Treatment: What happens After Diagnosis?
After a positive diagnosis of the presence of prostate cancer there are a number of possible treatment regimens that might be chosen. These will depend on the severity of the disease, the stage at which it was caught as well as the age and expected life-span of the patient as well as considerations of any other pre-existing conditions. The information presented below is only a guide to the types of treatments available. It is not an indication of the type of treatment that should be chosen.
Expectant Management
Expectant Management, sometimes also known as "watchful waiting', involves the close monitoring of the cancer without active treatment such as surgery or radiation therapy. It may be recommended if your cancer is not causing any symptoms, is expected to grow very slowly, and is small and contained within one area of the prostate. Indeed, In a large group of men who were watched without treatment, most did not experience problems with their cancer till after 10 to 15 years. However this approach probably will not be suggested if you are young or have a fast-growing cancer.
In this approach the development of the cancer is actively monitored (usually every six months) and if the accompanying symptoms become problematic or the tumour begins to develop more quickly then active treatment may be suggested.
Surgery
There are four main types of surgical procedure that may be recommended:
Radical Retropubic Prostatectomy:
In this operation the surgeon makes a skin incision in your lower abdomen, from the belly button down to the pubic bone. Some surgeons remove lymph nodes from around the prostate at this time. If any of the nodes contain cancer cells, which means the cancer has spread, they often will not continue with the surgery because it is unlikely that the cancer can be cured. Other surgeons only remove the prostate gland and may not remove lymph nodes (the decision usually depends on PSA levels and the aggressiveness of the tumour).
The surgeon will also pay close attention to the 2 tiny bundles of nerves that run on either side of the prostate. These nerves control erections. If they are both removed, you will be impotent (unable to have a spontaneous erection and will require additional treatments to achieve erections). If neither is removed, then you may be able to function normally. Usually this takes a few months after surgery because the nerves have been handled during the operation and won�'t work properly for a while.
This is the kind of operation that most urologists use.
Radical Perineal Prostatectomy:
In this operation, the surgeon makes the incision in the perineum, the skin between the anus and scrotum. This procedure is used less often because the nerves cannot easily be spared and lymph nodes can't be removed. But it is often a shorter operation and might be appropriate if you don't want the nerve-sparing procedure or require lymph node removal. It also might be used if you have other medical conditions that make retropubic surgery difficult for you. It can be just as curative as the retropubic operation if performed correctly.
Laparoscopic Radical Prostatectomy (LRP):
This procedure involves using several smaller incisions and specialized long instruments to remove the prostate. This has advantages over the historical open radical prostatectomy, including less blood loss and pain, and shorter hospital stays (usually no more than a day) and recovery times. However, LRP is a technically complex operation; though in experienced hands, LRP is as efficient as open radical prostatectomy.
Transurethral Resection of the Prostate (TURP):
Unlike the other procedures described above, this procedure is a palliative only (it is only done to remove immediate symptoms). This surgery may be used if you are having trouble urinating because of the cancer and are not a candidate for curative surgery. TURP is also (more commonly) used to treat men with noncancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). During this operation, the surgeon removes part of the prostate gland that surrounds the urethra and an instrument called a resectoscope is passed through the end of the penis into the urethra at the level of the prostate. Once it is in place, electricity is passed through a wire to heat it and cut or vaporize the tissue. Either spinal anesthesia or general anesthesia is used.
Radiation Therapy
Radiation therapy uses high-energy rays (x-rays or γ-rays) or particles (α- or β-particles) to kill cancer cells. Two main types of radiation therapy are used: external beam radiation and brachytherapy:
External Beam Radiation Therapy (EBRT):
n this technique, radiation is focused on the prostate gland from a source outside your body. It is much like getting a diagnostic x-ray but for a longer time. Before treatments start, imaging studies such as MRIs, CT scans, or plain x-rays of the pelvis are done to find the exact location of the prostate gland and marks are made on the skin to aid in the location of the prostate.
Three-dimensional conformal radiation therapy (3DCRT): is one of the latest radiation therapy techniques and uses special computers to precisely map the location of the prostate. The patient is fitted with a plastic mold resembling a body cast to maintain the body's position so that radiation beams can be focussed on the prostate from several directions. This makes it far less likely that the radiation will damage normal tissues.
Intensity modulated radiation therapy (IMRT): is a form of three-dimensional radiation therapy that uses a machine which moves around the patient as it delivers radiation. In addition to aiming beams from several directions, the intensity (or strength) of the beams can be adjusted to minimize the dose of radiation reaching the most sensitive normal tissues while delivering a uniformly high dose to the cancer.
Conformal proton beam radiation therapy: This technique is closely-related to 3DCRT but instead of using x-rays, this technique focuses proton beams on the cancer. Protons are the positive particles at the heart of atoms which cause little damage to tissues they pass through but are effective in killing cells at the end of their path. This means that proton beam radiation may be able to deliver more radiation to the prostate while reducing side effects on nearby normal tissues. However, this technique, whilst promising, is in early stages of development.
Brachytherapy:
Brachytherapy (also called seed implantation or interstitial radiation therapy) is a form of radiation therapy that uses small radioactive pellets, or "seeds," each about the size of a grain of rice which are that are placed directly into the prostate. In general, this technique is used only in men with early stage prostate cancer that is relatively slow growing. Imaging tests such as transrectal ultrasound, CT scans, or MRI help guide the placement of the radioactive pellets in the prostate so that radiation is delivered only to the prostate and not the surrounding (healthy) tissue. There are tow main kinds of Brachytherapy:
Permanent [Low Dose Rate (LDR) Brachytherapy: uses pellets of radioactive material (such as the isotopes 125I and 103Pd) which are placed in thin needles. These needles are inserted through the skin of the perineum and into the prostate. The pellets (seeds) are left in place as the needles are removed and give off low doses of radiation for weeks or months. Usually, anywhere from 40 to 100 seeds are placed. Because they are so small, their presence causes little discomfort, and they are simply left in place after their radioactive material is used up.
Temporary [High Dose Rate (HDR)] Brachytherapy: This is a relatively new technique where hollow needles are placed through the perineum into the prostate. Radioactive 192Ir is then introduced into the needles and left for between five to fifteen minutes. Generally, about 3 brief treatments are given, and the iridium is removed each time. These treatments are usually combined with external beam radiation given at a lower dose than it normally would be if used by itself. The total dose of radiation is high enough to kill all the cancer cells. The advantage is that most of the radiation is concentrated in the prostate gland itself, sparing the urethra and the tissues around the prostate such as the nerves, bladder, and rectum.
Chemotherapy
Chemotherapy is sometimes used if prostate cancer has spread outside of the prostate gland and hormone therapy isn't working. It is not recommended as a treatment if you have early prostate cancer. In chemotherapy anti-cancer drugs are injected into a vein or given by mouth. These drugs enter the bloodstream and reach throughout the body, making this treatment potentially useful for cancers that have spread (metastasized) to distant organs.
Cryosurgery
Cryosurgery (sometimes also called cryotherapy or cryoablation) is new technique to treat localized prostate cancer by freezing areas of the prostate. In this technique several hollow needles are placed through the skin between the anus and scrotum and guided into the prostate itself using transrectal ultrasound (TRUS). Very cold gases are then passed through the needles, creating ice balls that destroy the prostate gland. To be sure prostate tissue is destroyed without too much damage to nearby tissues, the doctor carefully watches the ultrasound images during the procedure. Warm saltwater is circulated through a catheter in the urethra to keep it from freezing.
Androgen Deprivation Therapy (ADT)
The goal of this form of therapy is to lower levels of the male hormones (androgens, such as testosterone) in the body. Androgens, produced mainly in the testicles, can actually stimulate prostate cancer cells to grow. Lowering androgen levels can usually make prostate cancers shrink or grow more slowly. But hormone therapy does not cure prostate cancer and is not a substitute for curative treatment. Side effects can also be very severe, and there are many issues, such as the best time to start and stop it and the best way to give it.