Prostate Cancer - Treatment
The traditional approaches to treating prostate cancer are surgery, radiation therapy, watchful waiting, and hormonal treatment. This document presents an overview of the risks and benefits of each of these approaches as well as 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 attempt to spare the nerves controlling your bladder and erections. These nerve-sparing surgeries reduce, but do not eliminate, the risk of incontinence and impotence.
The open radical prostatectomy procedure is performed through a 5 to 8 inch incision (cut) between the umbilicus and the pubic bone. The robotic-assisted laparoscopic radical prostatectomy involves inserting surgical instruments and a video camera though 5 to 6 small (0.5-inch) incisions in the abdomen; these are attached to a robotic 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 gaining popularity due to the appeal of smaller incisions and less blood loss. However, there do not appear to be substantial differences between the open and robotic procedures in the most important outcomes: cancer control, complications, urinary continence, and sexual function. The technical skill of the surgeon appears to be a major determinant of a successful outcome.
Most men lose control of their ability to urinate after surgery, and the problem could last for months. While most men gradually improve, about 10 percent will leak urine after coughing or other stressors. 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 will lose some degree of sexual functioning. Estimates of the number of men with impotence are wide ranging – from 20 to 70 percent – with this range being complicated by the number of men with possible pre-existing sexual dysfunction and the reported stage of cancer.
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 and increased frequency) commonly occur during treatment (but there is less risk of permanent urinary problems compared with surgery). Diarrhea, bleeding from the rectum, painful or difficult bowel movements, fatigue, and loss of appetite are other problems that are seen that tend to be temporary and subside over several months. The rate of impotence may rise to the same level as surgery after five years post-treatment (about half of all patients report impotence).
External beam therapy benefits: The benefits of this focused-beam therapy are that it minimizes damage to nearby tissue and structures. Also, treatment is not painful and is less debilitating compared with surgery. Beam therapy can be used to treat cancers that have spread into the pelvis and cannot be surgically removed, and can help reduce pain and shrink tumors in advanced disease that can’t be cured. Compared with surgery, incontinence is a less common occurrence. More research is needed to confirm the external beam radiation’s potential benefit and place 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 implanted (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. Although the pellets deliver a higher dose of radiation than the external beam procedure, the radiation travels only a few millimeters and therefore is unlikely to extend beyond the prostate.
Brachytherapy risks: Even though radiation does not travel far with this form of therapy, because of the prostate’s proximity to the urethra, brachytherapy may cause more urinary problems (and more severe problems) than external beam therapy. Some patients need a catheter at times 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 be fully depleted. Also, despite a low risk, because pregnant women and small children are more susceptible to the effects of radiation, patients undergoing brachytherapy are advised to stay at least six feet away from these types of individuals for the first few months of therapy.
Brachytherapy benefits: Compared with beam therapy, brachytherapy may be associated with fewer rectal symptoms and a lower incidence 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 compared with surgery. Incontinence is less common with radiation than with surgery. The urinary and bowel problems can last for months before gradually subsiding. 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 involved, radiation treatment is associated with a lower risk of death and other serious complications compared with 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 permanent bowel problems and bothersome bladder symptoms.
Active surveillance, referred to as "watchful waiting" in the past, is a treatment strategy that involves close monitoring of cancers that are believed to represent a low risk to man’s well-being and longevity (either because the cancer is small and slow-growing or because the patient has limited life expectancy due to advanced age or other medical problems). Close monitoring involves periodic clinic visits and PSA testing and a repeat prostate biopsy every 2 to 3 years.
When there is evidence that the cancer is becoming clinically more important (either due to an increasing quantity of cancer or higher grade cancer on biopsy or because of a rising PSA level), men are recommended to receive either surgery or radiation therapy. There is good evidence that the majority of men on active surveillance who ultimately receive treatment for cancers that are growing are cured of their disease. The appeal of active surveillance is that the majority of men with low-risk cancers are spared the side effects of treatment and that curability is not compromised for those who need treatment. Active surveillance is a reasonable management strategy for men who have low-risk features at diagnosis regardless of age, and for those with life expectancy less than 10 years who have more aggressive cancer.
There is a chance that the slow-growing cancer could suddenly speed up in growth and you could be caught with a cancer that spread beyond its original site or is no longer curable. A repeat prostate biopsy after diagnosis is recommended to better identify those potentially aggressive cancers that are better suited to be treated. For a man with low-risk features that are confirmed on a repeat biopsy, 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. Worry about having a cancer and knowing that it isn’t being treated may become emotionally overwhelming.
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. 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; argon and helium gas are used to freeze and thaw the prostate gland, respectively. As the water within the prostate cells freezes, the cells die. In the past, freezing of the prostate gland was accomplished using liquid nitrogen. Gas-driven probes enable greater temperature precision, which has resulted in fewer complications and increased efficacy. The urethra is protected from freezing by a catheter filled with warm liquid. Freezing probes are inserted into the prostate through the perineum, similar to prostate brachytherapy, and ultrasound guidance is used to position the probes and monitor the freezing and thawing process (along with temperature probes positioned around the prostate). The procedure is performed as an outpatient under anesthesia.
Third-generation cryotherapy technology is relatively new and long-term outcomes with this technique are not available. Short-term experience suggests favorable outcomes in appropriately selected patients. Prostate size is a limitation with this technique, which is generally restricted to glands less than 40 mL. Impotence occurs up to ninety percent of the time. Though rare, rectourethral fistula is a major complication 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 fewer bowel problems that external-beam radiotherapy.
Hormone therapies can’t kill prostate cancer but can be given alone or in combination with other forms of treatment in the hopes of improving the quality of life or extending survival. Research on the value and effects of hormonal therapies is ongoing.
The most common form of hormone therapy is drug therapy. Drugs such as leuprolide (Lupron, Eligard, Viadur) and goserelin (Zoladex) block the effect of testosterone, the male sex hormone. By blocking testosterone, the rate of growth of the cancer is slowed. Another class of drugs, the antiandrogens flutamide (Eulexin) bicalutamide (Casodex), and nilutamide (Nilandron), work by preventing your body – and thus the cancer cells -- from using testosterone.
Hormone therapies are associated with many side effects, including lowered libido, impotence, hot flashes, weight gain, breast tenderness and enlargement, loss of muscle and bone mass, nausea, diarrhea, fatigue, and liver damage. While it’s possible that hormones may delay death, they cannot prevent it. Eventually, advanced prostate cancer becomes resistant to hormone therapy and it no longer works. Men on hormone therapy appear to be at significantly increased risk of developing osteoporosis and bone fractures, metabolic syndrome, insulin resistance, and possibly cardiovascular disease.
Hormone therapy can shrink tumors, thus reducing your symptoms and pain and possibly extending your life.
Newer approaches to treating prostate cancer continue to emerge. Among the newer developments:
- Docetaxel (Taxotere), a drug previously 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 treatment strategies.
- 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 in the hopes of starving them) are other areas of ongoing research.
This document presents an overview of possible treatments for prostate cancer. The details of different surgical approaches were not discussed, nor were the different types of radiation therapies (for example, high-dose versus conventional beam radiation therapy and radioactive seed implants), and combinations of different treatment approaches. The field of knowledge regarding prostate cancer treatments is growing and changing all the time. Similar to breast cancer in women, the results of new studies can be confusing and even conflicting with the "current standard of care," raising even more questions. It is wise to seek out hospitals and doctors who 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 decision for your personal situation.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 11/15/2011…#12818