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Prostate Cancer (based on 2008 data)by John Faircloth, Medical Physicist, MMScIntroductionApproximately 240,890 new cases of prostate cancer are diagnosed eachyear in the United States, and 33,720 men will die from the disease. Prostate cancer is the second most common cause of cancer death in men ofall ages and is the most common cancer death in men over 75. However, earlystage prostate cancers are easily treated and have a high cure rate. (Estimates arefrom the American Cancer Society for 2011.)Race atatEastEAMC in ALProstate CancerWhite43.1Alabama MedicalCenterBlack56.9with prostate cancer, 43.1 percent and 56.9 perNationally36.638.5respectively. These numbers are below thecent,63.361.5Alabamaaverages of 36.6 percent and 63.3 per-At East Alabama Medical Center (EAMC), ancent, respectively. The national averages are 38.5average of 108 cases of prostate cancer have beenpercent and61.5 percent,which showPercentage of PatientsDiagnosedbyrespectively,Racediagnosed in each of the last four years (2006that wehave higher than average rates for white7063.32010). The original methodof detection has either61.5patients. This data is from the American Cancer56.960been a digital rectal exam (DRE) or from bloodSociety.work (a prostate-specific50antigen test,43.1or PSA). AfTo encourage men38.5to be tested for prostateterward, patients would have36.640 a biopsy to confirm acancer, especially medically underservedmen,Whitecancer diagnosis.30EAMC’s Cancer Center held seven free BlackprostateThe majority of the cases at EAMC are diag20screening events during 2008. These events notnosed in patients between the ages of 60 and 69only include the free PSA screening tests, but edu10years old, which is the same as the National Cancation about the disease and risk factors as well.0cer Data Base (NCDB) andthe Commission onat EAMCin ALNationallyCancer (CoC). In2008, EAMC hadPercentage of Patients Diagnosed by Race50 white patientsand 66 black hiteBlack3020Figure 1. EAMCshows a higher thanaverage rate for whitepatients.100at EAMCThe Cancer Center of East Alabama 2011 Annual Reportin ALNationally7

Prostate Cancer StagingEAMC physicians use the American JointCommittee on Cancer (AJCC) TNM staging system to describe the extent of disease for each patient. The staging is a uniform system so all physicians are comparing and discussing the diseaseaccurately. The T represents the extent of the primary tumor. The N represents whether the cancerhas spread to the nearby lymph nodes, and the Mcategory represents whether there is distant metastatic disease or not.There are several selections within theT category that can be made based onclinical presentation of each patient.o T 1 cancers of the prostate can’t be felt by thephysician during a digital rectal exam (DRE)or seen on ultrasound imaging.o A T1a cancer is found incidentally duringa transurethral resection of the prostate (orTURP) that was performed for the conditionBPH (benign prostatic hyperplasia). The cancer is present in less than 5 percent of the tissue removed.o A T1b is also found during the TURP, but thecancer involves more than 5 percent of thetissue removed.o A T1c cancer is found using a needle biopsydue to an increased PSA.o T 2 cancers can be felt by the physician duringa DRE, but are still confined to the gland.o A T2a cancer is in only one half or less of oneside of the gland.o A T2b cancer is in one half or more of oneside of the gland.8o A T2c cancer is in both sides of the gland.o T 3 cancers have begun to grow and spreadoutside of the prostate and may include theseminal vesicles.o A T3a cancer extends outside the prostate butdoes not involve the seminal vesicles.o A T3b cancer does involve the seminal vesicles.o T 4 cancers have invaded some of the tissuessurrounding the prostate.The N Category describes whetherthere is lymph node involvement.o A n NØ indicator reflects there is no lymphnode involvement.o A n N1 indicates there is lymph node involvement in one or more nearby lymph nodes inthe pelvis.The M Category describes whetherthere is metastatic disease present.o A MØ indicates there is no distant metastaticdisease.o A M1 indicates there is spread beyond the regional lymph nodes.o A M1a indicates there is spread beyond thepelvis lymph nodes.o A M1b indicates there is spread of the diseaseto the bones.o A M1c indicates there is spread of the diseaseto other organs (lung, liver, brain, etc.) andwith or without spread to the bones.Once the TNM staging is determined, it iscombined with the Gleason score and PSA valuesto finalize the stage of the cancer. The GleasonThe Cancer Center of East Alabama 2011 Annual Report

score indicates how aggressive the cancer may beand serves as a prognostic indicator. The Gleasonscore grades tumors on a scale of 1-5. Often, a tissue sample will have more than one grade withinthe sample, so the two predominant ones are added together. The PSA blood test relates to a proteinproduced by the prostate that is in the blood and isknown as a tumor marker for prostate cancer. Thefinal staging allows the physician to customize thetreatment options for each patient and to providethe best treatment options with evidence-based results.The treatment options at EAMC for prostatecancer are watchful waiting, surgery (includingthe da Vinci robotic surgery system), radiationtherapy, hormonal therapy, chemotherapy, andpalliative care.Watchful waiting is typically offered to patients who are believed to be at low risk of recurrence and reserve the right for treatment on anas-needed basis. The patients in this group are followed closely with DREs and PSA blood tests.The use of the da Vinci robotic surgery systembegan in 2010 with 21 prostatectomy surgeries andhas continued to grow. Some of the advantages ofthe system include less operative blood loss, betterpotency over conventional surgeries, shorter hospital stays, and faster return to normal activities.Radiation therapy has evolved at EAMC withthe introduction of intensity modulated radiationtherapy (IMRT) in 2006. After its introduction, radiation doses to the prostate have increased whilelowering the doses to normal tissues. We are seeing less radiation toxicity and still maintainingcancer control. One of the methods allowing thetherapists to keep very tight margins around theThe Cancer Center of East Alabama 2011 Annual Reportprostate is the use of fiducial markers. One of theurologists will place gold marker seeds (fiducialmarkers) in the prostate gland once the treatmentmodality (radiation therapy) has been agreed uponby the physician and patient. During the patientsimulation (set-up for treatment), a CT scan isperformed and the data is transferred to the treatment planning system, where the marker seeds areidentified. The treatment volume is identified andplanning resumes.Once a plan is approved, the patient is broughtback in and placed in the same treatment position as was simulated. The linear accelerator has asmall x-ray machine (OBI - on-board imager) thatallows x-ray images to be taken and compared tothe original CT scan data. The therapists align themarker seeds with the ones from the original scaneach day before treatment to ensure the prostate(target area) is in the same location day after day.The images of the placement are reviewed by theradiation oncologist on a daily basis to make sureeach treatment has been aligned to the best of everyone’s ability.Patients who have had a prostatectomy havethe option of using cone-beam CT (CBCT) for patient alignment on the treatment table. It is muchthe same as the OBI technique except that insteadof taking still x-ray images, the machine will rotatearound the patient, creating a CT image that can becompared to the original CT scan. The differencehere is that the prostate has been removed, and weare treating a volume where the prostate resided.The therapists will use the CT scan on the machineto compare with the original CT scan by anatomymatch. Aligning anatomy by overlaying each image and making minor adjustments helps ensure9

National 5-Year Relative Survival RateStages 1-4 for 5-year99relative survivalStage 4 patient with31distant disease 5-year relative survivalthat the treatment area is the same forNational 5-Year Relativeeach treatment delivered.Survival RateAnother form of radiation treat120ment for prostate cancer at EAMC is100the radioactive seed implant, called80brachytherapy. Brachytherapy plac60es a radioactive source very near the40cancer cells, and in our case, is a very20low activity source of radioactive io0dine (I-125). The sources (seeds) areStages 1-4 for 5-year relative Stage 4 patient with distantabout the size of a grain of rice. Sincesurvivaldisease 5-year relative survivalthe radioactive source has a very lowpenetrating energy and is low activity, the adjacent structures and normalthe category of watchful waiting or chose treattissues receive only small doses of radiation. Thement outside of EAMC. Prostate seed implantsimplants are permanent, meaning the radioactivenumbered 30 for the year. Radiation alone numseeds remain in the patient permanently. Howevbered 23. Radiation along with hormone therapyer, the radioactivity decays over time and deliversnumbered 14. Surgery alone numbered 12. Theabout 90 percent of the dose to the prostate withinother 6 were in a group with multiple modalitiesthe first six months following the implant. Fromand palliative care.2007 to 2009, EAMC performed an average of 32Stages 1-4 survival data based on the Nationalprostate seed implants annually, then 21 in 2010.Cancer Institute (NCI) for 5-year relative survivalMost likely, the newer technology and promisingis nearly 100 percent. The stage 4 patient with disbenefits of the da Vinci system is part of the reasontant disease 5-year relative survival is 31 percent.for the drop in patient volume. It gives the patients/The NCI does not group cancers by the AJCCphysicians more flexibility and treatment optionsstage, but instead uses local, regional, and distantto consider.disease groups. The local group corresponds toHormone therapy is used when the patient hasstages 1 and 2, and regional corresponds to stagesa high risk of recurrence, or radiation and surgery3 and 4 if one is converting from NCI to AJCCmay not have stopped the advance of the cancerdata. The data from EAMC appears to be closegrowth.to the national data, but is not shown because ofChemotherapy is typically reserved for patientsthe loss of patients in follow-up and the inabilitywho are hormone-resistant and have recurrent orto follow patient deaths from reasons other thanadvanced disease, including metastatic lesions.prostate cancer.At EAMC, 139 patients had a positive biopsyfor prostate cancer in 2008. Of those, 54 fell into10The Cancer Center of East Alabama 2011 Annual Report

Primary Site Table - 2010Primary SiteORAL CAVITY & PHARYNXTongueSalivary GlandsFloor of MouthGum & Other VE SYSTEMEsophagusStomachColon Excluding RectumCecumAscending ColonHepatic FlexureTransverse ColonSplenic FlexureDescending ColonSigmoid ColonLarge Intestine, NOSRectum & RectosigmoidRectosigmoid JunctionRectumAnus, Anal Canal & AnorectumLiver & Intrahepatic Bile DuctLiverIntrahepatic Bile DuctGallbladderOther BiliaryPancreasRESPIRATORY SYSTEMLarynxLung & BronchusSOFT TISSUESoft Tissue (including Heart)SKIN EXCLUDING BASAL & SQUAMOUSMelanoma -- SkinBREASTBreastFEMALE GENITAL SYSTEMCervix UteriCorpus & Uterus, NOSCorpus UteriUterus, NOSOvaryVulvaMALE GENITAL SYSTEMProstateTestisPenisURINARY SYSTEMUrinary BladderKidney & Renal PelvisUreterBRAIN & OTHER NERVOUS SYSTEMBrainCranial Nerves Other Nervous SystemENDOCRINE SYSTEMThyroidOther Endocrine including ThymusLYMPHOMAHodgkin LymphomaNon-Hodgkin LymphomaNHL - NodalNHL - ExtranodalMYELOMAMyelomaLEUKEMIALymphocytic LeukemiaAcute Lymphocytic LeukemiaChronic Lymphocytic LeukemiaOther Lymphocytic LeukemiaMyeloid & Monocytic LeukemiaAcute Myeloid LeukemiaChronic Myeloid LeukemiaMISCELLANEOUSMiscellaneousTotalExclusions: Not Male and Not FemaleTotal (%)32 (4.7%)9 (1.3%)1 (0.1%)6 (0.9%)5 (0.7%)1 (0.1%)5 (0.7%)2 (0.3%)3 (0.4%)103 (15.1%)10 (1.5%)6 (0.9%)39 (5.7%)85411212623 (3.4%)8153 (0.4%)5 (0.7%)323 (0.4%)1 (0.1%)13 (1.9%)104 (15.2%)8 (1.2%)96 (14.1%)4 (0.6%)4 (0.6%)10 (1.5%)10 (1.5%)112 (16.4%)112 (16.4%)38 (5.6%)12 (1.8%)11 (1.6%)10112 (1.8%)3 (0.4%)150 (22.0%)142 (20.8%)7 (1.0%)1 (0.1%)39 (5.7%)21 (3.1%)16 (2.3%)2 (0.3%)9 (1.3%)8 (1.2%)1 (0.1%)16 (2.3%)15 (2.2%)1 (0.1%)32 (4.7%)2 (0.3%)30 (4.4%)2559 (1.3%)9 (1.3%)16 (2.3%)10 (1.5%)1816 (0.9%)159 (1.3%)9 (1.3%)683SexClass ofMF Analy 8080593788822402240736473642110 10662110 554115133737310015362101042600110415072637263376 307 50443202011022174Stage Distribution - Analytic Cases OnlyStg 0 Stg I Stg II Stg III Stg IV 000000000000000000000000000000000000000

2 The Cancer Center of East Alabama 2011 Annual Report F rom the President The Cancer Center of East Alabama continues to serve as a resource in the community for cutting-edge cancer care, as well as cancer education, awareness and support. Technology is continually evolving. In 2010, EAMC added the da Vinci Robotic Surgery System, 3T MRI at the