Overview                                                                   

The prostate gland is an important component of the male reproductive system involved in the production of seminal fluid.  The prostate is located in the pelvis, in close proximity to the bladder and rectum.

Prostate cancer is diagnosed in over 200,000 men in the United States each year.  Overall, it is the most common non-skin cancer diagnosed in this country, occurring in nearly 1 of 6 men over their lifetime. 

Most commonly diagnosed in men age 50 or older, it may occur in younger men.  While any man may develop prostate cancer, the risk of developing prostate cancer has been correlated with both race and family history.  Overall, African-American men are much more likely than caucasians to develop prostate cancer.  Moreover, men with a single relative with prostate cancer are twice as likely to be diagnosed with prostate cancer themselves, particularly if the effected relative was young when diagnosed.

In the past, prostate cancer was commonly diagnosed only in men who present with symptoms including increased urinary frequency, difficulty initiating urination (hesistancy) and increased episodes of waking up at night to urinate (nocturia).  Symptoms of more advanced disease include blood in the urine (hematuria), pain on defecation, and bone pain due to bone metastases.

Today, prostate cancer is commonly found in asymptomatic men (no symptoms) on a routine prostatic specific antigen (PSA) test. PSA is a protein produced by the normal prostate which is typically elevated in patients with prostate cancer.  Levels of 4 ng/mL and below are considered “normal”.  However, it is important to note that a normal level does not ensure the absence of prostate cancer.

Interested in learning more about prostate and other genitourinary cancers? Check out the American Cancer Society website http://www.cancer.org/docroot/home/index.asp

Role of Radiation Therapy                                     

Radiotherapy has long occupied an important role in the treatment of prostate cancer.  In fact, it was over 100 years ago that the first prostate cancer patient received radiotherapy.

Today, radiotherapy and surgery are the cornerstones for treatment in prostate cancer patients.  Significant advancements in both have been realized over the past 25 years providing the early stage patient with two highly effective treatment approaches with comparable outcomes.

Radiation therapy may be delivered alone in patients with low risk disease (PSA ≤ 10 ng/mL, Gleason score ≤ 6 and no/limited palpable disease) (view paper).Radiation therapy is also commonly used following surgery, either immediately in patients with high risk factors (adjuvant radiotherapy) (view paper) or in those with a rising PSA (salvage radiotherapy) (view paper). 

Radiotherapy is also the treatment in patients with more advanced disease, typically in conjunction with hormone deprivation (view paper). Moreover, in patients with symptomatic bone metastases, radiation is a highly effective palliative approach reducing pain and in many patients relieving painful symptoms altogether (view paper).

Radiation Therapy Techniques                              

A variety of radiotherapy techniques are used in patients with prostate cancer.  Previously, the most common include external beam radiotherapy delivered using 3D conformal radiation therapy (3DCRT).  In this technique, multiple beams are used to focus the radiation dose on the target tissues reducing the volume of the bladder and rectum receiving high doses.

Today, the most common treatment approach in prostate cancer is intensity modulated radiotherapy (IMRT). Unlike conventional approaches, IMRT conforms the radiation dose to the shape of the target tissues in 3-dimensions, reducing the dose delivered to the nearby normal tissues including the rectum and bladder.  IMRT has been shown to be associated with excellent outcomes with less RT-induced toxicities.

IMRT Plan in a patient with early stage prostate cancer

IMRT treatment approaches are particularly appealing in patients with “high risk” factors (Gleason > 6, PSA >10 ng/mL) who receive “whole pelvic” radiotherapy.  IMRT is used in these men to reduce the volume of small bowel, rectum and bladder receiving high doses, in order to reduce the risk of potential acute and long term sequelae.

IMRT whole pelvic prostate plan

Ask your Radiation Oncologist whether IMRT is right for you. IMRT is the standard approach in all prostate cancer patients treated at UCSD.

Image-Guided Radiation Therapy (IGRT)                                               

Image-Guided Radiation Therapy (IGRT) is a broad concept applying both to the use of modern imaging to improve the target delineation and to improve the delivery of treatment. The key behind the second part of IGRT is the ability to image patients in the treatment room with the patient on the treatment table.

IGRT represents a major change in the practice of Radiation Oncology.  Before IGRT, patients were imaged once at the beginning of treatment and only periodically during treatment. Now, patients are imaged everyday immediately prior to treatment.

Varian Trilogy Machine

The OBI on the Trilogy consists of a kilovoltage (kV) source and a detector mounted at right angles to the treatment beam on the machine gantry.  The kV source and detector are operated via robotic arms and can be extended for imaging and retracted when not in use.

Planar images are used to ensure that patients are accurately setup every time every day.  Varian software rapidly compares the images with references images obtained at simulation and adjustments in table position are made automatically. 

In prostate cancer patients, small seeds are routinely implanted prior to treatment and used to daily localize the prostate.  The treatment couch is then adjusted to return the prostate to the same position as at simulation. 

Reference Image (left) obtained at simulation is compared with the kV OBI image (right) in a prostate cancer patient undergoing IMRT.  Note the 5 seeds outline in green on the reference image.  These markers are clearly seen on the OBI film.

An additional feature of the Varian Trilogy is the ability to generate volumetric images of the patient, known as cone-beam CT (CBCT) imaging.  CBCT images are obtained by rotating the OBI imager around the patient and reconstructing the 2D images into 3D ones.

Image of a prostate cancer patient undergoing IMRT

The ability to generate high-quality kV CBCT images of the patient on the treatment table immediately prior to treatment is nothing short of revolutionary.  Such images can be used to more accurately setup patients based on internal anatomy without the need for implanted fiducial markers.

In the future, it is hoped that volumetric imaging will allow treatment to be adapted to changes in the patient and/or tumor. Adaptive radiotherapy is a focus of intensive research at our center.

Other Genitourinary Tumors                                                                     

A variety of other genitourinary tumors are also treated with radiotherapy.  Patients with testicular seminomas are commonly treated following surgery to reduce the risk of relapse in the abdominal lymph nodes (view paper).

While commonly used in the past, chemoradiotherapy is less frequently used today in patients with bladder cancers due to significant advancements in surgery.  However, in medically inoperable patients, radiotherapy with or without chemotherapy is associated with favorable outcomes (view paper).

UCSD Prostate Cancer (Genitourinary) Team                             

The UCSD Prostate Cancer (Genitourinary) Team is comprised of dedicated professional with considerable experience in the treatment of patients with prostate cancer and other genitourinary malignancies.

Ajay Sandhu M.D. is the Chief of the Prostate Cancer (Genitourinary) Service in the UCSD Department of Radiation Oncology.

Ajay Sandhu, M.D. Chief, Prostate Cancer (Genitourinary) Service Department of Radiation Oncology

Dr. Sandhu has considerable experience in the treatment of prostate cancer and other genitourinary malignancies with latest radiotherapy techniques including intensity modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT).

Working with Dr. Sandhu in the Department of Radiation Oncology is Radiation Nurse, Polly Nobiensky, R.N.

Polly Nobiensky, R.N., B.S.N. Radiation Nurse Department of Radiation Oncology

The treatment of prostate cancer (genitourinary) patients is a team approach. Dr. Sandhu thus works together with other specialists including J. Kellogg Parsons M.D. and C. Lowell Parsons (Urologic Surgeons) and Fred Millard, M.D. and Greg Daniels, M.D. (Medical Oncology).

All patients consulted at UCSD are presented and discussed at a multi-disciplinary Prostate Cancer (Genitourinary) Conference.

Chris Kane, M.D. Chief, Division of Urology	J. Kellogg Parsons, M.D. Urologic Surgeon	C. Lowell Parsons, M.D. Urologic Surgeon
Tracey Downs, M.D. Urologic Surgeon	Fred Millard, M.D. Medical Oncologist	Greg Daniels, M.D. Medical Oncologist

Prostate Cancer (Genitourinary) Publications by UCSD Radiation Oncology Faculty

Listed below are Prostate Cancer (Genitourinary) Articles published by members of the UCSD Department of Radiation Oncology.  For a full list of published articles by UCSD Radiation Oncology faculty see Research section

Pawlicki T, et al. Prostate cancer therapy with stereotactic body radiation therapy. Front Radiat Ther Oncol 2007;40:395-406

Pawlicki T, et al. Investigation of linac-based image-guided hypofractionated prostate radiotherapy. Med Dosim 2007;32:21-29

Hsu A, Pawlicki T et al. A study of image-guided intensity-modulated radiotherapy with fiducials for localized prostate cancer including pelvic lymph nodes. Int J Radiat Oncol Biol Phys 2007;68:898-902

Hara W, Patel D, Pawlicki T, et al. Hypofractionated stereotactic radiotherapy for prostate cancer: early results. Int J Radiat Oncol Bio Phys 2006;66:S324-325

Xing L, de la Zerd A, Cao M, Li T, Armbrush B, Yang Y, Lee P, Pawlicki T, et al. On-board volumetric CT-based adaptive IMRT for improved prostate cancer treatment. Int J Radiat Oncol Bio Phys 2006;66:S624-625

Sandhu APS, Zelefsky MJ, et al. Long term urinary toxicity after 3-dimensional conformal radiotherapy for prostate cancer in patients with prior history of transurethral resection. Int J Radiat Oncol Biol Phys 2000;48:643- 647

Beard C, Buswell L, Rose MA, et al. Phase II trial of external beam radiation with etandidazole (SR 2508) for treatment of locally advanced prostate cancer. Int J Radiat Oncol Biol 1994;29:611-6

Coleman CN, Buswell L, Noll L, Riese N, Rose MA. The efficacy of pharmacokinetic monitoring and dose modification of etandidazole on the incidence of neurotoxicity: Results from a Phase II trial of etanidazole and radiation therapy in locally advanced prostate cancer. Int J Radiat Oncol Biol Phys 1992:22:565-568

Rose MA, Shipley WU. Radiation therapy in invasive bladder cancer: principles, results, patient selection and innovations. In Management of Malignant Disease. Peckham MJ (editor). Edward Arnold Ltd, London, 1988

Shipley WU, Rose MA. Bladder cancer: the selection of patients for treatment by full-dose irradiation. Cancer 1985;55:2278-2284