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PROSTATE CANCER TREATMENTS Selecting the Treatment Plan
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. The grade of prostate cancer relates to how "angry appearing" the 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. °Copyright 2006 BHUROLOGY.com |
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