Eleanor N. Dana Cancer Center

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Prostate Cancer Treatment

No two prostate cancers are the same, just as no two people are the same. This is why our prostate cancer team provides each patient with an individualized treatment plan.

The treatment for prostate cancer should focus on three main outcomes: cancer control, maintenance of continence (urinary control), and, if applicable, a healthy sex life.

Our urologists understand that all three of these outcomes are important to our patients and they work to maximize all three. However, treatment should be focused on a cure, and cancer control should never be compromised to ensure the other two outcomes.

Most prostate cancers are slow growing and will not metastasize or spread for years after diagnosed. As a result, our physicians determine the risk of this happening in a patient's lifetime. If the risk is extremely low, treatment may not be necessary. 

Here are the management strategies for prostate cancer, starting with the least invasive. 

Watchful Waiting
This management strategy involves doing nothing for the prostate cancer and waiting until it becomes symptomatic from growing or spreading. Should that occur during one's lifetime, the symptoms of the disease would be managed to allow for the greatest quality of life. Watchful waiting was developed for men with limited life expectancies. For example, a man of advanced age or a man with multiple, significant medical problems (such as other, more aggressive cancers, heart disease, emphysema, etc.) should be offered watchful waiting.

Because the risk of dying from prostate cancer is low for such an individual, there would be no reason for him to undergo treatment that could otherwise affect his quality of life.

Androgen Deprivation Therapy (ADT)
Prostate cancer growth is fueled by the sex hormones in your body (androgens such as testosterone). We know that limiting or eliminating testosterone from the body can help slow the growth of prostate cancer, and can even cause regression of the cancer in certain instances.

However, ADT does not cure or kill cancer on its own. All cancers eventually become resistant to ADT and will grow, even in the absence of androgens. As a result, we do not recommend ADT as a primary treatment strategy for men with curable prostate cancer. Instead, we reserve ADT for men with aggressive disease that has already spread beyond the prostate.

Active Surveillance (AS)
This is a relatively new management strategy and is very different and distinct from watchful waiting. Think of AS as a way of deferring treatment until the time is right to cure one's cancer. Ideal candidates for AS are those with very low risk cancer: low Gleason score, low PSA, low PSA density, low volume on biopsy and low risk on DRE. With AS, a patient and his urologist work together to determine the best method by which to track the cancer through time to ensure it remains low risk.

Many men worry that AS sounds too much like doing "nothing." However, large medical studies have shown that AS does not increase one's risk of dying from prostate cancer and does not decrease one's ability to cure the disease. In fact, the National Comprehensive Cancer Network (NCCN) lists AS as the optimal management strategy for men with very low-risk disease because it is associated with the fewest treatment side effects, since the patient is not actively being treated. Think of AS as the strategy that allows someone with prostate cancer to live his life as normal, without compromising cancer cure and longevity.

Ablative Therapy
Ablation is a minimally invasive treatment strategy that can be used to cure one's cancer. It is usually carried out under anesthesia by placing needles into the skin between the scrotum and anus, and inserting them into the prostate with ultrasound guidance. There are two basic methods used with ablation: ultracooling (cryotherapy) and ultraheating (HIFU/RFA). Both seem to work reasonably well for killing prostate cancer cells.

There are many advantages to ablative therapy. The procedure is minimally invasive and involves minimal recovery. Patients can usually be discharged from the hospital the same day and, if patients need a urinary catheter, it only stays in overnight. However, ablative therapy has its own risks. It is probably not appropriate for high-volume and high-risk disease. It can cause damage to the nerves responsible for erections and could possibly damage structures around the prostate, including the rectum, urethra and bladder.

The use of PSA as a tumor marker after ablative therapy is not well understood. We believe that PSA should fall rapidly and land close to zero, which indicates complete ablation of the prostate. However, a value greater than zero does not necessarily indicate persistence of cancer, which is why PSA is not a fully reliable tumor marker after ablation. Overall, ablative therapy is a reasonable option for men with low-risk and intermediate-risk disease.

Surgery (Radical Prostatectomy)
Surgical removal of the prostate remains a mainstay of treatment for cure. It is a time-tested procedure that offers excellent cure rates for almost all risk categories of disease. Surgery for prostate cancer involves removing the prostate and seminal vesicles and the lymph nodes at highest risk for being involved with the cancer. After removal of the prostate has been completed, the bladder is reattached to the urethra and a catheter is left in place to allow for this attachment to heal. Traditionally, this procedure was completed in an "open" fashion, in which an incision was made from the navel to the pubic bone. Advancements in laparoscopic and robotic technology now allow this procedure to be performed laparoscopically with robotic assistance.

Using these newer "closed" techniques, we have seen a decrease in post-operative pain, blood loss and hospital stay compared to the days when we did this procedure "open." In fact, most men who have robot-assisted laparoscopic procedures can be discharged from the hospital the day after surgery.

Surgical removal of the prostate offers many advantages. As a matter of convenience, it is a one-time treatment for cure. Also, in removing the prostate gland, we generate a specimen for the pathologists to review. They are able to determine whether the cancer was more or less aggressive than it appeared, and whether it was completely removed. After surgery, PSA becomes an excellent tumor marker, as it should fall to undetectable values post operatively. Should the patient's PSA rise after surgery, it is a very early indicator that his cancer has returned and additional treatment may be needed.

Patients should discuss with their physician whether or not they are a good surgical candidate based on their overall health status, as someone with a number of medical conditions may not be able to tolerate the surgery. Surgery is relatively invasive, as we have to go inside the body to remove the prostate, even when done robotically. After surgery, most surgeons will leave a catheter for about one week to allow the bladder and urethra to heal, and this can be uncomfortable for many men.

With surgery, there is always a risk of damaging structures around the prostate, specifically the rectum, blood vessels and nerves that go to the lower legs. With modern techniques and technology, however, these risks are extremely low. Surgery also carries a risk of incontinence and impotence. The rates for incontinence following robotassisted laparoscopic surgery are quite low. When looking at national averages, the rate is somewhere in the 5-10% range. This is similar to that following radiation therapy. The rates of erectile dysfunction are harder to determine, as not all men have the same erectile capacity prior to surgery. With a nerve-sparing prostatectomy, the rates of erectile dysfunction have fallen dramatically, but are not zero. 

Radiation Therapy
Radiation therapy for the treatment of prostate cancer offers excellent opportunities for cure. There are two main options for the delivery of the radiation: implantable seeds (brachytherapy) and external radiation generator (external beam radiation therapy). We will review each briefly here, but a full consultation with a radiation oncologist is warranted prior to choosing a treatment modality.

Brachytherapy
With brachytherapy, radioactive metallic seeds are implanted into the prostate while the patient is under anesthesia. These are placed with ultrasound guidance via needles placed in the skin between the anus and scrotum. Brachytherapy offers the advantages of being minimally invasive and a one-time treatment.

Brachytherapy is usually reserved for men with low to intermediate risk cancers and those with normal-sized glands. Solo brachytherapy is not ideal for more aggressive forms of prostate cancer, or for men with urinary symptoms resulting from enlarged prostates.

Finally, the brachytherapy seeds are not removed after treatment. Most data suggests that the rates of bladder and bowel damage are higher for brachytherapy when compared to external beam radiation therapy. Damage to these structures can be devastating and, in most cases, irreversible.

Following brachytherapy, PSA is a reasonable tumor marker, but patients should be aware that PSA may rise and fall for up to 18 months following treatment. A recurrence for brachytherapy, and external beam, is defined as a PSA value that is the lowest-ever PSA value plus 2. For example, if a patient's PSA falls to 0.6 after radiation therapy, a diagnosis of a recurrence would be at a PSA value of 2.6.

External Beam Radiation Therapy (EBRT)
With EBRT, an external source of radiation is used to eradicate prostate cancer. The beams of radiation are focused on the prostate based on CT scan imaging techniques. The amount of radiation and the number of treatments vary by treatment center, but usually involve anywhere from 28 to 40 treatments.Depending on the aggressiveness of one's cancer, patients may require concurrent androgen deprivation therapy (ADT) for 6 months up to 3 years.

The advantage of EBRT is the fact that it is non-invasive, so there is no recovery for treatment. Also, side effects of the therapy are typically not immediate, so patients can continue to live life as normal for some time following EBRT. The most common immediate side effect from EBRT is fatigue. The need for multiple consecutive treatments is usually seen as the major disadvantage of EBRT, especially if travel and taking time off work is difficult.

Also, just as with brachytherapy, damage to the bladder and rectum can result in debilitating side effects that can have a major impact on one's quality of life.

Following EBRT, PSA is a good marker to assess for cancer recurrence. The definition of recurrence is the same for EBRT as it is for brachytherapy: the lowest-ever PSA value plus 2. Again, before deciding on any form of radiation therapy, be sure to meet with a radiation oncologist to discuss treatment options and possible complications.

Learn more about radiation therapy at the Eleanor N. Dana Cancer Center: uthealth.utoledo.edu/centers/cancer/radiation-oncology

The diagnosis and treatment of prostate cancer is complex. No two men are exactly the same, and, similarly, no two prostate cancers are exactly the same. Once diagnosed, it is important for patients to gather as much information as possible prior to making a decision regarding treatment. Never hesitate to ask questions and get answers.

To make an appointment with a UT Health prostate cancer specialist, call 419.383.6644.

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Last Updated: 4/20/16