Prostate Cancer Treatments
There are several treatments available for prostate cancer. The best treatment for any given patient is based on the aggressiveness of his prostate cancer and his life expectancy. In many cases, one patient may be able to choose from several different treatment options, in which case he will have to weigh the risks and benefits of each option.
Active surveillance for prostate cancer has been in use for several decades and has proven to be a safe and effective treatment for well-selected patients. Ideal candidates for active surveillance are patients with low-risk disease, who have a very low chance of developing metastatic disease over time. In addition, men with significant competing health problems or who are elderly may also be good candidates for active surveillance.
Active surveillance for prostate cancer is a strategy of closely monitoring the cancer with the option of more aggressive treatment in the future, if necessary. Surveillance includes visits to your doctor several times a year to have your PSA checked and a rectal exam performed. It also includes periodic repeat prostate biopsies. Additional tools such as MRI and genomic tests are sometimes used as well.
When well-selected men are treated with active surveillance, the risk of cancer spread and death is extremely low. However, up to 50% of men will require more aggressive treatment at a later date. Active surveillance is now the preferred option for most men with low-risk prostate cancer.
When patients have more aggressive prostate cancer or are unable to have active surveillance, curative treatment is recommended. There are several types of curative treatment for prostate cancer.
Surgery: Radical Prostatectomy
Radical prostatectomy is a surgery that involves removal of the prostate, seminal vesicles, and possibly the pelvic lymph nodes. There are two ways to perform a radical prostatectomy: (1) through an open incision below the belly button, or (2) using a robotic/laparoscopic approach through several small incisions across the abdomen. Today, the majority of radical prostatectomies are performed robotically, which has the advantage of a shorter hospital stay and less intraoperative blood loss. Still, the long-term outcomes of prostatectomy are similar with open and robotic/laparoscopic surgery. Randomized trials have shown that compared to observation only, radical prostatectomy decreases the chance of prostate cancer metastasis and death for men with more aggressive tumors.
Radical prostatectomy requires a hospital stay and most men are discharged with a bladder catheter for 7-10 days.
There are two notable risks of radical prostatectomy: urinary incontinence and erectile dysfunction. The prostate is part of the continence mechanism in a man’s bladder. Therefore, stress urinary incontinence can occur after removing a part of this mechanism and will result in leakage of urine, particularly with activity (coughing, sneezing, bending over, lifting something, exercising). Almost all men have some incontinence initially after surgery and will have to wear pads to protect their underwear. With the use of pelvic floor exercises and several weeks to months of healing, men slowly regain their urinary control. Even after a full recovery, some men can continue to leak and require protective pads, and rarely a surgery may be required to correct the leakage.
Delicate nerve bundles lie adjacent to the prostate, which are responsible for carrying the signal to get an erection. When a prostate is removed, these nerves can become temporarily or permanently damaged, resulting in erectile dysfunction. Erectile dysfunction is extremely common after radical prostatectomy and can take a very long time to return. Still, erections are possible after radical prostatectomy, using oral or injectable medications, vacuum devices, or an implantable prosthesis. When men do achieve an erection, they will no longer have the ability to ejaculate after a radical prostatectomy.
Radiation therapy is another curative treatment for prostate cancer. Radiation therapy is given by a radiation oncologist, and there are several ways to deliver radiation to the prostate. The choice depends on the disease characteristics, available resources, and preference of the treating physician.
Radiation can be delivered externally or internally. There are multiple types of external beam radiation therapy, using either photons or protons. Today, most radiation centers use sophisticated equipment that focuses the radiation dose as close to the prostate as possible while attempting to spare the surrounding healthy tissues. The traditional treatment duration for external beam radiation has been to have a small daily dose, five days a week for up to nine weeks. However, advancements in technology have worked to shorten the duration of treatment.
Internal radiation can be delivered in the form of brachytherapy seed implants or a high-dose brachytherapy catheter. Both types of internal radiation require a procedure with anesthesia, and sometimes they are delivered with extra doses of external beam radiation.
Androgen Deprivation Therapy (ADT)
For patients with intermediate and high-risk disease, radiation is generally delivered with androgen deprivation therapy (ADT). Androgen deprivation therapy temporarily lowers testosterone to very low levels, from six months for up to three years. This is usually accomplished through either oral or injectable medications.
Although the chance of cancer cure is similar to radical prostatectomy, there are different risks involved. Whereas radiation therapy does not have a significant risk of urinary incontinence, it can also cause erectile dysfunction. Radiation can also cause irritation of the healthy tissues surrounding the prostate, specifically the bladder and rectum. Radiation effects on the bladder can cause urinary urgency, frequency, burning, and sometimes bleeding. Radiation effects on the rectum can cause fecal urgency, blood per rectum, and rectal pain. These rectal and bladder effects are usually mild and resolve after the radiation is complete, but occasionally they can be severe or permanent.
In addition, ADT can cause side-effects, including fatigue, weight gain, weakness, hot flashes, cognitive changes, bone weakness, and worsening of blood sugar and cholesterol control.
Other Ablative Therapies
Although radical prostatectomy and radiation have been the two gold-standard curative therapies for prostate cancer over the past several decades, there are other options that may be appropriate for certain patients including cryotherapy and high-intensity focused ultrasound (HIFU). You should discuss with your doctor whether you are a candidate for these options.
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