PROSTATE CANCER. Diagnosis and treatment in Israel

Israeli medical experts in prostate cancer

Dr. Raanan Berger – Head of the Cancer Institute, Head of Clinical Research, Medical Center, Chaim Sheba Tel Hashomer.

Dr. Zohar Dotan – Urology Expert, Senior surgeon, Head of the oncourology service at Sheba Medical Center, Tel Hashomer

Dr. Yaron Erlich
Head of the Urology Unit at Sharon Hospital (Beilinson). Prostate Cancer Specialist.
Senior Physician, Urology Department, Rabin Medical Center. Head of the Oncourology Department.

Prostate cancer diagnosis

♦ Digital Rectal Exam (DRE). During this procedure doctor examines the condition of the prostate by palpating it through the rectum wall. This allows to evaluate benign enlargement or identify prostate cancer. It is the most inaccurate method.

♦ Laboratory analysis of blood, including the PSA level (prostate-specific antigen, a protein produced by the prostate gland in case of illness)

♦ Transrectal ultrasound test (TRUS) and prostate tumor biopsy. The procedure is performed under local anesthesia and it is guided by the supervision of ultrasound small sensor located in the rectum. Tiny needle is inserted through the wall of the anus and a small tissue sample is taken from the prostate gland.

♦ Target biopsy using a combination of MRI and ultrasound («fusion biopsy»). This allows to increase the accuracy of taking a biopsy using a three-dimensional model of the prostate, and to move from a systematic screening to a point check-up, when it’s necessary.

♦ CT and PET-CT using GA68 isotope for abdomen, pelvis and thorax.

♦ Magnetic resonance imaging (MRI scan). This uses a magnetic field to construct body images in cross section. MRI helps to assess progression of prostate cancer and to detect metastases to nearby tissues or lymph nodes.

♦ Bone scanning. A bone scan test helps to diagnose tumorous areas, when prostate cancer has spread beyond the gland. As a rule, a cancerous tumor absorbs a larger amount of radioactive material then other bone parts.

♦ Onco-tests for personalized treatment using biomarkers in blood sample:

• 4KScore
• Decipher Prostate
• Onco-test ProMark Prostate
• Onco-test Prolaris Prostate
• Onco-test Oncotype DX Prostate

⇒ More details about diagnosis o prostate cancer in Israel

Stages of prostate cancer

There are several stages of prostate cancer:

♦ Early prostate gland carcinoma (localized prostate cancer), the tumor is located in the prostate gland (capsule) and does not extend into the surrounding tissue or other parts of the body.

♦ Locally advanced prostate cancer – cancer cells have spread to tissues around the prostate gland.

♦ Advanced or metastatic prostate cancer – cancer has spread beyond the prostate to other parts of the body. Cancer cells can sometimes spread in the blood. Once these cells reach a new area of the body, they can continue dividing and create tumor formation called metastasis. The most common sites of spread of prostate cancer are spine bones, pelvis, hips and ribs.

In some cases prostate cancer may affect bone marrow and lymph nodes, and sometimes it is spreading to the lungs, brain and liver.

Oncologists also use the TNM system to classify the stage of prostate cancer. It describes the tumor spread and metastases within the body. In addition, our Israeli doctors use Gleason index to assess the rate of the disease progression. Learn more about TNM system and the Gleason Index

Prostate cancer management

Active watching, observation

At an early stage, sometimes there is no treatment, and doctors monitor patients for performing regular tests and inspection. As prostate cancer has very slow progression, the tumor size is small and there are no risk factors, it usually does not cause problems in the future. In Israel, about a third of patients are monitored by active watching.

Sometimes prostate cancer treatments can cause side effects such as erectile dysfunction or urinary incontinence. It has more serious consequences in some cases than the disease itself. Treatment starts when the disease begins progressing, and the tumor is greatly increased. Only then cancer therapy is effective.

Surgery

♦ Radical prostatectomy

Surgery, in which the entire gland is removed through an incision in the abdomen or incision between the scrotum and the anus. Performed in cases where the cancer has not spread in the body (no metastases)

Removal of the entire gland helps stop the spread of early cancer in the body and can lead to a cure. As with any surgery, with radical prostatectomy there are risks such as bleeding problems or infections. But due to present knowledge of surgeons and technology risks of such complications is very small.

♦ Laparoscopic radical prostatectomy

Endoscopic surgery in which the surgeon uses a specially designed tools inserted through small puncture 4 in the abdomen. In the body the carbon dioxide gas is supplied to fill the stomach. A tiny video camera shows the prostate gland in a larger size on the video screen.

♦ Robotic laparoscopic radical prostatectomy (Da Vinci robot)

Sometimes LRP can be carried out using a robot. Manufactured robots for laparoscopic prostatectomy machine called da Vinci ® – so this type of surgery called da Vinci prostatectomy. This operation is used only by specially trained physicians.

Operating DaVinci robot enables precision surgical manipulations to do, due to the flexibility of robotic instruments and the possibility of their turnover by 360 degrees. Instead of moving cameras and instruments the surgeon or assistant joined robotic arms that move very delicately, stable and accurate (unlike human hands).

After radical prostatectomy in a few days set drip intravenous infusion into a vein in the arm and the tube (catheter) to drain urine from the bladder and fluids from surgical wounds. In few days catheter is removed. On the operational period the doctor prescribes pain relief and antibiotics.

Hospitalization for such operations may be 3-7 days, depending on the complexity of the operation and patient condition.

Radiation Therapy

Radiotherapy – the influence on the body a high energy X-rays or electron beams to kill cancer cells. External radiation therapy is usually daily sessions from Sunday to Thursday, with a rest at the weekend. Typically, radiation therapy lasts 4-8 weeks.

Before the procedure, performed CT-simulation modeling process where determined destination spot beams for irradiation. The computer program determines the exposure for each person individually.

Conformal radiotherapy (CRT) and intensity modulated radiotherapy (IMRT) may be applied for prostate cancer treatment.

When conformal therapy (CRT) with the construction of 3D images is used, the computer generates radiation beams carefully so as to conform to the shape of the prostate gland, thereby reducing the likelihood of damage normal cells in neighboring organs such as the bladder and rectum. This approach reduces the side effects of radiation therapy and allows to deliver the highest possible dose to the cancer cells. This is the most effective method.

IMRT is a more complex type of conformal radiation therapy and allows the physician radiologist varied doses of radiation required different parts of the tumor.

Image-guided Radiation Therapy  (IGRT) allows to direct radiation beam most precisely. The irradiation area is guided using CT, MRI or PET technologies. This helps to monitor the process in real time and to bypass healthy tissue aside.

Stereotactic body radiation therapy (SABR / SBRT) – is used to deliver an intense dose of radiation to small area of a prostate tumor. This treatment is selected in case when surgery is not an optimal option.

Proton radiation therapy. It combines various types of x-rays and delivers the exact dose to the desired area very precisely.

⇒ Learn more about the different types of radiation therapy in Israel

Side effects of radiotherapy may be:

• fatigue
• irritation of the rectum
• pain around the anus
• bladder inflammation (cystitis )
• burning sensation when urinating

Patient must follow the recommendations of the attending physician to mitigate and manage side effects. During this period it is also important to drink plenty of liquids.

Brachytherapy

This type of radiation therapy is named internal radiation therapy or implant therapy.

There are two ways to provide brachytherapy:

♦ Low dose rate brachytherapy

This way uses the “grain” of radioactive metals, which are implanted into the tumor, slowly releasing its radiation. The particles are not removed within six months when the radiation gradually disappears.

♦ High Dose Rate Brachytherapy

This method consists of placing a tiny plastic catheters into the prostate gland. Radioactive seeds are inserted into a catheter during a certain period of time and then removed. After treatment the catheters can be easily removed and the radioactive material remains in the prostate gland.

Brachytherapy is a simpler procedure than the external radiation therapy. Usually it includes one simulated session and one treatment session only.

This treatment may not be suitable for some men with very large prostate. Nevertheless, in some cases hormone therapy can be assigned to reduce prostate size before brachytherapy.

The side effects of brachytherapy are similar to the side effects of radiation therapy. Most men return to their normal activities within 1-2 weeks after treatment.

Hormone therapy

Typically, hormone therapy is prescribed before radiotherapy. This is called neo-adjuvant therapy, contributing to make radiation therapy more effective. Sometimes hormone therapy is also appointed after radiotherapy. In this case, its purpose is to decrease the likelihood of cancer recurrence.

Hormones control the growth and activity of normal cells. Prostate cancer depends on the hormone testosterone. Hormonal therapy is aimed to reduce this man hormone in the body. It is administered as an injection or tablets.

Immunotherapy

Immunotherapy of prostate cancer is a treatment with drugs that activate the human immune system to fight cancer cells of the prostate tumor.