How do I decide which treatment is best for me

Currently, the burden of medical decision making falls on you, the patient, and it is our job as physicians to provide you with the information that will allow you to make the decision. When forced to make a difficult decision, we often rely on loved ones, close friends, and knowledgeable individuals to help us, but these people do not have to live with the effects of that decision. As you weigh the pros and cons of each of the various treatment options, it is very important that you think of how they will affect you. Now is the time to be very honest with yourself about what side effects you can and cannot tolerate. It is your physician's responsibility to accurately inform you of the likelihood of side effects of each of the treatment options and the remedies that are available to treat those side effects. When faced with a diagnosis of prostate cancer, the first impulse may be to get rid of the cancer at any cost. Unfortunately, once the prostate cancer has been treated and that worry quiets down, the side effects of the treatment can become more bothersome—so you should think seriously about them beforehand.

When counseling a patient, the first question that I typically ask is "Can you live with your prostate inside of you over the long term?" If the answer is no, that you would be constantly worrying about whether cancer remained in the prostate if it were left in place, then a radical prostatectomy is probably best for you. Other issues to bear in mind are the impact of incontinence and erectile dysfunction on your lifestyle. Virtually all forms of therapy can cause erectile dysfunction. If this is particularly worrisome to you, then it may be appropriate to meet with an urologist who treats erectile dysfunction to discuss the treatment options before you begin treatment for your prostate cancer. Similarly, it may be helpful to discuss the various treatments for incontinence or inability to urinate (retention) with your urologist or radiation oncologist before undergoing treatment. Your physician may make some treatment recommendations based on your age, medical conditions, and

Retention

Difficulty in emptying the bladder of urine; may be complete, in which one is unable to void, or partial, in which urine is left in the bladder after voiding.

clinical stage of your prostate cancer. If you have questions as to why certain recommendations are being made, now is the time to ask them. Remember, no question is stupid. Your physician wants you to feel comfortable with your decision and will help you find the information that you need. There are also organizations that can provide you with information regarding treatment and side effects (see Appendix B).

In an effort to help determine which therapies have the best chance of curing you of your prostate cancer, researchers have stratified prostate cancer into low-risk, intermediate-risk, and high-risk for disease progression. The treatment recommendations vary with the risk.

Low-risk:

T1c or T2a prostate -cancer PSA < 10 ng/mL Gleason score < 6

Intermediate-risk:

Clinical stage T2b

Gleason score 7

PSA 10 ng/mL-20 ng/mL

High-risk:

Clinical stage T2c or higher PSA > 20 ng/ml Gleason score 8-10

Low-risk patients usually do well with a single therapy, such as radical prostatectomy, external beam radiation therapy, or interstitial seed therapy. High-risk patients are more likely to experience a treatment failure, and combination therapy, such as external beam therapy and hormonal therapy, is often recommended.

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