be located in this building.

Treatment Options at Penn for Prostate Cancer

There are different ways to treat prostate cancer. You will probably want to talk to different types of doctors before making a final decision. Since there haven’t been enough large clinical trials that compare the different treatments, there are different views on how best to treat a particular kind of prostate cancer. Before making a decision, you should talk to a urologist and radiation oncologist who are expert in the treatment of prostate cancer. They will tell you about the benefits and risks of surgery, hormonal therapy and radiation therapy for your particular situation. If your prostate cancer has already spread at the time of diagnosis, you should also talk to a medical oncologist about chemotherapy. It is important that you discuss your options with the right doctors. Together you can make the decision that is best for you.

Treatments for prostate cancer are:

• Surgery: Total Prostatectomy
• Radiation Treatment: External Beam, Photodynamic Therapy
• Hormonal Therapy
• Chemotherapy
• Watchful Waiting

Surgery: Total Prostatectomy Surgery is a common form of treatment for prostate cancer. Surgery seeks to cure prostate cancer by removing the entire prostate and getting all of the cancer out of the body. To sure early stage and low to intermediate grade prostate cancers, surgery is generally felt to be equal to radiation treatment in terms of survival. The decision to have surgery versus radiation is often made on the basis of age and health status. Recurrence rates may be lower for surgery than radiation treatment. These and other factors should be discussed with your doctors when making treatment decisions. The most common surgery for prostate cancer is a total (radical) prostatectomy. Total prostatectomy means that the entire prostate gland is removed from around the uretha. This surgery can be done in one of four ways: the retropubic approach, the perineal approach, the laproscopic approach, and the robotically-assisted laparoscopic approach.

• The retro public approach means the incision is made in the lower abdomen.
• The perineal approach means that the incision is made between the scrotum and anus.
• The laproscopic approach means that small punctures are made in the lower abdomen and a camera attached to a scope provides visualization with magnifications.
• The robotic-assisted laparoscopic approach means that a very small incision is made in the lower abdomen. Robotic instruments, which are controlled by the urologist, are used.

Possible Side Effects Radical prostatectomy is a very safe surgery with few life threatening complications. However, there are side effects that are common with this procedure. They are:

• Urinary incontinence – not being able to hold the urine stream resulting in leaking urine
• Impotence – inability to achieve and maintain an erection The risk for these side effects increases with age. This is why it is often recommended that younger men have surgery, and that older men have radiation. Talk to your surgeon about their complication rates before your operation. Sometimes, with lower grade and smaller cancers, a nerve-sparing prostatectomy can be done. This type of prostatectomy can help decrease the chances that you will be impotent after the procedure. However, there is always a risk and not every patient is a candidate for a nervesparing surgery.

With surgery, urinary incontinence and impotence are often most severe right after the operation and get better with time. Your doctor or nurse can offer exercises to help you deal with incontinence. If your ability to have an erection does not return on its own, there are many treatment options available. There are ways to reduce any long-term side effects. These include oral medications, urethral suppositories, penile injections and external vacuum devices, or penile prosthesis. Talk to your urologist about your options.

The Cancer Center holds weekly classes for patients who are about to have radical prostatectomy surgery. The class provides important information about what will happen before, during and after your surgery. The instructor will also tell you about possible side effects of surgery, and how to get help in dealing with them.

Radical Prostatectomy   The most common surgery for prostate cancer is a radical prostatectomy. Radical prostatectomy means that the entire prostate gland is removed from the urethra.

This surgery can be done in three different ways: the retropubic approach, the perineal approach and the robotically-assisted laparoscopic approach.

• The retropubic approach means that incision in made in the lower abdomen.
• The perineal approach means that the incision is made between the scrotum and anus.
• The robotic-assisted laparoscopic approach means that a very small incision is made in the lower abdomen. Robotic instruments, which are controlled by the urologist, are used.

  Radiation Treatment   Prostate cancer is commonly treated with radiation therapy. Radiation therapy uses high-energy rays (similar to x-rays) to kill cancer cells. Radiation therapy is an option for early stage prostate cancer. Advanced prostate cancer is typically treated with radiation therapy.

In addition, radiation therapy helps avoid surgery in patients who are too ill to risk having anesthesia. Radiation therapy is usually offered to older patients with early stage prostate cancer due to fewer side effects.

Radiation therapy can have impotence rates similar to surgery, but the risk of urinary incontinence is very low. Impotence may develop months to years after the radiation treatment, unlike with surgery, which tends to have the side effects occur immediately. Other side effects from radiation include:

• Proctitis – inflammation of the rectum with bleeding and bowel problems such as diarrhea.
• Cystitis – inflammation of the bladder, leading to problems with urination, such as urinary frequency and urgency as well as bladder pain.
• Fatigue – feeling extremely tired, which will go away once treatment is over.

Your radiation oncologist tries to limit the amount of radiation to other organs in order to minimize these side effects. However, the bladder and rectum can get some of the radiation because they are so close to the prostate.

Radiation therapy for prostate cancer can be given by using external beam radiation therapy, brachytherapy or photodynamic therapy.

External Beam Radiation Treatment External beam radiation comes from a machine outside the body. The machine directs high-energy rays at the cancer. The machine used to deliver the high-energy rays is called a linear accelerator. External beam radiation therapy has been a standard form of treating prostate cancer for decades. There are two types of external beam radiation treatment: conventional external beam radiation.

Conventional External Beam Radiation Treatment For this therapy, patients receive treatment 5 days a week for 6 to 8 weeks. The treatment takes just a few minutes, and it is painless.

With newer techniques, side effects may be fewer. Higher-energy radiation beams can be more precisely focused, while computer technology allows the radiation oncologist to tailor treatment to the individual patient.

Possible Side Effects of External Beam Radiation Because the radiation beam passes through normal tissues of the rectum, bladder, and intestines on its way to the prostate, it kills some healthy cells. Radiation to the rectum often causes diarrhea. The diarrhea clears up when treatment is over. Fatigue can also occur, and will clear up once treatment is over. Your doctors and nurses will work with you to help relieve any symptoms you have.

Usually symptoms go away after treatment. However, in some cases they may persist after treatment has ended. External beam radiation can also cause some long-term problems. These include proctitis and cystitis. Also, some 40 to 50 percent of men treated with radiation therapy become impotent. There are ways to manage long-term side effects. These include oral medications, urethral suppositories, penile injections and external vacuum devices, or penile prosthesis. Talk to your doctor about your options.

Proton Therapy Proton Therapyis the most precise form of radiation treatment for cancer possible, while minimizing damage to healthy tissue and surrounding organs.

Photodynamic Therapy

Photodynamic Therapy (PDT), also known as photoradiation therapy, phototherapy or photochemotherapy can be used to treat prostate cancer. It is based on the discovery that certain chemicals known as photosensitizing agents can kill cells when they are exposed to a particular type of light. PDT destroys cancer cells using a fixed-frequency laser light (an intense narrow beam of light) in combination with a photosensitizing agent.

In PDT, the photosensitizing agent is injected into the bloodstream and absorbed by cells all over the body. The agent remains in cancer cells for a longer time than it does in normal cells. When the treated cancer cells are exposed to laser light, the photosensitizing agent absorbs the light and produces an active form of oxygen that destroys the treated cancer cells. Light exposure must be timed carefully so that it occurs when most of the photosensitizing agent has left healthy cells but is still present in the cancer cells.

The laser light used in PDT can be directed through a fiber-optic device (a very thin glass strand). The fiber-optic device is placed close to the cancer to deliver the proper amount of light. The fiber-optic device can be directed through a scope for the treatment of prostate cancer.

An advantage of PDT is that it causes minimal damage to healthy tissue. However, because the laser light currently in use cannot pass through more than about 3 centimeters of tissue (a little more than one and an eighth inch), PDT is mainly used to treat tumors on or just under the skin or on the lining of internal organs. Patients having PDT need to avoid sun exposure during treatment and for two months after treatment.

Possible Side Effects of Photodynamic Therapy PDT can cause burns, swelling, pain, and scarring in nearby healthy tissue. Other side effects include coughing, trouble swallowing, stomach pain, painful breathing, or shortness of breath; however, these side effects are usually temporary.

Hormonal Therapy Both normal prostate tissue and prostate cancers depend on male sex hormones, called androgens, to grow. Testosterone is an androgen that is very important to the prostate gland. Men make androgens in their testicles. One of the ways to treat prostate cancer is through hormonal therapy, which removes androgens from the body. This causes the cancer to shrink and then grow more slowly.

There are a few different ways to remove or decrease androgens:

• Orchiectomy – surgical removal of the testicles
• Luteinizing Hormone-Releasing Hormone (LHRH) agonists – drugs used to control the growth and spread of prostate cancer by largely shutting down the normal hormonal functions in the male
• Anti-androgens – drugs that block androgen receptors
• Estrogens – hormones that reduce the level of testosterone

Different methods of deceasing androgens are often used in the same patient. LHRH agonists with anti-androgens can totally block the production of androgen.

Hormone therapy can also be used with other treatments, especially for advanced stage prostate cancer that is also being treated with radiation therapy. In this case, hormone therapy is given before the radiation. This is known as neoadjuvant hormone therapy. Another use for hormones is in patients whose prostate cancer has spread.

After a while, all prostate cancers will become resistant to hormonal therapy. However, this often takes many years. Hormonal therapy can add a lot of time in patients with extensive prostate cancer or patients who choose not to have surgery or radiation.

Possible Side Effects of Hormonal Therapy There are a number of side effects associated with hormonal therapy. Hormonal therapy will almost always cause:

• Impotence and the loss of your sex drive
• Breast enlargement
• Hot flashes
• Loss of muscle
• Bone loss (osteoporosis) There are some treatments your doctor can prescribe to help with bone loss and hot flashes. Unfortunately, little can be done about loss of sex drive and impotence.

Chemotherapy

Chemotherapy is the use of anti-cancer drugs that go through the entire body. Chemotherapy is prescribed by medical oncologists, who are experts in using this kind of treatment. Chemotherapy for prostate cancer is used only for very advanced cancers that no longer respond to hormonal therapy. There are a number of chemotherapy drugs that can be used for prostate cancer. They are often used in combinations. The use of chemotherapy in prostate cancer is currently being studied and men who get chemotherapy are encouraged to talk to their doctors about clinical trials. There are advantages and disadvantages to each of the different regimens that your medical oncologist will discuss with you.

Watchful Waiting

Some patients choose to receive no therapy for their prostate cancer in the hopes that it will grow very slowly. This is called Watchful Waiting. By avoiding any therapy, they avoid the side effects that come along with surgery, radiation or hormones. Watchful waiting is appropriate for older men with small, lowgrade tumors, slowly rising PSAs, and those who have multiple health issues. Watchful waiting can be considered in patients who are expected to live less than 10 years. This is only if the cancer isn’t large or of a high grade. Men who choose watchful waiting should have PSAs and digital rectal exams done every 3-6 months. They will also need to have biopsies of the prostate to make sure the grade hasn’t become less favorable. With watchful waiting, it is never clear what change should be the signal to begin treatment. Also, if the tumor has progressed, the patient may no longer be eligible for curative therapy.