CANCER - PROSTATE CANCER TREATMENTS:

Selecting the Treatment Plan


The selection of the treatment for prostate cancer is dependent upon
several factors. Patient preference as to the form of therapy, with its
associated risks and benefits, is most important. The stage and grade of
the cancer, as well as the age of the patient, are all considerations that go
into recommendations to assist the patient with a selection.  

There is no therapy for prostate cancer which is clearly the best, and
unassociated with any significant risks or side effects. As such, the
decision on form of therapy selected to treat prostate cancer must be one
carefully made, weighing the various factors of benefits vs risks.

The stage of a prostate cancer is the location of the cancer within the
body. Stage A is a prostate cancer which is microscopic and confined
within the prostate itself. Stage B is a prostate cancer which, while being
confined within the prostate, can be felt on rectal examination. Stage C is a
cancer  which is within the prostate and tissue adjacent to the prostate. It
can be felt on examination and may represent early local spread. Stage D
prostate cancer has spread outside the confines of the prostate to either
the lymph nodes adjacent to the prostate or distant sites, such as bone or
liver.

prostate cancer appears under the microscope. Common grading systems
employ the use of Roman numerals. A commonly used grading system
uses Grades I, II, III and IV. The higher the grade, the more angry
appearing the cancer is underneath the microscope, and the greater
likelihood that the prostate cancer will be aggressive in nature, with a
tendency to spread.

Observation

One of the therapies available for patients with prostate cancer is not really
a therapy in the sense that something is being done to cause the prostate
cancer to go into remission or cure; however, it is a manner in which to
observe the prostate cancer, since some prostate cancers have a low
likelihood of progression or spread, especially in men in the older age
group. Men who elect to enroll in observation therapy have surveillance of
their cancer performed on a regular basis. By no means are these men
neglected, and they are responsible for keeping regular appointments.
During most of the appointments, blood work (such as prostatic specific
antigen (PSA) will be drawn. A digital, rectal exam will be performed to
determine changes in the prostate and its cancer. Periodically, x-rays such
 as bone scans and other laboratory tests will be obtained. Often during
the first and subsequent years of observation, visits every three to four
months are requested. If problems arise, the frequency of visits may
increase. The patient will often have the option of progressing to another
form of therapy at a later date.

The goal of observation therapy is to minimize the risks of a therapeutic
intervention on a patient who would probably otherwise do well. It should
be understood that one of the first signs that the cancer is beginning to
become active is the sign of metastasis, or spreading. If local activity only
is detected, and the patient wants to progress to another form of therapy,
all of the subsequent therapeutic options are open to him. If metastatic
spread is the first sign detected of the cancer's advancement, then one of
the forms of therapy that addresses systemic cancer can be used, e.g.,
hormonal therapy.

Radiation Therapy

Radiation to the prostate cancer damages the prostate cancer cells and
causes them to go into a state of remission. This form of therapy should
not be considered a cure, in the sense that the cancer is eliminated. Thus,
frequent visits will be required by the patient for the rest of his life after
radiation therapy. The radiation therapy itself can be administered in one
of two ways. The radiation can be administered as external beam radiation
therapy. This type of radiation therapy is administered from a machine, and
requires no surgery to the patient. It is administered in the outpatient
setting over a six to eight week period.

Another form of radiation therapy is the implantation of radioactive metallic
seeds or pellets, directly into the prostate. To perform this, an operation is
required where the radioactive metallic seeds are placed directly into the
prostate, utilizing hollow core needles. These are introduced through the
skin (percutaneously) in the area between the rectum and base of scrotum.
This procedure is done under anesthetic, and is usually performed as an
outpatient procedure, rarely requiring an overnight hospital stay. The
radioactive metallic seeds are implanted directly into the prostate with the
assistance of a radiotherapist (a doctor who specializes in the
administration of therapeutic radiation). Often, external beam radiation
therapy, of a reduced course, is administered prior to the operation so that
the total dose of radiation received rises to therapeutic levels with the
introduction of the metallic seeds. This implantation of radioactive metallic
seeds is known as brachytherapy.  

The risks associated with radiation therapy should be discussed in detail
with the radiotherapist, who is familiar with that issue. Briefly, since
radiation therapy has to pass through otherwise normal areas of the body,
such as the bladder and bowel, problems related to urinary frequency,
urgency, and burning, and problems related to diarrhea, constipation or
painful defecation can be experienced. Often during the course of radiation
therapy, the patient experiences a feeling of fatigue and weakness. Most
often this goes away after the radiation therapy is completed.

One form of therapy involving radiation can be used if there are
metastases to the bone which are painful. In this form of radiation therapy,
radiation is directed to the painful metastases, thus causing the cancer in
that area to go into remission and reduce pain. This form of therapy, while
not curative, is helpful for those patients who have late-stage, widespread
prostate cancer. It must be understood, however, that this form of therapy
is limited, since radiation therapy can only be given in a certain amount to
an area once.

Hormonal Therapy

Most prostate cancers thrive in the presence of the male hormone,
testosterone. This hormone is produced by the testicles. While this
hormone does not cause prostate cancer, once the cancer is present, the
testosterone in the body serves as an important metabolite which the
cancer needs to flourish. By removing the testosterone, a significant
portion of men (approximately 80%) experience a remission of their cancer
which is durable (1-1/2- 3 to 5 years).

There are several ways to eliminate or decrease the testosterone from the
body. Since the testosterone is produced by the testicles, removal of the
testicles, called an orchiectomy, is a manner to completely eliminate the
testosterone produced by the testicles. Some men find this operation
psychologically repulsive. This form of therapy to eliminate testosterone is
very effective and inexpensive, since it eliminates the source of
testosterone and does not require further medication for this purpose, in
general.

Because some men do not wish to undergo an operation to remove the
testicles, which is performed on a Day Surgery basis, drugs are available
that do much the same thing, i.e., lower the serum testosterone.

One of the commonly used methods to reduce testosterone is the use of
an injectable drug which in a sense "tells the testicles not to produce
testosterone any more." There are a variety of these drugs available. One
commonly used is Lupron. This is administered as an injection once a
month in the doctor's office. This drug is very expensive, being
approximately $400 per shot; therefore, the office will assist in obtaining
the medication via the Medicare Program to minimize the patient's costs.
One side effect associated with this drug commonly experienced by
patients is hot flashes, a result of the reduction of testosterone in the body.
As with all forms of therapy used to decrease the serum testosterone,
impotence (the inability to attain and maintain erections) occurs and libido
(sexual drive) is decreased or eliminated.  

In addition to the injectable medication, there are pills which are taken
often to assist in hormone deprivation. There are three major brands of
pills available, all of which function to block any remaining circulating
testosterone, so that it is not "seen" by the prostate cancer cells. These
medications vary in the way that they are administered. Side effects
include skin rash, diarrhea, and liver enzyme elevation.

Surgical Removal of the Prostate

When the prostate cancer is locally confined to the gland itself, and if the
patient's age and general state of health permit, the only therapy which
actually has a chance of "curing" the prostate cancer, in the sense of
totally eliminating it, is the total removal of the prostate called radical
prostatectomy. This is a major operation in which the lymph nodes on
either side of the prostate are sampled. If at rapid review during surgery
the pathologist indicates that there is no evidence of spread to the lymph
nodes, the total prostate is removed. The bladder is then reconnected to
the urethra (urine tube). This operation requires approximately one week's
stay in the hospital. Since blood is often transfused with this operation, it is
suggested that the patient consider "banking" his own blood (autologous
transfusion) or obtaining blood from relatives or friends (donor specific
transfusion). (For information, contact the Gulf Coast Regional Blood
Center. (713)790-1200.)

Significant risks associated with this operation include postoperative
impotence (the inability to obtain and maintain erections for intercourse)
and urinary incontinence (the inability to control and store urine, with
leakage.) Although during surgery steps are taken to reduce the incidence
of these complications to a low number, the patient should understand that
radical prostatectomy is a major operation to remove the prostate organ
itself and that as a result, various nerves, blood vessels and adjacent
organs can be injured in the process of removing the gland and its cancer.
Should these complications occur, methods to correct them, such as penile
prostheses for impotence and urethral sphincters for incontinence are
available. Even if this operation is performed in an attempt to cure the
patient of prostate cancer, regular follow-ups will be required for the
remainder of the patient's life.

As you can see by carefully reading this patient education material, there is
no simple answer to the selection of prostate cancer therapy. As a
urologist, suggestions will be made to assist the patient in the choice of
therapy; the ultimate choice, however, is made by an educated patient.
This handout, as well as associated patient education materials and
discussion with the urologist, will help you in selecting the appropriate
therapy for you.


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