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Prostate Cancer Treatment Guide


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									Prostate Cancer
Treatment Guide
           Cleveland Clinic urologists tailor prostate cancer treatment plans to their

           patient’s needs, taking into account the type of cancer, the age of the

           individual, the degree to which the cancer has spread and the general

           health of the patient.

           This guide provides details about each of the treatment options we offer.

                                                                                          Choosing Your
                                                                                          Prostate Cancer Care
                                                                                          Through a multi-disciplinary approach, urologists in
                                                                                          the Glickman Urological and Kidney Institute explore
                                                                                          all medical and surgical options to ensure that our
                                                                                          prostate treatment program will result in a successful
                                                                                          outcome for each patient.
                                                                                          This guide gives an overview of the prostate cancer
                                                                                          treatment options we offer, many of which are pro-
                                                                                          vided in conjunction with our colleagues at the Taussig
                                                                                          Cancer Institute.
                                                                                          While there are many options to review when explor-
                                                                                          ing prostate cancer treatment options, you should also
                                                                                          consider the experience of the prostate cancer program.
                                                                                          For the past nine years, Cleveland Clinic has been
                                                                                          named one of the nation’s top two urology programs,
                                                                                          according to U.S.News & World Report. Additionally,
                                                                                          many prostate treatment methods were pioneered here,
                                                                                          giving us the world’s largest experience in treatments
                                                                                          like laparoscopic prostatectomy.
                                                                                          Please use this guide as a resource as you examine
                                                                                          your treatment options. Remember, it is your right as a
                                                                                          patient to ask questions, and to seek a second opinion.

    Glickman Tower, new home of the Glickman Urological and Kidney Institute

2    |                                                                         Call 800.223.2273, ext. 45600 to set up an appointment
Minimally Invasive Surgery

C   omplete removal of the prostate is one of the most
    common treatments for prostate cancer. Today, most of
the procedures are done in ways that attempt to spare the
                                                                  Who is eligible for laparoscopic prostatectomy?
                                                                  Men with cancer that has not spread outside the prostate
                                                                  are eligible for laparoscopic prostatectomy. Men who may
nerves that control erections. These nerve-sparing surgeries      not be eligible include those who have had previous open or
reduce, but do not eliminate, the risk of incontinence and        laparoscopic pelvic surgery, even for another reason, or a his-
                                impotence. There are two          tory of hormone treatment called LH-RH agonist (luteinizing
                                minimally invasive approach-      hormone-releasing hormone).
                                es to radical prostatectomy:
                                laparoscopic and robotic.         What are the side effects of laparoscopic prostatectomy?
                                (Radical prostatectomy may        Medical research so far has shown the frequency of inconti-
                                also be performed “open”,         nence and impotence to be similar between minimally inva-
                                removing the entire prostate      sive surgery and open surgery -- with men usually returning
                                with an incision in the lower     to normal urinary function within three months for both
                                abdomen.)                         types of surgeries. Both types of surgeries also have similar
                                                                  rates of incontinence.
                                 Laparoscopic Radical             Because this technique is nerve-sparing, postoperative
                                 Prostatectomy                    sexual potency rate should be comparable to that of conven-
                                 A minimally invasive proce-      tional open surgery.
                                 dure pioneered at Cleveland
                                 Clinic, laparoscopic prostate-   What happens during laparoscopic prostatectomy?
                                 ctomy removes the prostate       The surgeon places a small needle just below the belly but-
gland for qualifying prostate cancer patients. Unlike conven-     ton and inserts the needle into the abdominal cavity. The
tional surgery, a laparoscopic prostatectomy requires only five   needle is connected to a small tube, and carbon dioxide is
button-hole incisions. Through these incisions, a surgeon uses    passed into the abdomen. This gas lifts the abdominal wall
a laparoscope – a tiny camera – and surgical instruments to       to give the surgeon a better view of the abdominal cavity
conduct the operation and remove the prostate.                    once the laparoscope is in place. The surgeon is then guided
                                                                  by the laparoscope, which transmits a picture of the prostate
What are the advantages of laparoscopy?                           onto a video monitor.
As is the case with other minimally invasive procedures,
                                                                  Next, a small incision will be made near the belly button.
laparoscopic prostate removal has significant advantages.
                                                                  The laparoscope is placed through this incision and is con-
• About 50 percent of men are discharged one day after            nected to a video camera. The image the surgeon sees in the
  surgery. (The length of stay depends on the extent of           laparoscope is projected onto video monitors placed near the
  the surgery.)                                                   operating table.

• There is significantly less bleeding during the operation.      Before starting the surgery, the surgeon takes a thorough
                                                                  look at the abdominal cavity to make sure the laparoscopy
• Patients are less likely to need prescription painkillers
                                                                  procedure will be safe. If the surgeon determines that the
  after you leave the hospital.
                                                                  procedure will not be safe for because of the presence of
• At the follow-up appointment one week after surgery, the        scar tissue, infection or abdominal disease, the procedure
  tube – or catheter – draining the bladder is removed if         will not be continued.
  there are no signs of other problems. Occasionally, the
                                                                  If the surgeon decides the surgery can be safely performed,
  catheter must remain in place for another week, as is
                                                                  additional small incisions will be made, giving the surgeon
  routinely the case following conventional "open" surgery.
                                                                  access to the abdominal cavity. If necessary, one of these
• About 90 percent of patients can return to work or resume       small incisions might be enlarged to remove the pelvic
  full activity in only two to three weeks.                       lymph nodes.

clevelandclinic.org/myappointment                                                                                          | 3
                                  Las Vegas Man Relieved After Prostatectomy
                                  Bryan King (above) wasn’t sure what scared him more: being diagnosed with prostate cancer
                                  or the treatment he would have to undergo. A radical prostatectomy (removal of the prostate
                                  gland) might leave him incontinent and impotent.
                                  His concern was that a prostatectomy involved a surgeon deftly trimming the prostate gland
                                  away from surrounding bundles of nerve fibers that control urinary and sexual functions. And
                                  if they are severed, problems result.
                                  “I knew I had to stop the cancer before it spread to my lymph nodes,” says Bryan, 45, of
                                  Las Vegas. “I talked to four or five guys who’d had a prostatectomy and they all had problems
                                  with incontinence. I thought, ‘I’m too young to have to deal with that.’”
                                  Bryan searched the Internet for a surgeon who was greatly experienced with the robotics.
                                  Of the four he located, “I was very impressed with my surgeon at Cleveland Clinic and the
                                  amount of time he took explaining the procedure in depth to me. I went to him with a list of
                                  30 questions, and he answered them all.”
                                  The result: “From the first day after surgery, I’ve never had to wear [adult incontinence pads],
                                  and I’m maintaining my sexual function,” Bryan says. And, he no longer lives in fear. “I feel
                                  lucky that I was able to catch the cancer so early.”

Robot-assisted Surgery                                              arms remain steady at all times and robot wrists
                                                                    make it easier for surgeons to manipulate tissue and work
What is robot-assisted surgery?
                                                                    from all kinds of angles and positions they would have dif-
Robot-assisted surgery, a type of minimally invasive surgery        ficulty reaching otherwise.
(MIS), uses robotic equipment to imitate surgical move-
ments. MIS procedures allow surgeons to operate through             What are the benefits of robotic prostate surgery?
small ports rather than large incisions, resulting in shorter       The benefits are similar to those of a laparoscopic
recovery times, fewer complications and reduced hospital            prostate surgery.
stays. Surgical robotics combines minimally invasive tech-
                                                                    • Hospital stay is often shortened to one or two days.
niques with highly advanced clinical technology.
                                                                    • Patients may return to normal activities as early as seven
How does robot-assisted surgery work?                                 to ten days after surgery.
This type of surgery uses a computer-enhanced surgical              • Robotic surgery patients may experience less post-oper-
system that provides:                                                 ative pain, and there is often no need to prescribe pain
• A 3-D view of the surgical field, including depth, magnifi-         medication on discharge. Patients generally need nothing
  cation and high resolution                                          more than Tylenol following surgery.
• Instruments that are designed to mimic the movement               • Robotic surgery requires small incisions so scarring is
  of the human hands, wrists and fingers, allowing and                minimal
  extensive range of motion and more precision                      • The risk of incontinence is low. After prostatectomy, com-
• Master controls that allow the surgeon to manipulate                plete continence (no leakage at all) is obtained in 94% of
  the instruments, translating the surgeon’s natural hand             patients within six months.
  and wrist movements into corresponding, precise and
                                                                    What happens after surgery?
  scaled movements.
                                                                    Following surgery, patients typically stay one or two days
How does the new technology assist the surgeon?                     in the hospital. During this time, our staff checks patients
The 3-D vision system magnifies the surgical field up to            daily and provides detailed post-operative instructions at
15 times and improves the surgeon’s ability to perform pre-         discharge. Patients are able to continue follow-up either at
cise dissection of tissue, thereby reducing blood loss. Robot       Cleveland Clinic or with their local physician.

4   |                                                     Call 800.223.2273, ext. 45600 to set up an appointment

I n this treatment, four to eight small needle-shaped probes
  can be inserted into the prostate in order to freeze the
gland to temperatures lethal to a prostate cancer. This mini-
                                                                 Damage is also minimized by precise monitoring techniques
                                                                 currently in place. Probes placed near vital areas of interest
                                                                 tell us when to reverse the cooling process. Helium begins to
mally invasive, incision-free procedure is performed either as   warm the tissues within seconds so that the ice ball doesn’t
an outpatient or one-night hospital admission. Temperature       grow beyond its intended borders.
monitoring probes allow Cleveland Clinic urologists to cure
prostate cancer with minimal trauma and without radiation.       How is the procedure performed?
With this treatment, patients recover in a matter of days and    Temperature sensing probes are placed near the prostate
usually experience minimal after effects.                        to allow the surgeon to know when freezing has reached
                                                                 beyond the gland. Four or more cryoprobes are placed into
How does Cryotherapy work?                                       position. Freezing begins slowly under ultrasound and com-
Cryosurgeons use 3-mm or smaller diameter cryoprobes             puter monitoring. When the ice ball reaches a lethal chill,
supercooled with argon. Cancer cell death is essentially as-     the argon is turned off and helium is turned on to thaw the
sured at forty degrees below zero Celsius even for a moment.     gland. The process is repeated as soon as it is thawed, and
If the center reaches that temperature, the outer core of the    the entire procedure is completed within a couple of hours.
iceball may be substantially warmer and barely below zero.
                                                                 Following surgery most men are permitted to return home
This limitation is overcome by “double freezing.” This takes
                                                                 within 24 hours, usually on the day of the procedure. A
advantage of the fact that cells swell during thawing. After
                                                                 catheter or suprapubic tube may remain in place for a week
being frozen once, they are thawed by reversing the probe
                                                                 or longer. The punctures heal spontaneously within days.
temperature. This involves turning the argon off and turn-
ing the helium on for the opposite effect. As soon as the ice    Who is eligible for cryotherapy?
ball freezes, argon is turned on again and the procedure is
                                                                 The most important thing to make you a candidate for
                                                                 cryotherapy is having cancer limited to the prostate or its
What are the risks associated with Cryotherapy?                  immediate vicinity. Like other local therapies (prostatectomy
                                                                 and radiation), cryotherapy works only if cancer is contained
As with any prostate cancer therapy, cryotherapy can cause
                                                                 in its targeted site.
side effects or damage to adjacent organs. The urethra run-
ning right through the middle of the prostate is most vulner-    Men with persistent cancer in the prostate following radia-
able. In the early days of cryotherapy it was often frozen and   tion therapy are obvious candidates. Because salvage pros-
would literally slough or turn inside out. Its channel would     tatectomy (surgery following radiation therapy) is associated
remain, but the lining would at times melt away for a few        with significant complications, cryotherapy is appealing as a
weeks until it healed.                                           method of treating localized recurrent cancer without major
                                                                 surgery. Complication rates for cryotherapy following radia-
                                This complication has been
                                                                 tion are indeed higher than they are with cryotherapy as an
                                largely eradicated by the use
                                                                 initial treatment, but appear to be lower than the rates with
                                of a urethral warming cathe-
                                                                 salvage prostatectomy.2
                                ter that circulates warm fluid
                                through its chambers. Saline     Men with large prostates – measuring greater than 50-75
                                or salt water at approximately   grams on ultrasound – are harder to treat. It is difficult to
                                forty degrees Celsius (104       fully freeze all the tissue when the gland gets bigger than
                                Fahrenheit) usually protects     that. Those within about 10-15 grams of that volume can
                                the urethra.                     reach it by taking hormonal ablation to shrink the gland.

clevelandclinic.org/myappointment                                                                                           | 5
Radiation Therapy

R    adiation therapy is the use of high-energy X-rays, elec-
     tron beams or radiaoactive isotopes to kill cancer cells
and shrink tumors. Radiation ionizes or damages the chro-
                                                                 care providers will use measurements from scans and calcu-
                                                                 lations to determine the precise location to aim the radiation.
                                                                 Small tattoos are placed on the patient’s skin so that treat-
mosomes in the cell so that they cannot multiply. Radiation      ments can be properly directed throughout the entire course
can be produced from a machine outside the body (external        of radiation. Simulation may take several hours. During the
radiation) or by putting materials that produce radiation        treatment, the patient is positioned on a table so that a
(radioisotopes) through thin plastic tubes into the area where   beam from a machine outside the body may be aimed at the
the cancer cells are found (internal radiation).                 tumor. The radiation treatment itself lasts only a few minutes
                                                                 and is generally given five times a week for several weeks.
Radiation therapy is a local treatment – aimed directly at
the cancer. Even though the radiation is aimed only at the       Some technical variations of external beam radiation are
cancer, it must often pass through skin and other organs         stereotactic radiosurgery (Gamma Knife), high dose three
to reach the tumor. Thus, some healthy cells may become          dimensional radiation therapy (HD3D), intensity modu-
damaged, too. The body however is able to repair the             lated radiation therapy (IMRT), and intraoperative radiation
healthy cells that have been damaged and restore them to         therapy (IORT). These types of radiation therapy are highly
their proper function. Successful radiation therapy depends      specialized and used in very specific settings.
on delivering the proper amount of radiation to the cancer in
the best and most effective way.                                 What are the benefits of external beam therapy?
                                                                 The benefits of this focused-beam therapy are that it
There are two types of radiation therapy – external beam
                                                                 minimizes damage to nearby tissue and structures. Also,
radiation and brachytherapy.
                                                                 treatment is not painful and less debilitating compared with
                                                                 surgery. Beam therapy can be used to treat cancers that
External beam radiation therapy                                  have spread into the pelvis and cannot be surgically removed
External beam radiation therapy is the most common form of       and can help reduce pain and shrink tumors in advanced
radiation therapy. Before treatment begins, detailed planning    disease that can’t be cured. Compared with surgery, incon-
or simulation is performed. During simulation, the health        tinence is a less common occurrence. Cleveland Clinic pio-

    The Calypso 4D Localization System
    Cleveland Clinic is the only Ohio cancer program to          The Calypso System uses radiofrequency waves that
    offer the Calypso™ 4D Localization System for treating       allow very accurate alignment of your prostate before
    prostate cancer. This unique radiation targeting technol-    each treatment session. This technology now makes it
    ogy, developed with the help of our radiation oncologists    possible to determine the position of the prostate at all
    and urologists, works like a GPS system. It determines       times during treatment delivery and make adjustments,
    the exact position and movement of the prostate during       as needed, to optimize external beam treatment delivery.
    radiation therapy treatment – optimizing radiation target-
    ing and minimizing side effects.                             What are the advantages to the Calypso system?
                                                                 Calypso allows your doctor to know exactly where the
    Why does organ motion during radiation                       tumor is at all times. This means your radiation therapy
    therapy matter?                                              is more precise - making sure all the necessary radiation
    Your organs move naturally during therapy and the pros-      gets to your tumor and minimizing side effects, such as
    tate occasionally moves outside of the intended radiation    impotence, incontinence and rectal bleeding. Currently,
    field during treatment. Since your doctor can’t predict      no other realtime method for precisely tracking tumor
    which way – or how much – your organs will move,             location during radiation therapy exists.
    the tumor may not get the right amount of radiation. In
    addition, other nearby tissue and organs may receive
    radiation they shouldn’t receive.

6   |                                                     Call 800.223.2273, ext. 45600 to set up an appointment
neered the intensity-modulated radiotherapy (IMRT), which           What are the risks of brachytherapy?
has shortened the duration of prostate cancer treatment by          Even though radiation does not travel far with this form of
several weeks.                                                      therapy, because of the prostate’s proximity to the urethra,
                                                                    brachytherapy may cause more urinary problems (and more
What are the side effects of external beam therapy?                 severe problems) than external beam therapy. Some patients
The side effects of radiation therapy are, for the most part,       need a catheter at times to help them urinate while the
specific to the area of the body being radiated. Some general       radiation remains most active – usually about six months,
side effects may include skin irritation and fatigue. There are     although it may take up to a year for the radiation to be fully
medications and techniques that can be used to control side         depleted. Also, despite a low risk, because pregnant women
effects. Radiation therapy as a treatment for prostate cancer       and small children are more susceptible to the effects of
can cause erectile dysfunction. Urinary incontinence, or the        radiation, patients undergoing brachytherapy are advised to
loss of the ability to control urination, is a potential side ef-   minimize contact with these types of individuals for the first
                                   fect of radiation therapy for    few months of therapy.
                                   prostate cancer.
                                                                    What are the benefits of brachytherapy?
                                 Side effects should be
                                 discussed with the radiation       Compared with beam therapy, brachytherapy may be associ-
                                 oncologist so that they can        ated with fewer rectal symptoms and a lower incidence of
                                 be managed properly.               impotence (only reported by 30 to 50 percent of brachyther-
                                                                    apy patients versus 50 percent of beam-treated patients).
                                 What about follow-up care?         Cleveland Clinic began its prostate brachytherapy program
                                 After your radiation therapy       in 1996. We have treated more than 2,000 patients since
                                 sessions are complete, you         then. Our cure rates, as defined by PSA, are 90% for low-
                                 will visit your doctor for         risk patients (patients with a pre-treatment PSA of < 10 ng/
                                 periodic follow-up exams and       ml and a Gleason score of 6 or less) and 80% for patients
                                 tests. Your doctor will tell you   with intermediate-risk prostate cancer (patients with a pre-
                                 how often to schedule your         treatment PSA of < 10 ng/ml and a Gleason score of 7 or a
                                 follow-up appointments.            pre-treatment PSA between 10 and 10 ng/ml and a Gleason
                                                                    score of 6 or less). These cure rates for prostate brachyther-
Brachytherapy                                                       apy are exactly the same as patients treated at the Cleveland
                                                                    Clinic with radical prostatectomy.
In this form of radiation therapy, radioactive pellets – each
the size of a grain of rice -– are implanted into the prostate.     Some unique features of our program include:
These pellets can be temporary (removed after the proper            • The first group to publish the improvements gained by
dose is reached) or left permanently, as with I-125 for pros-         treating patients with one session in which the treatment
tate cancer. The number of pellets implanted (up to 200)              planning and treatment occurs on the same day. This also
depends on the size and location of the cancer. The implant           results in greater convenience for the patient since one less
procedure takes about 1 hour and is done on an outpatient             visit is necessary and less cost.
basis. Although the pellets deliver a higher dose of radiation
                                                                    • The first prostate brachytherapy program in the country
than the external beam procedure, the radiation travels only
                                                                      to use the Memokath prostate stent to help reduce side
a few millimeters and therefore is unlikely to extend beyond
                                                                      effects after prostate brachytherapy.
the prostate.
                                                                    • The lowest rectal side effect profile of any published series.
Who is eligible for brachytherapy?                                    Our rectal bleeding rate is 1% and we have not had any
This therapy may work best in small- to medium-sized                  rectal perforations or fistulas
cancers and may not be a good option for men with larger
tumors, more aggressive forms of prostate cancer, or cancer
that has spread just outside the prostate.

clevelandclinic.org/myappointment                                                                                             | 7
                                                                                                      Another surgical prostate
                                                                                                      cancer treatment, the open
                                                                                                      radical prostatectomy pro-
                                                                                                      cedure removes the entire
                                                                                                      prostate with an incision in
                                                                                                      the lower abdomen. Since
                                                                                                      the prostate wraps around
                                                                                                      the urethra, once it is
                                                                                                      removed the surgeon
                                                                                                      must reconnect the blad-
                                                                                                      der with the urethra.

Hormone Therapy

H     ormone therapy is a prostate cancer treatment that alters
      the body’s hormone balance to prevent certain cancers
from growing. This may be accomplished with drugs that
                                                                  Fortunately, this is a rare occurrence with current highly suc-
                                                                  cessful diagnostic and treatment strategies.

alter the way hormones work or with surgery that removes          What are the benefits of hormone therapy?
hormone-producing organs such as the testes. Hormone              Hormone therapy can shrink tumors, thus reducing symp-
therapies can’t kill prostate cancer but can be given alone or    toms and pain and possibly extending the lives of men with
in combination with other forms of treatment in the hopes of      prostate cancer. It can also shrink the prostate and improve
improving the quality of life or extending survival. Research     the outcomes with cryoablation or radiation therapy.
on the value and effects of hormonal therapies is ongoing.
The most common form of hormone therapy is drug therapy.          When is hormone treatment used for prostate cancer?
Drugs such as triptorelin (Trelstar), leuprolide (Lupron,         Hormone treatment is primarily used if prostate cancer has
Eligard, Vantas) and goserelin (Zoladex) block the effect of      spread outside the prostate. It does not cure cancer. The
testosterone, the male sex hormone. By blocking testosterone,     purpose of hormone therapy is first to delay the progression
the rate of growth of the cancer is slowed. Another class of      of the cancer, and second to increase your survival while
drugs, the antiandrogens flutamide (Eulexin), bicalutamide        maximizing your quality of life. If the patient doesn’t respond
(Casodex) and nilutamide (Nilandron), work by preventing the      to initial hormone treatment, your doctor might try other
body – and thus the cancer cells – from using testosterone in     hormonal methods before recommending another form of
selected patients.                                                treatment.

What are the risks of hormone therapy?                            Who is a candidate for hormone treatment?
Hormone therapies are associated with many side effects           Hormone treatment can be used in men with various degrees
including lowered libido, impotence, hot flashes, weight          of prostate cancer. For example, it is often used in men after
gain, breast tenderness and enlargement, loss of muscle and       surgery for better results, as well as in men who don’t want
bone mass, nausea, diarrhea, fatigue, and liver damage.           to have any other type of treatment. Factors for you, your
While it’s possible that hormones may delay death, they           family, and your doctor to consider are the effects on your
cannot prevent it. Eventually, advanced prostate cancer can       quality of life, cost of the treatment (and who is paying for it),
become resistant to hormone therapy and it no longer works.       and how effective and safe the hormone treatment is for you.

8   |                                                     Call 800.223.2273, ext. 45600 to set up an appointment

C   hemotherapy involves the use of drugs to kill cancer
    cells. Chemotherapy may be taken orally or injected
into a vein. Chemotherapy is usually a systemic treatment,
                                                                   ease may be present at diagnosis or, in some cases,
                                                                   cancer can return in a distant location months or years
                                                                   after initial treatment.
meaning the drugs enter the bloodstream, travel through
the body and can kill cancer cells anywhere in the body,           What are the side effects?
including the prostate.                                            Because chemotherapy acts to kill rapidly dividing cancer
                                                                   cells, it also kills other rapidly dividing healthy cells in our
Chemotherapy is the use of any one or combination of can-
                                                                   bodies, such as the membranes lining the mouth, the lining
cer-killing drugs given either intravenously (injected into the
                                                                   of the gastrointestinal tract, the hair follicles and the bone
vein) or by mouth to attack prostate cancer. Chemotherapy
                                                                   marrow. As a result, the side effects of chemotherapy relate
is given in cycles of treatment followed by a recovery period.
                                                                   to these areas of damaged cells. The good news is that the
The entire chemotherapy treatment generally lasts three to
                                                                   damaged non-cancerous cells will be replaced with healthy
six months, depending on the type of medications given.
                                                                   cells, so the side effects are only temporary.
NOTE: Chemotherapy may be used in cases of recurrent
                                                                   The specific side effects you experience will depend on the
or advanced prostate cancer that has not responded to
                                                                   type and amount of medicines you are given and how long
hormone treatment, but it is not used to treat early
                                                                   you are taking them. The most common, temporary side ef-
stage disease.
                                                                   fects of chemotherapy include:
How is chemotherapy given?                                         • Nausea and vomiting
Generally, chemotherapy drugs are given intravenously (di-         • Loss of appetite
rectly into the vein) or rarely, by mouth. Once the drugs enter
                                                                   • Hair loss
the bloodstream, they travel to all parts of the body to reach
cancer cells that may have spread beyond the prostate.             • Mouth sores
                                                                   • Diarrhea
When is chemotherapy given?
                                                                   • Infertility (a potential permanent side
Chemotherapy may be given for advanced prostate cancer               effect of chemotherapy)
that has not responded to hormone treatment. It may also
be given for metastatic disease (disease that has spread).         There are medications available to control certain side ef-
                                Chemotherapy is given to           fects, such as nausea and vomiting, or diarrhea. Although it
                                cause the cancer to shrink         may take some time, side effects related to chemotherapy
                                and, hopefully, disappear.         will resolve when chemotherapy is stopped. Cleveland Clinic
                                Even if the cancer does not        offers a sperm banking option for men who would like to pre-
                                disappear, symptoms may            serve their sperm before starting chemotherapy treatment.
                                be relieved. Metastatic dis-

                                  Follow-Up Care After Prostate Treatment
                                  If you choose to seek a method of prostate        From time to time, men experience side
                                  cancer treatment at Cleveland Clinic, you         effects from prostate cancer treatment such
                                  have options for post-treatment care. We          as incontinence or erectile dysfunction.
                                  would be happy to see you for follow-up,          Experts at the Glickman Urological and
                                  but if you would like to have your follow-        Kidney Institute are specially trained to
                                  up done locally you may do so with your           evaluate and treat these common conditions
                                  family physician or urologist. Your physician     should they occur following treatment.
                                  can work with you to make sure we receive
                                  your PSA, continence and erectile function
                                  data if applicable.

clevelandclinic.org/myappointment                                                                                              | 9
Watchful Waiting or Active Surveillance

W      atchful waiting, now more commonly called “active
       surveillance with selective delayed intervention,”
requires no treatment for a discovered prostate cancer until
                                                                                               cancer that spread beyond its original site or is no longer
                                                                                               curable. Waiting until you are older for treatment is riskier,
                                                                                               increases the chance of side effects, and lengthens the
your doctor detects signs that the cancer is growing more                                      recovery period. Also, you have to be willing to return to your
aggressively. This option is reserved for patients who have a                                  doctor’s office more frequently for blood tests, rectal exams,
cancer that is confined to the prostate gland and have a can-                                  and biopsies to check on your disease. Worry about having
cer that is defined as low to medium in aggressiveness. It is                                  a cancer and knowing that it isn’t being treated may become
most often offered as an option to older men who are in poor                                   emotionally overwhelming.
health because it avoids the risks and side effects of treat-
ment. Most of these men will die of some other cause before                                    What are the benefits of active surveillance?
the cancer would become a problem. Active surveillance can                                     The risk of impotence and incontinence associated with
be an option for younger men who want to avoid the side                                        treatment is avoided. There is a good chance that you may
effects of treatment or postpone it as long as possible. The                                   never develop symptoms or require treatment. Even if the
debate on the risk associated with this approach in younger                                    cancer grows, most prostate cancers grow very slowly. You
men is ongoing.                                                                                may benefit from newer treatments that may be developed
                                                                                               while your cancer is under surveillance. Research has shown
What are the risks of active surveillance?                                                     that at least for the first eight years, the life expectancy of
There is a chance that the slow-growing cancer could sud-                                      men who choose this option may be no different than those
denly speed up in growth and you could be caught with a                                        who choose to treat their cancer aggressively.

Glickman Urological and Kidney Institute Prostate Cancer Specialists
Kenneth Angermeier, MD                         James Finke, MD                                J. Stephen Jones, MD, FACS                  Derek Raghavan, MD, PhD
Urologic oncology                              Tumor Immunology, lymphokines/monokines,       Chairman, Deparment of Regional Urology     Chairman, Taussig Cancer Institute
                                               lymphocyte signaling, immunotherapy            Elevated PSA, robotic and nerve-sparing     Prostate cancer
Monish Aron, MD                                                                               prostatectomy, cryotherapy
Oncology, minimally invasive surgery           Stuart M. Flechner, MD                                                                     Brian I. Rini, MD
                                               Prostate cancer                                Jihad Kaouk, MD                             Genitourinary oncology, prostate cancer,
Jonathan C. Boyd, MD                                                                          Director, Advanced Robotic and Image        anti-angiogenic therapy, immunotherapy
Prostate cancer                                William Forsythe III, MD                       Guided Surgery
                                               Prostate diseases and general urology          Laparoscopic urologic oncology and          Gaurang Shah, MD, FRCS
Steven Campbell, MD, PhD                                                                                                                  Minimally invasive prostate surgery
Prostate cancer                                Inderbir S. Gill, MD, MCh                      reconstructive surgery, robotic surgery
                                               Chairman, Department of Urology                Eric A. Klein, MD                           Robert Stein, MD
George V. Coseriu, MD                          Laparoscopic and minimally invasive                                                        Urologic oncology, robotic surgery,
Urologic oncology                                                                             Vice-Chairman, Glickman Urological
                                               urologic cancer surgery                        and Kidney Institute                        laparoscopic surgery
Jay Ciezki, MD                                 Jorge Garcia, MD                               Prostate cancer, nerve-sparing radical      Andrew J. Stephenson, MD
Brachytherapy, prostate cancer and             Genitourinary malignancies, clinical trials,   prostatectomy,                              Prostate cancer, robotic prostatectomy
genitourinary oncology                         experimental therapeutics                      William A. Larchian, MD                     Robert Silverman, PhD
Mihir M. Desai, MD                             Timothy Gilligan, MD                           Urologic oncology, prostate disease, gene   Prostate cancer etiology and genetics,
Laparoscopic and minimally invasive surgery    Prostate cancer, cancer survivorship,          therapy for urologic tumors                 viral pathogenesis
Robert Dreicer, MD                             prostate cancer in black men                   David Levy, MD                              James C. Ulchaker, MD
Urologic oncology, experimental therapeutics   Michael Gong, MD, PhD                          Prostate cancer, cryotherapy                Prostate cancer
Khaled Fareed, MD                              Robotic and laparoscopic surgery, prostate     Cristina Magi-Galluzzi, MD, PhD
                                               cancer                                                                                     Ming Zhou, MD, PhD
Robotic nerve sparing prostatectomy,                                                          Genitourinary, surgical and molecular       Genitourinary pathology
prostate cancer                                Donna Hansel, MD                               pathology
                                               Genitourinary pathology, cancer research                                                   Craig D. Zippe, MD
Amr Fergany, MD                                                                               Charles S. Modlin, Jr, MD                   Urologic oncology, prostate cancer,
Urologic oncology, open and laparoscopic       Brian Herts, MD                                Prostate cancer                             prostate brachytherapy
surgery                                        Genitourinary radiology, and 3D imaging        Arthur Porter, MD
                                               Warren D.W. Heston, PhD                        Urologic oncology
                                               Prostate cancer

For more information about our staff including complete profiles, visit clevelandclinic.org/urology.

10    |                                                                              Call 800.223.2273, ext. 45600 to set up an appointment
                       Contacting Cleveland Clinic
                       We make it easy for you.

                       Still have questions about prostate cancer?
                       If after reviewing this guide, you have additional questions,
                       Cleveland Clinic’s Cancer Answer Line can help. Two oncology
                       clinical nurse specialists and their staff can provide information
                       and answer questions about cancer. The Cancer Answer Line is
                       operational from 8 a.m. – 4:30 p.m., Monday – Friday. Please
                       call 1.866.223.8100.

                       Ready to schedule an appointment with a specialist?
                       If you would like to set up a consultation with a Cleveland Clinic
                       urologist, please call our appointment center at 800.223.2273
                       ext. 45600.

                       Traveling from outside of Ohio?
                       Each year, thousands of patients come to Cleveland Clinic from
                       various cities and countries around the globe. We offer special free
                       services to our out-of-state patients and their families. Just like
                       concierge at a fine hotel, our medical concierge will help with the
                       coordinating multiple appointments, arranging hotel reservations
                       and transportation, and other services as needed. You may contact
                       the medical concierge at 800.223.2273 x55580 weekdays from
                       8 a.m. to 5 p,m. (EST) or by email at medicalconcierge@ccf.org.

                       Need a second opinion, but cannot travel to Cleveland?
                       Our MyConsult service offers secure online second opinions for
                       patients who cannot travel to Cleveland. Through this service,
                       patients enter detailed health information and mail pertinent test
                       results to us. Then, Cleveland Clinic experts render an opinion that
                       includes treatment options or alternatives and recommendations
                       regarding future therapeutic considerations. To learn more about
                       MyConsult, please visit clevelandclinic.org/myconsult.

clevelandclinic.org/myappointment                                                             | 11

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