What options do I have for treatment of my prostate cancer

Cliff's comment:

After finally realizing that, despite feeling great, I did indeed have prostate cancer, I had to figure out what the best treatment for me was. When faced with the option of leaving my prostate in place or removing it, I knew that, even though I was petrified of surgery, it would be the best thing for me in the long run. I knew that I could not live with my prostate gland and the continuous question of whether there were any viable cancer cells remaining in my prostate after interstitial seeds or radiation therapy.

Palliative

Treatment designed to relieve a particular problem without necessarily solving it. For example, palliative therapy is given in order to relieve symptoms and improve quality of life, but it does not cure the patient.

Watchful waiting

Active observation and regular monitoring of a patient without actual treatment.

Active surveillance

An alternative to immediate treatment for men with presumed low-risk prostate cancer. Involves close monitoring and withholding active treatment unless there is a significant change in the patient's symptoms or PSA.

Various treatment options are available for prostate cancer, each with its own risks and benefits (Table 7). The options available may vary with the grade of tumor, the extent of tumor spread, your overall medical health and life expectancy and your personal preferences. The treatments for prostate cancer can be divided into those that are intended to "cure" your cancer (definitive therapies) and those that are palliative, intended to slow down the growth of the prostate cancer and treat its symptoms. Definitive therapies for localized prostate cancer include: interstitial seed therapy (brachytherapy), external beam radiation (EBRT), and radical prostatectomy (open, laparoscopic, or robotic). Other therapies, such as cryotherapy, high intensity focused ultrasound (HIFU), and combination therapy (external beam radiation plus interstitial seed therapy) are not commonly used for men with localized prostate cancer.

Palliative therapies for prostate cancer include the use of hormonal therapies and radiation therapy for symptomatic bone metastases. In those individuals whose prostate cancer is refractory to hormonal therapy, chemotherapy may be an option.

The option of watchful waiting and active surveillance can also be chosen. Watchful waiting involves no treatment initially. Rather, your prostate cancer is monitored with periodic PSAs and DREs and possibly X-rays. The premise of watchful waiting is that some individuals will not benefit from definitive treatment for their prostate cancer. With watchful waiting, palliative treatment (treatment designed to slow down the growth of the

Table 7 Treatment Options for Prostate Cancer

Mode of Treatment

Hormonal therapy

• Therapy in which the male hormones (androgens) are eliminated from the body.

• Primary treatment for older men with prostate cancer who don't want surgery or forms of XRT but also don't want to watch and wait.

• Also used as therapy for men with metastatic disease.

Advantages

1. Orchiectomy: A one time procedure that avoids the need for shots; it drops testosterone quickly to almost zero and is permanent.

2. LHRH analogues and antagonists: Not permanent.

Disadvantages

Orchiectomy: Permanent outpatient procedure involves minor surgery, risk of infection, bleeding, pain.

2. LHRH: Can have flair of bone pain in those with bone metastases; need to pretreat these men with androgen receptor blocker; requires monthly to yearly visits/or shots, which can be expensive. Antagonists don't cause flair.

3. Antiandrogen therapy: Blocks cells' ability to absorb the hormone often used in conjunction with shots. Most antiandrogens are not effective as a single agent, however. Diarrhea, liver damage, impaired night vision.

4. Casodex monotherapy: Gynecomastia. Not approved in the U.S. Not permanent.

Curative: Yes/No

No: Hormone therapy stops the growth of those prostate cancer cells that are hormone sensitive. Used for treatment of metastatic diag-

Alternative If Fails

Chemotherapy

('Continued)

Mode of Treatment

Advantages

Disadvantages

Curative: Yes/No

Alternative If Fails

Cryotherapy

Minimally invasive, no blood loss. Quicker recovery; one-time procedure; can be used in those who cannot undergo RRPX or as salvage procedure for local recurrence after XRT.

Impotence, urethral strictures, urinary retention, urinary frequency, dysuria, hematuria, penile or scrotal swelling, fistula, incomplete treatment of cancer. Works better on smaller prostates; more difficult to perform if prior TURP (transurethral resection of prostate); incontinence up to 30% when used as salvage procedure.

Used primarily for XRT failures, but can be used as first line therapy.

Hormone treatment, radical prostatectomy, but there is increased risk of complication.

External beam radiation therapy

One-time procedure that may cure prostate cancer in earlier stages. Allows for pathologic staging of disease. PSA goes to undetectable if no remaining prostate cancer.

Incontinence; impotence; bladder neck contracture.

Rarely: a need for blood transfusion, nerve injury, rectal injury. Longer recovery period, 2-4% incidence of permanent incontinence. 20-40% incidence of permanent impotence.

Yes, in setting of localized diagnosis.

If it fails locally, external beam radiation therapy is used. If it fails in distant disease (metastases), hormones are used.

Mode of Treatment

External beam radiation therapy

Advantages

Avoids major surgery; may cure prostate cancer in early stages. Incontinence and impotence less common than with surgery. No transfusion risk.

Disadvantages

Fatigue; skin reaction in treated areas; urinary frequency and dysuria; proctitis, rectal bleeding, frequent stools, urgency; bowel function may remain abnormal; hematuria. Rare: fistula. No lymph node analysis or pathologic staging; requires treatments 5 days a week for 6 to 7 weeks; 30-50% chance of erectile dysfunction; 10-15% chance of bladder and/or rectal irritation. May have hair loss in area receiving full dose such as pubic hair. PSA doesn't go to undetectable levels.

Curative: Yes/No

Yes, in setting of localized diagnosis.

Alternative If Fails

Hormone treatment, which is palliative. Salvage prostatectomy with associated increased risk of incontinence.

Laparoscopic radical prostatectomy & robotic-assisted radical prostatectomy

Quicker recovery, less postoperative pain; possible better visualization of pelvic anatomy. Allows for accurate staging; same advantages as RRPX. Less blood loss compared to open radical prostatectomy. Robotic vs. lap—faster OR time, easier to perform. Comparable short-term outcomes to open surgery.

Laparoscopic A long procedure that was first pioneered by French in 1998; long-term data not available. Steep learning curve.

Robot is extremely expensive.

Yes, if localized diagnosis.

Locally, XRT; in distant disease, hormones are used.

Mode of Treatment Advantages Disadvantages Curative: Yes/No Alternative If Fails

Brachytherapy (interstitial seeds)

Minimally invasive; quick recovery, short hospitalization; no transfusions.

This therapy is not for every patient (men with high grade cancer, PSA > 10, Gleason score > 7, are more likely to fail). Large glands are more difficult. Urinary frequency, urgency, hematuria, rectal irritation, pain, burning, frequency and urgency with bowel movements. Chance of impotence or pain with ejaculation; 25-60% chance of impotence. No pathologic staging; urinary retention; harder to do if have had prior TURP.

Over the short term, if the diagnosis is localized, brachytherapy appears to be curative; long-term data need to be reviewed.

Salvage prostatectomy if localized; hormones if distant disease.

Chemotherapy

1. Kills and/or reduces growth of cancer.

2. Provides palliation (symptom relief).

Potentially significant side effects.

Some chemotherapy combinations have been shown to improve outcomes and significantly prolong survival.

cancer and to treat symptoms, but not cure the cancer) is instituted for local or metastatic progression, if it occurs. Palliative therapies include: trimming of the prostate (transurethral prostatectomy) if the prostate becomes large enough that it causes trouble urinating, hormonal therapy to decrease the size and growth of the prostate cancer and radiation therapy if symptomatic bone metastases occur.

Active surveillance differs from watchful waiting. The goal of active surveillance is to give definitive treatment to those men with prostate cancers that are likely to progress and to decrease the risk of treatment related side effects in those men whose cancers are less likely to progress. Thus, with active surveillance one also undergoes periodic PSAs and DREs, but definitive therapy is instituted when predefined changes are noted. There are no established active surveillance protocols, although studies are ongoing. You and your doctor would need to discuss a mutually agreeable protocol before starting active surveillance.

Monitoring with active surveillance is often more frequent than with watchful waiting. Active surveillance is better for older patients with shorter life expectancies and with lower risk prostate cancers

Surgery is currently the most commonly performed treatment with the intent to cure prostate cancer. The surgical procedure is called a radical prostatectomy (see Question 20) and involves the removal of the entire prostate gland. Radical prostatectomy may be performed through an incision that extends from the umbilicus to the pubic bone (Figure 9), through a perineal incision (between the scrotum and the anus) (Figure 10), laparoscopically (Figure 11), and more recently with the

Surgery is currently the most commonly performed treatment with the intent to cure prostate cancer.

Incision

Cutting of the skin at the beginning of surgery.

Figure 9 Surgical incisions for radical retropublic prostatectomy. A midline incision is made from the symphysis pubis to the umbilicis.
Figure 10 Radial perinal prostatectomy—incision lines.

Reprinted with permission from Gibbons RP, Radical Perineal Prostalectomy. Definitive Treatment for Patients with Localized Prostate Cancer. AUA Update Series, Vol. 13, Lesson 5. AUA Office of Education, Houston, TX 1994.

Figure 11 Trocar sites for laparoscopic radial prostalectomy.

Reprinted with permission from The Urologic Clinics of America, Volume 28, Number 2, May 2001, p. 424. © WB Saunders Company.

assistance of a robot (Figure 12). The choice of technique varies with the patient's body characteristics and the urologist's preference.

Interstitial seed placement (brachytherapy) is a procedure that is gaining in popularity because it is minimally invasive and requires a single treatment. Similar to radical prostatectomy, it is a procedure with intent to cure. This procedure involves the percutaneous placement of radioactive seeds into the prostate (see Question 22, Figure 13). Depending on the prostate cancer grade and stage and the PSA, conformal external-beam radiation therapy (EBRT), in which beams of

Interstitial

Within an organ, such as interstitial brachytherapy, whereby radioactive seeds are placed into the prostate.

Brachytherapy

A form of radiation therapy whereby radioactive pellets are placed into the prostate.

Percutaneous

Through the skin.

Figure 12 The da Vinci surgical system.

© 2009 Intuitive Surgical, Inc. Used with Permission.

high-energy radiation are aimed at the prostate (or other target organ), may be used in addition to the interstitial seeds.

Conformal EBRT

EBRT that uses CT scan images to better visualize radiation targets and normal tissues.

Conformal EBRT is a newer way of delivering EBRT to the prostate (see Question 23). Through the use of CT scanning and the improved ability to focus the maximum radiation effects on the prostate and less on the surrounding tissues, conformal EBRT may decrease side effects and improve results over those of traditional EBRT. This procedure is also performed with intent to cure.

Cryotherapy

A prostate cancer therapy in which the prostate is frozen to destroy the cancer cells.

Cryotherapy is a minimally invasive procedure in which probes are percutaneously placed into the prostate under ultrasound guidance. Liquid nitrogen is administered through the probes to freeze and kill the cancer cells (see Question 25). Currently, this procedure is more commonly used as a second-line procedure when an individual has not responded to EBRT. However, it, too, is used with intent to cure.

High-intensity focused ultrasound (HIFU) is a procedure that is being performed in Europe and appears to be an option for lower Gleason score prostate cancers and for local recurrence of prostate cancer after external beam radiation therapy. The procedure is performed by inserting a probe into the rectum. The probe delivers highly focused ultrasound to the prostate. The high intensity focused ultrasound heats the prostate to temperatures of 80-100 degrees centigrade, which is enough to kill prostate cancer cells. The effect is limited to the prostate and does not irritate the rectal tissue. HIFU is not currently approved for use in the United States.

Hormone therapy, through the use of pills, shots, both pills and shots, or bilateral orchiectomy, is a palliative approach to the treatment of prostate cancer. By removing or preventing the action of testosterone on the prostate cancer, these therapies shrink the prostate cancer and slow down its growth. However, they do not cure prostate cancer (see Question 26).

Various chemotherapy regimens are being evaluated to identify drugs that may be effective against prostate cancer. The ideal drug would be one that kills the prostate cancer, rather than just slowing down its growth. Recently, the Food and Drug Administration has approved the use of certain chemotherapies for men with hormone resistant prostate cancer (see Question 28). Clinical trials are being performed to identify new medications and combinations of medications in hopes of identifying more effective therapies with fewer side effects. You can contact your nearby medical center to see if they are participating in any clinical trials for prostate cancer.

Hormone therapy

The manipulation of the disease's natural history and symptoms through the use of hormones.

Use of radioactive beams or implants to kill cancer cells.

Chemotherapy

A treatment for cancer that uses powerful medications to weaken and destroy the cancer cells.

Radiation therapy is typically used as palliative treatment for patients with pain caused by bone metastases.

Intravenous (IV) medications, such as pamidronate, may also be used to treat painful bone metastases, and suramin may also be helpful in patients with extensive bone metastases (see Question 30).

Chemotherapy is the use of powerful drugs either to kill cancer cells or to interfere with their growth. Chemotherapy drugs are good at fighting cancer because they affect mostly fast-multiplying cancer cells. Some healthy cells in the body also divide quickly, such as cells that produce hair, blood, nails, and the lining of the mouth and intestinal tract. Cells in these parts of the body can be harmed by chemotherapy. Therefore, some common side effects of chemotherapy include hair loss, low white blood cell count, nail changes, mouth and throat irritation, nausea, and vomiting.

Chemotherapy can be either injected into a vein or taken by mouth. The medicine then travels throughout the body to reach some cancer cells that may have spread beyond the prostate. Often, patients who are given hormone therapy prior to chemotherapy continue their hormone treatment through the course of their chemotherapy. In studies, this treatment offered no survival benefit and helped only to reduce pain (see Question 28).

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