A National Cancer Institute-designated Comprehensive Cancer Center

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Prostate Cancer

Prostate Cancer
At City of Hope, we are actively developing tomorrow’s treatment protocols today for prostate cancer. As a patient at City of Hope, you have a highly experienced and dedicated team to treat you and help you cope with cancer.
Our involvement in managing a patient’s prostate cancer starts very early and includes all stages of disease, ranging from localized to recurrent and advanced prostate cancer.  City of Hope’s Prostate Cancer Program focuses on providing the most advanced, compassionate, multidisciplinary care to patients with various stages of prostate cancer while actively investigating promising new treatment strategies.
Our innovative treatment options and technologies can help you recover faster, with fewer side effects.  Also setting us apart:
  • City of Hope is a world leader in high-precision, robotic-assisted prostate surgery, and our doctors have performed more advanced procedures for prostate cancer than any other facility on the West Coast.
  • Our team of experts was the first in the western United States to offer TomoTherapy — a targeted radiation therapy that can kill cancer cells while sparing healthy tissues nearby.
  • We aggressively pursue and use the newest, most innovative treatments known, including novel research therapies not available elsewhere.
About Active Surveillance
There has been some debate about the value of regular prostate-cancer screening (prostate-specific antigen, or PSA, test), especially in men who have been diagnosed with prostate cancer. Many prostate cancers do not require immediate treatment because they are small, confined and slow growing. Aggressive treatment may be more disruptive to a man’s quality of life than "active surveillance," which closely monitors patients to detect early signs of disease progression and enables treatment before the cancer has spread beyond the prostate. For those men with low-grade tumors, City of Hope specialists may recommend active surveillance. Our specialists will determine the best course of treatment balanced with each man’s vision of a quality life beyond diagnosis.
New Prostate Cancer Markers
City of Hope has been an innovator in diagnostic research to more precisely track the progression of prostate cancer. Our researchers have developed a test using the TMPRSS2:ERG marker that supplements the PSA test and more accurately indicates if a biopsy is needed. The research was published in 2008 in the journal Clinical Chemistry in Work and presented at the Western Section of the American Urological Association Conference in 2013. Our researchers have discovered new markers for prostate cancer that will improve our ability to detect prostate cancer without a biopsy.
City of Hope ascribes to the American Urologic Association’s newest guidelines for prostate cancer screening, published in May 2013.
From diagnosis and treatment to recovery, prostate cancer patients at City of Hope have access to all of the best tools and strategies for beating the disease.
 About Prostate Cancer 
The prostate is a gland in the male reproductive system located just below the bladder (the organ that collects and empties urine) and in front of the rectum (the lower part of the intestine). It is about the size of a walnut and surrounds part of the urethra (the tube that empties urine from the bladder). The prostate gland produces fluid that makes up part of the semen.

Prostate cancer is found mainly in older men. As men age, the prostate may get bigger and block the urethra or bladder. This may cause difficulty in urination or can interfere with sexual function. The condition is called benign prostatic hyperplasia, and although it is not cancer, surgery may be needed to correct it. The symptoms of benign prostatic hyperplasia or of other problems in the prostate may be similar to symptoms of prostate cancer.
Prostate Cancer Risk Factors
There is no known exact cause of prostate cancer. Doctors often cannot explain why one man develops prostate cancer and another does not. However, research has shown that men with certain risk factors are more likely than others to develop prostate cancer.
  • Age
    Age is the main risk factor for prostate cancer. More than 70 percent of all prostate cancers occur in men over 65. Beginning at 50, you should have a prostate exam every year.
  • Family history
    A man's risk is higher if his father or brother had prostate cancer. Men with a first-degree relative diagnosed with prostate cancer are considered high risk, and should begin screenings at age 40.
  • Race
    African-American males over 40 have the highest rate of prostate cancer and should begin screenings at age 40.
  • Certain prostate changes
    Men with cells called high-grade prostatic intraepithelial neoplasia may be at increased risk for prostate cancer.
  • Diet
    Some studies suggest that men who eat a diet high in animal fat or meat may be at increased risk for prostate cancer. Men who eat a diet rich in fruits and vegetables may have a lower risk.
Talk to your doctor if you think you may be at risk. Your doctor may be able to suggest ways to reduce your risk and can plan a schedule for regular checkups.
Prostate Cancer Symptoms
These and other symptoms may be caused by prostate cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:
  • Weak or interrupted flow of urine
  • Frequent urination (especially at night)
  • Trouble urinating
  • Pain or burning during urination
  • Blood in the urine or semen
  • A pain in the back, hips, or pelvis that doesn't go away
  • Painful ejaculation

Screening and Diagnosing Prostate Cancer

Oftentimes prostate cancer does not cause symptoms, so screening is vital to ensure the disease is detected early when treatment is most likely to be effective. Starting at age 50, or earlier if you’re at high risk, schedule an annual prostate exam with your doctor.
Some of the screening methods City of Hope uses to detect prostate cancer include:
  • Prostate specific antigen (PSA) test
    A simple blood test to determine if your PSA level is higher than normal. A high PSA reading can be caused by either a benign or cancerous growth of the prostate, or simply by a prostate infection. There is even a chance of having cancer when your PSA level is low.
  • Digital rectal exam (DRE)
    During this procedure, the physician examines the prostate gland by inserting a gloved, lubricated finger into the rectum to check for any evidence of abnormalities in its texture, shape or size. The DRE, along with the PSA test, helps to detect prostate cancer in men who have no symptoms of the disease.
  • Biopsy
    A core needle biopsy is the most common method of diagnosing prostate cancer. Usually, six to 18 biopsy samples are taken from different areas of the prostate. Placing the ultrasound probe into the rectum can be temporarily uncomfortable, but is usually easily tolerated by most men. The biopsies themselves can be uncomfortable.
At City of Hope, our urologists have popularized the use of a local anesthetic prior to obtaining the prostate biopsies, much like the dentist uses when working on your teeth. This local anesthetic alleviates the pain and discomfort of the individual needle biopsies. Since today, most patients have 12 or more biopsies, this advance makes the entire procedure much more tolerable.
  • Transrectal ultrasound of the prostate (TRUSP)
    TRUSP uses soundwaves to create an image of the prostate on a video screen. There is a small probe, which is inserted into the rectum. The prostate is visualized and biopsies can then be taken through the probe while simultaneously imaging the prostate. The procedure takes approximately 10 to 20 minutes.
  • Bone scan
    This X-ray procedure can show whether the cancer has spread from the prostate to the bones. This is not routinely ordered unless there are signs of aggressive disease, such as an elevated PSA, a high Gleason score or localized bone pain.
  • Other radiologic imaging studies may be performed to determine the extent of the tumor and if it has spread. These tests include ProstaScint scan, endorectal magnetic resonance imaging, and/or computed tomography scan.

Our Approach to Treatment

City of Hope is home to California's largest prostate cancer program (according to data from the Office of Statewide Health Planning and Development, OSHPD) and one of the world’s leading prostate cancer treatment facilities. Our surgeons pioneered the use of the da Vinci Surgical System in high precision robotic-assisted prostatectomy. We employ a variety of treatments that are tailored to each man’s unique cancer. Because City of Hope offers the expertise of all cancer-related specialists in one location who work collaboratively to optimize outcomes, patients receive greater continuity of care and more coordinated treatment planning.  Our advanced treatments include:
  • Robotic-assisted prostatectomy (da Vinci S Surgical System)
  • Radiation therapy, including TomoTherapy, brachytherapy and intensity-modulated radiation therapy
  • Innovative chemotherapy and clinical trials of leading-edge treatments
In addition, we are actively working on new diagnostic techniques, such as merging MRI screening with digital imaging to detect prostate cancer.
State-of-the-art robotic-assisted surgery
City of Hope was one of the first cancer centers in the country to adopt this amazingly precise, minimally invasive surgical technology. The procedure requires five tiny incisions. First, a pencil-thin laparoscope (a lighted tube with a video camera) is inserted, so live images can be transmitted to a computer. Through the remaining incisions, four slender robotic arms with miniature surgical instruments go to the surgical site. The surgeon sits at a nearby console, viewing the procedure while using grippers to remotely control the tiny tools.

Because the robotic arms can rotate 360 degrees, these instruments can move with a full range of motion as they cut and suture with great precision. A highly magnified real-time three-dimensional image helps the surgeon avoid delicate nerves and muscles surrounding the prostate. Less surgical trauma means less risk of side effects for our patients.

Patients who undergo robotic surgery experience less pain and recover faster. Typically, recovery from conventional surgery takes three to four days in the hospital, and up to six weeks at home. With robotic-assisted surgery, the hospital stay is reduced to one or two days. Recovery time is only two to three weeks — less than half as long as traditional surgery.

With smaller incisions, patients also experience less blood loss. This helps reduce the need for transfusions, keeps blood pressure stable, and lowers the risk of complications. Patients typically emerge from surgery stronger, and can get back to normal life sooner.

Finally, because robotic-assisted surgery does not require a large abdominal incision, there’s less pain and less need for pain medicine. Most patients are on their feet within hours of surgery.
Robotic-Assisted Laparoscopic Radical Prostatectomy

Advanced Radiation Therapies

Specialists at City of Hope were the first in the western United States to offer TomoTherapy — a targeted radiation therapy that can kill cancer cells while sparing healthy tissues nearby. Combining three-dimensional imaging with intensity-modulated radiation therapy technology, TomoTherapy bombards the tumor from all directions with hundreds of pencil-thin energy beamlets. The radiation matches the contours of the tumor precisely, delivering the optimal dose while avoiding normal tissues nearby. With less unwanted exposure, TomoTherapy offers better results, reduced risk of complications and fewer side effects.


In this procedure, tiny pellets of radioactive material smaller than a grain of rice are inserted directly into the cancerous tissue. The radiation attacks the tumor from the inside out. By directly targeting cancer, brachytherapy minimizes radiation to healthy tissue. In most cases, complications are few, and recovery is relatively rapid.
Radiation Therapy Side Effects
Any radiation treatment affecting the pelvic region can cause difficulties with urination, bowel problems and sexual side effects such as erectile dysfunction. These are often temporary, and can usually be treated with medication or other strategies if necessary.
Medical Oncology

City of Hope’s Medical Oncology Prostate Cancer Program focuses on providing the most advanced, compassionate, multidisciplinary care to patients with various stages of prostate cancer while actively investigating promising new treatment strategies. Our involvement in the management of prostate cancer patients starts very early and includes all stages of disease, ranging from localized to recurrent and advanced prostate cancer.  Our multidisciplinary team includes specialists from urology and radiation oncology who meet regularly with City of Hope radiologists and pathologists to discuss challenging cases and to develop comprehensive treatment plans tailored to each individual’s unique aspects of disease.  Because psychosocial support plays an important role in patients’ well-being, we offer an Advanced Prostate Cancer Support Group to our patients.

Hormonal Therapy
Male hormones called androgens help the prostate develop normally during adolescence. But as time passes, these hormones can promote the growth and spread of prostate cancer. If androgen levels in the body are lowered, those same cancers can be made to shrink or to at least grow more slowly. Though it is not a cure, hormonal therapy can put the cancer in a kind of “hibernation” for many years.
There are three kinds of hormonal therapy:
  1. Anti-androgens - Drugs that block the body’s ability to use androgens; they are often used in conjunction with the two methods described below
  2. Luteinizing hormone-releasing hormone analogues - Drugs that decrease the production of androgens; they are injected either monthly or every four months, depending on which medication is used
  3. Orchiectomy - Surgery to remove the testicles, where most of the body’s androgen is produced
Chemotherapy – the use of anticancer medicines – includes a wide range of drugs and treatment strategies to treat prostate cancer. City of Hope provides standard chemotherapies, as well as access to newly developed drugs through an extensive program of clinical trials.
As part of the treatment team, a medical oncologist will evaluate the best options, so that a course of chemotherapy, if appropriate, can be tailored to the patient.
Dealing with potential side effects

Erectile dysfunction and loss of bladder control are potential — and most often temporary — side effects of prostate gland removal. At City of Hope, patients report a 70-percent continence rate six months after surgery. Regaining sexual potency depends on the extent of surgery, and how functional a patient was before the operation. Most men find that their erections return a week to 18 months after surgery. Medications may be used to assist with recovery.

Many men find City of Hope’s Prostate Support Group helpful, as well as our Continence Recovery Program and assistance for potency recovery.

Post Treatment Care

Therapies for Urinary Incontinence
The incidence of incontinence after radical prostatectomy is relatively low, and if it does occur, it is usually mild in nature. However, for those men who must contend with urinary incontinence following surgery, City of Hope offers the Continence Recovery Program through our Rehabilitation Services department. This program includes one-on-one sessions with a team of physical therapists for prostate cancer patients to help them retrain their pelvic muscles to stop leaky bladders using a combination of biofeedback and exercise that specifically targets the muscles of the pelvic floor which may be affected during surgery.
The return of continence may be immediate and usually occurs within the first few months post operatively but may take as long as one year. If, after one year, a patient is still not satisfactorily continent from an urinary standpoint, patients are thoroughly evaluated to determine the etiology of their incontinence. If they are determined to have stress urinary incontinence (leakage of urine with cough and sneeze), they may be a candidate for one of three therapies. These include transurethral collagen injection, a bone-anchored perineal urethral sling, or an artificial urinary sphincter.
For more extensive information about continence recovery, view our prostatectomy Frequently Asked Questions section or learn more about Urinary Reconstruction and Diversion.
Therapies for Erectile Dysfunction
After nerve-sparing robotic laparoscopic prostatectomy, the return of erectile function may take anywhere from one day to two years. It is thought that although the neurovascular bundles are spared, the cavernosal nerves can sustain a thermal or stretch effect, leading to a temporary loss of nerve function. During this time, oral medications for erectile dysfunction may be unsuccessful because they require intact nerve function. Therefore, there are a number of second-line therapies we offer at City of Hope that act independent of nerve function, that can serve as a temporary or sometimes permanent measure to attain satisfactory erections. These treatments include intraurethral medications, penile injection therapy, or a vacuum erection device.
If these treatments prove unsuccessful, we offer patients a penile prosthesis. While this does require a surgical procedure, a penile prosthesis can be an attractive option for treatment. It is associated with over a 90 percent patient and patient/partner satisfaction rate.
Erectile Dysfunction Study
A clinical study being conducted by City of Hope researcher Laura Crocitto, M.D. that evaluates whether patients who use regular, low doses of erectile function drugs soon after surgery return to potency faster than those who do not take the doses regularly. It may be important to start rehabilitation as early as possible to increase blood and oxygen flow to the penis, helping to prevent scarring and this study will start to answer that question. City of Hope researchers are looking to accrue 220 men for the study. All study related medications will be provided to men free of charge.
Counseling and Other Support Services
We provide an extensive program including a Prostate Cancer Support Group and psycho-social counseling. A clinical psychologist, Martin A. Perez, Ph.D. , with expertise in sexual dysfunction, is available to see patients. Dr. Perez’s clinical practice and research focuses on quality of life issues in cancer patients and their families, assessment and treatment of sexual dysfunction following cancer treatment.


All of our patients have access to the Sheri & Les Biller Patient and Family Resource Center, which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs such as music therapy, meditation and many others.
Additional Resources
American Urological Association
The American Urological Association ( AUA ) is the premier professional association for the advancement of urologic patient care, and works to ensure that its members are current on the latest research and practices in urology.
800-ACS-2345866-228-4327 for TYY
The American Cancer Society has many national and local programs, as well as a 24-hour support line, to help cancer survivors with problems such as travel, lodging and emotional issues.800-ACS-2345866-228-4327 for TYY
The American Cancer Society has many national and local programs, as well as a 24-hour support line, to help cancer survivors with problems such as travel, lodging and emotional issues.

City of Hope Patient Support Groups and Community
Support groups at City of Hope for patients with specific types of cancer or specific needs. View our calendar for specific groups and meeting times.
National Comprehensive Cancer Network
888-909- NCCN (6226)
The National Comprehensive Cancer Network, an alliance of 19 of the world's leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.
National Cancer Institute
The National Cancer Institute, established under the National Cancer Act of 1937, is the federal government's principal agency for cancer research and training.

Prostate Cancer Foundation
1.800.757.CURE (2873)
The Prostate Cancer Foundation (PCF) is a leading philanthropic organization funding and accelerating research globally. PCF is a primary source for new standard-of-care and research information. PCF connects patients, loved ones, care providers and scientists to critical updates, the latest developments, best practices and news from the treatment pipeline.
Prostate Cancer Survivorship Program
The Prostate Cancer Survivorship Program provides specialized follow-up care for patients who have completed surgical treatment for localized prostate cancer. Patients who participate in this program are seen every 6 to 12 months in a clinic specially designed to meet the follow-up needs of prostate cancer survivors.
Prostate Conditions Education Council
866-477-6788 (toll free)
A national organization committed to men’s health, the Prostate Conditions Education Council (PCEC) - formally the Prostate Cancer Education Council - is one of the nation’s leading resources for information on prostate health. PCEC is dedicated to saving lives through awareness and the education of men, the women in their lives, as well as the medical community about prostate cancer prevalence, the importance of early detection, and available treatment options, as well as other men’s health issues.
U.S. Dept. of Health & Human Services National Institutes of Health (NIH)
301-402-9612 for TYY
The National Institutes of Health (NIH) is one of the world's foremost medical research centers, and the federal focal point for medical research in the United States. The NIH, comprising 27 separate institutes and centers, is one of eight health agencies of the Public Health Service, which, in turn, is part of the U.S. Department of Health & Human Services.
Us TOO International
(800) 80-Us TOO (800-808-7866)
Us TOO International is a grassroots, registered 501(c)(3) non-profit prostate cancer education and support network of 325 support group chapters worldwide, providing men and their families with free information, materials and peer-to-peer support so they can make informed choices on detection, treatment options and coping with ongoing survivorship.
Women Against Prostate Cancer (WAPC) is a national organization working to unite the voices and provide support for the millions of women affected by prostate cancer, and their families. WAPC advocates prostate cancer education, public awareness, screenings, legislation, and treatment options.
ZERO - The Project to End Prostate Cancer, provides comprehensive treatment information to patients, education to those at risk and conducts free prostate cancer testing throughout the country. Zero increases research funds from the federal government to find new treatments and funds local grants to end the disease.

Research and Clinical Trials

City of Hope has long been a leader in prostate cancer research. Our goal is to bring the latest scientific findings into medical practice as quickly as possible. At City of Hope, patients often have access to promising new therapies long before they are available to the general public.
City of Hope’s Prostate Program is a collaborative, multidisciplinary prevention, treatment and research program with the goal of providing state-of-the art care for patients with prostate cancer. We lead and participate in numerous national and international clinical trials evaluating new treatments for prostate cancer. Our program conducts clinical, translational and laboratory research striving to improve our understanding of the disease process and to guide the development of new diagnostic, prognostic, and therapeutic interventions. From diagnosis and treatment to recovery, our renowned urologists, medical oncologists, radiation oncologists, surgical oncologists and researchers work in partnership, combining their expertise and skills to deliver exceptional patient care.

To learn more about our clinical trials program and specifically about clinical trials for prostate cancer, click here.
Some of the current research studies underway at City of Hope:
Clinical Research

Telomerase and Methylation: New Prostate Cancer Detection Tests
This new noninvasive test, which detects the presence in prostate fluid of telomerase, an enzyme associated with certain cancers, may prove to be more sensitive than prostate-specific antigen in the detection of prostate cancer.

This research could lead to the development of improved clinical tools for the early detection of prostate cancer, while substantially reducing the number of unnecessary biopsies. In addition, prognostic markers may also be identified, which could help to identify patients at highest risk for recurrence and who may benefit from additional therapy. The telomerase/methylation test is only available at City of Hope as part of a clinical trial.

Mapping Interactive Cancer Susceptibility Genes in Prostate Cancer
Cancer researchers have recently identified several biological factors that may be important in the development of prostate cancer. This study seeks to determine the role of more than two-dozen genetic factors in cancer research and specifically whether there is any relationship between any of these genetic factors and the risk of developing prostate cancer. We are studying whether genes with weak contributions to cancer risk can interact to produce a strong risk.

Erectile Dysfunction Study
A clinical study is currently under way to evaluate whether patients who use regular, low doses of erectile function drugs soon after surgery return to potency faster than those who do not take the doses regularly. This study will help determine if it is beneficial to start rehabilitation as early as possible to increase blood and oxygen flow to the penis. City of Hope researchers are looking to recruit 220 men for the study. Study-related medications will be provided to participants free of charge.

Quality of Life and Psychological Adjustment in Prostate Cancer Patients and Their Partners
This study examines the psychological adjustment and quality of life (QOL) issues that may affect prostatectomy patients and their partners. The primary focus is on understanding the role of social factors on partner psychological functioning, the impact of pre-surgical expectations on patient QOL outcomes one year later, and the trajectory of prostate-cancer specific QOL over time. This data will enhance our understanding of the impact of cancer on patients and family members, shed light on patient-partner interactions that may inhibit adjustment following diagnosis, and inform the development of psychological interventions aimed at improving psychosocial adjustment and QOL in prostate cancer survivors and their partners.

Prostate Cancer Outcomes Database

City of Hope has established a prostate cancer database to collect data on all consenting prostate-cancer patients receiving their primary treatment at City of Hope. The data is used to analyze clinical outcomes and quality of life, correlate with ongoing fundamental science research studies, and establish standards for newly developed treatment modalities, including laparoscopic radical prostatectomy and robotic-assisted laparoscopic prostatectomy.

City of Hope has one of the largest prostate cancer populations in the country. To date, approximately 4,500 minimally invasive laparoscopic radical prostatectomies, including about 4,000 robot-assisted laparoscopic radical prostatectomies, have been performed at City of Hope. Out of these, more than 2,900 minimally invasive laparoscopic radical prostatectomies are included in the database, including more than 2,800 that were performed with robotic assistance.The outcome information obtained from these patients is an invaluable resource for studying how this state-of-the-art technique benefits the patient’s overall quality of life following prostate cancer treatment. To see an example of how this research translates into knowledge for advancing the field, read a summary of “Perioperative complications of laparoscopic versus robotic assisted laparoscopic radical prostatectomy: the City of Hope experience.” Journal of Urology, 175: 541-546, 2006.

Exploring Research Potential of our Tissue Bank
Because of the volume of patients seen, City of Hope has created an enormous tissue bank comprised of samples gathered from more than 1,500 men treated for prostate cancer. This tissue bank is an invaluable resource, because it allows us to study the genetic and molecular characteristics of tumor samples as well as the demographic characteristics of the men being treated and their treatment outcomes. Through this research, we will improve our ability to predict which cancers are aggressive and to tailor treatment accordingly.

Follow-up Clinic for Survivors
The Department of Population Sciences and Center for Cancer Survivorship has collaborated with the Division of Urology and Urologic Oncology to form a long-term follow-up clinic for prostate cancer survivors. The overall goal is to provide specialized care for cancer survivors and, in the process, develop a critical resource of research in cancer survivorship. Care is provided as a consultative service in collaboration with the patient’s primary care provider in order to ensure that the unique medical needs of cancer survivors are addressed. All patients will be offered the opportunity to participate in ongoing research studies through the Center for Cancer Survivorship.

Currently, the Survivorship Clinic provides comprehensive long-term follow-up services for childhood cancer and prostate cancer survivors, with plans to expand care to breast cancer and hematopoietic cell transplant survivors. Specialized services such as support groups, vocational counseling, and physical/occupational therapy are provided to help survivors successfully return to their lives after cancer treatment. Each survivor seen at City of Hope receives personalized health information based on their diagnosis, treatment and current medical condition, empowering them to take steps to optimize their health. Other educational initiatives planned include a patient resource library, educational seminars for survivors and educational outreach programs for the community.

Translational Research

Translational research brings promising ideas from the lab into the clinical setting. Researchers and clinicians at City of Hope are engaged in ongoing communication and interaction to bring work from the lab to the bedside.
Developing More Sensitive Prostate Cancer Tests
Quantitative polymerase chain reaction (qPCR) is a technology used to quantify DNA sequences. This technique is useful in determining the presence and amount of a single, specific sequence within a sample of DNA. Our researchers are using qPCR to study biomarkers linked to chromosome damage in cells, RNA copies made from DNA and changes in DNA methylation patterning. We hope to use these biomarkers to predict the presence of certain indicators of poor prognosis such as the growth of cancer outside the prostate gland, known as extracapsular extension. Preliminary results show that the data gathered through the qPCR, coupled with the Gleason score and PSA test, can predict the absence of extracapsular extension very accurately. Tests of this type may be very useful in determining which patients have forms of prostate cancer that are less likely to spread. These men can then receive less-aggressive treatment

Pre-metastatic Niche Study
For more than a century, it has been posited that the “soil” (or environment) that surrounds a tumor is critical for its development. In fact, the “soil” may be as important as the “seed” (the cancer cell) itself. In the setting of prostate cancer, the pre-metastatic niche may represent the “soil” -- specifically, an environment that tumor cells from the prostate move toward. The potential impact of the pre-metastatic niche is two-fold. First, while PSA, Gleason grade and stage can offer important prognostic information, none are perfect in predicting clinical outcome. The pre-metastatic niche may be a way in which prognostic information can be offered to reflect the individual biology of the disease. Second, aside from improving prognostic capabilities, the pre-metastatic niche may also serve as a therapeutic target. We are interested in developing our understanding of the pre-metastatic niche in prostate cancer in order to accomplish these aims.

Predicting the Likelihood of Prostate Cancer Recurrence
The Department of Population Sciences is studying a gene known as Fragile Histidine Triad (FHIT), which is a tumor suppressor involved with a variety of cancers. Through collaborations with researchers at the National Cancer Institute and the American Cancer Society, we have identified several regions within FHIT affecting prostate risk. Variations in FHIT introns are associated with more aggressive forms of cancer. City of Hope researchers are investigating their association to tumor aggressiveness and cancer-specific mortality, as well as identifying genetic variations in the FHIT genetic sequences that predict protein expression level in prostate tumor tissue. This research holds promise for a non-invasive test to predict which prostate tumors are likely to spread, necessitating more aggressive treatment, and a potential target for future therapeutic intervention.

Basic Science Research

Scientists from a wide variety of disciplines at City of Hope are involved in pioneering basic prostate cancer research. Sometimes called investigational or laboratory research, this work is focused on making advances that will ultimately improve on our ability to treat patients with prostate cancer. This research may one day be translated into promising treatment for patients.

Using Nanotechnology to Predict Cancer Recurrence
City of Hope’s patented bionanotechnology uses engineered DNA and protein to build tiny programmable machines (smaller than one-thousandth the width of a human hair) called nanoparticles. City of Hope is pursuing a study using these nanoparticles as a means of detecting prostate cancer. There is evidence that the nanoparticles can be used to differentiate between aggressive cancer cells that are likely to come back after treatment and those that are less likely to recur.

Based on lab results, it appears that the amount of fluorescence may indicate how aggressive the cancer is and whether or not the cancer is likely to return. However, when the nanoparticles were tested using slices of tissue obtained from men after prostate cancer surgery, the results were surprising. The fluorescent glow was most pronounced in the regions near the tumor, but not within it. These tumor-bordering regions are known to be areas in which cells in the prostate are reacting to the presence of the tumor as the body loses its fight against the cancer.

The observations may be useful in detecting prostate cancer in non-invasively obtained prostate specimens like those used in previous studies on diagnosis and screening because they identify a new and previously unknown set of prostate cancer biomarkers. One of these (Thioredoxin Reductase I) is being readied for clinical testing in non–invasive specimens.

Evaluation of Anti-prostate Cancer Activity of Mushrooms
The Department of Medical Oncology and Therapeutics Research offers standard chemotherapies as well as access to newly developed drugs through an extensive program of clinical trials. In this study, our researchers have found that mushrooms contain chemicals that act as inhibitors of steroid 5-alpha reductase. An elevation of the steroid 5-alpha reductase activity in the prostate may cause benign prostate hyperplasia (a common problem in older men) and also promote the growth of prostate cancer. Inhibitors of steroid 5-alpha reductase have been developed to treat these prostate diseases.

The Department of Medical Oncology launched a Phase Ib Trial of Mushroom Powder in Biochemically Recurrent, Hormone Naive Prostate Cancer in collaboration with the Department of Cancer Biology. Optimal treatment options in biochemically recurrent prostate cancer remain presently undefined and new therapies with minimal toxicities need to be evaluated for this population. An ideal therapy would be provided on an outpatient basis and orally administered and would have minimal systemic toxicity, allowing long-term repeated administration. The mushroom powder being tested in this study has the potential to serve in that capacity.
Molecular Association between Prostate Cancer and Obesity
We are currently examining molecular biological and genetic approaches to address how obesity interacts with the development and progression of prostate cancer. In addition, emphasis is placed on prostate cancer cell-adipocyte interaction, signaling transduction and gene regulation by adipose cytokines in androgen-independent prostate cancer cell growth.

Visit the Department of Cancer Immunotherapeutics & Tumor Immunology to learn more.

Energy Balance and Functions of Homeobox Genes in Carcinogenesis
Visit the Department of Molecular and Cellular Biology to learn more.
Next generation hormone therapies 
Hormone therapy is a cornerstone of the treatment of prostate cancer. However, these drugs only work for a limited time span. Investigators at City of Hope have clinical trials underway that explore the next generation of hormone therapies -- drugs that are more potent and that may more completely suppress prostate cancer growth.  In addition, our laboratories on campus are actively developing new compounds that offer a similar and even more potent mechanism.
Vaccine therapies (Provenge) 
There are now approved vaccine therapies for prostate cancer that has spread outside of the prostate. These are not conventional vaccines; rather, they are generated by taking a patient’s white blood cells, stimulating them in the presence of various proteins, and then injecting these cells into the body. These cells are now primed to mount an immune response against the cancer.  Investigators at City of Hope have developed a trial to determine if radiation therapy may augment the activity of these vaccines.
Imaging prostate cancer
The treatment of prostate cancer depends very heavily on the degree to which it has spread.  If prostate cancer is localized, treatments like radiation or surgery might be relevant. However, if prostate cancer has moved elsewhere (typically, to the bones or lymph nodes), drug therapy may be more appropriate. At City of Hope, we are developing a protocol to incorporate new modes of imaging.  Specifically, we are using a scan technique called Sodium-fluoride PET to determine more precisely if prostate cancer has gone to the bones.  We are also introducing the use of a whole body MRI that will better capture the spread of prostate cancer to many structures. With these techniques, we hope to optimize the appropriate management of patients.
Treatment before surgery (Axitinib)
Investigators at City of Hope have discovered an association between a certain molecule, called VEGFR1, and recurrence of prostate cancer after surgery. There is an FDA-approved drug that targets VEGFR1, and investigators have created a protocol that treats patients with this drug prior to surgery for prostate cancer. Using this strategy, we hope to limit the situations in which prostate cancer recurs after surgical intervention.
Diagnostic Trials

City of Hope has been an innovator in diagnostic research to more precisely track the progression of prostate cancer. Using new biomarkers recently discovered at City of Hope, our research team is addressing some of the most pressing problems in the diagnosis of prostate cancer. Their research is making it possible to predict the outcome of a prostate cancer biopsy with a high degree of accuracy.
The new test addresses one of the vexing problems in diagnosing prostate cancer and may help many people avoid the unpleasant biopsy procedure. Our investigators’ research is also helping to detect prostate cancer that has grown outside the prostate gland itself among patients that are thought to have low-risk prostate cancers. These new biomarkers will also help our physicians counsel patients who are considering active surveillance.
Using Expressed Prostatic Secretions (EPS) to Rule Out Prostate Cancer

Clinicians and scientists are working together to develop a more accurate and easily-administered test. This screening test evaluates expressed prostatic secretion (EPS), a fluid that can be collected from the prostate, for various genetic markers that indicate the presence of cancerous cells. It will help determine whether EPS can be used to rule out cancer in patients being evaluated for prostate cancer in the urology clinic. These studies use the methods of molecular biology to identify whether cancer cells are present in EPS, which can be obtained non-invasively. The goal is to develop a new non-invasive tool for determining whether patients should proceed with further invasive testing like prostate biopsy.

Preliminary studies have demonstrated that when used in tandem with the PSA and a digital rectal exam, the EPS screening has a positive predictive value that approaches 85 percent. In addition, the test may help to predict the aggressiveness of the cancer. This is significant because if more-aggressive cancers can be identified early, men who are at greater risk for dying from prostate cancer or developing metastatic cancer can receive beneficial effects of treatment.
Taken together, these assays are proving to be valuable in determining if a biopsy is necessary.
Interoperative Optical Imaging (IOOI)
Likened to “seeing the invisible,” Interoperative Optical Imaging (IOOI) offers a way to paint a tumor to reveal exactly where the cancer is located in order to remove all the malignant cells while sparing normal tissue. The technique should help prevent subsequent treatments that are sometimes necessary when the surgeon could not initially detect all of the cancer. IOOI combines the precision of robotic surgery with fluorescent microscopy to illuminate cancerous cells “real time,” enabling surgeons to excise cancer more precisely. Clinical trials using patients begin in Fall 2013.

Prostate Cancer Team

Robotic Prostatectomy FAQs

What is robotic assisted prostatectomy?

Since 2003, City of Hope has been performing prostatectomy using the da Vinci surgical system (DVP), allowing our physicians to take a giant leap forward in the treatment of prostate cancer. The robotic technique provides unparalleled surgical accuracy to significantly reduce blood loss and improve postoperative recovery. City of Hope performs more robotic assisted prostatectomies than any other medical center in the Western U.S and is second in the nation.

How does robotic assisted prostatectomy work?

With the state-of-the-art da Vinci computer-enhanced minimally invasive surgery system, City of Hope surgeons perform the same procedure done in conventional laparoscopic prostatectomy, but are aided by a three-dimensional computer vision system to manipulate four robotic arms. A pencil-size video camera held by one of the arms is inserted through an incision to provide magnified, 3D images of the surgical site. The 3D view helps the surgeon more easily identify the delicate nerves and muscles surrounding the prostate. The robotic arms can rotate a full 360 degrees, allowing the surgeon to manipulate surgical instruments with greater precision, flexibility and range of motion. To view informational video on robotic assisted prostatectomy click here

What are the benefits of robotic assisted prostatectomy?

Patients experience significantly less pain and less blood loss than those undergoing conventional open incision procedures. In addition, patients tend to enjoy quicker recovery time. A traditional, open radical prostatectomy requires two days hospitalization and recovery lasting about 2-3 months. With robotic assisted surgery the recovery time is as little as two weeks - a greater than 50 percent reduction in recovery time.

How experienced is City of Hope at the robotic assisted prostatectomy procedure?

City of Hope was one of the first cancer centers in the United States to begin performing the robotic assisted laparoscopic radical prostatectomy. Since October 2003, our physicians have performed over 3100 cases, more than any other site in the Western U.S and second in the entire U.S.

What are City of Hope's outcomes?

The department of Urologic Oncology at City of Hope specializes in the diagnosis and treatment of prostate cancer, bladder cancer, kidney cancer, and other urologic malignancies, providing therapies for patients that not only treat the disease but also attempt to achieve the best quality of life. Since 2000, we have been using state-of-the-art minimally invasive techniques for the treatment of urologic malignancies. Both the institution and the department were recently named as America's Best Hospitals in cancer and urology by U.S. News and World Report. We were the first regional cancer center to implement and subsequently advance the use of standard laparoscopic techniques for the treatment of prostate and bladder cancers. In 2003, after an initial experience with over 500 laparoscopic radical prostatectomies we implemented the use of the da Vinci surgical system into our practice. Since then, we have become the busiest minimally invasive and surgical robotics program worldwide and have performed over 3,100 robotic prostatectomies. In 2007, we performed approximately 721 robotic prostatectomies. The robotic program at City of Hope includes robotic and oncology fellowship trained surgeons, fellows, a dedicated operating room team, nurse practitioners, physician assistants, and research coordinators. We currently have four new generation, four-arm robotic systems, including the da Vinici S High Definition platform. All of our procedures are performed in minimally invasive operating theatres, utilizing Karl-Storz OR1 integrated and automated suites. The operation typically takes 2 to 3 hours, and is performed under general anesthesia. Most patients have an estimated blood loss of 300 milliliters, and therefore less than 3% of patients are expected to need a blood transfusion). Most patients typically spend one night in the hospital, and can expect to get discharged the following afternoon if their laboratory tests are acceptable, pain is controlled with oral medications, and they are able to tolerated oral liquids. Patients are discharged with an indwelling foley catheter which will be removed in the clinic 5-7 days after the operation. Patients who do not reside in the local vicinity, can sometimes have their catheters removed by their community urologist. At the first post-operative visit, we review and discuss pathology results, and potential need for any adjuvant therapies if indicated. Most patients have a convalescence period of 2-3 weeks, and can expect to return to their normal activity 4 weeks after surgery. The primary concern for patients with localized prostate cancer who undergo prostatectomy is recurrence, or a return of their cancer. Biochemical recurrence, indicated with elevated levels of prostate-specific antigen, or PSA, affects an estimated 12% of our patients three years following robotic radical prostatectomy, and an estimated 17% of patients at five years. Secondary outcomes of concern to patients include regaining continence and potency. Among our patients who were continent prior to undergoing prostatectomy, 63% regained continence within the first four months following surgery. By 12 months, we found that 87% of patients had regained continence. The average time to return to continence is 1.8 months. Return to potency takes considerably longer for prostatectomy patients. At 12 months following prostatectomy, 46% of our patients had returned to desired potency levels. The number edges higher when we consider a 24 month follow-up period (63%), and the average time to return to potency is 14 months for our patients overall. Age, however, is a notable factor in these estimates. Among younger patients who were under the age of 65 at the time of surgery, the average time to return to potency was under 12 months, and 69% of these patients were said to have regained potency at 2 years. It is important to keep in mind that these results represent outcomes since robotic prostatectomy was started at City of Hope in 2003. Since that time, with growing experience, positive margin rates have declined and individual surgeon results have improved. The operation we do now is considered to be leading edge and state of the art.

Who is a candidate for robotic assisted prostatectomy?

Anyone diagnosed with localized prostate cancer may benefit from robotic-assisted prostatectomy. However, the decision to have prostate cancer treated surgically revolves around numerous considerations. Variables that enter into preoperative evaluation include age, pre-biopsy PSA, biopsy findings, previous prostate cancer treatments and other illnesses. Robotic prostatectomy can be done for men of all sizes and shapes. The surgery can be done in men who have had other operations: appendectomy, laparoscopic hernia repair, repair of abdominal trauma, transurethral prostatectomy (TURP), and in some men who have been treated with previous pelvic radiation.

Does robotic assisted prostatectomy remove the whole prostate?

Yes. This surgery removes the prostate, seminal vesicles, ends of the vas deferens, and, depending on oncological considerations, nerve bundles and/or lymph nodes.

Why is there less blood loss with robotic assisted prostatectomy?

The reduction in blood loss reflects the improved view of the operative field, especially behind the pubic bone, home of the venous plexus of Santorini. The improvement in view comes from using a lens that tracks directly into the operative field where the remote human eye has a hard time going. The robotic surgery also uses magnification and bright illumination. Overall, this improved view permits a more precise and gentle dissection, which means better control of potential sources of bleeding.

Does robotic assisted prostatectomy require general anesthesia?

Yes. Robotic assisted prostatectomy is considered major surgery and thus requires general anesthesia.

Does prostate size matter?

As a practical matter, prostate size is not much of an issue. We routinely remove prostates ranging from 10 to 100 ccs in size.

Can lymph nodes be removed with robotic assisted prostatectomy?

Yes. Lymph nodes, to which prostate cancer may spread, can be removed.

What are the risks of robotic assisted prostatectomy?

This is major surgery, done under general anesthesia and carries the same risks of any major operation, including heart attack, stroke, and death. Robotic-assisted prostatectomy is also associated with the specific risks of impotence and incontinence.

Can the neurovascular bundles be preserved?

Yes. The neurovascular bundles whose preservation is associated with the likelihood of maintaining erections can be preserved. Nerve preservation does not guarantee satisfactory erections after surgery.

Does it make sense to preserve the neurovascular bundles?

Not in all cases. The issue here relates to the physical proximity of the bundles to areas of malignancy, which can microscopically extend beyond the prostate and into the bundles. The decision to preserve one or both neurovascular bundle depends on an individual analysis.

When will the ability to have an erection be regained following surgery?

Return of potency depends on many physical and psychological factors including preoperative erectile function and type of surgery (such as unilateral or bilateral; nerve-sparing or non-nerve sparing). Function may return spontaneously as early as one week after surgery, or with the aid of medications (Viagra, Muse). Potency rehabilitation can be discussed at the one-month visit. Factors that can interfere with erectile function include hypertension, diabetes, obesity, atherosclerosis, history of smoking, and anxiety, among others.

Are venous compression devices used in this surgery?

Yes. As a precaution against developing blood clots each patient has venous compression devices placed prior to surgery. These are removed when the patient becomes ambulatory.

Does robotic assisted prostatectomy require a catheter, drain, dressings, or stitches?

Yes. Like any radical prostatectomy, robotic-assisted prostatectomy requires reconstruction of the bladder-urethra connection. A catheter is left in the urethra, connected to a drainage bag, and used to align the healing suture line and drain the bladder. In the immediate post-op period, the surgery also requires a drain that goes through the abdominal wall and left in the pelvis behind the pubic bone. The drain assures the collection of blood and urine that may accumulate immediately after surgery and is removes when the output drops, usually prior to leaving the hospital. There are stitches, but these dissolve by themselves and require no special care. The surgical dressings are five Band-Aid type dots used to cover the instrument entry sites. These dressings are generally removed 48 hours after surgery.

How long should the catheter stay in?

We routinely remove the catheter in five to seven days at the first follow-up visit.

What can I expect after the catheter comes out?

Almost all patients have some incontinence when the catheter comes out. Incontinence varies from person to person, but usually improves significantly or resolves by the one-month follow-up clinical visit. Continence function returns with time, and patience here is a real virtue.

How can I speed my continence recovery?

You will be given an instruction sheet for Kegel exercises and other suggestions that will help in the recovery of continence. In addition, a Continence Recovery Program is available through our Rehabilitation Services Department beginning 1 month after surgery. Ask your MD for a referral.

Can I bathe after robotic assisted prostatectomy?

Yes. Most patients may shower within 24 hours of surgery.

What can I expect immediately after robotic assisted prostatectomy?

Patients leave the operating room with an intravenous line, a urethral catheter, and a small rubber drain in their lower abdomen. In the first few hours, depending on strength and motivation, most patients get out of bed and stretch their legs, and begin walking by nightfall. Most leave the hospital within 48 hours. Most patients begin drinking fluids on the 1st day after the procedure. Patients are discharged with a catheter connected to a leg bag, which fits under their pants. Loose clothing and shoes that don't require tying seem easier to handle in the first few days.

What can I expect after getting home?

While relative to open surgery robotic assisted prostatectomy is generally less demanding, the experience is still demanding. The single most common complaint after hospital discharge seems to be sleep deprivation and fatigue. Most patients are anxious going into surgery, get little sleep the night before surgery, arrive at the hospital very early on the morning of surgery, and get very little sleep the night after surgery. Accordingly, most patients look forward to a good, long nap and a shower after getting home. The other major complaint seems to be a sense of bloating, with clothes fitting very tight. This bloating seems related to the effects of surgery, anesthesia, and bed rest on intestine function. Often this sensation responds well to walking, which helps the patient expel intestinal gas, which in turn helps the patient regain his overall comfort and appetite.

If I live far away, can I travel after surgery?

Many of our patients come from far away and we can help with numerous logistical issues related to travel, from finding a suitable hotel to arranging medical evaluations pre-operatively. After surgery, we have had patients leaving Duarte within two days, be it by car or plane to various destinations.

What happens to my medical records and who will take care of me when I get home?

We work with our patients to transmit any and all relevant medical data to their home physicians. For those who chose to stay a while, we provide all follow-up medical care.

Must I return for follow-up care?

We support our patients regardless of where their paths take them. In a practical sense, this means that once a patient has had a robotic assisted prostatectomy, we consider him a lifetime patient and are always available. In fact, most of our patients, having come to rely on us during a very trying time in their lives, stay in touch and regularly call and email to update us or ask for our help. While we deliver urological care to all our local patients, there may be no compelling reason for patients to make trips to Duarte for routine follow-up.

What is the long-term follow-up after robotic assisted prostatectomy?

Depending on the pathologist's report of the surgery specimen, a patient may or may not consider additional cancer treatments. In most cases, but not all, the wise course of action is surveillance: periodic measurement of blood PSA, thought to be the most sensitive indicator of cancer recurrence.

What is the Survivorship Clinic?

We are very excited to now offer a unique opportunity for eligible patients. If you are one year post treatment and free of disease, we believe that you would benefit from the Prostate Cancer Survivorship Clinic. Services provided in the Clinic include general health promotion, follow-up assessments, screening for other cancers, education and other support services. For more information, please see the Prostate Cancer Survivorship Program.

Support This Program

It takes the help of a lot of caring people to make hope a reality for our patients. City of Hope was founded by individuals' philanthropic efforts 100 years ago. Their efforts − and those of our supporters today − have built the foundation for the care we provide and the research we conduct. It enables us to strive for new breakthroughs and better therapies − helping more people enjoy longer, better lives.

For more information on supporting this specific program, please contact us below.

Rick Leonard
Associate Vice President
Direct: 213-241-7218
Email: rleonard@coh.org

Prostate Cancer Videos
Mushrooms to treat prostate cancer?
Urology and Urologic Oncology Research

City of Hopes's Division of Urology strives to improve quality of care through innovative research that helps expand our understanding of urologic cancers. This brochure provides the key areas of research and studies our division is focusing on.
Robotic-assisted Radical Prostatectomy
Read more about having your robotic-assisted radical prostatectomy at City of Hope.
PSA Screening Overview
The Division of Urology continually assesses practices related to urologic cancer care and prevention. So, when the United State Prevention and Safety Task Force (USPSTF) released a report on PSA screenings in 2013, the division presented an overview that summarizes the USPSTF findings.
To view this presentation, click the link below.
Medical Minute

Listen to the Prostate Cancer Medical Minute with Timothy Wilson, M.D., Director, Prostate Cancer Program and Pauline & Martin Collins Family Chair in Urology.
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