Treatment of Prostate Cancer
There are many ways prostate cancer can be treated. Understanding your options and making a decision between them, is complicated. Which options are right for you will depend on a number of factors, including your age, your overall health, your PSA value and how fast it is increasing. We also look at how far has the cancer spread (stage), how aggressive it is (grade), and how much cancer is found in your prostate. You and your physicians will review these factors and work out the treatment plan that is right for you.
Different kinds of treatment include active surveillance, watchful waiting, surgery, radiation, hormone deprivation therapy, chemotherapy. There are also a few alternative therapies, including cryotherapy and high intensity focused ultrasound. Other therapies are available for advanced prostate cancer, including transurethral resection of obstructing cancer, urinary diversion, and therapy for metastatic disease that targets disease in your bones.
Active Surveillance for Prostate Cancer
What is active surveillance for prostate cancer?
With Active Surveillance, you are closely watched to see if your disease worsens, but your prostate cancer is not yet treated. The goals are to avoid overtreatment of low risk disease and to catch advancing prostate cancer when it is still isolated to your prostate. If testing shows that your prostate cancer is progressing (by a rise in your PSA, a change in your rectal exam, or an increase in cancer grade or volume on repeat biopsy), therapy will be recommended.
Several studies looking at how prostate cancer grows and changes suggest that many cancers may have an slow course and that many patients may put off – if not avoid – surgery or radiation. The American Urological Association and The National Comprehensive Cancer Network, recommend that active surveillance be offered to carefully selected patients.
Who is appropriate for active surveillance?
There are several specific criteria which place you at low risk for progression. These include:
- PSA <10
- PSA density < 0.15 ng/ml / gram
- Gleason score <6
- Stage <T2a
- < 2 biopsy cores involved
- < 50% of any core biopsy
What is the follow up schedule for active surveillance?
In order to be on active surveillance, you must understand and adhere to this follow up schedule. If surveillance remains stable, the follow up will be:
- PSA and DRE every 3-6 months for 2 years, then every 6 months.
- Prostate biopsy at 18 to 24 months, then every 3-5 years.
What are reasons for intervention?
- Rise in PSA
- Change in rectal exam
- Increase in grade
- Increase in cancer volume
- You elect to proceed with definitive therapy
What are the risks and benefits of active surveillance for prostate cancer?
There is a risk of your prostate cancer progressing, which would then require definitive therapy. In the largest study to date (450 men with an average follow up of 6.8 years), about 30% of men went on to definitive therapy. Prostate cancer survival in this study was 97.2%. Overall survival was 78.6% [Klotz 2010]. There is also a risk that a window of opportunity to treat the cancer will be missed during surveillance, although this has not been shown to be the case in active surveillance studies.
The benefit to active surveillance is that you can avoid therapy and its possible side effects.
Watchful Waiting for Prostate Cancer
What is watchful waiting for prostate cancer?
Watchful waiting is another way to manage prostate cancer that does not involve upfront treatment, however it is different from active surveillance. Men who choose watchful waiting are older, or they have serious medical problems that would make the treatment risks of surgery or radiation would outweigh the benefits. The goal of watchful waiting is to delay treatment, unless the cancer begins to advance, and then begin hormone deprivation therapy.
What is the follow up schedule for watchful waiting?
Follow up will be tailored to your own case and will depend on your age, overall health, clinical stage, rate of rise of your PSA, grade, and symptoms.
When do I begin treatment?
Beginning treatment is also very individual, and will depend on the rate of rise of your PSA and whether you are developing symptoms.
Prostate Cancer Surgery
What is prostate cancer surgery?
Prostate cancer surgery, or radical prostatectomy, is the removal of your prostate, and possibly some surrounding tissue, as well as nearby lymph nodes in your pelvis. Surgery is a treatment option for localized prostate cancer. The goal of surgery is to remove all cancerous tissue. Once the prostate has been removed, the bladder is attached to the remaining part of the urethra.
How is prostate cancer surgery done?
There are three common ways to approach surgery to the prostate. The perineal approach removes the prostate through an incision between the scrotum and anus. The retropubic approach removes the prostate through a midline abdominal incision just above the pubic bone. Robotic and laparoscopic approaches remove the prostate using several small incisions in the lower abdomen.
How effective is prostate cancer surgery?
How well you will do will depend on the grade of your cancer and the stage. For low grade (Gleason 3+3=6) and low stage (clinical stage T1c) – the most common grade and stage of prostate cancer for which surgery is performed – cancer control rates are better than 90% to 95%. Cancer control is similar among the different surgical approaches.
Other types of surgery for prostate cancer include a pelvic lymphadenectomy and transurethral resection of the prostate (TURP). A pelvic lymphadenectomy is the removal of the lymph nodes in your pelvis where prostate cancer may go. This is usually done with a radical prostatectomy.
A TURP can help to relieve blockage of your urine flow from your prostate. Although it is often done for benign enlargement of the prostate, it can be done to relieve blockage from a cancer. A TURP is not a cure for prostate cancer, it only helps with blockage.
What are the side effects and complications of surgery?
Long term complications include incontinence and erectile dysfunction. The rate of incontinence is about 5% after 1 year. Your risk of erectile dysfunction depends to some extent on your erectile function before surgery, but may also depend on the stage of your disease and whether nerve-sparing surgery was possible. Risks of TURP include bleeding, urinary tract infection, incontinence, and erectile dysfunction.
Radiation Therapy for Prostate Cancer
What is radiation therapy for prostate cancer?
Radiation therapy is treatment of prostate cancer with high doses of radiation to kill cancer cells. Radiation can also be used to treat localized prostate cancer.
How is radiation therapy for prostate cancer done?
Radiation may be given in two ways – from the outside (external beam) or from the inside (brachytherapy or seeds). External beam radiation therapy is given in many small doses over several weeks. Brachytherapy is done as an outpatient procedure under ultrasound guidance and general anesthesia. In all cases, pre-procedure planning is done to maximize the dose of radiation delivered to the prostate and minimize the amount of radiation scattered to nearby structures.
How effective is radiation therapy for prostate cancer?
Similar to surgery, outcome of radiation will depend on the cancer stage and grade. Overall cancer control is similar to surgery.
What are the side effects and complications?
Side effects of radiation therapy can include urinary symptoms, such as frequency, burning with urination, blood in the urine, and urinary retention. It can also cause changes in bowel function, such as constipation, softening of stool, diarrhea, and rectal bleeding. In addition, brachytherapy may cause scarring of the urethra, and prostatitis (inflammation of the prostate). Radiation therapy can also cause long term side effects such as incontinence and erectile dysfunction.
Cryotherapy for Prostate Cancer
What is cryotherapy for prostate cancer and how is it done?
Cryotherapy is the destruction of prostate cancer by freezing it. Similar to brachytherapy, it is done as an outpatient procedure under ultrasound guidance and general anesthesia. It may be done as primary treatment (first line treatment for localized prostate cancer) or as "salvage" treatment (second line treatment for localized cancer in a patient who has already undergone primary treatment with either radiation or prior cryotherapy). Cryotherapy is done in specialized centers, however it is not offered at Middlesex Hospital. If you are interested in cryotherapy as a treatment option, please speak with your doctor.
How effective is cryotherapy for prostate cancer?
In carefully selected patients, cryotherapy can be effective in destroying cancer and lowering PSA. Data about the efficacy of cryotherapy are limited and variable depending on the center which offers it.
What are the side effects and complications?
Side effects can include irritative urinary or bowel symptoms, incontinence or urinary obstruction, scarring of the urethra, impotence, chronic pelvic pain, or an abnormal connection between the rectum and urethra.
High Intensity Focused Ultrasound for Prostate Cancer
What is high intensity focused ultrasound for prostate cancer and how is it done?
High intensity focused ultrasound (HIFU) destroys prostate cancer using ultrasound. Like brachytherapy and cryotherapy, it is done as an outpatient procedure under ultrasound guidance and general anesthesia. Like cryotherapy, it may be done as a primary (first line) or salvage treatment of prostate cancer. It may also be repeated if there is a recurrence of cancer. HIFU is not yet approved by the FDA and not done at Middlesex Hospital. A number of trials are open. If you are interested in HIFU, please speak with your doctor.
How effective is high intensity focused ultrasound for prostate cancer?
In carefully selected patients, HIFU can be effective in destroying cancer and lowering PSA. Data about its efficacy are limited at this point.
What are side effects and complications?
Side effects can include irritative urinary or bowel symptoms, incontinence or urinary obstruction, scarring of the urethra, or an abnormal connection between the rectum and urethra.
Androgen (Hormone) Deprivation Therapy for Prostate Cancer
Androgens, such as testosterone, are male hormones. They help the prostate develop, however, they also feed prostate cancer. By taking away androgens, most prostate cancers will shrink. Androgen deprivation therapy (ADT) is used to treat advanced prostate cancer and may also be used at the time of radiation for prostate cancer that has not spread. ADT is done in several ways:
- GNRH agonists are medications such as goserelin (Zoladex) and leuprolide (Lupron), given by injection, are similar to a hormone made in the brain that controls the production of testosterone. They are typically given every three months, but some are given more or less often.
- GNRH antagonists are medications given by injection such as degarelix (Firmagon) which stops a hormone made in the brain and also stops testosterone production. They are usually given every month.
- Antiandrogens are oral and injectible medications such as bicalutamide which blocks testosterone. They are rarely used alone, but may be added to another type of androgen deprivation therapy.
Other medications include ketoconazole and abiraterone which block a step in testosterone production.
Orchiectomy is also an option to remove testosterone. It is the surgical removal of the testicles. Testicles make most of the testosterone in the body. Removal of the testicles will cause the most rapid drop in testosterone and is an option for men with advanced life-threatening disease or men who do not want to undergo long-term medical therapy.
Although ADT can work very well in preventing prostate cancer from spreading, it is not a cure and it only works well for cancer cells that are sensitive to testosterone. In most cases, ADT will be a long-term therapy. Even if prostate cancer progresses on ADT, it is helpful to continue treatment.
Side effects of ADT include hot flashes, night sweats, decreased energy and appetite, decreased libido, erectile dysfunction, weight gain, loss of muscle mass, and osteoporosis. Cardiac (heart) problems have also been reported. Nutritional counseling is available through the Middlesex Hospital Cancer Center for men on ADT to help prevent some of the long term side effects.
Chemotherapy for Prostate Cancer
Chemotherapy is treatment of a cancer with drugs. There are many types of chemotherapy which work in different ways and which are used for different cancers. The chemotherapeutic drugs we frequently think of are cytotoxic – in other words, they kill cancer cells – but there are also drugs which stop bone loss and which stimulate your immune system. Chemotherapy is used for prostate cancer which grows despite ADT. Like ADT, chemotherapy is not a cure for prostate cancer, but can help slow the progression of the disease. The chemotherapy of choice for prostate cancer is most commonly docetaxel combined with prednisone. The most common side effects are fatigue and bone marrow depression.
Medications which stop bone loss include zoledronic acid (Zometa) and denosumab (Xgeva). Both medications may be used for prostate cancer that has already spread to the bones. Side effects of both medications are similar, and include fatigue, nausea, shortness of breath, and osteonecrosis of the jaw. Prior to receiving either of these medications, it is recommended that you see a dentist for a full evaluation.
One of the newest medications for advanced prostate cancer is Sipileucel-T (Provenge). This is the “prostate cancer vaccine” – a medication which can stimulate your immune system to fight the cancer. The vaccine is made from your own cells and given over three infusions.
It is the hope of the physicians and staff of the Comprehensive Prostate Cancer Program at the Middlesex Hospital Cancer Center that this overview will help you both understand the array of treatment options available for prostate cancer at all its stages and work with your doctors to make an informed decision about the best treatment plan for you.