If the digital rectal exam or a high PSA level suggests cancer, the next step would be a transrectal ultrasound (TRUS) and perhaps a biopsy. TRUS uses sound waves to create an image of the prostate on a video screen. TRUS can also be used to guide a biopsy needle into exactly the right area of the prostate.

A biopsy is the only way to know for sure if you have prostate cancer. Cells from your prostate are removed so they can be studied in the lab. The doctor will put a thin needle through the rectum and into the prostate. Ultrasound is often used to guide the needle. This can be done in the doctor's office. This test may briefly cause a small amount of pain, but most men find it is not as bad as it sounds.

Early prostate cancer often has no symptoms. Problems with urinating may be a sign of prostate cancer. But more often this problem is caused by a less serious disease known as BPH (benign prostatic hyperplasia).

Symptoms of advanced prostate cancer include trouble having or keeping an erection (impotence), blood in the urine, swollen lymph nodes in the groin area, and pain in the pelvis, spine hips, or ribs. Once again, these symptoms can be caused by other diseases.

Staging

If the prostate biopsy finds a cancer, more tests are done to find out whether the cancer has spread and if so, how far. This process is called staging. Staging is very important because your treatment and the outlook for your recovery depend on the stage of your cancer.

There is more than one system for staging prostate cancer. The TNM system, described below, is the one used most often.

The TNM system for staging gives three key pieces of information:

• T refers to the Tumor. There are actually two types of T classifications for prostate cancer. The clinical stage is based on digital rectal exam, needle biopsy, and transrectal ultrasound findings. The pathologic stage is based on what the doctor finds when the entire prostate gland, both seminal vesicles and, in some cases, nearby lymph nodes are removed and examined.
• N describes how far the cancer has spread to nearby lymph Nodes.
• M shows whether the cancer has spread (Metastasized) to other organs of the body.

Knowing the clinical stage is important because it can help in making treatment decisions, such as whether a man might benefit from having the prostate removed. But the clinical stage might not show how much the cancer has spread. The pathologic stage, determined after surgery, is more useful in predicting the outlook for survival. Men who don't have surgery, of course, don't have a pathologic T stage determination.

Letters or numbers after the T, N, and M give more details about each of these factors. To make this information somewhat clearer, the TNM descriptions can be grouped together into a simpler set of stages, labeled stage 0 through stage IV (0-4).

In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious cancer.

After looking at your test results, the doctor will tell you the stage of your cancer. Be sure to ask your doctor to explain your stage in a way you understand. This will help you both decide on the best treatment for you.

Grading

Some prostate cancers grow slowly while others grow more quickly. Cells taken during your biopsy are studied in the lab to help decide how fast your tumor is growing. This process is called grading. A fast growing tumor is called aggressive. The Gleason system is used most often for grading. Under this system a lower number like 2-4 means a slower growing tumor. A higher number such as 8-10 means the cancer cells are likely to grow more quickly. Scores of 5-6 are considered in between. Ask your doctor to explain the grade of your tumor because the grade is also an important factor in making treatment decisions.

Treatment for Prostate Cancer

There are many treatments for prostate cancer. The best one for you depends on a number of factors. These include your age, your overall health, and the stage and grade of your cancer.

This section provides an overview of the types of treatments available to men with prostate cancer. However, the treatment information is not official policy of the American Cancer Society and it is not intended as medical advice to replace the judgment or advice of your cancer care team.

More detailed information about treatment options is available from several sources. The American Cancer Society provides a version of the NCCN (National Comprehensive Cancer Network) guidelines written with patients and families in mind. You can request a copy of these by calling 1-800-ACS-2345 or by visiting the ACS website at www.cancer.org.

The National Cancer Institute (NCI) also provides treatment guidelines through its telephone information center (1-800-4-CANCER) and website.

There is a lot for you to think about when choosing the best way to treat or manage your cancer. You may feel that you need to make a decision quickly. But give yourself time to absorb the information you have learned. The short delay until treatment does no harm. Talk to your cancer care team. Look at the list of questions at the end of this piece to get some ideas. Then add your own.

You may want to get a second opinion. Your doctor should not mind your doing this. In fact, some insurance companies require you to get a second opinion. You may not need to have tests done again since the results can often be sent to the second doctor. If you are in an HMO (health maintenance organization), find out about their policy concerning second opinions.

Each type of treatment has benefits and drawbacks. There may be side effects. Your age, your overall health, and the stage and grade of your cancer are all factors to consider. Surgery, radiation, and hormone treatment are the most common treatments for prostate cancer. Chemotherapy may be used in some cases, and watchful waiting, though not actually a treatment, may be an option for some men. Each of these approaches is explained below.

Surgery

Most treatments for cancer, including surgery, have some side effects. If you know about these beforehand, you can be better prepared. Knowing the side effects can also help you in choosing the right treatment. It's a good idea to talk to your doctor about your treatment choices ahead of time. Some treatments can have side effects such as not being able to have or keep an erection (impotence) or problems with urinating (incontinence). You and your partner will want to know all the facts so you can make the best choice for your own situation.

The two most common operations for prostate cancer are radical prostatectomy and transurethral resection of the prostate (TURP). Each is explained in more detail below.

Radical prostatectomy removes the entire prostate gland and some tissue around it. This surgery is done only if it appears that the cancer has not spread outside the prostate. There are two main types of radical prostatectomy. In one, a radical retropubic prostatectomy, the incision is made in the lower abdomen. In the other, a radical perineal prostatectomy, the incision is made in the skin between the scrotum and the anus.

In the first type, it is sometimes possible for the surgeon to avoid removing the nerves that control erections and bladder muscles. This lowers, but does not eliminate, the risk of impotence and incontinence following surgery.

Nerve-sparing operations are harder to do with the perineal approach, and lymph nodes cannot be removed through this incision. However, the surgeon can remove some lymph nodes through a very small incision in the abdomen using a narrow lighted tube called a laparoscope.

These operations last from 1 1/2 to 4 hours, with the perineal approach taking less time than the retropubic approach. They are followed by an average hospital stay of three days and average time away from work of three to five weeks. In most cases, you will be able to donate your own blood before surgery. The blood can be given back to you during the operation, if needed. Usually a tube for draining urine (catheter) is placed into the bladder through the penis after surgery while you are still asleep. The catheter stays in place for 10 to 21 days and allows you to urinate easily while you are healing. You will be able to urinate on your own after the catheter is removed.

The main side effects of radical prostatectomy are lack of bladder control (incontinence) and not being able to get an erection (impotence).

 Normal bladder control returns for many patients within several weeks or months after the operation. Mild stress incontinence, that is, passing a small amount of urine when coughing, laughing, sneezing, or exercising may happen permanently in up to 35% of men. A few men may have more serious incontinence, which may be permanent.

During the first 3 months to one year after this surgery, most men will not be able to get an erection without using medicine or some other treatment. The nerves that allow men to get erections may be damaged or removed in this surgery. Later, some men will be able to get an erection and some will still have trouble. The effect of this operation on a man's ability to have an erection is related both to the man's age and the type of surgery that was done. But the feeling of pleasure (orgasm) during sex will still be there. The orgasm will be "dry," though, since semen is not being made.

If you are concerned about erection problems, be sure and talk to your doctor. There are ways to help. There are medicines and even devices such as vacuum pumps that could prove useful. The American Cancer Society has a booklet called Sexuality and Cancer: For the Man Who Has Cancer and His Partner. Call the American Cancer Society for a free copy.

If you have pain, it can be managed with medicines and other methods. Good pain relief can help you recover more quickly. Do not ignore pain; tell your doctor or nurse about it and ask for help.

Transurethral resection of the prostate (TURP) is used for men who can't have a radical prostatectomy for some reason. It may be done to relieve symptoms before other treatments begin. It is not done to cure the disease or to remove all the cancer. It is used even more often to relieve symptoms of non-cancerous prostate enlargement.

A tool with a small loop of wire on the end is placed inside the prostate through the urethra. The wire is heated and it cuts out the cancer tissue. No incision is needed with this method.

The operation takes about one hour. You can usually leave the hospital after 1-2 days and return to work in 1 to 2 weeks. You will need a catheter afterwards for about two or three days. There may be some bleeding into the urine after surgery.

You may have some trouble with bladder control afterwards, but permanent loss of control is rare.

Cryosurgery involves placing a small metal tool into the tumor and killing the cancer by freezing it. The probe is placed through an incision between the anus and the scrotum. Spinal or epidural anesthesia is used during this procedure. Men usually remain in the hospital for one or two days.

A catheter is also put in place so that when the prostate swells, urine does not collect in the bladder. The catheter is removed one or two weeks later. After the procedure, there will be some bruising and soreness of the area where the probe was inserted.

Freezing can damage nerves near the prostate and cause impotence and incontinence. These side effects occur about as often as they do after radical prostatectomy. In addition, freezing may damage the bladder and intestines, leading to pain, a burning sensation, and the need to empty the bladder and bowels often.

Short-term results for cryosurgery look encouraging, although it is not yet known if the long-term survival rates are as high as with standard treatments. For now, this procedure is an option mostly for men who cannot have surgery or radiation therapy.

Radiation therapy is another way to treat prostate cancer. In this treatment, high-energy x-rays are used to kill cancer cells. Radiation is used most often for cancer that has not spread outside the prostate gland, or has spread only to nearby tissue. If the disease is more advanced, radiation may be used to shrink the tumor and provide pain relief. While radiation usually eliminates the need for surgery, men who do not have a good response to radiation might still have surgery at a later date.

Two methods of giving radiation are used to treat prostate cancer:

External beam radiation is much like getting a regular x-ray, but for a longer time. Each treatment lasts only a few minutes. Patients usually have five treatments per week on an outpatient center over a period of seven or eight weeks. The treatment itself is painless.

Side effects can include diarrhea with or without blood in the stool, and irritated intestines. Sometimes, normal bowel function does not return after treatment is stopped. Both during and after treatment, other side effects might include frequent urination, feeling like you have to urinate all the time, burning while urinating, and blood in the urine.

Also, external radiation therapy can cause tiredness that may not go away until a month or two after treatment stops. In about half the men, some degree of impotence may occur within two years of radiation. Impotence usually does not begin right after treatment (as it often does with surgery) but develops slowly over one or more years.

Internal radiation uses small radioactive pellets (each about the size of a grain of rice) placed directly into the prostate. They may be permanent or temporary. Because they are so small, they cause little discomfort and are simply left in place after their radioactive material is used up. In another method, needles containing a higher amount of radioactive material can be used to place the material for less than a day. This approach is called high dose rate brachytherapy. For about a week after the needles are put in place, there may be some pain in the area and a red-brown color to the urine.

While radiation therapy can be used as the main treatment for prostate cancer, it can also be used to treat bone pain for cancer that has spread to the bone. Strontium 89 (Metastron) is the substance used for this purpose.

Side effects of internal radiation therapy can include impotence, urinary incontinence, and bowel problems. Rectal problems such as burning, pain, and diarrhea my occur in a small number of men. They can be hard to treat once they develop. Impotence is less likely to be a problem after internal radiation than after surgery or external beam radiation. Be sure to talk to your doctor if you have any of these side effects. Often there are medicines or other methods to help.

Hormone Therapy

Hormone therapy is often used for men whose cancer has spread to other parts of the body or has come back after earlier treatment. While hormone therapy does not cure the cancer, it can provide relief from symptoms.

The goal of hormone therapy is to lower the levels of the male hormones or androgens The main androgen is called testosterone. Androgens, which are produced mostly in the testicles, cause prostate cancer cells to grow. Lowering androgen levels can make prostate cancer shrink or grow more slowly.

There are several methods used for hormone therapy. Most involve giving various drugs to lower the amount of testosterone or to block the body's ability to use androgens. Some of these drugs are called LHRH analogs or agonists. They are given as shots either monthly or every three months.

Another method, however, is surgery to remove the testicles. This operation is called an orchiectomy (castration) and is mentioned here because it works by removing the main source of male hormones.

Other drugs called anti-androgens are given as pills, once or three times a day. They may be used along with orchiectomy and the LHRH analogs to provide total androgen blockade,or total blocking of all androgens produced by the body.

Hormone treatment can have serious side effects. These vary and depend on the kind of treatment, hormone, or drug you are taking. About 90% of men who have an orchiectomy have reduced or no sexual desire and impotence. There may also be temporary hot flashes, breast tenderness and growth of breast tissue.

Other treatments that lower testosterone levels can cause infertility, loss of interest in sex, not being able to have an erection, and hot flashes. You should feel free to talk to your doctor or nurse about these side effects before you begin treatment.

If you are having hormone therapy, ask you doctor to explain which drugs are being used and what side effects you might expect to have.

Chemotherapy

Chemotherapy is used for patients whose prostate cancer has spread outside of the prostate gland and for whom hormone therapy has failed. It will not destroy all the cancer cells, but it may slow tumor growth and reduce pain. Chemotherapy is not used as a treatment for men with early prostate cancer.

Chemotherapy uses drugs to kill cancer cells. The drugs are given in the form of shots or pills. While these drugs kill cancer cells, they also damage some normal cells causing side effects.

The side effects of chemotherapy depend on the type of drugs, the amount taken, and the length of treatment. These side effects might include nausea and vomiting, loss of appetite, loss of hair, and mouth sores. Because chemotherapy can damage the blood-producing cells of the bone marrow, patients may have low blood cell counts. This can increase the chance of infection, and cause bleeding or bruising after minor cuts or injuries, as well as tiredness.

Most side effects go away once treatment is over. If you have problems with side effects, talk with your doctor or nurse about what can be done because there are remedies for many of the side effects of chemotherapy. For example, there are drugs to prevent or reduce nausea and vomiting.

Watchful Waiting

"Watchful waiting" (also called expectant therapy) is not active treatment, but it may be a good choice for some men. Your doctor may suggest a watch and wait approach if your cancer is in a very early stage, is expected to grow very slowly, and is not causing any symptoms. Because prostate cancer often spreads very slowly, many older men who have the disease may never need any treatment. Active treatment can always be started later if the cancer begins to grow more quickly or causes problems.

Clinical Trials

Before a new treatment is used on people, it is studied in the lab. If lab studies suggest the treatment will work, the next step is to test its value for patients. These studies are called clinical trials. The main questions the researchers want to answer are:

• Does this treatment work?
• Does it work better than the one we're now using?
• What side effects does it cause?
• Do the benefits outweigh the risks?
• Which patients are most likely to find this treatment helpful?

During your course of treatment, your doctor may suggest that you look into a clinical trial. This does not mean that you are being asked to be a human guinea pig. A clinical trial is done only when there is some reason to believe that the treatment being studied may be of value. Nor does it mean that your case is hopeless and your doctor is suggesting a last-ditch effort.

Clinical trials are carried out in steps called phases. Each phase is designed to answer certain questions. Ask your doctor if there is a clinical trial that might be right for you. Then learn all you can about that trial. There can be risks as well as benefits; you can leave a clinical trial at any time.

To learn more about clinical trials, call the National Cancer Institute at 1-800-4-CANCER.

Some Questions to Ask Your Doctor

When talking about cancer and cancer treatment, you need to have frank, open discussions with your doctor. You should feel free to ask any question that's on your mind, no matter how small it might seem. Here are some questions you might want to ask. Be sure and add your own.