Prostate Cancer Treatment
 
  What are my options for treating prostate cancer?
There are many options for the management of prostate cancer including active surveillance, watchful waiting, surgery, radiation, cryotherapy, hormonal therapy, and other experimental therapies. Sometimes multiple treatment types are used together (such as radiation and hormone therapy). The best treatment for your cancer depends on many factors such as your age, general health, how aggressive your cancer is, and whether the cancer has spread beyond the prostate. 

There are two main goals during prostate cancer treatment:
1)    Cancer control (attempting to cure your cancer)
2)    Maintaining a high quality of life (minimizing any side effects of cancer treatment so that you can live as normal of a life after therapy)

How soon do I have to make a decision?

While you don’t want to unnecessarily put off making a choice, there is no need to rush into a decision.  Remember, prostate cancer is typically a slow growing cancer and usually will not spread very fast. Therefore, there is time to gather information and make a good informed decision that you’ll be happy with.  In fact, if you decide to have surgery, it is usually necessary to wait six-eight weeks after the biopsy in order to allow the inflammation from the biopsy to resolve.

Active Surveillance / Expectant Management

You may have heard that “most people die with prostate cancer and not from prostate cancer.” While that is partly due to improvements in earlier detection and treatments, some prostate cancers are probably not life-threatening. With active surveillance, your urologist will monitor your cancer by closely following the PSA levels and digital rectal exam and performing repeat biopsies periodically to make sure the cancer has not become more aggressive. Your doctor can then intervene and begin active treatment if the cancer shows signs of progression. Low-risk cancer patients or patients who have other medical problems with shorter life expectancies are candidates for active surveillance.

Advantages: Avoids or at least postpones the side effects of therapy such as erectile dysfunction and urinary problems
Disadvantages: There is no way to predict with certainty which cancers are not life-threatening. Therefore, there is a risk that the cancer can progress at some point to an incurable stage. In other words, there is a chance of missed opportunity for cure. Some patients also experience more anxiety living with an untreated cancer.

Surgery (Radical Prostatectomy)
Surgical treatment for prostate cancer involves removal of the entire prostate and the seminal vesicles. Surgery is usually considered when the cancer is thought to be confined to the prostate (localized prostate cancer). In select cases, the pelvic lymph nodes are also removed. Candidates for surgery are usually healthy, active, and younger men with at least a 10-year life expectancy.  

Advantages: Radical prostatectomy is a well-tested treatment for prostate cancer that has been demonstrated to result in long-term cancer survival. It is the only treatment that has definitively demonstrated a survival advantage over watchful waiting therapy for men less than 65 years old. Surgery allows for complete examination of the prostate and the lymph nodes if indicated. All known prostate cells are completely removed from the body and therefore, the PSA level in the blood should fall to undetectable levels after radical prostatectomy. Thus, after surgery, PSA becomes an excellent test to detect even small amounts of residual or recurrent cancer.
Disadvantages: There are possible side effects with surgical removal of the prostate (most importantly urinary leakage and erectile dysfunction).  While many men can recover function in both of these areas, others may have long-term problems.  

Surgery is followed by an average hospital stay of about one-two days and average time away from work or strenuous activity is four-six weeks. Patients undergoing surgery need to wear a catheter for about 7-14 days to allow the bladder and urethra to heal.

Although rare, the risks associated with radical prostatectomy are similar to those of any major surgery including bleeding, infection, blood clots, heart or lung problems. The level of risk depends largely on the age and overall health of the patient. The primary long term side effects associated with radical prostatectomy are incontinence (urinary leakage) and erectile dysfunction.

Following surgery, significant bladder control can return in about 8-12 weeks, but often can take longer and will usually continue to improve even up to 1 year after surgery. All men initially leak urine uncontrollably after the catheter is removed. Patients are instructed on how to perform special exercises called Kegel exercises to help improve urinary control. Your doctor may recommend seeing a physical therapist both before and after surgery to help you perform exercises that can aid in improving bladder control.  About 4% of patients who undergo radical prostatectomy have severe incontinence that persists after surgery. This group of patients will need to wear pads, take medication, or undergo further procedures to treat this side effect. Another 4% of patients will have mild stress incontinence that persists after surgery, which is passing a small amount of urine when coughing, laughing, sneezing, or engaging in heavy exercise. These men may choose to wear a protective pad to protect against unexpected leakage. The remaining 90-92% of men will recover excellent urinary control and will not require pads or other means of protection in the long term.

Sexual dysfunction is a common problem in both men and women. Sexual problems become progressively more common with aging, heart disease, high cholesterol, diabetes, and high blood pressure. Prostate cancer and the treatment of prostate cancer can have significant impact on sexual function depending on baseline sexual function, patient age, medical risk factors, and disease stage. We provide counseling to the patient and their significant other about anticipated changes in sexual function and try to predict the likelihood of preserving and recovering sexual function after prostate cancer treatment.

The nerves that help control erections are positioned along each side of the prostate.  Nerve-sparing surgery is performed if there is no indication of tumor involvement within or near the nerves surrounding the prostate, called the neurovascular bundles. Your surgeon will discuss whether a nerve-sparing procedure is appropriate for you depending on your specific situation. If there is concern of leaving cancer behind, your surgeon will usually recommend removing the nerves on the involved side.

Men who have “normal” pre-operative erectile function have about a 70-75% chance of having erections that are adequate for sexual intercourse following a bilateral (both left and right) nerve-sparing operation.  About half of these patients do require Viagra®, Cialis®, or Levitra® to obtain optimal erectile function. Men who are younger than age 60 and those with the highest levels of pre-surgery erectile function have the best outcomes in terms of being able to get erections after surgery.  Men who have only one nerve spared, are older than age 65, have pre-existing erectile dysfunction, or have other medical problems that may contribute to erectile problems have a lower chance of recovering spontaneous erections. It is important to remember that there are now many options for treating erectile dysfunction. Aside from oral medications, there are also injectable medications, vacuum pump devices, and surgical options to help men regain the ability to get erections after radical prostatectomy.

Recovery of erections after surgery is a gradual process that takes several months and can continue to improve up to 1 ½  years after surgery. One way to help improve the chances of return of erections after radical prostatectomy is to participate in “penile rehabilitation.” Within a couple of weeks after removal of the catheter, attempts to have an erection with sexual stimulation along with the help of prescribed oral medications (Viagra®, Cialis®, or Levitra®) can enhance the flow of blood and oxygen to the penile tissue.  The most common side effects of these medications are headache, flushing, upset stomach, visual disturbance, and nasal congestion. By attempting to have at least three erections per week in the months after surgery, patients can maximize post-operative recovery.

What are the different surgical techniques for removing the prostate?
Radical Retropubic Prostatectomy (RRP)
RRP has traditionally been the most commonly performed type of radical prostatectomy.  It involves a skin incision in the lower abdomen from just below the umbilicus (belly button) to the pubic bone just above the penis. The prostate and seminal vesicles plus the pelvic lymph nodes (if indicated) are removed. Patients are usually discharged from the hospital in two-three days and wear a catheter for about 10-14 days. Recovery time is approximately four-six weeks and requires no heavy lifting or strenuous activity/exercise for six weeks.

Radical Perineal Prostatectomy (RPP)

RPP has also been traditionally used as an approach to removing the cancerous prostate. While not as commonly performed, it can be just as effective as the retropubic approach in experienced hands. It involves a skin incision in the perineum (between the scrotum and rectum). It can be advantageous in patients with a very large abdomens or prior abdominal surgery. The prostate and seminal vesicles are removed. However, the pelvic lymph nodes cannot be removed through this incision and if indicated would require a separate incision for removal. Preservation of erections may be more difficult with this approach. Patients are usually discharged from the hospital in one-two days and wear a catheter for about 10-14 days. Recovery time is approximately four-six weeks and requires no heavy lifting or strenuous activity/exercise for six weeks.

Robotic-assisted Laparoscopic Radical Prostatectomy (RLRP)

RLRP has been performed since 2001. Robotic or laparoscopic radical prostatectomy involves removal of the prostate and seminal vesicles plus removal of the pelvic lymph nodes (if indicated) just like open surgery except with five or six small one cm incisions.  Magnified and three-dimensional visualization of the prostate and surrounding structures along with specialized small surgical instrumentation allows precise dissection of the prostate. The advantages of this technique are shorter hospital stay, quicker recovery, less blood loss, and shorter catheter time. Early studies have also suggested improved cancer control, quicker time to continence, and possibly improved erectile function after RLRP. While these studies are encouraging, we are currently awaiting the results of long-term studies to determine if RLRP is truly superior to open surgery.

Radiation Therapy
Radiation therapy is also a well tested treatment for prostate cancer. The goal is to deliver the highest possible doses of radiation to the prostate while minimizing the amount of radiation to surrounding structures including the bladder and rectum. There are various methods of delivering radiation to the prostate to kill the cancerous cells and not all types of radiation may be appropriate options for all patients. Hormonal ablation therapy (described subsequently) may need to be given with radiation therapy when a patient has a more aggressive prostate cancer.  In addition, sometimes radiation is used after surgery (adjuvant radiation) for more aggressive cancers or for cancer recurrence (salvage radiation).

Like surgery, side effects after radiation treatment can include urinary and erectile problems. In addition, patients can rarely experience bowel problems such as rectal bleeding or pain, diarrhea, or fistula (formation of a connection between the rectum and urinary tract). There is a small increased risk for development of secondary cancers of the bladder or rectum due to radiation.

Advantages: Avoids a major surgery for patients particularly those who are either medically unfit to undergo surgery or who simply wish to avoid an operation. It is a well tested treatment with durable long-term results for treatment of men with prostate cancer.  
Disadvantages: There are potential side effects including urinary, erectile, and bowel problems as mentioned above. PSA surveillance after treatment is somewhat more complicated and cancer recurrences may therefore be more difficult to detect. The prostate and/or lymph nodes are not able to be fully evaluated since the prostate is not removed.

External Beam Radiotherapy

External beam radiation involves using beams of gamma radiation (usually photons) directed at the prostate and surrounding tissues through multiple fields. To minimize radiation injury to the bladder and rectum, 3-D conformal radiotherapy and now intensity-modulated radiation therapy (IMRT) have been developed and can accurately target the highest doses of radiation to the cancerous areas of the prostate and lower the doses near the bladder, rectum, and urethra.  Most patients with localized or locally advanced prostate cancer are candidates for external beam radiation. It is usually administered every day (five days per week) for five-eight weeks depending on your treatment dose.

Brachytherapy (Radiation Seed Implantation)

Brachytherapy or radiation seed implantation involves the placement of radioactive seeds directly into the prostate gland. These radiation sources then continue to administer radiation to the prostate over a period of time. Patients with aggressive prostate cancer, large prostates, or those patients with lot of urinary symptoms are not appropriate candidates for brachytherapy. Sometimes seeds may be used in conjunction with external beam radiation therapy for more aggressive cancers. If the prostate is large, sometimes hormonal therapy is necessary to shrink the prostate before seed implantation can be performed. Brachytherapy requires an outpatient procedure in the operating room and most patients can go home the same day.

Surgery vs. Radiation

My doctor says I am a candidate for either treatment. What are the differences and which one should I choose?
Radiation therapy and surgery are both good treatments for attempting to cure prostate cancer. They are the two best-tested treatments for prostate cancer and both have demonstrated long-term cancer control. Although surgery and radiation have never been directly compared in a head-to-head trial, they have been shown to have similar rates of cancer cure and control. They also have comparable effects on patients’ quality of life with similar risks of urinary and erectile problems after treatment.  

Cancer surveillance after treatment is somewhat different for patients who have surgery and those who have radiation. After surgery, the PSA level should decrease to undetectable levels 6-12 weeks after surgery if no more cancer is present. PSA then becomes a very sensitive test to detect any cancer recurrence after surgery since the prostate has been completely removed. Unlike surgery, after radiation treatment the PSA level may not decrease to undetectable levels and also can fluctuate up and down. It can, therefore, be somewhat more difficult to define when or if a patient has recurrent cancer after radiation treatment.  

Radiation is also commonly used after surgery (adjuvant or salvage radiation) for aggressive or recurrent cancers. When radiation is used after surgery, it is not typically anymore difficult to administer than it is as a primary treatment. While surgery after radiation is possible, most patients are not candidates for surgery in this setting and the risks are greater in patients undergoing surgery who have already had radiation than when surgery is used as a front-line treatment. There are, however, other options for recurrent prostate cancer after radiation such as cryotherapy that may still be used if surgery is not indicated.    

    Reasons to choose surgery over radiation

1.    I am a young healthy man with a long life expectancy and without many health problems
2.    It is very important to me to have my cancerous prostate removed from my body
3.    I want the added information that removal of the prostate (and possibly lymph nodes) provides to better assess my prognosis
4.    I want to have radiation as a possible treatment option if I have a cancer recurrence

    Reasons to choose radiation over surgery
1.    I am somewhat older or have other health problems which may increase the risks associated with a major surgical procedure
2.    I would like to avoid being put to sleep and undergoing a major surgical procedure
3.    If the PSA fluctuates some after treatment or does not go all the way down to zero, this will not cause unnecessary anxiety for me

In summary, both surgery and radiation are excellent treatments for prostate cancer. If you have any doubt about which treatment is right for you, you should see both a urologic surgeon and a radiation oncologist to learn more about each treatment. Again, the most important thing is to become well educated about your options, and then to choose the treatment that is best for you.

Hormonal Deprivation Therapy
Testosterone, the major male hormone in the body, stimulates prostate cancer growth.  Hormonal deprivation therapy involves medication or orchiectomy (surgical removal of the testicles) to stop the production of testosterone or the effects of testosterone in the body. While not curative, hormonal deprivation can significantly slow the growth of prostate cancer often delaying its progression for many years. Over time, hormone-resistant cancer cells eventually develop leading to cancer that is no longer responsive to hormonal treatments. The most appropriate candidates for primary hormonal deprivation therapy are typically older men with a shorter life expectancy, those with significant medical problems that would make surgery or radiation unsafe, or those patients who do not wish to choose curative therapies (i.e. surgery or radiation, etc.).  

Often, hormonal deprivation may be used in conjunction with another therapy to optimize the ability to control the cancer. This is typically recommended for men with more aggressive prostate cancers who choose radiation therapy. In addition, hormonal therapy may be used after surgery if cancer is found in the lymph nodes at the time of surgery or if cancer recurs during surveillance after surgery.

The major side effects of hormone deprivation depend on the type of hormone therapy used. However, in general, the side effects may include decreased sexual desire or libido, hot flashes, fatigue, decreased bone density, and mood alteration. Due to the risk of decreased bone density, your physician may recommend monitoring of your bone health as well as calcium/vitamin D supplementation and other preventive measures to avoid bone loss. Other longer term side effects may include increased risk of cardiovascular disease, hypertension, diabetes, high cholesterol, and/or weight gain.

Advantages: Avoids invasiveness, inconveniences, and potentially permanent side effects of surgery or radiation treatment. Treatment targets cancer cells throughout the body.
Disadvantages: Is not curative and does have the significant side effects as listed above.

Cryoablation
Cryotherapy or cryoablation of the prostate involves the destruction of prostate tissue and cancer cells by freezing. Patients who choose cryoablation undergo an outpatient procedure in the operating room where needles are placed into the prostate. These needles are then used to freeze the prostate while measures are taken to warm the urethra to minimize damage to the urinary tract.

While cryotherapy has been used for many years to treat prostate cancer, it previously was associated with a high complication rate. However, improved technology has greatly reduced the risk of these complications today.  The major use of cryotherapy has been for patients who have been initially treated with radiation therapy and then have a cancer relapse.  However, some men are choosing to have cryotherapy as their initial primary therapy as well.  Unfortunately, long-term results are currently lacking for the primary treatment of prostate cancer with cryoablation making it somewhat more experimental than radiation or surgery in this setting.

There are no established guidelines on how to monitor prostate cancer after cryotherapy or how to determine if cancer is recurrent based on PSA.  Side effects include urinary problems including leakage, fistula formation, rectal or perineal pain, and erectile problems.

Advantages: It is minimally invasive and does not involve radiation exposure or surgical risk.  Repeat treatments are possible with cryotherapy.
Disadvantages: In comparison to surgery or radiation, there are no available long-term results on cancer control for cryotherapy as a primary therapy for prostate cancer.  Erectile dysfunction is very common after this type of therapy. Defining recurrent cancer after cryotherapy is difficult.

Chemotherapy

Chemotherapy is drug therapy that is administered to the entire body to kill cancer cells. Currently, chemotherapy is used most commonly for prostate cancers that have spread beyond the prostate. These drugs are very powerful and work by killing cancer cells which tend to be fast-growing cells. Unfortunately, chemotherapy is not very selective and so also kills other cells in the body that grow and divide quickly resulting in side effects such as anemia, weakness, fatigue, nausea, diarrhea, etc. Chemotherapy rarely cures prostate cancer, but recent information has found that certain chemotherapy regimens (docetaxel-based) can improve survival in certain patients with advanced disease.

Dietary / Herbal Therapy
In general, it is believed that a “heart-healthy” diet is also “prostate-healthy”. That means that a diet low in fat and high in fruits and vegetables is probably also good for the prostate. No evidence currently exists to suggest that diet or herbal treatments can cure prostate cancer.

Experimental Therapies
High-Intensity Focused Ultrasound (HIFU):
Acoustic energy is used with ultrasound focusing to generate heat within the prostate to either kill focal areas of the prostate or the entire prostate gland. This type of therapy can be repeated.  Side effects may include fistula, urinary leakage, urethral stricture, perineal pain, and erectile dysfunction.  Currently, HIFU is not FDA approved for the treatment of prostate cancer in the United States and there is insufficient information to recommend it as a standard therapy.  However, some men have chosen to have HIFU treatment with the understanding that it should be considered experimental at this time.

Radiofrequency Interstitial Tumor Ablation:
Like HIFU, heat is used to selectively kill prostate cancer cells. Long-term results and information regarding complications and cancer control are not available at this time.  



 
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