Personalized care for every stage of prostate cancer
With the addition of our new Comprehensive Prostate Cancer Clinic (CPCC), Urology Associates is now able to address every aspect of prostate cancer with state-of-the-art care. The same medical team provides care throughout diagnosis and treatment, a key factor in improving outcomes and quality of life for our patients.
The Comprehensive Prostate Cancer Clinic combines evidence-based medicine with our compassionate care to give patients personalized, unparalleled prostate cancer treatment options. Focused solely on prostate cancer, CPCC provides total care, from diagnosis, through a variety of treatment options, on to monitoring, and including end-of-life care and support if necessary.
Prostate cancer begins in the tissues of the prostate gland, the male sex gland responsible for the production of semen. According to the American Cancer Society, prostate cancer is the second most common cancer in American men and it is estimated that in 2017 there will be around 161,000 new cases and 27,000 deaths. If caught early, prostate cancer is one of the most treatable malignancies. The rise in routine screenings has improved the diagnosis of prostate cancer and the survival rate.
Every case of prostate cancer is different, making it important to evaluate the treatment options available and find the best options for each patient. Many new treatments are available that can lead to longer life and better quality of life for men with prostate cancer.
Below are types of prostate cancers that would change the type of treatment received.
- Hormone-sensitive (castrate-sensitive) prostate cancer refers to a patient that has prostate cancer but has not been exposed to androgen deprivation therapy (ADT). The goal of ADT is to lower the level of male hormones in the body and in turn stop or reduce the growth of prostate cancer cells. ADT alone cannot cure prostate cancer but rather stops it from growing.
- Hormone-resistant (castrate-resistant) prostate cancer is when the cancer is no longer responding to a medical or surgical treatment to lower testosterone. The cancer is still growing when the testosterone levels are low.
- Non-metastatic prostate cancer is cancer in the prostate that has not spread to other parts of the body. If the PSA levels continue to rise despite treatment, it is a sign that the prostate cancer has spread. Other signs include elevated liver enzymes or new lower back pain. To check if the cancer has spread, a physician will use a bone scan, CT scan, MRI or a PET scan.
- Metastatic prostate cancer refers to when the cancer has spread to other parts of the body. This is also known as the cancer metastasized. It is most common that prostate cancer spreads to the bones or lymph nodes. But it can spread to any organ in the body.
Following are the treatment options the Clinic currently offers patients with prostate cancer.
Leuprolide (brand name Lupron). These injections decrease testosterone in the body and are an ADT, also classified as a gonadotropin-releasing hormone (GnRH) agonists. Testosterone is an androgen (a reproductive hormone) that stimulates prostate cancer growth. Leuprolide is injected intramuscularly in the medical office and given either once a month or every three, four or six months.
Degarelix (Firmagon). Another form of ADT and a GnRH antagonist the Clinic offers to decrease a patient’s testosterone.
Bicalutamide (Casodex). An androgen receptor blocker taken daily to prevent testosterone production and in turn stop the growth of prostate cancer cells. Casodex is often given for a couple of weeks and up to a month prior to starting leuprolide or degarelix in order to block a testosterone flare that can cause pain or complications. This pill can also be prescribed later in treatment when it appears the prostate cancer is progressing.
Secondary hormonal treatments. An alternative for those who don’t respond to other hormonal agents includes ketoconazole, estrogen, 5-alpha reductase inhibitors (finasteride or Proscar).
Treatments for advanced prostate cancer
Sipuleucel-T (Provenge). An immunotherapy treatment that stimulates the immune cells already in the body to attack the prostate cancer cells. In sipuleucel-T therapy, white blood cells are removed from the man’s blood, are enhanced to fight the prostate cancer, then reinfused into the patient. This is repeated every two weeks in the clinic for three treatments. Sipuleucel-T can be used alone or with other treatments such as hormone therapy or radiation.
Apalutamide (Erleada). This pill was approved by the FDA in February 2018 for non-metastatic castration-resistant prostate cancer. This drug is used for patients in combination with gonadotropin-releasing hormone (GnRH) analog or in patients who have had surgical castration (bilateral orchiectomy).
Enzalutamide (Xtandi). An oral androgen receptor inhibitor that is indicated for men with hormone-resistant prostate cancer.
Abiraterone (Zytiga). A prescription medication that is used to treat men with hormone-resistant metastatic prostate cancer. This oral pill must also be taken with prednisone. This drug works in a different manor than other adrenal inhibitors by targeting the enzymes in the adrenal glands that are responsible for making androgens.
In 2017 this drug’s use was expanded to be able to treat hormone-sensitive prostate cancer. It was already a recommended treatment for hormone-resistant prostate cancer.
Chemotherapy. Given to patients with advanced prostate cancer by medical oncologists. CPCC can refer patients to an oncologist that best fits their needs. Below are the two common chemotherapy drugs for patients with advanced prostate cancer.
- Docetaxel (Taxotere). An IV chemotherapy drug that can be used alone or in combination with other drugs such as Lupron. This is the first-line chemotherapy choice for advanced prostate cancer.
- Cabazitaxel (Jevtana). This is a common second-line treatment for prostate cancer progression. It is an infusion medicine that follows other anti-cancer medicines, including Taxotere.
Other regimens are available, as well as treatments with clinical trials that the medical oncologist can prescribe due to the given progress of the prostate cancer.
Radium-223 (Xofigo). An IV radiopharmaceutical infusion used for prostate cancer that has only spread to the bones (metastatic hormone–resistant prostate cancer). Xofigo is offered at our partner practice Anova Cancer Care and is injected once a month for six months.
Radiation therapy uses high-energy rays or particles to make small breaks in the DNA inside the cancer cells, causing them to die. Radiation therapy can be used in combination with ADT, especially if the cancer has spread beyond the prostate or if the cancer is aggressive. There are two main types of radiation therapy for prostate cancer, external beam radiation therapy (EBRT) and brachytherapy (internal radiation or seed implantation).
In EBRT the prostate glands are targeted by beams of radiation from a machine outside of the body. At Urology Associates we refer patients to our partner company Anova Cancer Care for CyberKnife treatment. The CyberKnife Robotic Radiosurgery System is the most advanced system for delivery of radiosurgery. It provides high-dose radiation to targeted body areas, which allows for patients to receive treatment with fewer appointments and virtually no side effects.
Brachytherapy places small radioactive seeds, about the size of a grain of rice, directly into the prostate. The placement can be permanent or temporary, depending on the dose of radioactive materials in the pellet. This can be combined with EBRT.
The main surgery for prostate cancer is a radical prostatectomy, which consists of removing the entire prostate gland and some of the tissue in the area. This surgery can be completed laparoscopically or with an open approach.
Maintaining bone health is important for men with prostate cancer to decrease the risk of fracture. This can be due to both low bone density (osteopenia and osteoporosis) related to androgen deprivation therapy and also for those men who have prostate cancer that has spread to the bone.
The patient’s healthcare provider may order a bone density scan (DEXA) to monitor bone density while on ADT. A bone scan may be ordered at diagnosis and at any time there is a concern of the cancer progressing to check for cancer spread (metastasis) to the bone.
Lifestyle modifications such as smoking cessation, limiting alcohol intake (2 drinks or less a day), weight-bearing activity with exercise of at least 30 minutes five days a week (unless the patient is at risk for fracture and needs to limit high impact exercise), along with calcium and vitamin D supplementations will be discussed.
Bone directed therapies are medications that can help strengthen bones and decrease the risk of skeletal related events, such as fracture, will be recommended as needed. These include oral agents called bisphosphonates or denosumab (Prolia) given as a subcutaneous injection for osteoporosis. For those men with bone metastasis, denosumab (Xgeva) can be given as a monthly injection. The doctor will help discuss which medication may be best in each patient’s situation.
Observation and surveillance
Prostate cancer often grows very slowly. For some men, especially those who have serious health problems, are older or not experiencing any symptoms, the doctor may not recommend treating the cancer. In these cases, there are two approaches known as watchful waiting and active surveillance that can be used.
Watchful waiting or observation is a less invasive follow-up routine that requires fewer tests and looks at symptom changes to decide if treatment is needed.
Symptom management, palliative care and hospice services
The patient’s prostate cancer team is here to help manage symptoms related to cancer and cancer treatments throughout the entire cancer journey. There are many treatment choices depending on the specific cancer stage, risk factors, symptoms, overall health and if the cancer has metastasized.
We will work with each patient to help make the best decision specific to his cancer to manage, control or palliate (make less severe) symptoms and their impact on the quality of life and daily activities. The doctor and team are available to answer questions and have discussions about any healthcare decisions, from initial diagnosis and early disease all across the spectrum including those who need to talk about comfort or hospice care when advanced treatments are not good options.
Get the care you deserve with the Comprehensive Prostate Cancer Center team
The CPCC care team assists all patients at any step of their prostate cancer journey. We provide individualized care that gives each man with prostate cancer the best options for a good outcome.
James Fagelson, MD, FACS – Medical Director
Dr. Fagelson has been caring for prostate cancer patients in the Denver area since 2000. His goal is to treat each patient with compassion and make sure they understand their options for every level of prostate cancer care and treatment.
For each drug mentioned on this page, the physician will go over possible side effects and monitoring guidelines prior to starting treatment. For more details on most of the drugs listed, please head over to chemocare.com.