Prostate cancer treatment
Your urologist and radiation oncologist will advise you on the best treatment after considering your age, general health, and the stage and grade of the prostate cancer. The side effects you are prepared to accept are also important.
Your doctor may recommend active surveillance, which means you don't have immediate treatment, but your cancer is actively monitored. If you have treatment, you may be offered one type of treatment or a combination. Surgery, radiotherapy or hormone therapy may be used.
Active surveillance is when your doctor recommends no treatment or deferred (postponed) treatment but will closely monitor the cancer with regular checkups. This is sometimes called watchful waiting.
While there is no standard protocol for active surveillance, it generally involves:
- frequent PSA testing, every 3-6 months;
- digital rectal examinations (DREs);
- repeat biopsies to monitor cancer growth.
Having no immediate treatment may be an option if the cancer is small (low volume) and slow growing (low grade).
Active surveillance may be suggested for men over 50 years old, or men who could have treatment but wish to avoid the side effects. It may be a good option if the possible treatment side effects would have more impact on your life than the cancer itself. You can always change your mind and have treatment later. If the cancer starts to grow, treatment is usually still possible with a good cure rate.
Living with an untreated cancer may make you feel anxious. You may find it helpful to talk to your urologist or radiation oncologist, or you can contact the hospital social worker.
Your doctor may suggest surgery if you have early prostate cancer, are fit for surgery and expect to live longer than 10 years. There are different types of surgery for prostate cancer.
A radical prostatectomy is the removal of the entire prostate gland, part of the urethra, and the seminal vesicles, which are nearby glands that store semen.
This surgery is usually done through a 10-12 cm cut in your lower abdomen. After the prostate is removed, the urethra is rejoined to the bladder. You will need to stay in hospital for 3-7 days to recover. A thin tube (catheter) will be used to collect your urine in a bag and you may need a catheter for 6-14 days after the surgery.
You may have some side effects from the surgery. Depending on your work and lifestyle, you should be able to return to normal activities within 4-6 weeks. Most men can resume driving within a couple of weeks, but should avoid heavy lifting for 6 weeks.
Nerve-sparing surgery involves the removal of the prostate and the preservation of the nerves controlling erections.
These nerves can only be saved if the cancer has not spread along them and there were no problems with the nerves prior to surgery. This surgery works best with men who had good quality erections before the operation. Problems with erections are common after nerve-sparing surgery, but there are ways to manage them.
Some patients may be able to have the prostate removed via keyhole surgery. This is called a laparoscopic prostatectomy or a robot-assisted laparoscopic prostatectomy.
In this procedure, several small cuts are made in the skin and a small tube is passed into the abdomen. A small telescope with a camera attached (the laparoscope) is passed through the tube to allow the surgeon to see inside the abdomen. The prostate is cut away and removed through the tube.
Men who have keyhole surgery instead of open surgery have a smaller scar, faster healing and a shorter hospital stay. They usually return to normal activities within 2-3 weeks. However, there is currently no long-term evidence to show if keyhole surgery leads to fewer side effects than conventional prostatectomy. See below for information about possible side effects.
Keyhole surgery is not suitable for all men. As with other types of surgery, the surgeon needs to be experienced. Also, robot-assisted surgery is more expensive than conventional prostatectomy. It is becoming more widely available as expertise is developed.
Side effects of surgery
Surgery may cause some or all of the following side effects:
- Bladder control - A radical prostectomy may cause you to have difficulty controlling your bladder. Known as urinary incontinence, this condition usually improves within a year of the surgery. Advances in surgical techniques have made major urine control problems uncommon. There are aids and exercises for this problem and it may be helpful to see a physiotherapist as soon as possible after your operation.
If you have cloudy urine or notice any other changes when passing urine, speak to your doctor. You may have a urinary infection.
- Nerve damage - The nerves and muscles needed for erections and bladder control are near the prostate. They can be damaged suring surgery, causing problems.
- Erectile dysfunction - Most men experience impotence (erection problems) after surgery. Recovery of erections can take a few years.
- Infertility - As the tubes from the testicles (vas deferens) are sealed and the prostate and seminal vesicles are removed, semen is no longer ejaculated during orgasm. This results in infertility. If you wish to have children, speak to your doctor before treatment about sperm banking or other options.
External beam radiotherapy
External beam radiotherapy uses high-energy x-rays to kill cancer cells or injure them so they cannot multiply. Radiotherapy is usually considered if you have early cancer and are otherwise in good general health. It may be used instead of surgery or in combination with surgery.
Before your treatment session, a radiotherapy technician will set up the machine. You may see the radiation oncologist and have blood tests. Preparation can take 1-3 hours. There can sometimes be delays with machine set-up and maintenance.
During the treatment session, you will lie on an examination table under the machine that aims at your prostate. Treatment is painless and each session usually takes about 15 minutes.
Treatment is planned to ensure as little harm as possible to the normal tissue surrounding the prostate. Modern machines are become more accurate and are able to limit radiation exposure to surrounding healthy tissue. One radiotherapy technique (conformal) uses three-dimensional beams to match the size and shape of the tumour.
If you live close to a hospital with radiotherapy facilities, you usually have treatment every weekday for up to 8 weeks. You can have this treatment as an outpatient and go to the treatment centre or hospital each day for your treatment session. Many men continue to work during the course of the treatment.
Side effects of radiotherapy
Radiotherapy can cause erection difficulties in some men. Other side effects, such as tiredness and problems with the bowel and bladder are becoming less common due to the use of conformal machines, which are able to target the tumour more accurately.
- Erectile dysfunction - Problems with erections are common after external radiotherapy in about 50 per cent of men because of damage to the blood vessels needed for erections. Problems may not occur immediately, but may develop over time and be ongoing.
- Tiredness - When your body has to cope with the effects of radiation on normal cells, it becomes fatigued. Your weariness may build up slowlyl during treatment but should go away when treatment is over.
- Urinary problems - You may experience burning or scalding when urinating, or an increased urgency to urinate. These side effects usually go away after treatment, but your doctor can prescribe medication to reduce any discomfort you experience. Injury to the lining of the bladder can sometimes cause bleeding. This is called radiation cystitis. Radiation is unlikely to cause incontinence but it can cause a build-up of scar tissue that makes it difficult to urinate.
- Bowel problems - Some men may bleed when passing a bowel motion. This is caused by damage to the fine blood vessels in the lower bowel. It is important to let your doctor know if you experience rectal bleeding. A few men may have diarrhoea or experience difficulty holding on to their bowel motions. These problems are usually temporary, but you should see your doctor if they continue.
Brachytherapy is a type of targeted internal radiotherapy where the radiation source is placed directly within a tumour. This allows higher doses of radiation to be given with minimal effect on nearby healthy tissues such as the rectum.
Brachytherapy can be given at either a low-dose rate by inserting permanent radioactive seeds, or at a high-dose rate through temporary needle implants. Brachytherapy is not suitable for men with significant urinary symptoms.
Low-dose rate brachytherapy
Permanent radioactive seeds are used for small tumours with a low Gleason score and a low PSA level.
Low-dose radiotherapy is implanted in the prostate in seeds about the side of a rice grain. The seeds, which release radiation that kills cancer cells, are inserted using needles and are guided into place by ultrasound. They lose their radiation effect over time.
This procedure takes 1-2 hours and is done under general anaesthetic. It usually requires an overnight stay in hospital.
Some seeds can be dislodged during sexual activity, so use a condom for 2 weeks after the implantation procedure.
This therapy is minimally invasive and more targeted, allowing a quicker recovery than external radiotherapy. It is most suitable for men with a small prostate gland and few urinary symptoms.
High-dose rate brachytherapy
High-dose rate brachytherapy is given through temporary needle implants. The treatment is usually given to men with a high PSA level, a high Gleason score and more advanced cancer. It is often combined with external radiotherapy and hormone treatment.
Hollow needles are placed in the prostate under general anaesthetic and high-dose radioactive wires are passed down the needles. After a few treatments over 36 hours, the needles are removed. The procedure usually requires a couple of nights in hospital. Some cancer treatment units now perform the implant as a day procedure and repeat it 2 weeks later.
Side effects of brachytherapy
You may experience the following side effects:
- Urinary problems - Inserting the radioactive seeds causes minimal discomfort, but side effects may include pain when urinating, poor urine flow and bladder irritation. These are temporary and can be treated. They usually start a week after treatment and last up to 6 months.
- Erectile dysfunction - Around 50 per cent of men experience impotence problems after temporary needle implants. Permanent radioactive seeds have the lowest chance of causing erection problems comparent with other treatments.
High intensity focused ultrasound treatment (HIFU) and cryotherapy are emerging prostate cancer treatment options. HIFU destroys the cancer cells using heat and cryotherapy destroys cells by freezing them.
Most cancer centres reserve these treatments for patients who do not want to have surgery or radiotherapy, or who are not suitable for those treatments.
Prostate cancer needs the male hormone testosterone to grow. Slowing the production of testosterone may slow the growth of the cancer or shrink it. This is called hormone treatment.
Hormone treatment will not cure prostate cancer. It can help with symptoms such as pain caused by the cancer spreading. It will put the cancer into temporary remission. This treatment is often given for several months before radiotherapy and may be continued after radiotherapy to increase the effectiveness of treatment.
Injections of luteinising hormone-releasing hormone (LHRH) are used to control the production of testosterone. It will not cure the cancer but will often slow its growth for years.
LHRH is usually given as a monthly, 3-monthly or 6-monthly injection. Treatment can also be given at irregular intervals depending on the needs of the patient. This approach can help relieve side effects caused by treatment.
Hormone treatment by surgery
Most men choose LHRH injections over surgery, however it is also possible to reduce testosterone levels by removing the testes. These types of surgery are uncommon, but they offer a permanent solution:
- Orchidectomy - the removal of the testes. After surgery, a plastic prosthesis can be put into the scrotum to keep its shape.
- Subcapsular orchidectomy - The removal of only the inner part of the testes. This does not require a prosthesis.
Side effects of hormone therapy
Hormone treatment may cause side effects because of the low testosterone levels. These include tiredness, erection problems, reduced sex drive, weight gain, hot flushes, breast tenderness, depression and loss of bone strength (osteoporosis). These side effects can be significant, but your doctor can help minimise the impact.
Hormone treatment is also known as androgen deprivation therapy (ADT).
Palliative treatment helps to improve people's quality of life by alleviating symptoms of cancer without trying to cure the disease. It is particularly important for people with advanced cancer. However, it is not just for end-of-life care and it can be used at different stages of cancer.
Often treatment is concerned with pain relief and stopping the spread of cancer, but it also involves the management of other physical and emotional symptoms. Treatment may include radiotherapy, chemotherapy, or other medication.
Grading prostate cancer
Prostate cancer is given a grade indicating how fast the cancer may grow. A system called the Gleason score is used for grading. The score is obtained by giving the two most common tissue types from the biopsy a grade between 3 and 5. These two grades are added together to get a final score out of 10.
A low or moderate Gleason score (6) indicates a slow-growing less aggressive cancer. A higher score (8-10) indicates a faster-growing, more aggressive cancer.
The grade tells you how fast the cancer is growing. The stage tells you how far the cancer has spread.
Your doctor will also consider the volume of the cancer. For example, if you have one small cancerous spot, your doctor would consider this a low-volume cancer. If you have a low-volume, low-grade cancer, you might choose to have less aggressive treatment.
Staging prostate cancer
A standardised international system called TNM is used to stage different cancer types, including prostate cancer.
In the TNM system, each letter is assigned a number that shows how advanced the cancer is. The lower the number, the less advanced the cancer.
|T (Tumour)||Indicates the size and depth of a tumour invasion.|
|N (Nodes)||Indicates whether the lymph nodes (glands) are affected.|
|M (Metastasis)||Indicates whether the cancer has spread|
Your doctor will explain your test results to you. You can also call the Cancer Council Helpline (13 11 20) for more information about how prostate cancer is staged.
Prognosis means the expected outcome of a disease. You will need to discuss your prognosis with your doctors, but it is not possible for any doctor to predict the exact course of your disease.
Your doctor will consider your test results, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as your age, fitness and medical history. These factors will also help your doctor give you advice on the best treatment options and let you know what to expect.Prostate cancer usually grows slowly, and even fast-growing prostate cancer grows slower than other types of cancer. Thsi means that for many men, the prognosis will be favourable and generally there will be no urgency for treatment.
With surgery, the prognosis is good, but side effects can occur long term and reduce quality of life. With other treatments, the tumour may shrink or stop growing, resulting in a remission, which means the cancer has been controlled. Even if the prostate gland is not removed, the cancer cells can still be killed.
Most men with prostate cancer usually return to normal or near normal good health after treatment.
For further information and advice, call the Cancer Helpline on 13 11 20.
For more information, call the Helpline on 13 11 20 for free copies of Understanding Palliative Care or Living with Advanced Cancer, or view them online at www.cancercouncil.com.au.