Prostate Cancer

Prostate cancer normally grows at a very slow pace and can even grow for years without any symptoms. Nevertheless, a small proportion of the tumour may be highly aggressive, and spread rapidly to other parts of the body.

Prostate cancer rarely occurs before the age of 45. The risk of prostate cancer increases with age.

• Frequent urination
• A weak urinary steam
• Interruption while urinating
• Pain or burning while urinating
• Inability to urinate
• Blood in the urine

Various diagnostic tools are used for the detection of prostate cancer:

Digital rectal examination
The physician inserts a gloved finger into the rectum and palpates the prostate. Due to the lose proximity of the rectum to the prostate, abnormalities of the gland can be felt. DRE is very useful in detecting prostate cancer but requires a certain size and position of the tumour. Therefore many early stage cancers are missed using this method alone.

PSA (prostate specific antigen)
PSA is a substance that is produced by the prostate. Its concentration can be measured via a simple blood test. A healthy prostate releases very little PSA into the bloodstream. A high result of PSA indicates an abnormal situation of the prostate, but does not mean automatically that prostate cancer exists. It also may be the result if a benign enlargement of the prostate or other circumstances. If the PSA level is high additional evaluations should be performed.

TRUS (Transrectal Ultrasound)
Via a transrectal ultrasound probe (TRUS) the prostate can be visualised on an ultrasound screen, which allows the physician to analyse the prostate tissue. It is used to further define the condition of the prostate gland. A thin ultrasound probe is inserted into the rectum to a distance that permits visualization of the prostate gland. In this way the physician obtains a precise picture of the gland, which can then be examined.
During a biopsy a small amount of tissue is removed via a special needle and examined. This is the only way to definitively confirm prostate cancer.

Fortunately, various treatment options are available nowadays.
At Hattat Hospital, the appropriate treatment is carefully selected considering the stage of the disease, current medical conditions, and the patients and the physicians concern.

The main treatment options are:

1. Radical prostatectomy Complete surgical removal of the prostate, which the gland is completely removed. This is normally performed through an incision in the lower abdomen. By tradition the most common treatment for early stage cancer.

2. Radiation therapy The cancer cells are exposed to high doses of radiation. This therapy takes advantage of the effect that cancer cells are much more susceptible to radiation than normal tissue. The radiation can be delivered externally (external beam radiation) or internally (brachytherapy).

2.1. Seed implantation - Permanent brachytherapy Small radioactive sources with a length of 4.5 mm are permanently placed inside the prostate . The treatment takes advantage of the fact that cancer cells are more susceptible to radiation than normal tissue. Each seed emits a certain radiation dose to its surrounding tissue. By placing the seeds all over the prostate in well defined distances the organ is covered with exactly the required doses to destroy the cancerous cells. The tissue and organs surrounding the prostate are nearly not affected by the radiation as it is applied directly within the prostate.

2.2. External beam Focused radiation is applied from outside the body : This treatment option is delivered using a so-called linear accelerator that emits a high energy X-ray beam. The beam is targeted using various configurations at the prostate cancer. The treatment is delivered once a day (5 days/week) for approximately six to seven weeks. This treatment at daily intervals, also known as fractionation, allows to minimize the damage to the normal tissue that the beam has passed through.

2.3. High dose rate (afterloading therapy) Highly radioactive sources are temporarily inserted into the prostate. Tubes are surgically inserted into the tumour and a radioactive iridium wire is deposited temporarily into the tubes. Due to the high dose rate this treatment has to be split into various sessions. This modality is mainly used as a boost treatment after external beam radiation or radical prostatectomy.

3. Hormone treatment Hormonal therapy is a treatment option for cancer which has already spread beyond the prostate region, or has recurred following initial treatment by surgery or radiotherapy. It is also sometimes used for short periods in combination with radiotherapy. Male hormones (also called androgens)are important for prostate growth - Indeed the normal development of the prostate to its adult form is very dependent on testosterone, the principal male hormone released from the testicles. Prostate cancer cells that have left the prostate and are growing in other areas of the body (metastases) are also stimulated to grow by male hormones. Consequently one relatively common treatment for prostate cancer which has spread outside the prostate region is to lower the levels of male hormones in the body and thereby stop the growth of cancer cells. This happens irrespective of whether the cells are in the prostate or in other areas of the body. Indeed, prostate cancer cells typically respond to the withdrawal of male hormones by dying. Unfortunately, not all prostate cancer cells die, and with time, often several years later, the cancer returns. Nevertheless, good cancer control and a symptom-free lifestyle can be achieved for many years by men on hormone therapy.

4. Watchful waiting No treatment is applied, but the cancer is closely watched at regular intervals.

5. Cryotherapy In cryotherapy the prostate is frozen solid. Ultrasound guidance controls the extent of the freeze. The procedure is done under anesthesia and requires at least an overnight stay in the hospital. This technology has improved in recent years but is still associated with a very high incidence of impotence and urinary incontinence. In addition, fistulae (or holes) between the prostate and rectum can occur, especially in patients who have had unsuccessful EBRT. There are also a large number of patients who undergo cryotherapy after unsuccessful EBRT who experience pelvic and/or rectal pain.

6. HIFU Transrectal High Intensity Focused Ultrasound : Ablatherm is a medical device piloted by a computer designed to treat localized prostate cancer using high intensity focused ultrasound (HIFU). Ablatherm® HIFU is a procedure where the temperature inside the prostate is raised to 85° Celsius using a focused ultrasound beam.

Under a spinal or epidural anesthetic an ultrasound probe is inserted in the rectum to map the exact outline of the prostate gland. Using this map, high intensity ultrasound waves are delivered through the rectal wall precisely focused on the prostate. This focusing produces intense heat and causes the destruction of the tissue inside the targeted zone without damaging surrounding tissues. The treatment generally takes 1 to 3 hours depending upon the size of the prostate and is usually performed on an outpatient basis.

Is My Cancer Curable by Treatment with Ablatherm® HIFU?

Ablatherm® HIFU is an appropriate treatment option for essentially any male who has prostate cancer which can be cured by any other means. The stages of cancer of the prostate are:

1. T-1 Prostate cancer - This is a cancer which has no signs or symptoms and is totally unsuspected. The prostate feels normal to the physician on rectal exam. The cancer is detected either by an elevated Prostatic Specific Antigen (PSA) blood test and subsequent biopsies or by examination of tissue removed during treatment of an enlarged prostate. This tumor can be cured by surgery, radiation, and Ablatherm® HIFU.

2. T-2 Prostate cancer - This is a tumor which is suspected on rectal exam. One or both lobes of the prostate have areas of firmness and biopsies reveal the cancer. The PSA is also usually elevated. This tumor can be cured by surgery, radiation, and Ablatherm® HIFU.

3. T-3 Prostate cancer - This is a tumor that has spread outside the prostate capsule and may have reached the seminal vesicles. This tumor is not curable by surgery, radiation, or HIFU.

4. T-4 Prostate cancer - This tumor may have spread to the rectum or bladder or to distant organs or bone. This tumor is not curable by surgery, radiation, or HIFU.

Patients with both T-1 and T-2 prostate cancer will have an imaging scan, such as an MRI or CT, to try to detect cancerous extension outside the prostate or to other organs (lymph nodes, liver, etc.). A Bone Scan is used to rule out spread to bone. These tests will show no spread of tumor outside the prostate in T-1 or T-2 cancer.

Patients with T-1 and T-2 prostate cancer who have had external beam radiation therapy (EBRT) and recurrent cancer, but no spread outside the prostate, can be treated for cure by Ablatherm® HIFU. The sooner a patient is treated after the diagnosis of failed EBRT the better the chance he has for cure by Ablatherm® HIFU.

Patients with T-1 and T-2 prostate cancer who have had a radical prostatectomy and have recurrent cancer localized to the area of the prostatic fossa can be treated for cure by Ablatherm® HIFU. In fact, Ablatherm® HIFU remains one of the only therapy options for these patients.

It is important to know that the ability to detect microscopic spread of the tumor beyond the walls of the prostate is limited by today's technology. It is estimated that approximately 30% of patients diagnosed as having T-2 prostate cancer actually have a spread of cancer cells outside the prostate wall (T-3) and are therefore not curable. This is particularly true if the PSA is equal to or greater than 10 or the Gleason score is greater than 7.

What Do the Clinical Studies Show?

Ablatherm® HIFU has been extensively used in Europe. One report of 137 patients showed that 93% of the patients had negative prostate biopsies and 87% had PSA levels of less than 1.0 five years after the treatment.

Over 90% of patients undergoing Ablatherm® HIFU therapy will not require further treatment for their prostate cancer. Indeed, among the patients treated by Maple Leaf HIFU, fewer than 3% of patients have required retreatment in our first two years of operation. In those developing a recurrence, they remain candidates for surgery, radiation or hormone therapy. Ablatherm® HIFU treatment has a similar success rate to radical prostatectomy but has the major advantage of using non-invasive technology with many fewer side effects.

Is Ablatherm® HIFU a Proven Therapy?

In 1989, three prestigious European research groups united in their efforts and initiated a project to develop an efficient and non-surgical treatment for localized prostate cancer. After ten years of development Ablatherm® HIFU was approved for treatment in Europe. At present, Ablatherm® HIFU is being used throughout Europe, Russia and other Asian countries. To date, thousands of patients have been treated successfully in many European centers and throughout the world.

What are the Benefits of Ablatherm® HIFU?

The treatment of localized prostate cancer with High Intensity Focused Ultrasound has many advantages:

• Destruction of the cancerous tissue with no incident of injury to the rectum since parameters were updated in 2002.
• Patient does not undergo any radiation exposure.
• No hospital stay is required.
• Treatment is performed under spinal anesthesia.
• Treatment can be repeated if necessary.
• Other therapeutic alternatives can be considered in case of incomplete results.
• Ablatherm® HIFU can be used for the treatment of local recurrences (i.e. after external beam radiotherapy).