Prostate Cancer - Treatment
The traditional approaches to treating prostate cancer are surgery, radiation therapy, watchful waiting, and hormonal treatment. Here is an overview of the risks and benefits of each of these approaches and a peek into newer treatment approaches.
Complete removal of the prostate is one of the most common treatments for prostate cancer. Today, most of the procedures are done in ways that try to spare the nerves controlling your bladder and erections. These nerve-sparing surgeries reduce, but do not eliminate, the risk of incontinence (accidental urine leakage) and impotence (inability to have an erection).
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The open radical prostatectomy procedure is performed through a 5- to 8-inch incision (cut) between the navel (“belly button”) and the pubic bone. In a robotic-assisted laparoscopic radical prostatectomy, the surgeon places surgical instruments and a video camera though 5 to 6 small incisions in the abdomen; these are attached to a robot that the surgeon controls using a video console. A small (3-inch) incision is made to remove the prostate specimen at the end of the robotic procedure.
Robotic prostatectomy is becoming more popular because of the use of smaller incisions and because there is less blood loss. However, there are no major differences between the open and robotic procedures in terms of cancer control, complications, urinary continence, and sexual function. The technical skill of the surgeon appears to be a major reason for a successful outcome.
Risks of surgery
Most men lose control of their ability to urinate after surgery, and the problem can last for months. While most men gradually improve, about 10 percent will leak urine after coughing or in other stressful situations. One percent or less will have a more severe long-term problem that can be fixed by the placement of an artificial sphincter.
Despite the reduced risk of impotence with nerve-sparing surgery, many men--from 20 to 70 percent--will lose some degree of sexual functioning.
Benefits of surgery
Prostate cancer surgery often provides peace of mind because it removes the cancer. Men whose cancer has not spread beyond the prostate have a 90 percent chance of surviving and being cancer-free 10 years after surgery.
Radiation is about as effective as surgery to prevent cancer from spreading over a 10-year period. There are two types of radiation therapy – external beam radiation and brachytherapy.
External beam radiation
This form of radiation therapy uses powerful x-rays to attack the cancer. Body scans and computer technology are used to pinpoint the exact location of the cancer to which the radiation beam is applied. Treatments take only about 15 minutes but are time-consuming, because you will likely need to go to the hospital every day for about two months of treatments.
External beam therapy risks: Urinary problems (burning pain during urination, and having to urinate more often) commonly occur during treatment, but there is less risk of permanent urinary problems compared with surgery. Other problems include:
These are usually temporary and go away over several months. Five years after treatment, about half of all patients report impotence.
External beam therapy benefits: The benefits of this focused-beam therapy include the following:
- It reduces damage to nearby tissue and structures.
- Treatment is not painful and is less draining compared with surgery.
- It can be used to treat cancers that have spread into the pelvis and cannot be removed with surgery.
- It can help reduce pain and shrink tumors in advanced disease that can't be cured.
- Compared with surgery, incontinence occurs less often with external beam therapy.
More research is needed to confirm external beam radiation's potential benefit and role in prostate cancer therapy.
In this form of radiation therapy, radioactive pellets – each the size of a grain of rice -- are implanted into the prostate. The number of pellets (up to 200) depends on the size and location of the cancer. This therapy may work best in small- to medium-sized cancers and may not be a good option for men with larger tumors, more aggressive forms of prostate cancer, or cancer that has spread just outside the prostate.
The implant procedure takes about 1 hour and is done on an outpatient basis (the patient goes home the same day). Although the pellets deliver a higher dose of radiation than the external beam procedure, the radiation travels only a few millimeters and is unlikely to spread beyond the prostate.
Brachytherapy risks: Even though radiation does not travel far from the prostate with this form of therapy, there are some risks. Because the prostate is close to the urethra, brachytherapy may cause more severe urinary problems than external beam therapy. Some patients need a catheter (a thin, hollow tube) to help them urinate while the radiation remains most active – usually about six months, although it may take up to a year for the radiation to completely leave the body. Also, because exposure to radiation can be dangerous for pregnant women and small children, patients who have brachytherapy should stay at least six feet away from these individuals for the first few months of therapy.
Brachytherapy benefits: Compared with beam therapy, brachytherapy may cause fewer rectal symptoms. There is also a lower rate of impotence (only reported by 30 to 50 percent of brachytherapy patients versus 50 percent of beam-treated patients).
Overall/additional risks of radiation therapy:
- Urinary problems (burning and increased frequency) and bowel problems (diarrhea, bleeding from the rectum, painful or difficult bowel movements) are more common with radiation treatment than with surgery.
- Incontinence is less common with radiation than with surgery. The urinary and bowel problems can last for months before gradually going away.
- Radiation therapy may cause impotence in up to 50 percent of patients.
Overall/additional benefits of radiation therapy:
- Because there is no surgery or anesthesia with external beam radiation, treatment has a lower risk of death and other serious complications than surgery.
- Radiation therapy can be less painful and easier to recover from than surgery.
- Radiation therapy can be used to treat cancers that have spread into the pelvic cavity, and can be used to help shrink tumors and reduce pain in advanced disease.
- Compared with surgery, there is less risk of permanent urinary problems; however, with certain types of radiation therapy, there is a higher risk of secondary malignancies (tumors), permanent bowel problems, and bothersome bladder symptoms.
Active surveillance is a treatment strategy that involves closely watching cancers that are believed to be a low risk to man's health and longevity because the cancer is small and slow-growing. With close monitoring, the patient visits his doctor on a regular basis for PSA testing and a prostate biopsy every 2 to 3 years.
When the cancer is becoming more of a problem (because it has grown, or there is a higher grade cancer on biopsy, or because of a rising PSA level), it is recommended that men have either surgery or radiation therapy. Most men on active surveillance who end up being treated for cancers that are growing are cured of their disease.
The appeal of active surveillance is that most men with low-risk cancers don’t have to go through the side effects of treatment, and that those who need treatment can still be cured. Active surveillance is a reasonable management strategy for men who are low risk when they are diagnosed.
Risks of active surveillance
The main risk of active surveillance is that a slow-growing cancer could suddenly speed up in growth, and you could be caught with a cancer that has spread beyond its original site, or can no longer be cured. Therefore, you should have a second prostate biopsy after you are diagnosed to better identify a potentially aggressive cancer that should be treated. If the second biopsy shows no aggressive cancer, the risk that a man on active surveillance will have rapidly growing cancer appear to be low, at least within the next 5 to 10 years.
Waiting until you are older for treatment is riskier, increases the chance of side effects, and lengthens the recovery period. Also, you have to be willing to return to your doctor's office more frequently for blood tests, rectal exams, and biopsies to check on your disease. In addition, you may find it emotionally overwhelming to worry about having a cancer and knowing that it isn't being treated.
Benefits of active surveillance
- The risk of impotence and incontinence associated with treatment is avoided.
- There is a good chance that you may never develop symptoms or require treatment. And even if the cancer grows, most prostate cancers grow very slowly.
- You may benefit from newer treatments that may be developed while your cancer is under surveillance.
- Research has shown that at least for the first eight years, the life expectancy of men who choose this option appears to be no different than those who choose to treat their cancer aggressively.
Cryotherapy is a method of treating prostate cancer by freezing the prostate gland. Freezing probes are inserted into the prostate (similar to brachytherapy) through the perineum (the area between the anus and the scrotum). The probes are guided by ultrasound into position to manage the freezing and thawing process (along with temperature probes positioned around the prostate). As the water within the prostate cells freezes, the cells die. The urethra is protected from freezing by a catheter filled with warm liquid. The procedure is performed on an outpatient basis under anesthesia (the patient is unconscious).
Risks of cryotherapy
Third-generation cryotherapy technology is relatively new and long-term outcomes with this technique are not available. Short-term experience suggests that this technique is successful in the appropriate patients (those with smaller prostates). Impotence occurs up to 90% of the time with this technique. Though rare, rectourethral fistula is a major complication of cryotherapy.
Benefits of cryotherapy
Cryotherapy is a minimally invasive treatment that can be performed as an outpatient procedure. In general, cryotherapy causes fewer problems with urinary control than other treatments, and causes fewer bowel problems than external-beam radiotherapy.
Hormone therapy can't kill prostate cancer, but it can be given alone or in combination with other forms of treatment to improve the quality of the patient’s life or help him live longer.
The most common form of hormone therapy is drug therapy. Injectable drugs such as leuprolide (Lupron, Eligard, Viadur) and goserelin (Zoladex) block the effect of testosterone, the male sex hormone. Blocking testosterone slows the rate of growth of the cancer. Another class of oral drugs, the antiandrogens flutamide (Eulexin), bicalutamide (Casodex), and nilutamide (Nilandron), work by preventing your body--and the cancer cells--from using testosterone.
Risks of hormone therapy
Hormone therapy is associated with many side effects, including:
- Lowered libido (sex drive)
- Hot flashes
- Weight gain
- Breast tenderness and enlargement
- Loss of muscle and bone mass
- Liver damage
While hormones may delay death, they cannot prevent it. There is a potential that advanced prostate cancer can become resistant to hormone therapy and no longer works. Men on hormone therapy are at a greater risk of developing osteoporosis and bone fractures, metabolic syndrome, insulin resistance, and possibly cardiovascular disease.
Benefits of hormone therapy
Hormone therapy can shrink tumors, which can relieve your symptoms and pain and possibly help you live longer.
Newer approaches to treating prostate cancer continue to appear. Among the newer developments:
- Docetaxel (Taxotere), a drug that is approved to treat breast cancer, has now been approved to treat advanced prostate cancer. Studies are underway to determine if the drug is beneficial in earlier stages of the cancer and in combination with other treatments.
- Cryosurgery (using liquid nitrogen to freeze and kill cancer cells) is being studied. While it seems to reduce urinary problems caused by surgery, it is associated with a high rate of impotence (as much as 80 percent).
Vaccines (using the body's own immune system to kill off cancer cells) and angiogenesis inhibitors (drugs that work by cutting off the blood supply to cancer tumors to try to starve them) are other areas of continuing research.
This document presents an overview of possible treatments for prostate cancer. The field of knowledge regarding prostate cancer treatments is growing and changing all the time.
The results of new studies can be confusing and can raise even more questions. It is wise to seek out hospitals and doctors that have a lot of experience with prostate cancer care. In addition, do your own research and bring your questions and concerns to your doctors. Together, you can make the best, well-informed decisions for your situation.
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