The first two sessions of cancer therapy for former President Nelson Mandela has come and gone. Two down, 33 to go. What does it involve?
Every day South African doctors diagnose new cases of prostate cancer. If you’re a wise guy like our former president Nelson Mandela – opting for regular check-ups – you can help doctors to diagnose your prostate cancer early.
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With a clinical examination of the patient and a blood test to determine levels of PSA (Prostate Spesific Antigen), doctors can diagnose prostate cancer early, even before any other signs or symptoms of this slow growing disease surface.
After diagnosis, treatment follows. Patients with cancers confined to the prostate (T1 and T2) and no involvement of the lymph nodes or other organs (N0 and M0) are potentially curable by surgery or radiotherapy. Patients with disease beyond the prostate are not curable. This fact stresses the importance of early detection.
Treatment
What are the treatment options and what does it mean?
The treatment options for postate cancer localised in the prostate gland alone, are:
A radical prostatectomy
External beam radiotherapy (the treatment option for Mandela, and often used in SA and world wide )
Brachytherapy (radiotherapy seeds)
Watchful waiting
Due to the slow-growing nature of the disease the benefit of cure usually only becomes apparent after 10 - 15 years.
The radical treatment of prostate cancer carries a high morbidity. The younger patient who will gain the most from the survival benefit of radical treatment also stands to suffer the greatest from the potential complications of erectile dysfunction and incontinence. Patients with less than 10 years life expectancy due to their age or other co-morbid disease should not be offered radical treatment for prostate cancer.
Radical prostatectomy involves the surgical removal of the prostate and surrounding structures. Radical prostatectomy provides the best chance of cure for early prostate cancer. Cure rates are quoted at 70 - 80% in the literature. The main complications are incontinence and erectile dysfunction. 5% of patients suffer total incontinence and 30% suffer a degree of wetness needing some protection. The incidence of erectile dysfunction varies with age and is quoted at 30 - 70%.
More about radiotherapy
Radiotherapy treats cancer by using high energy rays which destroy cancer cells while doing as little harm as possible to normal surrounding cells. Radiotherapy for prostate cancer is usually given from a linear accelerator (external beam radiotherapy), but for some men with very early prostate cancer, it can be given by inserting small radioactive seeds into the tumor.
In early prostate cancer the aim of the therapy is to destroy the cancer cells, but doing as little harm as possible to the rectum and the bladder next to the prostate.
External beam radiotherapy is not quite as effective as radical surgery in providing a cure, but has a slightly lower incidence of complications.
Treatment planning is very important and may take a few visits to the radiotherapist. Marks will be made on the skin to show the radiographer where the rays are to be directed. Before each session of radiotherapy the radiographer will position the patient carefully on the couch. During the short period of treatment, the patient will be left alone in the room but he will be able to talk to the radiographer, who will be watching carefully from the adjoining room. Radiotherapy is painless.
Mandela’s first therapy session on Tuesday involved 1-2 hours of radiation therapy. The second and following daily sessions last about 20 minutes, from Monday to Friday, with rest at the weekend.
Radiotherapy side-effects
Discomfort should be minimal. In a small percentage of patients bladder irritation might follow after radiation, and in 2-3 percent of patients receiving radiotherapy for prostate cancer, scar tissue can develop which can lead to temporary bleeding from the rectum. Radiotherapy to the prostate can make it more difficult to achieve an erection.
Tiredness, from mild to troublesome, might follow. And pubic hair may fall out, but will grow back again after completion of the treatment. Most side effects of radiotherapy will gradually disappear once the treatment has ended.
Brachytherapy with radioactive seeds has the lowest incidence of complications. The results of brachytherapy are comparable to surgery in patients with well-differentiated cancers and low PSA levels. Brachytherapy is only suitable for patients at a very early stage and grade of prostate cancer.
A PSA that fails to reach nadir level or rises after an initial drop indicate residual disease or metastases.
Watchful waiting involves regular surveillance of the tumor, but no active treatment initially. It is a suitable option for patients with less than 10 years life expectancy and some patients with very early low-risk cancers.
Treatment for locally advanced disease without metastases (T3a, N0, M0)
The overall results of treatment of patients with disease beyond the prostate are not good. The most widely used treatment regimens consist of a combination of radiotherapy and hormonal treatment.
Treatment options for locally advanced and metastatic disease (T3b, T4, N1, M1)
The options are early hormonal treatment, and watchful waiting with hormonal treatment once symptoms develop.
Disease that has spread to the seminal vesicles and beyond is not curable. Prostate cancer is dependent on the male hormone testosterone. 80% of patients will respond to hormonal treatment that deprives the tumour of testosterone. This response usually involves the shrinkage of metastases and symptomatic improvement for the patient. The response to hormonal treatment is not a cure but can last for many years in some patients. The average duration of response is 2 years.
When to see a doctor
You need to see a doctor urgently when you show more than one of the following symptoms:
Inability to pass urine (retention)
Severe difficulty passing urine
Blood in urine
Unexplained backache or bone pain
Enlarged lymph glands
Unexplained weight loss
Suspected kidney impairment
When should all men see a doctor?
All healthy men over 50 years should have a yearly prostate check to rule out prostate cancer
Black men and men with a positive family history of prostate cancer should start their prostate checks at age 40 years
The aim of screening is to diagnose the disease at an early stage while it is still potentially curable. By the time prostate cancer becomes symptomatic it is usually beyond cure. The screening tests consist of a digital rectal examination and a PSA blood test. The prostate gland may feel entirely normal despite the presence of an early cancer. The combination of PSA and digital rectal examination is more sensitive than either test alone. If one or both of these tests are abnormal a transrectal ultrasound and needle biopsies of the prostate gland are performed.
Information from Prostate Cancer on our A-Z of Health, as written by Dr Pieter J le Roux MBChB, FRCS(Eng), FRCSI, FCS(SA)Urol Consultant Urologist, Tygerberg Hospital and the University of Stellenbosch Medical School.
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