Cancer - Localized Prostate

LOCALIZED PROSTATE CANCER

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 7O-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.