Cancer.net Guide to Prostate Cancer PDF

8/6/2019 Cancer.net Guide to Prostate Cancer PDF

1/28

GUIDE TOPROSTATE CANCER

Comprehensive, oncologist-approved cancer informationfrom the American Societyof Clinical Oncology (ASCO)

www.cancer.net

Made available through:


2/28

ABOUT ASCOThe American Society of Clinical Oncology (ASCO) is the worldsleading professional organization representing physicians of all

oncology subspecialties who care for people with cancer.

ABOUT THE CANCER.NET GUIDES TO CANCERThe Cancer.Net Guides to Cancer provide patients withcomprehensive, peer-reviewed information based on contentfrom Cancer.Net (www.cancer.net), ASCOs patient information

website. All the information and content on Cancer.Net wasdeveloped and approved by the cancer doctors who aremembers of ASCO, making Cancer.Net an up-to-date andtrusted resource for cancer information.

The best cancer care starts with the best cancer information.Well-informed patients are their own best advocates and

invaluable partners for physicians. ASCOs patient educationmaterials are available both in print and online to providetrusted, authoritative information for people living with cancerand those who care for and about them.


3/28

1

TABLE OF CONTENTS

Overview .................................................................................2

About the prostate gland .....................................................2Types of prostate cancer .......................................................2

Statistics...................................................................................3

Risk Factors and Prevention ......................................................3Prostate cancer screening .....................................................5

Symptoms ................................................................................7

Diagnosis .................................................................................7

Staging ....................................................................................9Cancer stage grouping .......................................................10

Prognostic factors .............................................................. 11

Treatment ..............................................................................12Active surveillance (watchful waiting) .................................. 13Surgery ..............................................................................13Radiation therapy ...............................................................14Hormone therapy ...............................................................15

Chemotherapy ...................................................................17Advanced prostate cancer ..................................................18

Clinical Trials Resources ..........................................................19

Side Effects ............................................................................20

After Treatment .....................................................................21

Current Research ....................................................................22

Questions to Ask the Doctor ..................................................24

The ideas and opinions expressed in the Guide to Prostate Cancer do not

necessarily reflect the opinions of ASCO or The ASCO Cancer Foundation.

The information in this guide is not intended as medical or legal advice, oras a substitute for consultation with a physician or other licensed health

care provider. Patients with health care-related questions should call or

see their physician or other health care provider promptly, and should

not disregard professional medical advice, or delay seeking it, because of

information encountered here. The mention of any product, service, or

treatment in this guide should not be construed as an ASCO endorsement.

ASCO is not responsible for any injury or damage to persons or property

arising out of or related to any use of ASCOs patient education materials,

or to any errors or omissions.


4/28

2 OVERVIEW

OVERVIEWCancer begins when normal cells in the prostate begin tochange and grow uncontrollably, forming a mass called a tumor.

A tumor can be benign (noncancerous) or malignant (cancerous,meaning it can spread to other parts of the body).

About the prostate glandThe prostate is a walnut-sized gland located behind the baseof the penis, in front of the rectum, and below the bladder. Itsurrounds the urethra, the tube-like channel that carries urine

and semen through the penis. The prostates main function is tomake seminal fluid, the liquid in semen that protects, supports,and helps transport sperm.

Types of prostate cancerProstate cancer is a malignant tumor that begins in the prostategland of men. Some prostate cancers grow very slowly and may

not cause symptoms or problems for years. In this situation, thecause of death is usually not from prostate cancer, but othercauses. Many times, when a man develops prostate cancermuch later in life, it is unlikely to cause symptoms or shorten themans life; aggressive treatment may not be needed. However,if cancer does metastasize (spread) to other parts of the body,it can cause pain, fatigue, and other symptoms. Prostate cancer

is somewhat unusual, compared with other types of cancer,because many tumors that are diagnosed do not spread fromthe prostate. And often, even metastatic prostate cancer can besuccessfully treated, with the person surviving in good health forsome years.

More than 95% of prostate cancers are adenocarcinomas,

cancers that develop in glandular tissue. A rare type of prostatecancer known as neuroendocrine cancer or small cell anaplastic

Anatomical and staging illustrations for many types of cancer are available at

www.cancer.net.


5/28

3STATISTICS & RISK FACTORS AND PREVENTION

cancer tends to spread earlier but usually does not makeprostate-specific antigen (PSA), a tumor marker discussed laterin the Risk Factors and Prevention section. Read more about

neuroendocrine tumors at www.cancer.net/neuroendocrine.

STATISTICSProstate cancer is the most common cancer and the secondleading cause of cancer death in men. Although the number

of deaths from prostate cancer is declining among all men, thedeath rate remains more than twice as high in black men thanin white men.

More than 90% of all prostate cancers are found when thedisease is located only in the prostate and nearby organs. Nearlyall men who develop prostate cancer are expected to live at

least five years after diagnosis. The 10-year and 15-year relativesurvival rates (the percentage of people who survive at least 10or 15 years after the cancer is detected, excluding those whodie from other diseases) are 91% and 76%, respectively. Thesesurvival rates are a combination of early-stage and later-stageprostate cancers; a mans individual survival depends on thetype of prostate cancer and the stage of the disease.

Cancer survival statistics should be interpreted with caution.These estimates are based on data from thousands of cases ofthis type of cancer in the United States each year, but the actualrisk for a particular individual may differ. It is not possible totell a man how long he will live with prostate cancer. Becausesurvival statistics are often measured in multi-year intervals, they

may not represent advances made in the treatment or diagnosisof this cancer.

Statistics adapted from the American Cancer Society.

Find out more about basic cancer terms used in this section at www.cancer.net/

dictionaryresources.

RISK FACTORS AND PREVENTIONA risk factor is anything that increases a persons chance ofdeveloping cancer. Although risk factors can influence thedevelopment of cancer, most do not directly cause cancer. Somepeople with several risk factors never develop cancer, while

others with no known risk factors do. However, knowing yourrisk factors and communicating them to your doctor may helpyou make more informed lifestyle and health care choices.

Because the exact cause of prostate cancer is still unknown, itis also unknown how to prevent prostate cancer. The followingfactors can raise a mans risk of developing prostate cancer:


6/28

4 RISK FACTORS AND PREVENTION

Age. The risk of prostate cancer increases with age, risingrapidly after age 50. About 60% of prostate cancers arediagnosed in men who are 65 or older.

Race/ethnicity. African Americanmen have a higher risk of prostatecancer than white men. They aremore likely to develop prostatecancer at an earlier age and tohave aggressive tumors that grow

quickly. The exact reasons forthese differences are not knownand probably involve both biologicand socioeconomic factors. Somescientists believe that a high-fatdiet, which can be common inmany parts of the African American

community, plays a role in thedevelopment of prostate cancer (see the Diet heading belowfor more detail). It may also be due to genetic factors withinthe African American community, but the specific genes are notknown. Prostate cancer occurs most often in North America andnorthern Europe and is less common in Asia, Africa, and LatinAmerica. However, it appears that prostate cancer is increasing

among Asian people living in urbanized environments, suchas Hong Kong, Singapore, and North American and Europeancities, particularly among those who have a more westernlifestyle.

Family history. A man who has a father or brother withprostate cancer has a higher risk of developing the disease

than a man who does not. Researchers have discovered specificgenes that may possibly be associated with prostate cancer,although these have not yet been shown to cause prostatecancer or to be specific to this disease. Learn more about thegenetics of prostate cancer at www.cancer.net/genetics.

Diet. No study has shown conclusively that diet and nutrition

can directly cause or prevent the development of prostatecancer, but many studies indicate there may be a link. There isnot enough information yet to make clear recommendationsabout the role diet plays in prostate cancer, but the followingmay be helpful: A diet high in fat, especially animal fat, may increase prostate

cancer risk. In fact, many doctors believe that a low-fat diet

may help to reduce the risk of prostate cancer. A diet high in vegetables, fruits, and legumes (beans and

peas) may decrease risk of prostate cancer. It is unclear whichnutrients are directly responsible. Lycopene, found in tomatoesand other vegetables, may slow or prevent cancer growth. Inany case, such a diet does not cause harm and can lower apersons blood pressure and risk of heart disease.

Selenium, an element that people get in very small amountsfrom food and water, and vitamin E have been tested to find


7/28

5RISK FACTORS AND PREVENTION

out if either or both of these nutrients can lower the riskof prostate cancer. However, in a clinical trial (a researchstudy involving people) of more than 35,000 men called the

Selenium and Vitamin E Cancer Prevention Trial (SELECT),researchers found that selenium and vitamin E supplements(pills), taken alone or together for an average of five years,did not prevent prostate cancer and may even cause harm insome men. Because of this risk, the National Cancer Institutehas stopped the SELECT study. Men should talk with theirdoctor before taking selenium and vitamin E supplements to

prevent prostate cancer.

Its important to remember that specific changes to diet maynot stop or slow the development of prostate cancer, and itspossible such changes would need to begin early in life to havean effect.

Viruses. Researchers have discovered a virus called xenotropicmurine leukemia virus-related virus (XMRV) in tissue from somemen with prostate cancer. Men infected with this virus may bemore likely to develop prostate cancer, but more studies areneeded to understand the role of XMRV in prostate cancer.

Hormones and chemoprevention. High levels of

testosterone (a male sex hormone) may speed up or causethe development of prostate cancer. For instance, it isvery uncommon for a man whose body no longer makestestosterone to develop prostate cancer, and stopping thebodys production of testosterone, called androgen deprivationtherapy, often shrinks advanced prostate cancer.

A class of drugs called 5-alpha-reductase inhibitors (5-ARIs)that includes finasteride (Proscar) and dutasteride (Avodart)may lower a mans risk of prostate cancer. In clinical trials,both drugs lowered the risk of prostate cancer. Initially, oneof these trials suggested that a very small percentage of menwho took finasteride had a higher risk of developing a moreaggressive type of prostate cancer than the patients who did

not receive finasteride. With further review, it now seems thatfinasteride causes the prostate gland to shrink, which may haveallowed the doctors to find these more aggressive cancers inthe biopsies (tissue removed for further examination) takenafter treatment. But, the data are still being reviewed, and thesubject is controversial. Learn about finasteride for prostatecancer prevention at www.cancer.net/whattoknow.

Prostate cancer screeningScreening for prostate cancer is done to find evidence ofcancer in otherwise healthy men. Two tests are commonly usedto screen for prostate cancer: the prostate-specific antigen(PSA) blood test and digital rectal examination (DRE, a testin which the doctor inserts a gloved, lubricated finger into a

mans rectum and feels the surface of the prostate for anyirregularities). PSA is found in higher-than-normal levels in


8/28

6 RISK FACTORS AND PREVENTION

men with various conditions of the prostate, including benignprostatic hyperplasia (BPH, an enlarged prostate), inflammationor infection of the prostate, and prostate cancer.

There is controversy about using the PSA test to screen largenumbers of men with no symptoms for prostate cancer. On onehand, the PSA test is useful for detecting early prostate cancer,which helps men get the treatment they need before the cancerspreads. On the other hand, PSA screening has not yet beenproven to lower death rates from prostate cancer in the general

community. And, this test identifies conditions that are notcancer and misses some prostate cancers.

Unlike other types of cancer, prostate cancer grows slowly inmany menso slowly that in some men it would not threatentheir life, even if not treated. Because of this, screening forprostate cancer may mean that some men have surgery and

other treatments that may not ever be needed. For this reason,many men and their doctors may consider active surveillance(watchful waiting; see the Treatment section) of the cancerrather than immediate treatment.

Because prostate cancer treatments have significant side effects,such as impotence (inability to get an erection) and incontinence

(inability to control urine flow), treating it unnecessarily mayseriously affect a mans quality of life. However, it is importantto note that it is not easy to predict which tumors will grow andspread quickly and which will grow slowly. This has led somedoctors to believe that it is wise to use relatively safe screeningtests, such as the PSA test, to detect aggressive cancers early,even if it means that some patients will receive unnecessary

treatment.

Three clinical trials have reported results on prostate cancerscreening: In the Prostate, Lung, Colorectal, and Ovarian (PLCO)

Cancer Screening Trial, researchers found more cancers withscreening, but they also found no difference in deaths from

prostate cancer in men who were screened with PSA and DREtests compared with men who were not screened for up to 11years after the screening began.

In the European Randomized Study of Screening for ProstateCancer (ERSPC) trial, researchers saw a small reductionin prostate cancer deaths of men who were screened forprostate cancer (7 deaths per 10,000 men screened), but the

overall survival was the same in the two groups. Another clinical trial called the Gteborg Trial found prostate

cancer screening reduced deaths from prostate cancer byalmost half. However, the study did not look at whether thescreening improved the survival of the men diagnosed withprostate cancer. Results also showed that many men neededto be screened and diagnosed in order to prevent one death

from prostate cancer.


9/28

7SYMPTOMS & DIAGNOSIS

Every man should discuss his individual situation and risk ofprostate cancer and work with his doctor to make a decision.For example, men older than 75 may not need screening.

No study definitely proves that screening is more beneficial formen at higher risk of prostate cancer, or for African Americanmen versus white men. Many experts feel that it is generallysafer to use screening for these men in the hope of findingaggressive types of prostate cancer earlier when it may beeasier to treat. However, as noted above, this has not been

proven in clinical trials. Read about talking with your doctorabout PSA screening at www.cancer.net/features.

SYMPTOMSOften, prostate cancer is found through a PSA test or DRE (see

Risk Factors and Prevention) in otherwise healthy men whohave not had any symptoms or signs. When prostate cancerdoes cause symptoms or signs, they may include the following: Frequent urination Weak or interrupted urine flow Blood in the urine The urge to urinate frequently at night

Blood in the seminal fluid Pain or burning during urination (much less common)

None of these symptoms is specific to prostate cancer. Thesame symptoms occur in men who have a noncancerouscondition known as BPH, or enlarged prostate. Urinarysymptoms also can be caused by an infection or other

conditions. In addition, sometimes men with prostate cancer donot have any of these symptoms.

If cancer has spread outside of the prostate gland, a man mayexperience: Pain in the back, hips, thighs, shoulders, or other bones Unexplained weight loss

Fatigue

If you are concerned about a symptom or sign on this list,please talk with your doctor.

DIAGNOSISDoctors use many tests to diagnose cancer and find out ifit has metastasized. Some tests may also determine whichtreatments may be the most effective. For most types ofcancer, a biopsy is the only way to make a definitive diagnosisof cancer. If a biopsy is not possible, the doctor may suggestother tests that will help make a diagnosis, but this situation

is rare for prostate cancer. For example, a biopsy may not be


10/28

8 DIAGNOSIS

done when a patient has another medical problem thatmakes it difficult to do a biopsy, or when a person has a veryhigh PSA level and a bone scan that indicates cancer. Imaging

tests may be used to find out whether the cancer has spread.Your doctor may consider these factors when choosing adiagnostic test: Age and medical condition The type of cancer suspected Severity of symptoms Previous test results

In addition to a physical examination, the following tests may beused to diagnose prostate cancer:

PSA test. As described in Risk Factors and Prevention, PSA isa type of protein released by prostate tissue that is found inhigher levels in a mans blood when there is abnormal activity

in the prostate, including prostate cancer, BPH, or inflammationof the prostate. Doctors can look at features of the PSA valuesuch as absolute level, change over time, and level in relationto prostate sizeto decide if a biopsy is needed. In addition, aversion of the PSA test allows the doctor to measure a specificcomponent, called the free PSA, which can sometimes helpdetermine if a tumor is benign (noncancerous) or malignant.

DRE. This test is used to find abnormal areas in the prostate byfeeling the area using a finger (see Risk Factors and Prevention).It is not very precise; therefore, most men with early prostatecancer have normal DRE test results.

If the PSA or DRE test results are abnormal, the following tests

can confirm a diagnosis of cancer:

Transrectal ultrasound (TRUS). A doctor inserts a probe intothe rectum that takes a picture of the prostate using soundwaves that bounce off the prostate.

Biopsy. A biopsy is the removal of a small amount of tissue

for examination under a microscope. Other tests can suggestthat cancer is present, but only a biopsy can make a definitediagnosis. To get a tissue sample, a surgeon most often usesTRUS and a biopsy tool to take very small slivers of prostatetissue. The sample removed with the biopsy is analyzed by apathologist (a doctor who specializes in interpreting laboratorytests and evaluating cells, tissues, and organs to diagnose

disease). This procedure is usually done as an outpatientprocedure, and the patient is given local anesthesia beforehandto numb the area.

To find out if cancer has spread outside of the prostate, doctorsmay perform the following imaging tests:

Bone scan. A bone scan uses a radioactive tracer to look atthe inside of the bones. The tracer is injected into a patients


11/28

9STAGING

vein. It collects in areas of the bone and is detected by a specialcamera. Healthy bone appears gray to the camera, and areas ofinjury, such as those caused by cancer, appear dark.

Computed tomography (CT or CAT) scan. A CT scan createsa three-dimensional picture of the inside of the body with anx-ray machine. A computer then combines these images into adetailed, cross-sectional view that shows any abnormalities ortumors. Sometimes, a contrast medium (a special dye) is injectedinto a patients vein to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magneticfields, not x-rays, to produce detailed images of the body. Acontrast medium may be injected into a patients vein to createa clearer picture.

Learn more about what to expect when having common tests, procedures, and

scans at www.cancer.net/tests.

Find out more about common terms used during a diagnosis of cancer at

www.cancer.net/dictionaryresources.

STAGING

Staging is a way of describinga cancer, such as where it islocated, if or where it has spread,and if it is affecting the functionsof other organs in the body.Doctors use diagnostic tests todetermine the cancers stage,

so staging may not be completeuntil all of the tests are finished.Staging for prostate cancer also involves reviewing test resultsto determine if the cancer has spread from the prostate to otherparts of the body. Knowing the stage helps the doctor decidewhat kind of treatment is best and can help predict a patientsprognosis (chance of recovery). There are different stage

descriptions for different types of cancer.

There are two types of staging for prostate cancer: The clinical stage is based on the results of tests done before

surgery, such as a biopsy, x-rays, CT scans, and bone scans.X-rays, bone scans, and CT scans may not always be needed.They are recommended based on the level of serum PSA, the

grade and volume (size) of the cancer, and the clinical stage ofthe cancer.

The pathologic stage is based on information found duringsurgery, plus the laboratory results (pathology) of the prostatetissue removed during surgery (which often includes theremoval of the entire prostate and some lymph nodes).

One tool that doctors use to describe the stage is the TNMsystem, developed by the American Joint Committee on Cancer


12/28

10 STAGING

(AJCC) and the Union International Contre le Cancer (UICC).This system is most commonly used in the United States anduses three criteria to judge the stage of the cancer: the tumor

itself, the lymph nodes around the tumor, and if the tumor hasspread to other parts of the body. The results are combinedto determine the stage of cancer for each person. There arefour stages: stages I through IV (one through four). The stageprovides a common way of describing the cancer, so doctorscan work together to plan the best treatments.

After gathering information with the TNM method, the resultscan be grouped together into a simpler set of stages (calledstage grouping).

TNM is an abbreviation for tumor (T), node (N), and metastasis(M). Doctors look at these three factors to determine the stageof cancer:

How large is the primary tumor, and where is it located?(Tumor, T) Has the tumor spread to the lymph nodes? (Node, N) Has the cancer metastasized to other parts of the body?

(Metastasis, M)

Tumor. Using the TNM system, the T plus a letter or number

(0 to 4) is used to describe the size and location of the tumor.Some stages are also divided into smaller groups that helpdescribe the tumor in even more detail.

Nodes. The N in the TNM staging system stands for lymphnodes, the tiny, bean-shaped organs that help fight infection.Lymph nodes near the prostate in the pelvic region are called

regional lymph nodes. Lymph nodes in other parts of the bodyare called distant lymph nodes.

Distant metastasis. The M in the TNM system indicateswhether the prostate cancer has spread to other parts of thebody, such as the lungs or the bones.

For specific information on substages for T, N, and M, visit www.cancer.net/prostate.

Cancer stage groupingDoctors assign the stage of the cancer by combining the T, N,and M classification; the PSA level; and the Gleason score. Finda table with all of the TNM combinations for each stage atwww.cancer.net/prostate.

Stage I: Cancer is found in the prostate only, usually duringanother medical procedure. It cannot be felt during the DREor seen on imaging tests. A stage I cancer usually has well-differentiated cells and is likely to grow slowly.

Stage IIA and IIB: This stage describes a tumor that is too small

to be felt or seen on imaging tests. Or, it describes a slightlylarger tumor that can be felt during a DRE. The cancer has not


13/28

11STAGING

spread outside of the prostate gland, but the cells are usuallymore abnormal and may tend to grow more quickly. It has notspread to lymph nodes or distant organs.

Stage III: The cancer has spread beyond the outer layer ofthe prostate into nearby tissues. It may also have spread to theseminal vesicles, the glands in men that help make semen.

Stage IV: This stage describes any tumor that has spread toother areas of the body, such as the bladder, rectum, bone, liver,

lungs, or lymph nodes.

Recurrent: Recurrent prostate cancer is cancer that comes backafter treatment. It may come back in the prostate area again orin other parts of the body.

Anatomical and staging illustrations for many types of cancer are available at

www.cancer.net.

Prognostic FactorsIn addition to stage, doctors use other prognostic factorsto help plan the best treatment and predict how successfultreatment will be. Below are prognostic factors for patients withprostate cancer.

PSA test. As described in Risk Factors and Prevention, PSA isa measurement of prostate-specific antigen levels in a mansblood. These results are usually reported as nanograms permilliliter (ng/mL), such as 7 ng/mL for a PSA level of 7. For menalready diagnosed with prostate cancer, the PSA level (and theGleason score, described below) helps the doctor understand

and predict a patients prognosis. This measurement givesdoctors more information about the cancer to help maketreatment decisions. Its important to note that some prostatecancers do not cause an increased PSA level, so a normal PSAdoes not always mean that there is no prostate cancer.

Gleason score for grading prostate cancer. Prostate cancer

is also given a grade called a Gleason score, which is based onhow much the cancer looks like healthy tissue when viewedunder a microscope. Less dangerous tumors generally look morelike healthy tissue, and more dangerous tumors that are morelikely to invade and spread to other parts of the body look lesslike healthy tissue.

The Gleason System is the most common prostate cancergrading system used. The pathologist looks at how the cancercells are arranged in the prostate and assigns a score on ascale of 1 to 5. Cancer cells that look similar to healthy cells aregiven a low score, and cancer cells that look less like healthycells are given a higher score. To assign the numbers, thedoctor first looks for a dominant pattern of cell growth (area

where the cancer is most prominent), looks for any other lesswidespread pattern of growth, and gives each one a score. The


14/28

12 TREATMENT

scores are added to come up with an overall score between2 and 10. The interpretation of the Gleason score by doctorshas changed recently. Originally, there was a broader spread,

with doctors using a range of scores. Today, doctors tend todescribe a score of 6 as a low-grade cancer, 7 as medium-grade, and 8, 9, or 10 as high-grade cancer. A lower-gradecancer grows more slowly and is less likely to spread than acancer with a higher grade.

Used with permission of the American Joint Committee on Cancer (AJCC),

Chicago, Illinois. The original source for this material is theAJCC Cancer

Staging Manual, Seventh Edition (2010), published by Springer-Verlag New York,www.cancerstaging.net.

TREATMENTThe treatment of prostate cancer depends on the size and

location of the tumor, whether the cancer has spread, andthe mans overall health. In many cases, a team of doctors willwork with the patient to determine the best treatment plan.

This section outlines treatments that are the standard of care(the best treatments available) for this specific type of cancer.Patients are also encouraged to consider clinical trials when

making treatment plan decisions. A clinical trial is a researchstudy to test a new treatment to prove it is safe, effective, andpossibly better than standard treatment. Your doctor can helpyou review all treatment options. For more information, see theClinical Trials section.

It is important to discuss

the goals and possibleside effects of treatmentwith your doctor beforetreatment begins,including the likelihood ofsuccess of that treatment,the potential side effects

of therapy (includingpossible urinary, bowel,sexual, and hormone-related side effects), andthe patients preferences.Men should talk with theirdoctor about how the

various treatments affectrecurrence (the return of the cancer after treatment), survival,and quality of life. In addition, the success of any treatmentoften depends on the skill and expertise of the physician orsurgeon, so it is important to find doctors who have experiencetreating prostate cancer.

Descriptions of the most common treatment options forprostate cancer are listed below.


15/28

13TREATMENT

Active surveillance (watchful waiting)for early-stage cancerIf a prostate cancer is in an early stage, growing slowly, and

treating the cancer would cause more discomfort than thedisease itself, a doctor may recommend watchful waiting,also called active surveillance or watch-and-wait. The canceris monitored closely with periodic PSA tests, DRE tests, andwatching for symptoms. Treatment would begin only if thetumor shows signs of becoming more aggressive or spreading,causes pain, or blocks the urinary tract. This approach may

be used for much older patients, those with other serious orlife-threatening illnesses, or those who wish to delay activetreatment because of possible side effects. However, realcaution must be taken not to make errors of judgment aboutthe disease. In other words, doctors must collect as muchinformation as possible about the patients other illnesses andpotential life expectancy, so they dont miss the chance to

detect an early, aggressive prostate cancer. For this reason,many doctors recommend a repeat biopsy shortly afterdiagnosis to confirm that the cancer is in an early stage andgrowing slowly before considering active surveillance for anotherwise healthy man. New information is becoming availableall the time, and it is important for men to discuss these issueswith their doctor to make the best decision about treatment.

SurgerySurgery is used to try to cure cancer before it has spread outsidethe prostate. A surgical oncologist is a doctor who specializesin treating cancer using surgery. For prostate cancer, a urologistor urologic oncologist is the surgical oncologist involved intreatment. The type of surgery depends on the stage of the

disease, the mans general health, and other factors.

Radical (open) prostatectomy. A radical prostatectomyis the surgical removal of the whole prostate and seminalvesicles; lymph nodes in the pelvic area may also be removed.This operation has the risk of interfering with sexual function.Nerve-sparing surgery, when possible, increases the chance

that a man can maintain his sexual function after surgery byavoiding surgical damage to the nerves that allow erections andorgasm to occur. Orgasm can occur even if some nerves are cutsince these are two separate processes. Urinary incontinence(inability to control urine flow) is also a possible side effect ofprostatectomy. To help resume normal sexual function, men canreceive drugs, penile implants, or injections. Sometimes, another

surgery can fix urinary incontinence.

Robotic or laparoscopic prostatectomy. This type ofsurgery is possibly much less invasive than an open radicalprostatectomy and may reduce recovery time. A camera andinstruments are inserted through small, keyhole incisions inthe patients abdomen. The surgeon then directs the robotic

instruments to remove the prostate gland and surroundingtissue. In general, robotic prostatectomy has less bleeding and


16/28

14 TREATMENT

less pain, but sexual and urinary side effects can be similar toan open radical prostatectomy. This procedure has not beenavailable for as long as open radical prostatectomy, so longer-

term follow-up information, including permanent cure rates,are not yet certain. Talk with your doctor about whether yourtreatment center offers this procedure and how it compareswith the results of the conventional open radical prostatectomy.

Transurethral resection of the prostate (TURP). TURP ismost often used to relieve symptoms of a urinary blockage,

not to cure cancer. In this procedure, with the patient under afull anesthetic, a surgeon inserts a cystoscope (a narrow tubewith a cutting device) into the urethra and into the prostateto remove prostate tissue. This is rarely used to treat prostatecancer in current clinical practice.

Cryosurgery. This procedure is commonly used only in

research studies. Cryosurgery (also called cryotherapy orcryoablation) is the freezing of cancer cells with a metal probeinserted through a small incision in the area between therectum and the scrotum, the skin sac that contains the testicles.Cryosurgery may be useful for early-stage cancer and for menwho cannot have a radical prostatectomy. A common sideeffect of cryosurgery is impotence, so this approach is not

recommended for men who desire to preserve their sexualfunction. Another side effect may be the development offistulae (holes between the prostate and the bowel), althoughthis appears to be much less common with newer cryosurgerytechniques.

Learn more about cancer surgery at www.cancer.net/features.

Radiation therapyRadiation therapy is the use of high-energy rays to kill cancercells. A doctor who specializes in giving radiation therapy totreat cancer is called a radiation oncologist. The most commontype of radiation treatment is called external-beam radiationtherapy, which is radiation given from a machine outside the

body. When radiation treatment is given using implants, it iscalled internal radiation therapy or brachytherapy. A radiationtherapy regimen (schedule) usually consists of a specific numberof treatments given over a specific time.

External-beam radiation therapy. External-beam radiationtherapy focuses a beam of radiation on the area with the

cancer. Some cancer centers use conformal radiation therapy(CRT), in which computers help precisely map the location andshape of the cancer. CRT reduces radiation damage to healthytissues and organs around the tumor by directing the radiationtherapy beam from different directions with the intention offocusing the dose on the tumor.

Intensity-modulated radiation therapy (IMRT). IMRT isa form of three-dimensional (3-D) CRT. CRT uses CT scans to


17/28

15TREATMENT

form a 3-D picture of the prostate before treatment. With IMRT,high doses of radiation can be directed at the prostate withoutincreasing the risk of damaging nearby organs.

Brachytherapy. Brachytherapy is the insertion of radioactivesources directly into the prostate. These sources (called seeds) giveoff radiation just around the area in which they are inserted andmay be used for hours (high-dose rate) or for weeks (low-doserate). Low-dose rate seeds are left in the prostate permanently,even after all the radioactive material has been used up.

Radiation therapy may cause such side effects as diarrhea orother problems with bowel function; increased urinary urge orfrequency; fatigue; impotence (erectile dysfunction); and rectaldiscomfort, burning, or pain. Most of these side effects usuallygo away after treatment, but erectile dysfunction is usuallypermanent.

Learn more about radiation therapy at www.cancer.net/features.

Hormone therapyBecause prostate cancer growth is driven by male sex hormonesknown as androgens, lowering levels of these hormones canhelp slow the growth of the cancer. Hormone treatment is

also called androgen ablation or androgen deprivation therapy.The most common androgen is testosterone. The productionof testosterone can be lowered either surgically, with surgicalcastration (removal of the testicles), or with drugs that turn offthe function of the testicles (see below).

Hormone therapy is used to treat prostate cancer that has

continued to grow after surgery and radiation therapy, orwhen it is widespread at the time of diagnosis. More recently,hormone therapy has also been used with radiation therapy formen with a cancer that is more likely to recur. For some men,hormone therapy will be used first to shrink a prostate cancertumor before radiation therapy or surgery. In some men withprostate cancer that has spread locally (as found during a radical

prostatectomy), hormone therapy is given after the surgery fortwo to three years as adjuvant therapy (treatment that is givenafter the first treatment).

Traditionally, hormone therapy was used until it stoppedcontrolling the cancer. Then the cancer was said to be hormonerefractory (meaning that the hormone therapy has stopped

working), and other treatment options were considered.Recently, researchers have begun studying intermittent hormonetherapy, which is hormone therapy that is given for specificperiods and then stopped temporarily according to a schedule.Giving hormones in this way appears to lower the symptomsof this therapy. In addition, intermittent hormone therapy maypossibly maintain hormone responsiveness for a longer time

than standard (continuous) hormone treatment; this approach iscurrently being tested in clinical trials.


18/28

16 TREATMENT

One important side effect of hormone therapy is the risk ofdeveloping metabolic syndrome. Metabolic syndrome refersto a set of conditions, such as high levels of blood cholesterol

and high blood pressure that increases a persons risk of heartdisease, stroke, and diabetes. Currently, it is not certain howoften this happens or exactly why it happens, but it is quite clearthat patients who undergo a surgical or medical castration (evena temporary medical castration) with hormone therapy have anincreased risk of developing metabolic syndrome. The risks andbenefits of castration should be carefully discussed with your

doctor. For men with metastatic prostate cancer, especially if itis advanced and causing symptoms, most doctors believe thatthe benefits of castration far outweigh the risks of metabolicsyndrome.

Types of hormone therapyBilateral orchiectomy. Bilateral orchiectomy is the surgical

removal of both testicles. Even though this is surgery, it is calleda hormone treatment because it removes the main source oftestosterone production, the testicles. This surgery is permanentand cannot be reversed.

LHRH agonists. LHRH stands for luteinizing hormone-releasinghormone. LHRH agonists are drugs that reduce the bodys

production of testosterone by interfering with hormonal controlmechanisms within the brain, which control the functioning ofthe testicles.

Anti-androgens. While LHRH agonists lower testosteronelevels in the blood, anti-androgens block testosterone frombinding to so-called androgen receptors, chemical structures

in the cancer cells that allow testosterone and other malehormones to enter the cells.

LHRH antagonist. This type of drug, also called agonadotropin-releasing hormone (GnRH) antagonist, stops thetesticles from producing testosterone by acting like LHRH. TheU.S. Food and Drug Administration (FDA) has approved one

drug, degarelix (Firmagon), given by injection, to treat advancedprostate cancer. One side effect of this drug is that it may causea severe allergic reaction.

Female hormones. Estrogen can lower testosterone levels.When it is given as a pill, side effects can include heartproblems and blood clots. More recently, estrogen has been

given as injections or as skin patches, and this type of treatmentmay be associated with a lower chance of heart and clottingside effects.

Combined androgen blockade. Sometimes, LHRH agonistsare used in combination with peripheral-blocking drugs, suchas anti-androgens, to more completely block male hormones.

Many doctors feel that this combined approach is the safestway to start hormone treatment, as this prevents a potential


19/28

17TREATMENT

flare-up or increase in activity of the prostate cancer cellsthat sometimes happens because of a temporary surge intestosterone production by the testicles (in response to the

LHRH agonists). Major studies have not shown a big differencein long-term survival from the use of combined androgenblockade as permanent therapy; therefore, some doctorsprefer to give combined drug treatment only for the first two tothree months.

Hormone therapy may cause significant side effects. Side

effects generally go away after hormone treatment is finished,except in men who have had an orchiectomy. Patients mayexperience impotence, loss of libido (sexual desire), hot flashes,gynecomastia (enlarged breasts), and osteoporosis (weakeningbones). Men who have received LHRH agonists for more thantwo years will often have ongoing hormonal effects, even if thedrugs are no longer given.

ChemotherapyChemotherapy is the use of drugs to kill cancer cells. Systemicchemotherapy is delivered through the bloodstream, targetingcancer cells throughout the body. Chemotherapy is given by amedical oncologist, a doctor who specializes in treating cancerwith medication. Some people may receive chemotherapy in

their doctors office or outpatient clinic; others may go to thehospital. A chemotherapy regimen (schedule) usually consists ofa specific number of cycles given over a specific time.

Chemotherapy can be taken orally (by mouth) or intravenously(injected into a vein), and it may help patients with advancedor hormone-refractory prostate cancer. There is no standard

chemotherapy for prostate cancer, but clinical trials are exploringchemotherapy for advanced prostate cancer. The most popular,current approach is the use of a drug called docetaxel (Taxotere)given with a steroid called prednisone (multiple brand names).This combination has been shown to help men with advancedprostate cancer live longer than another chemotherapy,mitoxantrone (Novantrone), which is most useful for controlling

prostate cancer symptoms.

The FDA has approved the drugs mitoxantrone and docetaxelfor use in men with prostate cancer that is resistant to hormonetherapy. Also, the drugs paclitaxel (Taxol) and estramustine(Emcyt) have shown some beneficial effects in treatingadvanced prostate cancer. Estramustine is being used less

often in current clinical practice because of its side effects,which include an increased risk of blood clots. Although clinicaltrials have shown that docetaxel increases survival and has ahigher rate of remission (temporary or permanent absence ofdisease) than mitoxantrone, the difference in survival is onlyan average of a few additional months, and the side effects ofmitoxantrone are generally milder than for docetaxel. Many new

medications for prostate cancer are in development and may beavailable in clinical trials.


20/28

18 TREATMENT

The side effects of chemotherapy depend on the individualand the dose used, but can include fatigue, risk of infection,nausea and vomiting, loss of appetite, and diarrhea. These side

effects usually go away once treatment is finished.Learn more about chemotherapy and preparing for treatment at

www.cancer.net/features. The medications used to treat cancer are continually

being evaluated. Talking with your doctor, oncology nurse, or pharmacist is

often the best way to learn about the medications prescribed for you, their

purpose, and their potential side effects or interactions with other medications.

Learn more about your prescriptions by using searchable drug databases at

www.cancer.net/druginforesources.

Advanced prostate cancerProstate cancer that develops the ability to grow without usingmale sex hormones and causes hormone treatments to stopworking is called androgen-independent, hormone-refractory,or castrate-resistant prostate cancer. Although there is no

cure for this type of cancer, it is often treatable with radiationtherapy or chemotherapy.

In 2010, the FDA approved cabazitaxel (Jevtana) for patientswith hormone-refractory prostate cancer who have alreadyreceived treatment with docetaxel. Cabazitaxel is similar todocetaxel, but research studies have shown that it can be

effective for prostate cancer that is resistant to docetaxel.The side effects are similar to docetaxel and include lowwhite blood cell counts, increased risk of infections, allergicreactions, nausea, vomiting, diarrhea, and kidney and liverproblems.

Another option for

men may be animmunotherapy calledsipuleucel-T (Provenge).Immunotherapy (alsocalled biologic therapy)is designed to boost thebodys natural defenses

to fight the cancer. Ituses materials madeeither by the body or ina laboratory to bolster,

target, or restore immune system function. Learn more aboutimmunotherapy at www.cancer.net/features.

In 2010, the FDA approved sipuleucel-T for men withhormone-refractory metastatic prostate cancer with few orno symptoms after it increased survival by an average of alittle more than two months. Sipuleucel-T is adapted for eachpatient. Before treatment, blood is removed from the patientin a process called leukapheresis. Special immune cells areseparated from the patients blood, modified in the laboratory,

and then put back in the patient. At this point, the patientsimmune system recognizes and kills the prostate cancer cells.


21/28

19CLINICAL TRIALS RESOURCES

Because this treatment is tailored for each patient, it may not beavailable in many areas.

These clinical trials were sponsored by drug companies; criticshave suggested that the small increase in survival comes at asignificant cost, and many doctors are waiting for results ofindependent clinical trials.

If all treatments have failed to control prostate cancer, or ifcancer comes back after treatment, a patient may experience

pain, fatigue, and weight loss. At this point, the goal oftreatment switches from curing the cancer to slowing it downand relieving symptoms.

It is important to note that many men outlive their prostatecancer, even those with advanced disease. Often, the prostatecancer grows slowly, and there are now effective treatment

options that extend life even further. A few drugs can help treatthe symptoms of advanced cancer to enhance the quality of thepatients life; this is called palliative or supportive care.

Chemotherapy (see above). Chemotherapy is most commonlyused for patients with advanced, hormone-refractory prostatecancer. It can be effective in relieving symptomssuch as pain,

weight loss, and fatigueand may prolong life for some patients.

Strontium and samarium. Given by injection, theseradioactive agents are absorbed near the area of bone pain.The radiation that is released helps relieve the pain, probably bycausing local tumor shrinkage.

Pamidronate (Aredia) and zoledronic acid (Zometa). Givenby injection, these drugs reduce the level of calcium in theblood and cause a reduction of bone complications (such aspain, fracture, and need for surgery) due to metastases. A highcalcium level is called hypercalcemia and is sometimes found inmen with advanced prostate cancer.

Hormone therapy. Some types of hormone therapy maybe used to treat advanced cancer (see above). Read ASCOsguideline about hormone therapy for advanced prostate cancerat www.cancer.net/whattoknow.

Find out more about common terms used during cancer treatment at


CLINICAL TRIALS RESOURCESDoctors and scientists are always looking for better ways totreat patients with prostate cancer. A clinical trial is a way totest a new treatment to prove that it is safe, effective, andpossibly better than a standard treatment. The clinical trial

may be evaluating a new drug, a new combination of existingtreatments, a new approach to radiation therapy or surgery,


22/28

20 SIDE EFFECTS

or a new method of treatment or prevention. Patients whoparticipate in clinical trials are among the first to receive newtreatments before they are widely available. However, there is

no guarantee that the new treatment will be safe, effective, orbetter than a standard treatment.

Patients decide to participate in clinical trials for many reasons.For some patients, a clinical trial is the best treatment optionavailable. Because standard treatments are not perfect, patientsare often willing to face the added uncertainty of a clinical

trial in the hope of a better result. Other patients volunteer forclinical trials because they know that finding new drugs andother therapies is the only way to make progress in treatingprostate cancer. Even if they do not benefit directly from theclinical trial, their participation may benefit future men withprostate cancer.

Sometimes people have concerns that, by participating in aclinical trial, they may receive no treatment by being given aplacebo or a sugar pill. The use of placebos in cancer clinicaltrials is rare. When a placebo is used in a study, it is done withthe full knowledge of the participants. Find out more aboutplacebos in cancer clinical trials at www.cancer.net/features.

To join a clinical trial, patients participate in a process known asinformed consent. During informed consent, the doctor shouldlist all of the patients options, so the person understandshow the new treatment differs from the standard treatment.The doctor must also list all of the risks of the new treatment,which may or may not be different from the risks of standardtreatment. Finally, the doctor must explain what will be required

of each patient in order to participate in the clinical trial,including the number of doctor visits, tests, and the schedule oftreatment.

Learn more about clinical trials, including patient safety, phases of a clinical trial,

deciding to participate in a clinical trial, questions to ask the research team, and

links to find cancer clinical trials at www.cancer.net/clinicaltrials.

For specific topics being studied for prostate cancer, learn more in the Current

Research section.

SIDE EFFECTSCancer and its treatment can cause a variety of side effects.

However, doctors have made major strides in recent years inreducing pain, nausea and vomiting, and other physical sideeffects of cancer treatments. Many treatments used today areless intensive but as effective as treatments used in the past.Doctors also have many ways to provide relief to patients whensuch side effects do occur.

Fear of treatment side effects is common after a diagnosisof cancer, but it may be helpful to know that preventing and


23/28

21AFTER TREATMENT

controlling side effects is a major focus of your health careteam. Before treatment begins, talk with your doctor aboutpossible side effects of the specific treatments you will be

receiving. The specific side effects that can occur depend on avariety of factors, including the type of cancer, its location, theindividual treatment plan (including the length and dosage oftreatment), and the persons overall health.

Ask your doctor which side effects are most likely to happen(and which are not), when side effects are likely to occur, and

how they will be addressed by the health care team if they dohappen. Also, be sure to communicate with the doctor aboutside effects you experience during and after treatment. Learnmore about the most common side effects of cancer anddifferent treatments, along with ways to prevent or controlthem, at www.cancer.net/sideeffects.

In addition to physical side effects, there may be psychosocial(emotional and social) effects as well. Learn more about theimportance of addressing such needs, including concerns aboutmanaging the cost of your cancer care, at www.cancer.net/patientcare and www.cancer.net/managingcostofcare.

Learn more about late effects or long-term side effects by

reading the After Treatment section or talking with your doctor.

AFTER TREATMENTAfter treatment for prostatecancer ends, talk with your

doctor about developing afollow-up care plan. This planmay include regular physicalexaminations and/or medicaltests to monitor your recovery forthe coming months and years.ASCO offers cancer treatment

summary forms at www.cancer.net/treatmentsummaries tohelp keep track of the cancertreatment you received anddevelop a survivorship care planonce treatment is complete.

Men recovering from prostate cancer are encouraged to followestablished guidelines for good health, such as maintaining ahealthy weight, not smoking, eating a balanced diet, and havingrecommended cancer screening tests. Talk with your doctor todevelop a plan that is best for your needs. Moderate physicalactivity can help rebuild your strength and energy level. Yourdoctor can help you create an appropriate exercise plan based

upon your needs, physical abilities, and fitness level.


24/28

22 CURRENT RESEARCH

Learn more about healthy living after cancer at www.cancer.net/features.

Find out more about coping with cancer, including important topics for men

with prostate cancer, such as self-image and cancer, fertility and cancer

treatment, and talking with your spouse or partner at www.cancer.net/coping.

Learn more about common terms used after cancer treatment is complete at


CURRENT RESEARCHResearch for prostate cancer is ongoing. The following advancesmay still be under investigation in clinical trials and may not be

approved or available at this time. Always discuss all diagnosticand treatment options with your doctor.

Finding causes of prostate cancer. Researchers continue toexplore the link between nutrition and lifestyle factors in thedevelopment of prostate cancer.

PSA test improvements.Researchers are developinga better PSA test, either amore specific and precise testor another test altogether.With improved testing, largernumbers of healthy men could

be screened for prostate cancer,so more prostate cancers can befound and treated early.

Improved surgical techniques.Better techniques for nerve-

sparing surgery can improve the likelihood that men who need

radical prostatectomy retain their urinary continence and sexualfunction after surgery.

Shorter courses of radiation therapy. With better, moreprecise external-beam radiation therapy, researchers areexploring much shorter and more convenient treatmentschedules. Instead of 40 treatments, researchers are evaluating

28, 12, or only five treatments.

High-intensity focused ultrasound (HIFU). This procedure,which is still being researched in the United States, usestransrectal ultrasound to heat and destroy cancer cells.

Tests that evaluate the success of treatment. These tests

can help doctors know if chemotherapy is working. Circulating tumor cells (cells that have broken free of the

tumor) can be used to monitor the effectiveness of treatment;this test uses a patients blood sample to collect the circulatingtumor cells.

A biomarker called prostate cancer gene 3 (PCA3), measuredwith a urine test, is a test designed to help decide who needs

immediate treatment and who can wait. Learn more aboutresearch on PCA3 at www.cancer.net/canceradvances.


25/28

23CURRENT RESEARCH

Therapy for advanced prostate cancer. Researchers areexploring different chemotherapy options for advanced prostatecancer through a series of clinical trials. In addition, several other

immunotherapy options are being tested in clinical trials.

Reducing side effects from bone metastases. Recentresearch has looked at the use of denosumab (Prolia) to helpslow the damage to bone from metastases and reduce boneside effects for men with castration-resistant prostate cancer.Results indicate that denosumab may be more effective at

protecting the bones than zoledronic acid (see Treatment).

To find clinical trials specific to your diagnosis, talk with yourdoctor or search online clinical trial databases now atwww.cancer.net/clinicaltrials.


26/28

24 QUESTIONS TO ASK THE DOCTOR

QUESTIONS TO ASK THE DOCTORRegular communication with your doctor is important in makinginformed decisions about your health care. Consider asking the

following questions of your doctor:

Before diagnosis/risk reduction and screening What type of prostate cancer screening schedule do you

recommend for me, based on my individual medical profileand family history?

Are there any changes I can make to my diet that can help me

lower my risk of prostate cancer?

After a diagnosis of prostate cancer What type of prostate cancer do I have? What stage and grade is my prostate cancer, and what does

this mean? Can you explain my pathology report (laboratory test results)

to me? What are my treatment options? What clinical trials are open to me? What treatment plan do you recommend and why? What is the goal of this treatment? Who will be part of my health care team, and what does each

member do?

Who will be coordinating my overall treatment and follow-up care?

What are the possible side effects of each treatment option,both in the short term and the long term?

What experience do you have in treating this type of cancer? How will this treatment affect my daily life? Will I be able to

work, exercise, and perform my usual activities?

Will this treatment affect my fertility (ability to producechildren)?

Could this treatment affect my sex life? What type of recovery should I expect following treatment? What follow-up care tests will I need, and how often will I

need them? If Im worried about managing the costs related to my cancer

care, who can help me with these concerns? What support services are available to me? To my family?

Patient Information ResourcesFind organizations that offer information for prostate cancer atwww.cancer.net/support.


27/28

Dear Partner in the Fight Against Prostate Cancer,

We know in the wake of a cancer diagnosis, knowledge is

power. Thats why The ASCO Cancer Foundation

brings youresources developed through the expertise of the worldsleading cancer doctors. We support breakthrough research,education, and cancer care programsso you can bemore informed, ask better questions, get involved, and beempowered.

The Foundations charitable mission is founded upon four coretenets: (1) research is at the heart of progress against cancer; (2)cutting-edge knowledge is essential when it comes to treatingpeople with cancer; (3) getting good cancer care starts withgetting good cancer information; and (4) all people with cancerdeserve access to the best possible care.

Since 1984, The ASCO Cancer Foundation Grants Programhas awarded more than $67 million in grants to more than800 clinical researchers. We are pleased to be able to increaseour grants opportunities each year, but we always have morefundable grant applications than we are able to support.

The ASCO Cancer Foundation is also proud to provide support

for ASCOs patient information resources including the award-winning website: Cancer.Net (www.cancer.net). Cancer.Netwas developed and approved by the cancer doctors at ASCO,making it an up-to-date and trusted resource for cancerinformation on the Internet.

If you are a current supporter of The ASCO Cancer Foundation,

thank you! For those of you who have not partnered with TheASCO Cancer Foundation before, we invite you to join us nowin making a world of difference in cancer care.

Warmest regards,

Nancy R. Daly, MS, MPH

Executive DirectorThe ASCO Cancer Foundation

The ASCO Cancer Foundation is a four-star charity, asrated by Charity Navigator. To learn more or support thework of the Foundation, please visit our website:www.ascocancerfoundation.org or call us at 571-483-1700.


28/28

American Society of Clinical Oncology

2318 Mill Road, Suite 800 | Alexandria, VA 22314

Phone: 571-483-1300 | Fax: 571-366-9530

www.asco.org | www.cancer.net

For more information about ASCOs patient information resources,

call toll-free 888-651-3038 or e-mail [email protected]. 2010 American Society of Clinical Oncology.

For permissions information, contact [email protected].

Date post:	08-Apr-2018
Category:	Documents
Upload:	muganga-patrick
View:	220 times
Download:	0 times

Cancer.net Guide to Prostate Cancer PDF

Documents