Newly Diagnosed Prostate Cancer Guide

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Newly diagnosed with prostate cancer? You are not alone.

We are here to help.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

ZERO — The End of Prostate Cancer is the leading national nonprofit with the mission to end prostate cancer and help all who are impacted. ZERO advances research, provides support, and creates solutions to achieve health equity to meet the most critical needs of our community.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE Table of Contents

Page

Prostate Cancer Basics.........................................................................4

Diagnosing Prostate Cancer................................................................7

Prostate Cancer Imaging.....................................................................8

Understanding Your Diagnosis and Stage...........................................9

Genetic Testing..................................................................................12

Genomic Testing and Biomarkers......................................................13

Prostate Cancer Progression and Treatment......................................14

Prostate-Specific Membrane Antigen (PSMA) . .................................. 18

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

Managing Treatment Side Effects ...................................................... 20

Your Healthcare Team........................................................................21

Living with Prostate Cancer...............................................................23

Getting a Second Opinion.................................................................25

Prostate Cancer Terms to Know.........................................................27

Newly Diagnosed Worksheet............................................................29

Questions for Your Doctor: Newly Diagnosed ................................... 30

Questions for Your Doctor: Advanced Prostate Cancer ..................... 31

ZERO Support Programs....................................................................32

Prostate Cancer Family Tree..............................................................33

Notes Pages.......................................................................................34

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Basics Now What?

Hearing the words “you have prostate cancer” can be scary and overwhelming. Once you recover from the shock of hearing those words, it’s important to arm yourself with information about prostate cancer diagnosis, treatment, side effect management, and, most importantly, survivorship. This guide provides easy-to-understand information on prostate cancer and a variety of support resources that you and your family may be interested in. We want you to be informed and supported so you can make the best possible decisions for you and your family. It’s important to know that you are not alone. More than 3.1 million American men are living with prostate cancer today. Diagnosis and treatment advances happen often, and staying informed and connected will help you in this fight.

“Don’t panic. Do your research. Seek out support – whether that might be with a support group or with your family or friend – continue to do your research, as the disease doesn’t affect all men the same way.” Johnny Payne, prostate cancer survivor

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Facts and Stats Knowing how many men are affected by prostate cancer, as well as basic facts and figures, will help you better understand this disease, and may help you feel comfortable spreading awareness to those around you. One in eight American men will have prostate cancer during their lifetime. Prostate cancer is the second leading cause of cancer death among American men and is the most commonly diagnosed. The American Cancer Society estimates that 268,490 men will be diagnosed with prostate cancer this year and 34,500 will die from the disease. The five-year survival rate for all prostate cancer diagnoses is nearly 98%. More than 3.1 million Americans are living with prostate cancer — roughly equivalent to the population of Chicago. Prostate Cancer Risk Factors The most common risk factor for prostate cancer is age, but other risk factors include family history, race, and exposure to chemicals that are thought to, or known to, cause cancer. Family History

RISK FACTORS

Understanding your genetics should play a role in how you think about and treat prostate cancer, so talking with your family about your family health history is important. A man with at least one close relative, such as a father, brother, or son, who has had prostate cancer has twice the risk of the disease as the general population. In addition, it is important to know about a family history of breast, ovarian, or pancreatic cancers. BRCA1 and BRCA2 gene mutations found in those cancers have also been identified in prostate cancer and have been linked to more aggressive disease and increased lifetime risk of developing one or more cancers. Learn more about genetic testing on page 12 of this guide. Racial Disparities in Prostate Cancer

FAMILY HISTORY

RACE

DIET

AGING

GENE CHANGES

CHEMICALS

Prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer death in Black men in the United States. Not only are Black men more likely to get prostate cancer, but they are also more likely to be diagnosed with advanced disease than white men. In fact, Black men are 1.7 times more likely to be diagnosed with prostate cancer and 2.1 times more likely to die from the disease.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Recent research suggests that these differences in health outcomes are likely caused by several factors within the U.S. healthcare system, including: access to care, insurance status, racial biases, and distrust in the medical system – it cannot be solely explained by genetic differences. ZERO is committed to bridging the gap between racial and health disparities in prostate cancer among Black men. Learn more at www.zerocancer.org/racialdisparities . Veterans and Prostate Cancer One in eight men will be diagnosed with prostate cancer in their lifetime. However, the prostate cancer incidence rate for Veterans is 1 in 5, making prostate cancer the most commonly diagnosed cancer among U.S. Veterans. Studies have shown Vietnam and Korean War Veterans with exposure to defoliants like Agent Orange have a higher occurrence of prostate cancer. ZERO is committed to bringing the Veteran community the education, resources, and tools needed to fight and prevent prostate cancer. Learn more at www.zerocancer.org/veterans .

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Diagnosing Prostate Cancer Prostate cancer is diagnosed using a number of tests described below. You may have already had some of these, but additional tests could help you find out if the cancer has spread or how aggressive the cancer is. PSA Test – The PSA test is a blood test that measures the amount of prostate-specific antigen (PSA) in your blood. PSA is a protein produced by normal cells in your prostate and also by prostate cancer cells. It is normal to have a small amount of PSA in your blood, and the amount rises as you get older. Digital Rectal Examination (DRE) – During a digital rectal examination (DRE) a doctor or nurse feels your prostate through the wall of the rectum to check for any lumps or hard areas and to get an idea of its size. The DRE only lasts a few seconds and your healthcare provider will wear a glove and use lubricant to reduce discomfort. DREs are also used to determine the T (Tumor) stage. Prostate Biopsy – If the results of the PSA test and/or DRE indicate any abnormalities, the doctor will recommend a biopsy as the next step. A biopsy involves using a thin needle to take small pieces of tissue from the prostate. The tissue is then looked at under a microscope to check for cancer. Cancer can only be diagnosed with a biopsy. Biopsy results will determine your Gleason score. Different types of prostate biopsies are available, including transrectal, transperineal, and transurethral. Talk to your doctor about which one is right for you. If prostate cancer is confirmed by the biopsy, your doctor may want to test nearby lymph nodes for signs of cancer as well. Several other tests and procedures can be used to determine more about the location and/or severity of your cancer. “If your doctor suggests you may need a future biopsy based on PSA and/or DRE results, you should also ask your doctor whether or not you qualify for an MRI as an additional part of your screening process. This technology provides additional helpful information in many situations of what could be happening within specific areas of the prostate and near the prostate. It also estimates the size of the prostate with good accuracy, and the MRI has already helped many men and their doctors make more informed decisions.” Dr. Mark Moyad, University of Michigan Medical Center, Department of Urology, and Public Health Educator/Clinical Researcher

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Imaging A variety of imaging scans may be used to help your doctor biopsy, diagnose, and stage prostate cancer. Imaging scans can also help determine if and where the cancer has spread, help plan treatment, or determine if treatment is working.

IMAGING TYPE

ABOUT THE IMAGING SCAN

Conventional Imaging

Ultrasound

• Used to look for suspicious areas in the prostate

• Shows prostate cancer that may have spread to bones • Requires other tests to confirm cancer in the bones • Used to determine if a biopsy is needed • Guides a needle for a biopsy • Can help determine the stage of prostate cancer • Detects prostate cancer in lymph nodes • After a recurrence, can help determine organ involvement • Shows images of prostate cancer that may have spread • Are often less detailed than MRI or CT images • Uses new and advanced imaging agents to detect cancer

Bone Scan

MRI Scan

CT Scan

PET/CT Scan

Advanced Imaging

Advanced Imaging and New Imaging Agents All imaging tests have limitations. Some are better at detecting cancer in lymph nodes, some work best if the PSA levels are rising, and others may miss small areas of prostate cancer that have come back or spread. With the discovery of new imaging agents, these pictures of the inside of the body make it easier to see prostate cancer cells, even in small amounts, that have traveled outside the prostate to other places in the body. These advances are improving how a patient’s prognosis (forecasted outcome) is determined, how treatment decisions are made, and if the treatment is working.

Be sure to talk to your doctor about which scans might be best for you. Here are some questions to get you started:

What are the differences between a CT scan, MRI scan, and PET/CT scan? Will I need more than one imaging scan? How long do these scans take and how do I prepare? How often will I need to have scans? What kind of imaging agent will be used? Should I be concerned about side effects from any of the imaging agents? Does my PSA level have to be rising to qualify for any of these imaging scans? What will the results tell me?

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE Understanding Your Diagnosis and Stage Stages The stage of the prostate cancer tells you if, and how far, the prostate cancer has spread beyond the prostate. There are four stages of prostate cancer: I through IV. You might have an MRI, CT, or bone scan to determine the stage of your cancer. The results should help you and your doctor decide which treatments might be suitable for you. Information used to determine your stage of cancer may include results from your DRE, biopsy (Gleason score), PSA, and imaging studies.

PROSTATE CANCER STAGES

Stage I

The cancer is small and only in the prostate.

Stage II

The cancer is larger and may be in both lobes of the prostate, but is still confined to the prostate.

Stage III

The cancer has spread beyond the prostate to nearby lymph glands or seminal vesicles.

The cancer has spread to other parts of the body, such as to the bones, liver, or lungs. This is referred to as metastatic or advanced prostate cancer. If prostate cancer spreads, or metastasizes, to the bone, you have prostate cancer cells in the bone, not bone cancer.

Stage IV

Gleason Score The Gleason score indicates what the prostate cancer cells look like under a microscope. The Gleason score is determined by assigning a grade to the most common type of cells in the biopsy, and a second grade to the second most common type of cells in the biopsy. Those grades are then added together for the score. For example, 3 + 4 = 7.

The five historical Gleason grades of prostate cancer (Humpath.com – Human pathology, Paris, France).

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Grade Group The Gleason score can be misleading for some prostate cancer patients. The Grade Groups will likely replace the Gleason score over time but, for now, you might see one or both on a pathology report. GLEASON SCORES IN CATEGORICAL ORDER Gleason X Gleason score cannot be determined

The tumor tissue is well differentiated, less aggressive and likely to grow more slowly

Grade Group 1 Gleason 6 (or less)

Grade Group 2 Grade Group 3 Grade Group 4 Grade Group 5

Gleason 3 + 4 = 7 Gleason 4 + 3 = 7

The tumor tissue is moderately differentiated, moderately aggressive and likely to grow but may not spread quickly

Gleason 8 Gleason 9–10

The tumor tissue is poorly differentiated or undifferentiated, highly aggressive and likely to grow faster and spread

Tumor Categories The standardized Tumor, Node, and Metastasis (TNM) system is used to stage prostate cancer. The T category is based on the extent of the tumor itself. The N category is based on whether the cancer has spread to nearby lymph nodes. The M category is based on whether the cancer has spread beyond nearby lymph nodes. T1: The tumor cannot be felt with a DRE or seen with imaging. T1a: The tumor is found accidentally during a surgery for benign prostatic hyperplasia or another prostate condition. The tumor takes up less than 5% of the removed tissue. T1b: The tumor is found accidentally during a surgery, and the tumor takes up more than 5% of the removed tissue. T1c: The tumor is diagnosed with a needle biopsy, usually because of an elevated PSA. T2: The tumor is confined to the prostate and can be either felt with a DRE or seen with imaging. T2a : The tumor is confined to half of one lobe of the prostate. T2b: The tumor is present in more than half of one lobe, but is not in both lobes. T2c: The tumor is present in both lobes of the prostate. T3: The tumor has grown outside of the prostate and may be present in the seminal vesicles. T3a: The tumor is outside of the prostate, but is not in the seminal vesicles. T3b: The tumor is outside of the prostate and has spread to the seminal vesicles. T4: The tumor has grown into tissues beyond the seminal vesicles. For more on TNM staging, please visit zerocancer.org/staging-and-grading .

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Localized vs. Locally Advanced vs. Advanced It’s important that you know the difference between localized, locally advanced, and advanced prostate cancer. These are terms that are often used in addition to, or in place of, stage (I-IV). Treatment options vary greatly based on how far (or not) the prostate cancer has progressed. Localized Prostate Cancer – the cancer is confined to the prostate. Locally Advanced Prostate Cancer – the cancer has spread just outside the prostate. Advanced Prostate Cancer – the cancer has spread to the lymph nodes or distant organs. This is also known as metastatic, or stage IV, prostate cancer. Men with localized prostate cancer (stages I-III) can be divided into risk groups: low, intermediate, and high risk. Low Risk vs. Intermediate Risk vs. High Risk For those patients with localized or locally advanced prostate cancer, the cancer can be further divided into risk groups: Low-risk prostate cancer must have all of the following features to be classified as low risk: cT1-cT2a Grade Group 1 PSA less than 10 ng/mL Intermediate-risk prostate cancer has one or more of the following features: cT2b-cT2c Grade Group 2 or 3 PSA 10-20 ng/mL Intermediate-risk prostate cancer can be further subdivided into favorable and unfavorable : Favorable intermediate risk has one of the above features with a Grade Group of 1 or 2 and less than 50% of biopsy cores positive Unfavorable intermediate risk has 2-3 of the above features with Grade Group 3 or greater than or equal to 50% biopsy cores positive

High-risk prostate cancer has any of the following features: cT3a Grade Group 4 or 5 PSA greater than 20 ng/mL

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Genetic Testing Genetic testing identifies gene mutations that can impact patients and their families. Two different types of genetic tests in prostate cancer are germline and somatic. These are clinical tests that are used by doctors to learn more about a patient’s prostate cancer and to help develop treatment plans. Understanding the differences between these tests is important to decide which one may be right for you. GERMLINE SOMATIC Inherited, or hereditary, mutations Acquired mutations

Inherited - passed from parent to child

Not passed from parent to child

Inherited gene mutations exist in every cell of the body 10% of prostate cancer is thought to be caused by inherited, germline mutations

Acquired gene mutations exist only in the tumor itself

90% of prostate cancer is thought to be due to non-inherited, acquired mutations Provides eligibility for targeted cancer therapies Provides eligibility for targeted cancer therapies May provide information on family member’s risk of developing certain cancers Does not provide information on cancer risk in other family members Identified through a blood or saliva sample Identified by testing the tumor itself or tumor cells that are circulating in the blood Approximately 10% of prostate cancers are thought to be caused by an inherited gene mutation. Inherited genetic mutations can be found in the BRCA1, BRCA2, and HOBX13 genes, among others. Genetic testing is done with a simple blood or saliva test. A genetic counselor can help you better understand the pros and cons of genetic testing. It is important to know that, while prostate cancer can run in some families, most prostate cancers occur in men without a family history of it. Targeted therapies are available for men with a genetic mutation and metastatic castrate-resistant prostate cancer (mCRPC). Germline testing also provides family members with valuable information regarding their cancer risks. Family members of men with hereditary cancer have a 50% chance of having the same genetic mutation. Germline testing can help family members know if they should also be tested or take measures to reduce their risk of developing cancer. All men with prostate cancer should consider genetic testing.

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Genomic Testing and Biomarkers Genetics vs. Genomics Genomics is the study of all the genes in the genome and their interactions with the environment. This is related to, but not the same as genetics - which is the study of individual genes and inherited traits from one generation to the next. What is Genomic Testing in Prostate Cancer?

GENETICS vs. GENOMICS

• Genetics is the study of inherited traits and genes • Genomics is the study of how a set of genes behave

Genomic testing is done on cancerous tissue taken from the prostate to provide information about how your prostate cancer might behave. It can be performed on both biopsy tissue and on tissue from an entire prostate following a prostatectomy. Genomic testing is useful for helping prostate cancer patients and their doctors decide on a treatment, so these tests are most helpful for those who are newly diagnosed with prostate cancer that is still confined to the prostate. However, men who have had surgery and want to understand their risk of recurrence may also find this information helpful. By looking at the genetic makeup of the prostate cancer, genomic tests may help predict whether a person’s prostate cancer will grow slowly or aggressively. Biomarker Testing and Precision Medicine Biomarker testing and precision medicine are somewhat newer terms in the cancer space. Biomarker testing looks for genes, proteins, and tumor markers that tell us more about your specific cancer. Biomarkers can help doctors diagnose cancer and monitor cancer, and can also affect how some treatments will work for you. Prostate-specific antigen (PSA) is the most widely used prostate cancer biomarker but new and emerging blood, urine, and tissue biomarkers are also now available. The prostate health index, or PHI, as well as the 4Kscore, are newer biomarker tests that help in diagnosing prostate cancer and identifying more aggressive disease, which also may reduce the number of prostate biopsies performed in men with low PSA levels. Biomarker testing uses a single test to examine a person’s genes. Biomarker testing may also be called comprehensive genomic profiling (CGP), tumor testing, molecular profiling, tumor subtyping, or somatic testing. The test looks for mutations in genes that are relevant in cancer and that may drive cancer growth. Some of these biomarkers tell your doctors how aggressive your prostate cancer might be. Biomarker testing may help you and your doctor better understand your particular cancer and choose the best treatment option for you.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE Prostate Cancer Progression and Treatment Prostate cancer can be diagnosed at various stages, depending on when the prostate cancer is detected and how far the disease has progressed. Many patients respond immediately to treatment and don’t require any further treatment. Others may already have metastatic disease by the time the cancer is first diagnosed or later develop metastatic disease after treatment completion for early-stage disease. Treatment to lower testosterone is a mainstay of therapy for patients with metastatic disease. When prostate cancer becomes resistant to this type of therapy it is called castrate resistant . The definitions and ways prostate cancer can progress may be confusing, but here is a chart to help you: Prostate Cancer and Treatment Progression

Targeted Therapy, Chemotherapy, Immunotherapy

Radiation, Surgery

Novel Antiandrogens, Chemotherapy

Hormone Therapy

Clinical Trials

Non-Metastatic Prostate Cancer

Metastatic Prostate Cancer

Castration-Sensitive Prostate Cancer (CSPC)

Castration-Resistant Prostate Cancer (CRPC)

Castration-Sensitive Prostate Cancer (CSPC, also called Hormone-Sensitive Prostate Cancer) This is a form of prostate cancer that still responds to testosterone suppression therapy. CSPC can be referred to as non-metastatic, or nmCSPC, when there is no detectable metastases - spread of cancer - upon imaging. It can be referred to as mCSPC when it has advanced to metastatic stage. Castration-Resistant Prostate Cancer (CRPC) This is a form of prostate cancer that keeps growing even when the amount of testosterone in the body is reduced to very low levels. CRPC can be referred to as non-metastatic, or nmCRPC, when there is no detectable metastases upon imaging, and as mCRPC when it has advanced to metastatic stage. Before deciding on a treatment, learning about all treatment options, as well as clinical trials, is important. Treatment decisions should be based on many factors, including your age, overall health, family history, stage at diagnosis, aggressiveness of the disease, and results of genetic testing, among others. In addition, understanding possible side effects of each treatment, how side effects can be managed, weighing quality of life issues, and deciding what is most important to you and your family should all be considered.

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Types of Prostate Cancer Treatment Active Surveillance

Active surveillance is a disease management strategy for low-risk, early stage prostate cancer. This strategy regularly monitors the disease for progression but avoids immediate treatment with surgery or radiation. Watchful Waiting Watchful waiting is another conservative approach to treatment. It is generally for those who may have other illnesses, those who are older in age, those for whom prostate cancer treatment may be difficult to perform, or those for whom treatment might do more harm than good. The intent is not to cure the cancer, but instead to manage any symptoms should they arise. Surgery Surgically removing all or part of the prostate, also known as a prostatectomy, aims to remove all of the prostate cancer. The full removal of the prostate is called a radical prostatectomy, but several types of prostatectomy exist. Robotic-assisted surgical removal of the prostate is the most widely used form of localized prostate cancer treatment in the United States. Like other surgical methods, this procedure still requires an experienced surgeon, but robotic surgery often leads to a faster recovery time, reduced blood loss, and a lower risk of infection. Radiation Therapy Radiation therapy, or radiotherapy, uses various forms of radiation to safely and effectively treat prostate cancer. It works by damaging the genetic material within the prostate cancer cells and limiting their ability to successfully reproduce. When these damaged cancer cells die, the body naturally eliminates them. The goal of radiation is to kill the tumor while sparing as much healthy tissue as possible. Radiation therapy can be given externally (directed from outside the body) or internally (placed inside the body) when treating localized prostate cancer. These two categories are further broken into several types of treatment that vary by method, dose, frequency, and intended use. In patients with more advanced prostate cancer, radiation can be used to relieve pain from bone metastases and may also be used in combination with hormone therapy. This can be done using external beam radiation or radiopharmaceuticals. Radiopharmaceuticals are medications that can be used for the targeted delivery of radiation and are typically given intravenously. Cryotherapy Cryotherapy, also called cryoablation or cryosurgery, freezes prostate tissue, causing cancer cells to die. This type of treatment is sometimes used as an alternative to surgical removal of the prostate or if the cancer has come back after radiation therapy. Cryotherapy is an option for those with localized or locally advanced prostate cancer.

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Ultrasound Ultrasound is a minimally invasive and precise procedure that involves aiming ultrasound waves directly at the prostate tumor, heating the tumor cells to a very high temperature in order to ablate (destroy) them. Ultrasound is most often a treatment option for patients whose prostate cancer is considered low- to intermediate-risk and is confined to the prostate. High Intensity Focused Ultrasound (HIFU): HIFU is an FDA-approved, minimally invasive procedure for the treatment of prostate cancer. It destroys prostate cancer cells through precise and focused ultrasound energy, or sound waves. The targeted approach leaves healthy tissue unharmed and minimizes the risk of side effects. Transurethral Ultrasound Ablation (TULSA): The TULSA Procedure is an FDA-approved, minimally invasive procedure that uses directional ultrasound to produce very high temperatures to destroy prostate cancer cells. Hormone Therapy Hormone therapy is also called androgen deprivation therapy (ADT), hormone deprivation therapy, or hormone suppression therapy. Prostate cancer is fueled by male hormones, called androgens. The primary male androgen is testosterone. Hormone therapy stops or slows the body’s ability to make testosterone, aiming to stop tumor growth and/or shrink the tumor. Several types of hormone therapy exist, but it is important to know that hormone therapy alone does not cure prostate cancer. Hormone therapy is especially important for those with advanced disease, whose cancer has returned (recurrence) after surgery or radiation, or whose cancer is considered high-risk for metastasis (spread). It can also be used in combination with other treatments or to shrink a tumor to make other treatments more effective.

The main types of hormone therapies are:

LHRH Agonists – Luteinizing hormone-releasing hormone (LHRH) is a key hormone released into the body before the body produces testosterone. LHRH agonists block the release of LHRH, causing testosterone levels to drop gradually, usually over a month’s time. LHRH Antagonists – These block the pituitary gland from making hormones, causing the testicles to stop making testosterone, resulting in a more immediate drop in testosterone levels. Anti-Androgens – These keep testosterone from binding to androgen receptors, which may keep prostate cancer cells from growing. Inhibitors and Blockers – A few inhibitors are approved by the FDA for the treatment of prostate cancer. They inhibit the synthesis of the androgen and block androgen receptors to slow the production of testosterone. Orchiectomy – This is surgery to remove one or both testicles, thereby drastically reducing the body’s ability to produce testosterone.

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An exciting advancement in hormone therapy is a recently approved oral ADT option. While many forms of ADT are given by injection, an oral ADT option provides patients with more flexibility in scheduling appointments and perhaps even reduced side effects. Ask your doctor which option is best for you. Chemotherapy Chemotherapy is a type of prostate cancer treatment that is used to kill cancer cells throughout the body. They are given intravenously (through the veins) or orally (as a pill), depending on the drug. Because chemotherapy also attacks other cells in the body, this treatment can cause significant side effects. Chemotherapy is often used when a patient’s prostate cancer has metastasized (spread) and is often given in combination with ADT or after hormone therapy stops working. Immunotherapy Immunotherapy, also called biologic therapy, treats the whole body by attempting to activate a person’s immune system so that it will recognize and destroy prostate cancer cells. It uses materials either made by the body or in a lab to improve, target, or restore immune function. Different types of immunotherapies include vaccines, monoclonal antibodies, and non-specific immunotherapy. Targeted Therapy Targeted therapy for prostate cancer is a type of therapy that identifies, or “targets”, a particular genetic mutation in the tumor. The goal is to interfere with the specific molecules that drive the growth of the tumor. A targeted therapy approach is a form of personalized cancer treatment and is often associated with fewer side effects than other treatments. Targeted therapies may be used by themselves or in combination with other therapies. PARP Inhibitors – A type of targeted therapy. They affect how DNA is repaired in cancer cells. They target mutations in the BRCA genes (BRCA1 and BRCA2) and therefore are only used in patients who are known to have a mutation in their BRCA gene found through genetic testing. There are two major ways to repair DNA damage in cells. If one fails, the other can make up the difference. PARP inhibitors interrupt (or prevent) one DNA repair system from working. Cells with mutations like BRCA1 and BRCA2 have a decreased ability to repair DNA damage in the second system. If both ways to repair the DNA in a tumor cell are stopped, DNA damage adds up and that causes the tumor cells to die. Two oral PARP inhibitor medications are approved by the FDA for treatment of certain types of advanced prostate cancer. Previously, PARP inhibitors were approved to treat women with certain breast, ovarian, and pancreatic cancers.

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Prostate-Specific Membrane Antigen (PSMA) PSMA is a protein found on the surface of normal prostate cells, but it is found in higher amounts on prostate cancer cells. It is present in more than 80% of prostate cancer cells in men with prostate cancer. PSMA has been the subject of extensive and promising research over the last several decades. It is now used as a target for imaging to diagnose metastatic or recurrent prostate cancer, and it is also being explored as a target for medications that can treat prostate cancer. This dual purpose is why some refer to PSMA as a “theranostic” - a combination of the terms “therapeutics” and “diagnostics”. How is PSMA Targeted for Detecting Prostate Cancer? A PSMA PET (positron emission tomography) scan is an imaging procedure used to help detect prostate cancer cells within the body. For this procedure, a radioactive agent is injected into the bloodstream prior to the PET scan. The agent then attaches to the PSMA protein on the prostate cancer cells. Once there, it glows in the PET images that are taken to indicate where prostate cancer cells that have traveled outside the prostate may be. This procedure allows prostate cancer cells to be found that may not have been picked up on traditional scans like CT scans and bone scans. Multiple PSMA PET imaging agents are now approved by the FDA for use in patients whose prostate cancer has recurred or spread. How is PSMA Targeted for Treating Prostate Cancer? Targeting PSMA proteins on a prostate cancer cell enables very active treatments against prostate cancer to be focused on the cancer cell itself, rather than on normal healthy cells in the body, allowing a precision medicine approach to treatment. PSMA treatments will likely be made available to patients who have PSMA protein detected on their cancer cells using a PSMA PET scan. The FDA recently approved a drug for the treatment of PSMA-positive mCRPC, and other forms of treatment that target

PSMA are being developed. Questions For Your Doctor

Is the PSMA PET scan right for me? Do you offer PSMA PET scans? Are they covered by my health insurance?

Is exposure to the radioactive agent in a PSMA PET safe? What are the side effects of PSMA targeted treatment?

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Clinical Trials After consulting with your doctor, you may consider enrolling in a clinical trial to gain access to potential new treatments or techniques that are still in the investigational stage. A clinical trial is a research study investigating experimental treatment to see if it is safe to use and effective in fighting a disease. All treatments used today for prostate cancer are available because of past clinical trials and thanks to past clinical trial participants. Many times people do not participate in a clinical trial because they did not know they were eligible or that one was available, so be sure to ask your doctor when making your treatment decisions. Participating in a clinical trial is a way to gain access to promising new drugs that are yet to be approved by the FDA. Hundreds of research projects are currently ongoing and investigating the potential of new drugs and new combinations of drugs. Historically, people of color are underrepresented in clinical trials. Diversity in clinical trial participation is critical to understanding the safety and efficacy of treatment options. When clinical trials lack diversity and participants are of the same age, race, and ethnicity, data from that clinical trial will fail to help researchers learn how different people may respond differently to the same medication.

CLINICAL TRIALS BY THE NUMBERS

10–15 the average number of years for a drug to be developed and get on the market for patients

6–7 the average number of years drugs are studied in clinical trials

80% of clinical trials fail because they don’t recruit enough patients

35 + number of drugs approved by the FDA for prostate cancer

Additional information about clinical trials, as well as a free clinical trial matching service, can be found at www.zerocancer.org/clinicaltrials .

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Managing Treatment Side Effects There are many side effects of prostate cancer treatment. Just as prostate cancer varies from patient to patient, so will the side effects experienced. Your healthcare team will work hard to ensure you will experience minimal side effects as a result of treatment. Side effects related to prostate cancer treatments vary by the type of treatment you receive. Some common side effects of treatment are urinary incontinence (the inability to control your bladder) and erectile dysfunction (the inability to achieve a full erection). Other side effects can include fatigue, depression, and infertility. It is important to talk to your doctor and your partner about all potential side effects before choosing treatment, as these potential changes can impact your self-esteem and personal relationships. Once you determine your treatment, work with your doctor on a plan to manage any side effects you experience.

POSSIBLE SIDE EFFECTS

TREATMENT

WHAT IT DOES

Removes the cancerous tissues and the prostate

Urinary incontinence, erectile dysfunction (ED), and infertility

Surgery

Minimizes presence of androgens which fuel prostate cancer growth

ED, hot flashes, cardiovascular events, and bone loss

Hormone Therapy

ED, increased urinary urgency and frequency, diarrhea, rectal bleeding, and discomfort during urination and bowel movement

Slows prostate cancer cell growth by targeting cells externally or by injection

Radiation

Changes the body’s immune system to kill cancer cells Targets a particular protein or genetic mutation in the tumor

Immunotherapy

Fever, chills, fatigue, and joint or body ache

Nausea, fatigue, anemia, vomiting, diarrhea, decreased appetite, headache

Targeted Therapy

Inhibits bone loss and fractures and relieves pain from prostate cancer in the bone

Bone-Related Treatments

Low grade fever, tingling around mouth or hand cramps from low calcium, dental pains

Targets cancer cells that grow quickly including cancer cells metastasized to the bone

Hair loss, fragile bones, nausea, and nervous system disorders like confusion, depression, or headaches

Chemotherapy

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Your Healthcare Team To receive the best care possible, seek care from a multidisciplinary team. A multidisciplinary team is a group of healthcare professionals from different specialties who work together to suggest a treatment plan for you based on your diagnosis, personal health, and preferences. This approach helps ensure you have the best health outcome and highest quality of life. Keep in mind that you have a choice in who manages your care. This is about finding the right treatment team to work with to make the right decisions for you and with you.

A multidisciplinary team may include: Urologist

A urologist is a physician specializing in diseases of the male reproductive organs and male and female urinary tract. Some urologists have oncology training. Many urologists are also involved in certain aspects of other forms of therapy including radiation therapy, hormone therapy, treatment of advanced disease, clinical trials, and active surveillance. All urologists are surgeons as well, and many perform prostate cancer surgery. Radiation Oncologist A radiation oncologist is a highly trained physician specializing in the treatment of prostate cancer using the various types of radiation approved to treat the disease. Medical Oncologist A medical oncologist is a physician who specializes in the non-surgical treatment of cancer with medicines such as chemotherapy, hormonal therapy, immunotherapy, and other drugs. Primary Care Physician A primary care physician (PCP) is often an internist or family medicine physician who treats common illnesses and oversees general care. Oncology Social Worker Oncology social workers are trained to work with cancer patients and their families. It is important to understand your emotional well-being and get the support you need mentally, as well as physically.

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An oncology social worker provides individual counseling, access to support groups, and referrals to related services for men with prostate cancer. Physical Therapist A physical therapist can help deal with the physical changes caused by cancer treatment. Before or after surgery or radiation therapy, working with a physical therapist to strengthen the pelvic floor can help to manage or prevent side effects such as urinary incontinence. Nutritionist A nutritionist provides information and guidance about good nutrition. This can help a patient combat cancer-related or treatment-related weight loss or gain by recommending foods that provide adequate calories, vitamins, and protein. In addition, a nutritionist provides helpful tips and recipes customized to fit your specific dietary needs. Nurse, Patient, or Financial Navigator A navigator is an expert in understanding the details of cancer treatment and will support, inform, guide, and answer questions for you through all stages of treatment and beyond. As advocates for patients and their families during prostate cancer treatment and beyond, they enhance the quality of care you receive. If a patient navigator is not made available to you, ZERO can help with our ZERO360 patient support program. Visit zerocancer.org/zero360 for more information. Genetic Counselor A genetic counselor is a healthcare professional who will collect your personal and family health history and use this information to help determine the likelihood of having a genetic condition. The genetic counselor can help you decide whether or not genetic testing might be right for you or your family members, and can help explain genetic testing results. Sexual Health Professional A sexual health professional specializes in helping patients and their partners manage erectile dysfunction, low testosterone, hormone therapy, and incontinence related to prostate cancer treatment and side effects. Mental Health Professional A prostate cancer diagnosis can be overwhelming. Consider whether or not speaking with a mental health professional might be helpful to you.

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Living with Prostate Cancer Monitoring for Recurrence

Completing your prostate cancer treatment can bring both relief and worry. When caught early, your initial treatment may mean you are considered free of disease. Most men will live cancer-free for years, and some even for the rest of their lives. But you may also feel worried, anxious, or fearful that your cancer may come back. Up to 40% of men will experience a recurrence, so it is important to understand your risk. Cancer recurrence is the return of cancer after a period when no cancer cells could be detected in the body. Your doctor will recommend how often and when your PSA screening should be scheduled to continue monitoring your health. When PSA levels in the blood rise after prostate cancer treatment, this is known as biochemical recurrence. This can occur even if the patient has no symptoms. If this happens, the doctor will order additional tests and make recommendations for how to manage your disease. Survivorship Survivorship focuses on the overall health and well-being of cancer patients. This includes not only monitoring for recurrence, but also providing follow-up care for the long-term physical and emotional side effects from treatment. This may include monitoring for secondary cancers and interventions to improve quality of life. Ask your healthcare team if they have a survivorship care plan for you. Nutrition and Exercise For many, the diagnosis and treatment of cancer leads people to improve their diet and exercise behaviors. Maintaining a healthy diet and exercise regimen can help you prepare for and recover after cancer treatment. It may also help to prevent prostate cancer from coming back. Some of the treatment options for prostate cancer, such as androgen deprivation therapy, can result in weight gain and bone loss. Depression and fatigue, which are common lingering effects of prostate cancer, can make it hard for even the most motivated person to exercise or eat healthy foods. Take small steps to take care of yourself and make a conscious choice to live a healthier life. Nutrition to Fight Prostate Cancer Although there is no diet to prevent or cure prostate cancer, you can make healthy choices that will help you fight your disease. Watching your weight may reduce your risk of dying from prostate cancer. Recent studies have indicated that the risk of dying from prostate cancer is more than double in obese men when compared to men of normal weight at the time of diagnosis.

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Nutrition During Cancer Treatment Maintain a healthy weight. For many men, this means avoiding weight loss by getting enough calories on a daily basis. For men who are overweight and are obese, this may mean losing some weight. If you are trying to lose weight, it should be moderate, meaning only about a pound a week. Get essential nutrients the body needs, such as protein, carbohydrates, fiber, vitamins, minerals, and water. Not only will your body function better, you will feel better. Be as active as you can, such as taking a daily walk. If you sit or sleep too much, you may lose muscle mass and increase your body fat, even if you are not gaining weight. Nutrition After Cancer Proper nutrition and a prostate-healthy diet can help survivors live longer, receive more enjoyment out of life, and feel more empowered about their choices. Eating a healthy diet may help you regain strength after prostate cancer treatment. In addition, recent research suggests that making healthy food choices after active treatment may lower your risk of recurrence and help you live longer. Exercise to Fight Prostate Cancer Physical activity and exercise are crucial factors in prostate health for both fighting the disease and preventing recurrence. In addition, it can be important for managing your weight, maintaining muscle and bone strength, improving mental health, and helping with potential side effects of prostate cancer treatment. Walking, gardening, climbing the stairs, playing soccer, or dancing are all good examples of being active. For greater health benefits, physical activity should be of moderate or vigorous intensity that makes you breathe harder and your heart beat faster, such as running, bicycling, or swimming. Benefits of Regular Exercise During and After Cancer Treatment The side effects of prostate cancer treatment can impact your quality of life. Exercise can help: Reduce anxiety, depression, and fatigue Improve self-esteem Increase feelings of optimism Improve heart health Maintain a healthy weight Boost muscle strength and endurance Mental Health It is normal to experience a wide range of emotions if you or a loved one has been diagnosed with prostate cancer. Emotional reactions can include feelings of vulnerability, sadness, loneliness, and fear of recurrence or death. Many of these emotions fade over time, but some may develop into clinical depression, intense anxiety, or panic. Talk to your healthcare team if you are feeling depressed or emotionally distressed. Many prostate cancer survivors find valuable information and perspective from others who have “been there.” ZERO offers several peer support options, including Us TOO support groups and mentor programs. ZERO360 can also provide emotional and psychosocial support service referrals.

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Getting a Second Opinion Seeking a second opinion following a prostate cancer diagnosis is very common and doing so can make you feel more confident in the treatment decision that you make. It’s OK to get a second opinion at any point during your care. Why Get a Second Opinion? To understand all available treatment options and have peace of mind with your treatment decision To get the opinion of another prostate cancer expert To confirm a diagnosis or treatment plan To hear information about your cancer explained in a different way To share the opinion of more than one healthcare expert with your insurance company How to Ask About a Second Opinion Some people find it hard to tell their doctors that they’d like a second opinion. Your doctor shouldn’t discourage you from getting a second opinion. If you are unsure of how to begin, here are a few ways to start the conversation: “I’m thinking of getting a second opinion. Can you recommend someone?” “Before we start treatment, I’d like to get a second opinion. Will you help me with that?” “If you had my type of cancer, who would you see for a second opinion?” “I think that I’d like to talk with another doctor to be sure I have all my bases covered.” The Process Before you start looking for a second opinion, contact your insurance company to find out what your policy covers. In some cases, you may have to get a second opinion from another doctor who is part of your health plan before the plan will pay for your treatment. It’s important to be able to give the new doctor the exact details of your diagnosis and planned treatment.

Make sure you have the following information handy and always keep copies for yourself:

A copy of your pathology report from any biopsy or surgery If you had surgery, a copy of your operative report If you were in the hospital, a copy of your discharge summary A summary of your doctor’s current treatment plan or the plan that has been given to you as an option Since some drugs can have long-term side effects, a list of all your drugs, drug doses, and when you take/took them

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