CANCER - LOCALIZED PROSTATE CANCER:

LOCALIZED PROSTATE CANCER
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Observation?  Radiation Therapy?  
Radical Prostatectomy?

Prostate cancer occurs in more than 30% of men 50 years old or
older. It has become the cancer diagnosed most frequently in
American men and is the second leading cause of cancer deaths in
men. That is the bad news. The good news is that the cancer
remains localized in the prostate throughout the remaining life of up
to 70% of those who have it; in fact, patients frequently die with
prostate cancer rather than from it.

Unfortunately, we do not have any tests today that can predict
reliably which cancer will remain harmlessly localized in the
prostate and which will spread. We cannot, therefore, identify which
patients will do well with no treatment --with observation alone--
and which ones need treatment for their localized prostate cancer.
This state of uncertainty is what makes it difficult for physicians to
advise patients on the best course of action.

We present here a summary of what medicine knows about
prostate cancer. Although this general information applies to most
men with localized prostate cancer, it may not apply to you. Each
patient is different. If your physician has recommended one
treatment over another, he has done so only after carefully
considering a number of factors that apply to you alone--your
family's longevity , any preexisting medical problems such as heart
disease or diabetes that could shorten your life or affect your
treatment, the histologic appearance of the tumor (Its grade) , the
level of prostate-specific antigen (PSA) in your blood, and the
results of other pertinent laboratory tests and diagnostic
procedures.

You and your physician have three treatment options to consider:
observation alone, radiation, and surgery.

Observation ("Watchful Waiting")

This approach involves no specific treatment. It consists of
long-term observation by your physician, during which you return
for regular follow-up examinations. If, at any time, the cancer
spreads, your physician can prescribe hormone therapy. The
rationale for this approach is based in part on the encouraging
results reported by several recent studies: men electing no therapy
had only a 1% risk of dying from prostate cancer at 5 years and a
16% risk at 10 years. The risk of cancer spreading was 8% at 5 years
and 18% at 10 years. These results are similar to those reported for
patients treated with either radiation or radical surgery.

Your personal risk of dying from prostate cancer is directly related
to your life expectancy and, therefore, to your age. Medicare has
provided some useful statistics. Among Medicare beneficiaries,
only men as young as 65 can, on an average, look forward to an
additional 15 years of life. For 70-year-olds, average life expectancy
is about 12 years; for those 75 years old, about 8 or 9 years. A
recent study based on a review of the medical literature and
analysis of Medicare claims data suggests that treatment, rather
than just observation, offers patients with localized prostate cancer
a less-than-1-year longer life expectancy. The study concludes,
therefore, that watchful waiting is a reasonable choice over
aggressive treatment for many men with localized prostate cancer.

As a result of this information, Veterans Administration hospitals
have begun a large-scale investigation of men with localized
prostate cancer. Those who agree to participate are randomized
either to undergo radical surgery or to receive no therapy, but to be
examined carefully at regular intervals. We will not know the results
of this investigation for many years, but the study underscores the
unanswered question: Will patients who receive active therapy
(radiation or surgery) live longer than patients monitored carefully
and treated only when the cancer begins to spread?

Radiation Therapy

Radiation has been used extensively since 1970 to treat some
patients who have localized prostate cancer. It can be delivered
exclusively by a machine (external-beam radiotherapy), be
administered by placing radioactive seeds or needles into the
prostate (interstitial or brachytherapy), or by combining both
approaches. We believe that when radiation is the treatment
chosen, then the external-beam technique is preferred.

Current results using radiation suggest that 75% of patients with
localized prostate cancer will still be free of disease at 5 years and
that over 80% will be alive, either with or without disease, at 10
years. Side-effects most commonly associated with radiation
therapy include diarrhea during the last several weeks of treatment;
easy tiring, which resolves in several months after the radiation
therapy is completed; and, less often, frequent and burning
urination. Late complications, those problems that develop after
radiation therapy is over, can include changes in bowel habits
(more frequent bowel movements, lose bowel movements, fecal
soilage), blood on the tissue after bowel movements, and, rarely,
rectal stricture and/or scores that require diverting the bowel to the
skin (forming a colostomy). Impotency, the loss of ability to achieve
a penile erection, develops in approximately 40% of patients as a
result of radiation therapy.

Radical Prostatectomy

The use of a surgical procedure called radical prostatectomy to treat
localized prostate cancer has increased six-fold in the United States
over the last 5 years. The major reason for this rapid increase is an
increase in the number of localized prostate cancer cases identified.
This is primarily because of better methods of diagnosis, chiefly the
availability and use of the test for PSA in the patient's blood.

In a radical prostatectomy, the surgeon removes the entire prostate,
the portion of the urethra passing through the prostate, and the
seminal vesicles. The neck of the bladder is then pulled deeper into
the pelvis and is reattached to the urethra so that urination may
proceed normally. Results of this procedure for patients with
localized prostate cancer show that 75% to 80% are alive and
disease free at 5 years and 70% to 80% are alive, either with or
without disease, at 10 years. In addition, several studies  have
suggested that 10 to 15 years after surgery patients treated
surgically enjoy a significantly higher survival rate than those
treated nonsurgically.

Patient age, as we can see, is an important factor in considering
radical surgery . In general, the older a patient is, the less he stands
to gain from radical prostatectomy. Older patients are more likely to
die in surgery or shortly thereafter, to remain permanently impotent
or incontinent, and, because spreading (metastasis) occurs at a
slow rate of 1% to 11% every 5 years, to die of another cause.
Younger patients are more likely to survive surgery , retain
potency, recover from other side effects, and live long enough to
realize a benefit from the treatment. Consequently, all things being
equal, we believe that the benefits of radical surgery are
increasingly marginal for patients between the ages of 70 and 74
and that the procedure is difficult to justify at all for patients 75 or
older .

The complications that occur most frequently as a result of radical
prostatectomy include impotence (in 60%-100%), incontinence (in
5%), or stricture of the bladder neck (in 15%). We have a number of
methods (noninvasive suction devices, drugs injected into the
penis, or surgically implanted inflatable prostheses) that can restore
potency and allow men to return to satisfactory sexual activity
.Most patients do lose urinary control temporarily but regain it
within 3 or 4 months. If scar tissue develops at the bladder neck, it
can usually be treated by a relatively minor operation in which the
surgeon cuts the stricture endoscopically.

Summary

It is important that every patient with localized prostate cancer
understand that he has a choice--between observation, radiation
therapy, and radical prostatectomy. We are available to make
recommendations based on your individual situation and to help
you understand your options, but in the final analysis, the decision
is yours.

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