Prostate Cancer

The experts at DCI Center for Prostate & Urologic Cancers specialize in diagnosing prostate cancer. Finding prostate cancer early and getting an accurate diagnosis are key to your health and outcomes. If you are experiencing symptoms, please consult your physician. Based on their evaluation, further testing may be ordered that can help in diagnosing and assessing cancer.

These tests can include:

Prostate-Specific Antigen (PSA):

• Blood test that measures levels of PSA produced by your prostate. High levels may indicate cancer.  Duke integrates a risk and age-based PSA screening algorithm into primary care for the early detection of aggressive prostate cancers and to inform on decisions to perform a prostate biopsy or imaging studies, as well as to decide how often to have your PSA repeated over time for screening.
   
• Additional blood tests such as free PSA, the Prostate Health Index, and PSA isoforms such as the p2 PSA can be used to help better decide if a biopsy is needed in men with an elevated serum PSA level.

Digital Rectal Exam:

• Your doctor inserts a lubricated gloved finger into your rectum to exam your prostate to feel for irregularities (nodules) on your prostate that may represent cancer. This still has a role in identifying more aggressive cancers, including those that may not make much PSA, and to determine if your prostate is enlarged such as with benign conditions like benign prostatic hypertrophy (BPH). This exam is also helpful in determining the extent of cancer (or the stage) if cancer is present. 

Biopsy:

• A needle inserted into your prostate collects a tissue sample that can be analyzed for the presence of cancer. This can be done under ultrasound guidance or through MRI-ultrasound fusion technologies to pinpoint more aggressive cancers.

Multi-Parametric MRI and Body Imaging

• Specialized prostate MRI exam that can determine the size, number, location and aggressiveness of tumors within the prostate.
   
• Bone scans, CT scans, and nuclear medicine scans such as the AXUMIN and Sodium Fluoride PET/CT can be used in specific situations to determine if prostate cancer has spread beyond the prostate.

Additional tests, such as genetic tests of tumor tissue, blood, and saliva, may be useful to more accurately predict your risk of aggressive cancer or recurrence after treatment, the chance that your prostate cancer may be hereditary, and how to best treat your cancer. These include tests such as Prolaris, Oncotype DX, and Decipher, as well as germline testing of saliva, tumor mutational profiling such as with Foundation Medicine or cell free plasma DNA testing.  Ask your doctor if these tests may be helpful for your care.

DCI Center for Prostate and Urologic Cancers offers a variety of minimally invasive treatments, such as:

Surgery:

• Robotic prostatectomy — a procedure to remove the entire prostate. The surgeon uses finely-controlled robotic instruments to perform the prostatectomy safely, while improving patient recovery time and outcomes. 
• Open prostatectomy—a procedure which allows the surgeon to directly remove the entire prostate safely and with proven efficacy over decades of follow-up.

Radiation Therapy: 

• High-dose brachytherapy radiation — radiation treatment that targets and kills cancer cells in your prostate while potentially preserving healthy tissue.
• Intensity modulated image-guided radiation—radiation treatment that targets prostate cancer while preserving healthy tissue, now being performed in shorter courses to allow men to return to normal activities faster without compromising cure or safety.

Energy Ablative Technique:

• Cryosurgery — a type of focal therapy that targets a section of the prostate gland containing the cancer rather than the whole prostate.
• High intensity focal ultrasound—a procedure to use heat to ablate prostate tissue, FDA cleared and utilized in selected men with lower risk prostate cancer.

Targeted Therapies:

• Hormone therapy – also known as androgen deprivation therapy (ADT), reduces the production of testosterone in the body. This therapy may be used by itself or in conjunction with other types of treatments. Newer hormonal therapies are being used in earlier stages of prostate cancer to attempt to improve cure rates through clinical trial participation.
• Immunotherapy – Duke offers access to both proven immune therapies and clinical trials of immune therapies, each designed to work in concert with a patient’s own immune system to develop an immune response to his prostate cancer and improve survival.  Duke offers sipuleucel-T as well as immune checkpoint inhibition to certain men with aggressive forms of prostate cancer, and is developing novel approaches to combine immune therapies with other approaches, ranging from oncolytic viruses, PARP inhibitors, chemotherapy, and novel hormonal therapies.
• Radiopharmaceutics—Duke provides access to radium-223, a bone targeted radiopharmaceutical proven to extend life in men with bone metastases from their prostate cancer.  Duke investigators are researching how to optimize the use of bone targeting therapies to prevent or delay bone metastases, combining radium with immune and hormonal therapies and using genetic and tumor biologic information to understand how bone metastases form and develop resistance to standard therapies.  A major goal of our program is the prevention of metastatic disease, particularly bone metastases.
• Chemotherapy—Docetaxel and cabazitaxel are proven chemotherapy agents that play an important role in improving survival for men with metastatic prostate cancer. Duke investigators are researching how to improve upon chemotherapy and to develop agents that may delay the need for chemotherapy.  In addition, through multi-disciplinary research, our team is integrating the early use of chemotherapy into trials designed to improve the cure rates of men with early stages of recurrent prostate cancer.
• Clinical trials — as leaders in the field of prostate research, our collaborations allow cutting-edge treatments to be available for our patients. These trials include precision medicine approaches, genetic sequencing (germline and tumor), immunotherapies, molecularly targeted therapies based on a personalized genetic test, circulating tumor cell biology studies, radiopharmaceuticals, and combination approaches across all stages of prostate cancer.  These trials are intended to improve survival, quality of life, and optimize care to those patients most likely to benefit.

We are also strong advocates of active surveillance for small, nonaggressive prostate cancer. Duke has an active surveillance registry and clinical program incorporating molecular testing of tumor tissue, prostate MRI, and lifestyle and dietary approaches to better identify men most likely to benefit from treatment and those who can safely defer therapy.  We try to keep men on active surveillance until treatment is necessary and believe surveillance is a safe and important course for certain men with low risk prostate cancer. Some men are candidates for watchful waiting, where patients who are not candidates for surgery or radiation are carefully observed until treatment is needed.

Duke practices a first do no harm approach, optimizing treatment tailored to those men most likely to benefit while minimizing risks, and incorporates a multi-disciplinary team based approach to patient counseling, risk stratification, and therapy based on individual patient’s health conditions, prostate cancer subtypes, and preferences.

The multidisciplinary team includes surgeons, radiation oncologists and medical oncologists. The team explores all options, including active surveillance, before recommending surgical removal of your prostate or external radiation therapy.

We understand that each patient's cancer possesses unique characteristics that can manifest itself in a variety of behaviors and outcomes. Thus, we take a personalized approach to determine the best therapies for each individual patient, including utilizing precision medicine to examine a patient’s urine or blood-based biomarkers, tissue-based biomarkers and imaging biomarkers.

Breaking down traditional barriers to rapid innovation, our prostate cancer specialists are leading national research efforts while developing novel treatments. Clinical research is critical to our collective mission of reducing the burden of prostate cancer, and we're committed to designing better treatments and preventive approaches.

Duke is also one of only 10 institutions nationwide selected to participate in the Department of Defense's Prostate Cancer Clinical Trials Consortium, which facilitates patient enrollment in phase I and phase II clinical trials and improves drug development for prostate cancer.  Duke also provides access to phase 3 clinical trials, registries, biomarker studies, and genetic testing and counseling for men with prostate cancer.