Prostate Cancer: A Range of Treatment Options

If your health care provider has told you that you have prostate cancer, you may soon face a difficult choice of treatment options.

"One of the critical issues right now in prostate cancer is that all these men have a big decision to make after they're diagnosed," says David L. Perlow, M.D., a urologist in Atlanta who performs mostly "seed" radiation treatments. "Frankly, many of the patients I have are torn by the decision."

And men will often find that the specialists performing one treatment usually espouse that treatment over others. A survey of urologists and oncologists published in the Journal of the American Medical Association (JAMA) found that although urologists and radiation oncologists agree on a variety of issues regarding detection and treatment of prostate cancer, they usually recommend the therapy that they offer.

Ironically, almost all the specialists may be right in many cases, according to the study, which said that no conclusive evidence currently backs any particular treatment over another.

So how can you know which treatment is best for you?

Before you pick a treatment

The first thing you should do, according to the American Cancer Society (ACS), is ask your health care provider many questions about the extent (stage) and grade (aggressiveness) of your cancer. The medical field has a letter and number system for different stages and scope of prostate cancer, identifying everything from one splotch to out-of-control spreading.

Ask about the chances of treating it effectively, what will happen if it goes untreated and what will be the likely side effects of any surgery or other treatments.

Then ACS recommends that you consider other factors, such as your age, what lifestyle you wish to have, whether you can live with potential incontinence or sterility and what chances you're willing to take comfortably. For example, some elderly men choose to have no treatment at all because of operation dangers and lifespan issues. Other men with localized prostate cancer (cancer in just one spot) may feel they need no operation at all.

"Unfortunately, although we are getting much more proficient at diagnosing prostate cancer, we are not very good at distinguishing the cancers that need active treatment from those that can be followed without treatment," says George L. Wright, Jr., Ph.D., scientific director of the Virginia Prostate Center.

Treatments

The two primary treatments for early-stage prostate cancer are prostatectomy, in which the prostate and in some cases tissues that surround it are removed, and radiation therapy, in which radiation is beamed into the prostate or inserted with a "seed" pellet (called brachytherapy) to kill the cancer cells.

The JAMA survey found that urologists and radiation oncologists agree that prostatectomy, radiation therapy, and brachytherapy are all effective treatments for localized prostate cancer in men expected to live at least 10 more years.

Other treatments include hormone therapy, chemotherapy, and deferred therapy (watchful waiting). This is often a reasonable choice for older men with other medical problems and early-stage disease. Watchful waiting means closely monitoring the condition but not starting treatment until symptoms appear.

The following information on treatments comes from the National Comprehensive Cancer Network (NCCN), which has gathered experts from many of the nation's leading cancer centers to develop cancer treatment guidelines for cancer care professionals.

"Cancer specialists regard the NCCN treatment guidelines as the defining treatment standard," says Louis M. Weiner, M.D., a Philadelphia oncologist.

Radical prostatectomy

This operation removes the entire prostate gland and some tissue around it and is used most often when the cancer is believed to have not spread past the prostate.

Conventional prostatectomies require incisions near the rectum or in the abdomen and can lead to incontinence (inability to control the bladder) and impotence (inability to get the penis erect because nerves were cut during surgery). Normal bladder control usually returns within several weeks or months after a radical prostatectomy but persists in some men. Impotence can be as high as 65 to 90 percent, but is 25 to 30 percent when surgery does not remove nerves on either side of the prostate. Many factors affect the risk of impotence, including a man's age and his ability to have erections before surgery.

A newer "keyhole," or laparoscopic, prostatectomy uses a thin, lighted tube with a camera on the end and several other long, thin instruments. They are inserted through several small incisions in the abdomen to remove the prostate. Men usually recover more quickly than they do from standard prostatectomy, although it is not yet clear how this approach compares, regarding long-term results.

An even newer technique is robotic-assisted laparoscopic prostatectomy. In this approach, the surgeon sits at a control panel and precisely maneuvers long, thin surgical instruments with robotically controlled arms. Again, surgical recovery tends to be shorter, although there are no results comparing long-term outcomes with older, more established treatments.

Radiation therapy

High-energy rays (such as X-rays) and particles (such as electrons and protons) are used to kill cancer cells. This therapy is sometimes used to treat prostate cancer that is still confined to the prostate gland or has spread to nearby tissue. If the disease is more advanced, radiation may be used to reduce the size of the tumor.

The two main types are external beam radiation and brachytherapy (internal radiation). External radiation focuses a beam from outside the body onto specific spots. A small percentage of men experience permanent incontinence, and 40 to 60 percent of patients have some impotence afterward.

Brachytherapy uses needles to insert radioactive pellets about the size of a grain of rice into the prostate. The radiation dies out after several weeks or months, and the pellets are allowed to harmlessly remain in the prostate. This therapy is becoming more popular. Doctors who support this treatment say it has much lower rates of incontinence and impotence. Critics of this method say that not enough studies have been done to confirm its effectiveness.

Hormone therapy

This treatment is often used for men whose cancer has spread beyond the prostate or has recurred after treatment. Its aim is to reduce the levels of androgens (male hormones), such as testosterone, which cause prostate cancer cells to grow.

Side effects of this therapy include reduced or absent sexual desire, impotence and hot flashes. Some men also have breast tenderness and growth of breast tissue. To greatly reduce androgen levels, some doctors recommend an orchiectomy, which is the removal of the testicles. The side effects are similar to other types of hormone therapy.

Chemotherapy

This is an option for men whose cancer has spread outside the prostate and for whom hormone therapy has failed. Chemotherapy doesn't destroy all the cancer cells, but it may slow tumor growth and reduce pain. One side effect of this treatment is that it may lower blood cell counts, resulting in an increased chance of infection or bleeding.

Deferred therapy (watchful waiting)

The best strategy for some men is to simply "watch and wait," with careful observation but no immediate treatment. This approach may be recommended if a prostate cancer is not causing any symptoms, especially if it is very small and contained to one area of the prostate or expected to grow slowly. Also, if a man is elderly, frail or has some serious health problems, this treatment may be an option. Some men may decide that the side effects of more aggressive treatments outweigh the benefits of an operation.

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