Treatment and side effects

On being diagnosed with prostate cancer, most men experience very strong emotions. Most men expect their doctor to recommend whatever treatment they need.

The many treatments available, some of them quite new, for localised prostate cancer make it difficult to choose which is the best treatment for you. Options include

  • active surveillance (watchful waiting),
  • surgery with a radical prostatectomy in all its various forms, including nerve-sparing, non-nerve-sparing and non-nerve-sparing with sural nerve graft. These operations can be performed open or laparoscopically, with or without robotic assistance.
  • Radiation including conformal external beam radiotherapy, brachytherapy with seeds and high dose rate brachytherapy
  • High intensity focused ultrasound, and
  • Hormone therapy.

With every person it is important to discuss all these options, including their cure rates, the side-effects, where the treatment takes place and the experience of the person treating you.

The type of treatment advised will depend on a number of factors including:

  • The stage of the cancer
  • The Gleason score
  • The level of PSA in the bloodstream
  • The mans age and general health
  • The side effects of treatment
  • And possibly - the treatment that the consulting doctor specialised in.

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Side Effects

The prostate is surrounded by the nerves controlling erections and lies close to the bladder and bowel. Risks of damage during treatment include loss of sexual potency, erectile dysfunction, continence (ability to control urine retention) and bowel function are very real.

There are also risks with any surgery regarding anaesthetics and infection that should be taken into account. These risks should be pointed out by your doctor and you should understand the risks before starting any treatment.

So before choosing a treatment you should be aware of side effects and consider the following steps.

  • Take your time to understand about your cancer, particularly its grade and stage. Study all treatment options available to you before making any firm plans.
  • Speak with your doctor, and raise any questions you have
  • Make a second appointment with your Urologist - prepare and take your questions and also a support person if it will help
  • Share the information with family and those close to you if it helps.
  • Get a second opinion if you think that will help you get confirmation or a different perspective.
  • You may like to speak with others who have experienced treatment for the disease. If possible, contact a support group.. You may find talking through the personal aspects of having to decide between treatments with others who have been there before. This will help put your natural fears about survival into a better perspective and can be extremely reassuring at this critical time

You should also be aware that a few large teaching hospitals which offer a range of treatments (e.g. surgery, EBRT and brachytherapy, discussed below) also offer the opportunity for multi-disciplinary treatment planning. Under this highly recommended method, each patient’s treatment is considered by a panel of experts (usually a surgeon, radiotherapist, medical oncologist, palliative carer, etc). The objective is to recommend the best course of treatment procedures for the patient, based on the combined views of experts from several medical disciplines, rather than having just the initial treating specialist make the recommendation. If multi-disciplinary treatment planning is available to you, you should consider taking advantage of the obvious benefits it offers.

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Cure Rates

Special tables or nomograms (known as Kattan Tables) have now been developed which help predict the likely cure rates of many of these different therapies. More information on these tables can be found at www.nomograms@mskcc.org. Individual institutions maintaining results should also give results to patients

At the very least, you should read all the literature you can find and seek reliable information from PCFA, your local Cancer Helpline and from reliable sources on the internet.

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Watchful Waiting.(also called Active Survellience)

This is the name given to monitoring a diagnosed prostate cancer without actually treating it. It is popular with men over 70 who have been diagnosed with low grade cancers or who have other illnesses that make traditional treatments inappropriate. It is sometimes used for younger men with the lowest grade cancers who are reluctant to be treated for life-style reasons. These tumours can be safely watched, using six-monthly PSAs and yearly or second-yearly biopsies to ensure that they do not progress. The risk lies in the possibility that a cancer may progress to an incurable stage during watchful waiting.

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Surgery.

Surgical removal of the whole prostate is called radical prostatectomy. For some patients it is a very appropriate attempt for a cure. It involves four to five days in hospital and another four to six weeks recuperating at home and has a relatively short treatment and recovery period.

The disadvantages are that the risk of impotence (inability to get an erection) and incontinence (inability to fully control leakage of urine) . There is a risk of infection, as with any surgery.

Radical prostatectomy side-effects have considerably improved over the last ten years. Long-term severe incontinence is down to very low figures (about 2%). Sexual side-effects after surgery are also far less common in certain groups of patients. Nerve-sparing techniques in experienced hands can now give far more rapid return

The skill, experience and result record of the surgical and theatre team who would be treating you are paramount to the outcome. Intending patients should enquire carefully into these matters before making a selection. Some specialists offer "nerve sparing" and "nerve grafting" procedures during surgery to minimise the risk of impotence

Early post-operative use of Viagra-like medications and/or penile injections appears to speed up the recovery of natural erections. Erections do, however, take quite a long time to recover and generally take 12 to 18 months to return, but may even take up to three years. Erection recovery after open or minimally invasive surgery depends more on the skill of the nerve sparing technique rather than the type of surgery. With both open and minimally invasion surgery nerve sparing techniques require considerable skill and experience. The other sexual side-effects that occur with surgery are the loss of ejaculation fluid and infertility, some penile shortening and a small risk of ejaculating urine at the time or orgasm. Most men state that their quality of orgasm is maintained.

After treatment, you will have further PSA tests, which should drop to 0.1 or zero within a few months if the surgery has been successful. Failure to achieve this may result in your doctor recommending further treatment. Your removed prostate will have been sent to a pathologist for examination. You should ask your doctor for details of what the pathologist’s report discloses, as this may have a bearing on your prospects of being "cured" or whether further treatment may be necessary.

Detailed information about radical prostatectomy, which has the best track-record of curing organ-confined disease, can be found in the book "Localised Prostate Cancer - a guide for men and their families".

New treatments for localised prostate cancer include different approaches for a radical prostatectomy

Nerve-sparing surgery aims to protect the erection nerves, minimising the side-effects of surgery. The technique of nerve-sparing surgery is becoming more common and potency rates, now as high as 80% or 90%, can be achieved in young patients who are potent with very early stage cancer.

Laparoscopic radical prostatectomy and Robot assisted laparoscopic radical prostatectomy

This is keyhole surgery involving the insertion of telescopes through small incisions in the body. Robotic means with the assistance of a machine in conducting the surgery.

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Radiation.

Radiotherapy involves the use of various types of X-rays to treat cancer.

External beam radiotherapy (EBRT) has been the traditional method of delivering the radiation. Short pulses of tightly focused beams of X-rays are delivered from outside the body into the prostate for a few minutes each day. Treatment continues five days a week for seven weeks. Conformal Radiotherapy, allows the X-rays to be directed very accurately to the prostate in three dimensions. EBRT has a track-record of success in "curing" cancers confined to the prostate that is very close to that of surgery.

From a patient’s perspective, the advantages of EBRT are that it is less intrusive and stressful than surgery, with no risk of infection. It particularly suits older men or those with fitness or other health problems that make the risk of surgery greater. The disadvantages are that time for treatment is much longer and may involve travel and accommodation problems, particularly for country patients. Radiation can damage other organs, particularly the bowel and bladder. Irritation of the bowel is a common side effect that can trouble patients for six months or longer after treatment. Rates of occurrence of incontinence and impotence are similar to surgery, but tend to occur later. With radiotherapy up to 50% of men develop erection problems and many develop mild to moderate inflammation of the bowel, although only approximately 3% of men develop severe, ongoing bowel problems. It is also important to mention that it is not uncommon after radiotherapy to develop a change in bowel habit, with looser and more frequent bowel movements, increased flatus and possible bleeding.. Once again, the skill, experience and result record of the radiotherapist and standard of the treating equipment are paramount to the outcome. Intending patients should enquire carefully into these matters before making a selection.

After treatment you will have further PSA tests to monitor developments. Your PSA should gradually reduce over about 12 months to between 1 and 2. If it fails to reduce to these levels, your doctor may recommend further treatment, probably by hormone therapy. However, regardless of the post-treatment movement of the PSA reading, it is quite common for doctors to recommend hormone therapy immediately after radiation as part of the total treatment.

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Brachytherapy

This is a more recent development in which radiation is delivered from inside the prostate

Low Dose Brachytherapy (prostate seed brachytherapy) employs radioactive seeds which are permanently placed within the prostate to kill the tumour. The process is done under anaesthetic and usually requires a stay in hospital. Usually recovery is quick compared to conventional surgery. Brachytherapy side effects are mainly urinary frequency and urgency. Brachytherapy using seeds appears to have the lowest side-effects on sexual function.

Advantages include:

  • Minimally invasive one-off procedure
  • Lower risk of impotence, urinary incontinence and bowel problems
  • Patients are usually able to return to their normal activities within a few days

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High Dose Brachytherapy

This procedure is more commonly used for tumours with higher PSA and Gleason scores. It involves placing hollow needles very accurately into the prostate and briefly pumping in, then removing, highly radioactive material to kill the tumour with minimum damage to adjacent tissues and organs. The process is performed under anaesthetic and most men are in hospital for less than two days. A follow-up procedure involves applying external beam radiation at lower dose over several weeks, and usually is accompanied by a period of hormone therapy. Recovery and treatment advantages are similar to those of brachytherapy treatment with seeds.

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HIFU (High Intensity Focused Ultrasound)

HIFU is an emerging new therapy which uses intense heat applied through the rectum to destroy the prostate and the contained prostate cancer.. It is extremely useful in older patients who are unsuitable for surgery or radiotherapy or who refuse surgery or radiotherapy and particularly suits patients who have had a previous TURP. Furthermore, it is one of the only therapies that can be used after radiotherapy has failed. High Intensity Focused Ultrasound initially causes difficulty in passing urine with frequency and burning and some risk of infection and temporary incontinence, but by three months, most of these symptoms have disappeared. Sexual side-effects depend on the extent of the treatment

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Hormone Therapy.

It has long been known that once prostate cancer develops, the male hormone testosterone, produced by the testicles, is closely involved in stimulating the cancer’s growth and spread. Earlier treatments for the disease often involved removing the testicles surgically to reduce testosterone production by the body. Now products are available that can be taken in the form of tablets or injections to suppress testosterone even more effectively. The process is known as hormone therapy.

Hormone therapy is often used to shrink the prostate and the tumour before commencing radiotherapy. It is now quite common for a course of hormone therapy to be administered after primary treatment by radiation or surgery, particularly if there is evidence that the tumour may have spread beyond the capsule (tissue immediately surrounding the prostate). There is emerging evidence that better outcomes are being achieved from these combined techniques.

If the prostate cancer has already spread to other organs or to bone at the time of diagnosis, hormone therapy becomes the primary method of treatment. Monthly or three monthly injections, possibly also accompanied by tablets, are used to try to reduce the PSA reading as close as possible to zero. Most advanced cancers respond well to hormone therapy for several years. Some doctors apply the therapy intermittently - six or twelve months on treatment then some months off - known as "pulsing". This gives the patient some respite from side effects and may extend the period of effective treatment, although this has not been proved.

The advantages of hormone therapy are that it is simple to administer. The disadvantages are the side effects, which can be distressing. They include hot flushes, loss of libido and erections, sweating, mood swings, disturbed sleep, loss of energy and personal motivation, body hair loss, bone loss, weight gain and breast development or tenderness. Unfortunately, most advanced cancers eventually become resistant to hormone therapy, after which the disease resumes its progress.

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Other Treatments.

Other methods of treatment are being offered by some specialists, but until detailed track-records of success are documented they are considered experimental Any man considering such treatment is advised to make very detailed and searching enquiries into the record of outcomes from the treatment before committing himself.

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