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Various options exist for the treatment of prostate cancer.
These include:
• Surgery (radical prostatectomy)
• Radiation (external beam radiation and brachytherapy).
• Hormonal treatment
• Watchful waiting and active surveillance
The choice of treatment depends on the stage of the cancer as well as factors pertaining to each specific patient, such as life expectancy and co-morbid diseases. Surgery and radiation as treatment modalities are aimed at complete cure for early-stage prostate cancer. Hormonal treatment is used with radiation in some cases to limit the progression of advanced disease when the cancer cannot be eradicated with surgery or radiotherapy.
Surgery
Surgery for prostate cancer is called a radical prostatectomy. During this procedure the entire prostate and seminal vesicles are removed. The bladder is then re-connected to the urethra. The pelvic lymph nodes may also be removed for staging. The surgery can be done via the retropubic, perineal or laparoscopic method. A new technique using robotic surgery is now used in some parts of the world. A retropubic prostatectomy involves a 10 cm cut in the lower midline abdomen. With a perineal prostatectomy, the incision is made in the perineum, the area between the scrotum and the anus. With a laparoscopic prostatectomy, four small incisions are made in the abdomen through which the procedure is done. Robotic surgery is done by specialised remote control machinery.
Surgery is a treatment option only when the prostate cancer is still localized to the prostate gland (T1 – 2), no lymph node or metastatic spread is present (N0, M0), and life expectancy is more than 10 years. Due to the slow-growing nature of the disease, the benefit of cure usually only becomes apparent after 10 - 15 years. For this reason, a patient who receives treatment with curative intent should have a life expectancy of longer than ten years. This prediction is made based on patient age and co-morbid diseases.
What to expect
A radical prostatectomy takes about two to four hours. Post-operatively there is a urinary catheter that stays in for 10-14 days. A wound drain stays in for two days. Patients are urged to mobilize from day two, and are usually discharged after about five days. The patient should expect to be booked off from work for at least four to six weeks.
The prostate and lymph nodes that have been removed will be sent for histological assessment to confirm whether all of the cancer has been removed, and whether the pelvic lymph nodes are involved or not.
The two main complications after surgery are impotence and incontinence. Although newer surgical techniques have dramatically reduced these complications, patients should be aware of the risk. The incidence of impotence is around 30% and incontinence about 4-10%. The erectile dysfunction can be treated with oral medication or penile injections at an early stage. Urinary incontinence is usually transient and will improve over a period of three to six months.
These complications and their management can be discussed with the urologist during the post-operative follow-up visits.
Radiotherapy
Radiotherapy is a treatment method also with curative intent, whereby radiation energy is used to kill the cancer cells. This radiation can be delivered via external beam radio therapy (EBRT) or brachytherapy:
• EBRT stretches over a few weeks, during which daily sessions of small doses of radiation are delivered to the prostate.
• Brachytherapy, done under general anaesthesia, is a procedure that involves implanting radioactive seeds under ultrasound guidance into the prostate. Patients are discharged the same or next day after this relatively painless procedure. The advantage of brachytherapy over external radiation is that the radiation is delivered only to the prostate and not to adjacent organs like the bladder and rectum, limiting possible side-effects. The treatment also takes only one day, compared to multiple visits with EBRT. 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. This type of treatment however should not be used in patients with high-grade prostate cancer, or with obstructive urinary symptoms. Hormonal therapy is then sometimes used as well to improve the outcome of this treatment.
After treatment with curative intent, with either surgery or radiotherapy, the PSA should drop to an undetectable level. A PSA that fails to reach an undetectable level or rises after an initial drop indicates residual disease or metastases.
Hormone therapy
Hormone therapy is used in cases where the cancer has spread outside the prostatic capsule (T3-T4), or where there is lymph node involvement or metastatic spread or the patient is not suitable for a curative approach due to various factors. In other words, hormone therapy is used where the cancer is not curable by either surgery or radiotherapy.
Prostate cancer is dependent on the male hormone testosterone; 80% of patients will respond to hormonal treatment, which deprives the tumour of testosterone. This response usually involves shrinkage of metastases and symptomatic improvement for the patient, with a significant decline in PSA values.
The response to hormonal treatment is not a cure but can last for many years in some patients.
The two most common types of hormonal therapy that are used include:
• Surgical orchidectomy– surgical removal of the testes (castration), stopping testosterone production. Cessation of testosterone production with this procedure is permanent.
• Medical orchidectomy– three-monthly injections (LHRH analogues) that prevent the testes from producing testosterone. This can be given continuously on a three monthly basis or intermittently, based on the response of the cancer. Intermittent LHRH-analogue administration is called intermittent androgen deprivation (IAD).
The side effects of hormonal therapy (castration) include hot flushes (short-lived and transient), impotence and a decrease in sexual drive (libido), osteoporosis and weight gain.
Watchful waiting and active surveillance
These approaches involve surveillance of the diagnosed prostate cancer only, but no active treatment. Due to the slow-growing nature of the disease, the benefit of cure usually only becomes apparent after 10 - 15 years. It is a suitable option for patients with shorter than 10 years life expectancy and some patients with very early low-risk cancers.
Active surveillance is done for those patients who wish to delay treatment and subsequent side effects (impotence, incontinence) for as long as possible. The patient is monitored by having regular PSA checks and occasional re-biopsy. Only if a rise in PSA or increase in tumour stage warrants it, is treatment then initiated.
Watchful waiting is when a patient declines or is not a candidate for active treatment where they are seen regularly and tests are only done if and when any new symptoms arise.
All these options need to be discussed with every patient newly diagnosed with this cancer so that appropriate choices that are suitable for each individual can be made. It is important that a patient is seen if possible by a multi-disciplinary panel so that a balanced opinion can be given.
