Prostate Cancer Treatment Options

Spain, Basque Country, Gipuzkoa, San Sebastian, Hospital Donostia, Surgeons performing prostate surgery
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You’ve been diagnosed with prostate cancer, what do you do now? Everyone is different and the treatment choice depends on many factors. To help you decide on a treatment path, most doctors will look at your age, general health, Prostate Specific Antigen (PSA), Gleason Grade, Cancer Stage (including any radiographic studies that may have been done), Cancer Volume (how much cancer is in your prostate) and your past medical history (what surgeries and medical problems you’ve had in the past).

Many patients are looking for the “right” answer.  They feel if they look hard enough and read enough they will find the answer. What we find are many opinions mixed in with facts and study results. I counsel my patients to find the answer that’s “right” for them. The treatment of a 50-year-old man with Gleason 8 cancer should be different than a 78-year-old man with small volume, Gleason 6 cancer.  All treatments are reasonable for some patients but not every patient. The pros and cons of each treatment should be carefully weighed before embarking on a treatment option.

One of the first decisions you will have to make is whether your cancer needs to be treated or if it can safely be watched. 

Watchful Waiting

In certain patients, a course of holding any active treatment and following the PSA is the best option. We call this Watchful Waiting or Active Surveillance. This is typically done with lower grade and lower stage prostate cancers.

  It is also a good option in the less healthy or older male. Active surveillance implies frequent PSA checks and usually includes a second biopsy (Recommendations range from 3 months to 1 year after diagnosis).  If at any time the cancer starts to progress an active treatment may be implemented.  It is estimated that about 25% of appropriate patients enrolled in watchful waiting protocols will need definitive treatment at a later date.

Active Treatments

Active treatment is a treatment with intent to cure, to either remove or kill all the cancer cells.  There are 3 standard active treatment options.

Surgery

Surgery for prostate cancer removes the entire prostate gland and surrounding tissue.  This may include the seminal vesicles and lymph nodes. The surgery is referred to as a Radical Prostatectomy and can be approached in different ways.

Robot-Assisted Radical Prostatectomy

With this type of surgery your surgeon will usually make 6 small incisions in your lower abdomen.  Through these incisions instruments are placed that are controlled by your surgeon via the robot.  The most common brand of robot is the da Vinci Surgical System.  The benefits of a robotic prostatectomy are that there is usually less blood loss, better visibility and a shorter length of time for catheter placement.  The downside is that there is no tactile feedback to the surgeon (the surgeon can’t feel your tissue) and there is a steep learning curve to this procedure.

  Most new urologists are only being trained to perform radical prostatectomy in this fashion.

Radical Retropubic Prostatectomy

An incision is made from below the umbilicus to above the pubic bone.  The benefits include a shorter surgery and therefor less anesthesia and full tactile sensation by the surgeon.  The downsides are usually a slightly greater blood loss and length of catheter stay.

Historically the prostate was removed via a perineal incision (between the anus and scrotum) but this does not allow access to the lymph nodes and is rarely done.  A pure laparoscopic approach (without the use of a robot) is used by few surgeons.

Risks of all surgeries include blood loss, incontinence, erectile dysfunction and injury to surrounding structures.  There is little evidence to suggest that any one technique significantly decreases the risk of incontinence or erectile dysfunction. Regardless of the approach used you want to make sure your surgeon is competent and comfortable in the chosen technique. 

Radiation Therapy

Radiation uses high-energy x-rays to kill cancer cells.  There are several types of radiation treatments and the new forms use markers placed into the prostate gland so there is a target to aim the energy at.  Newer forms of radiation such as Proton Beam Therapy have yet to be proven better or safer than current modalities.

Radiation is delivered in two different ways.  External beam has an external source that aims the radiation at the prostate.  Brachytherapy is a technique where radioactive seeds are placed in the prostate. Success depends on the accuracy of delivering the radiation and the susceptibility of the cancer cells.  Radiation will often be combined with hormones in more aggressive cancers.

Cryotherapy

Cryotherapy for the prostate is a procedure in which the prostate cells are frozen and thawed to kill the cells.  Modern techniques use argon and helium to achieve this and the freeze/thaw process is repeated twice.  The procedure is done in an operating room under anesthesia.  Cryotherapy only works when the cancer is contained within the prostate.  It is a technique often used when the cancer is only in one location or after failed radiation treatment.  The benefits include a short hospital stay and quick return to activity in comparison to surgery.  Downsides include higher rates of Erectile Dysfunction than radiation if the entire gland is frozen.

Non-Curative Treatments

Hormonal Therapy

Prostate cancer grows in response to testosterone, the male sex hormone. Blocking or removing testosterone will cause many of the cells to regress or die.  For many years this was the only treatment for metastatic disease.  In the past, the testicles had to be removed (orchiectomy) but now temporary medication may be injected to achieve the same goal. Hormonal therapy is often used in conjunction with radiation therapy.

Two main techniques are used to block testosterone: stopping it’s production and blocking the receptor. These are available in many forms including pills, implants, and injections. Several new treatments for prostate cancer utilize better ways of stopping testosterone production or blocking the receptor.

Chemotherapy

Chemotherapy for prostate cancer is typically used when hormones have failed. Many advances have been made in the last ten years.

HIFU

High-Intensity Focused Ultrasound is a technology that uses ultrasound waves that are focused on a small area.  This generates intense heat and kills cells.  Because of poor initial performance, this technique is only available under research protocol in the US. 

Provenge

Sipuleucel-T (Provenge) Sipuleucel-T is a therapeutic cancer vaccine for prostate cancer.  It is meant for asymptomatic or minimally symptomatic patients with metastatic castrate resistant prostate cancer.  

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