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Prostate Cancer Treatment Options for Localized Disease

If your prostate cancer is confined to the gland, or localized (Stage I or II/low Gleason score), you are a good candidate for treatments that can result in long-term survival. There are three main approaches to managing localized cancer: watchful waiting, surgery, and radiation therapy.

Watchful Waiting

Watchful waiting is based on the premise that cases of localized prostate cancers may advance so slowly that they are unlikely to cause men -especially older men-any problems during their lifetimes. Some men who opt for watchful waiting, also known as "observation" or "surveillance," have no active treatment unless symptoms appear. They are often asked to schedule regular medical checkups and to report any new symptoms to the doctor immediately.

Watchful waiting has the obvious advantage of sparing a man with clinically localized cancer- who typically has no symptoms- the pain and possible side effects of surgery or radiation. On the minus side, watchful waiting risks decreasing the chance to control disease before it spreads, or postponing treatment to an age when it may be more difficult to tolerate. Of course, treatments may also improve over time if watchful waiting is chosen. Another potential disadvantage is anxiety; some men don't want the worry of living with an untreated cancer.

The most obvious candidates for watchful waiting are older men whose tumors are small and slow growing, as judged by low grade/ Gleason score and low stage.

Many men who choose watchful waiting live for years with no signs of disease. A number of studies have found that, for at least 10 or even 15 years, the life expectancy of men treated with watchful waiting (primarily older men with less lethal forms of prostate cancer) is not substantially different from the life expectancy of men treated with surgery or radiation - or, for that matter, of the population at large.

Surgery

In the early 1990s, roughly 30 percent of prostate cancer patients in the United States were treated by surgery, 30 percent by radiation, and 20 percent by watchful waiting. (Most of the rest were treated with a combination of therapies.) In Europe, by contrast, watchful waiting constitutes the standard treatment for asymptomatic prostate cancer.

The popularity of surgery in this country has grown tremendously in recent years. A study of Medicare patients' records found that the number of men nationwide receiving radical prostatectomy by 1990 was six times greater than the number recorded for 1984, and the increase was seen in all age groups, from the youngest (that is, age 65) to men in their eighties. Recent statistics, however, indicate that since 1993, the rate of prostatectomies has been dropping.

The procedure
An operation called radical prostatectomy completely removes the prostate and nearby tissues. A radical prostatectomy is further described in terms of the incisions used by the surgeon to reach the gland. In a retropubic prostatectomy, the prostate is reached through an incision in the lower abdomen; in a perineal prostatectomy, the approach is through the perineum, the space between the scrotumand the anus. In radical prostatectomy, the surgeon excises the entire prostate gland, along with both seminal vesicles, both ampullae (the enlarged lower sections of the vas deferens), and other surrounding tissues. The section of urethra that runs through the prostate is cut away (and with it some of the sphincter muscle that controls the flow of urine).

Pelvic lymph node dissection is done routinely as part of a retropubic prostatectomy; with a perineal prostatectomy, lymph node dissection requires a separate incision.

Possible problems
Radical prostatectomy is a complicated and demanding procedure that typically requires general anesthesia and takes 2 to 4 hours. Patients stay in the hospital for about 3 days, and need to wear a tube to drain urine (catheter) for 10 days to 3 weeks. About 5 to 10 percent of patients experience surgery-related complications such as bleeding, infection, or cardiopulmonary problems. There is a small risk of death from surgery; it is less for men who are young and healthy than men who are older and frail.

Prostatectomy also carries the risk of serious long-term problems, notably urinary incontinence, stool incontinence, and sexual impotence. (The procedure also makes it very unlikely for a man to father children, since little ejaculate is produced without the prostate.)

Most men experience urinary incontinence following surgery. Many continue to have intermittent problems with dribbling caused by coughing or exertion. A few men permanently lose all urinary control. Some men can be helped with an artificial urinary sphincter, surgically implanted, or with injections of collagen to narrow the bladder opening.

Infrequently men may develop stool or fecal incontinence after radical prostatectomy. Fecal incontinence is the loss of normal muscle control of the bowels. Muscle damage can occur during rectal surgery. Stool incontinence may also be caused by a reduction in the elasticity of the rectum, which shortens the time between the sensation of the stool and the urgent need to have a bowel movement. Surgery or radiation injury can scar and stiffen the rectum.

At one time, prostatectomy almost invariably resulted in sexual impotence. Today, the risk of impotence may be reduced by nerve-sparing surgery. This technique carefully avoids cutting or stretching two bundles of nerves and blood vessels that run closely along the surface of the prostate gland and are needed for an erection.

However, nerve-sparing surgery is not possible for everyone. Sometimes the cancer is too large or is located too close to the nerves. Even with nerve-sparing surgery, many men-especially older men - become impotent. Most men will lose a degree of sexual function. (If a man has trouble with erections prior to treatment, nerve-sparing surgery is probably not indicated.) Depending on age, extent of disease, and type of surgery, the chances of impotence vary widely-somewhere between 20 and 90 percent.

Radiation Therapy

Radiation therapy uses high-energy x-rays, either beamed from a machine or emitted by radioactive seeds implanted in the prostate, to kill cancer cells. When prostate cancer is localized, radiation therapy serves as an alternative to surgery. External beam radiation therapy is also commonly used to treat men with regional disease, whose cancers have spread too widely in the pelvis to be removed surgically, but who have no evidence of spread to the lymph nodes. In men with advanced disease, radiation therapy can help to shrink tumors and relieve pain.

External beam radiation therapy
External beam radiation therapy generally involves treatments 5 days a week for 6 or 7 weeks. The treatments cause no pain, and each session lasts just a few minutes. In many cases, if the tumor is large, hormonal therapy may be started at the time of radiation therapy and continued for several years.

The primary target is the prostate gland itself. In addition, the seminal vesicles may be irradiated (since they are a relatively common site of cancer spread). Radiating the lymph nodes in the pelvis, once common practice, has not proven to produce any long-term benefits for most patients, but it may be necessary in certain circumstances.

Possible problems
Because the radiation beam passes through normal tissues-the rectum, the bladder, the intestines-on its way to the prostate, it kills some healthy cells. Radiation to the rectum often causes diarrhea, but the diarrhea -as well as radiation-induced fatigue-usually clears up when treatment is over.

Radiation can also cause a variety of long-term problems. These include proctitis, inflammation of the rectum, with bleeding and bowel problems such as diarrhea, and cystitis, inflammation of the bladder, leading to problems with urination. In addition, some 40 to 50 percent of men treated with radiation therapy become impotent.

With newer techniques, available at state-of-the-art radiation therapy centers, side effects may be fewer. Higher-energy radiation beams can be more precisely focused, while computer technology allows a radiation oncologist to tailor treatment to the anatomy of the individual patient.

Internal radiation therapy
Radiation can also be delivered to the prostate from dozens of tiny radioactive seeds implanted directly into the prostate gland. This approach, known as interstitial implantation or brachtherapy, has the advantage of delivering a high dose of radiation to tissues in the immediate area, while minimizing damage to healthy tissues such as the rectum and bladder.

As practiced today, internal radiation therapy relies on ultrasound or CT to guide the placement of thin-walled needles through the skin of the perineum. Seeds made of radioactive palladium or iodine are delivered through the needles into the prostate, according to a customized pattern-using sophisticated computer programs- to conform to the shape and size of each man's prostate.

The implantation procedure can be completed in an hour or two under local anesthesia; the patient typically goes home the same day. The seeds emit radiation for several weeks, then remain permanently and harmlessly in place. Alternatively, some doctors use much more powerful radioactive seeds over a period of several days. Such temporary implants, which require hospitalization, may be combined with low doses of external beam radiation.

Because the experience with modern internal radiation therapy techniques is relatively recent and limited to carefully selected patients, long-term results are not yet known. At 5 years, more than 90 percent of patients remain free of disease.

Internal radiation therapy is not well suited for large or advanced tumors, or for men previously treated with transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), who run an increased risk for urinary complications. For men with small, well-differentiated tumors, it may provide an option that is less invasive, has fewer side effects, takes less time to do, requires less time in the hospital, and is less costly than either external radiation or surgery.

Possible problems
Post-implant discomfort can usually be controlled by oral painkillers. The man can expect a few weeks of incontinence, but long-term complications such as prostatitis or urinary incontinence are uncommon and generally not severe. Sexual impotence occurs in about 15 percent of men under age 70 and 30 to 35 percent of men over age 70.

Prostate Cancer Treatment Options for Disease That Has Spread

If your cancer has grown beyond the prostate gland (Stage III), it cannot be stopped with local therapies -although radiation therapy can help to keep the tumor in check and hormonal therapy may slow its advance. If your prostate cancer is metastatic (Stage IV), it is usually treated with hormonal therapy, which can relieve painful or distressing symptoms and slow the progress of disease. Another option for metastatic disease is to enter clinical trials and accept new treatments that are being studied.

Hormonal Therapy

Hormonal therapy combats prostate cancer by cutting off the supply of male hormones (androgens) such as testosterone that encourage prostate cancer growth. Hormonal control can be achieved by surgery to remove the testicles (the main source of testosterone) or by drugs.

Hormonal therapy targets cancer that has spread beyond the prostate gland and is thus beyond the reach of local treatments such as surgery or radiation therapy. Hormonal therapy is also helpful in alleviating the painful and distressing symptoms of advanced disease. Further, it is being investigated as a way to arrest cancer before it has a chance to metastasize. Although hormonal therapy cannot cure, it will usually shrink or halt the advance of disease, often for years.

Surgery to remove the testicles (orchiectomy) or surgical (castration) is usually an outpatient procedure. The testicles are removed through a small incision in the scrotum; the scrotum itself is left intact. To help offset the operation's psychological toll, some men opt for reconstructive surgery in which the surgeon replaces the testicles with prostheses  shaped like testicles.

A variety of hormonal drugs can produce a medical castration by cutting off supplies of male hormones. Female hormones (estrogens) block the release and activity of testosterone. Antiandrogens block the activity of any androgens circulating in the blood. Still another type of hormone, taken as periodic injections, prevents the brain from signaling the testicles to produce androgens.

Possible problems
Either surgical castration (orchiectomy) or medical castration (hormonal drug therapy) can produce a striking response. Both approaches cause tumors and lymph nodes to shrink and PSA levels to fall. However, both castration methods can cause hot flashes, impotence, and a loss of interest in sex. Medical castration by treatment with hormonal drug therapy can cause breast enlargement and can increase a man's risk of cardiovascular problems, including heart attacks and strokes.

Hormonal therapy has been tried in many combinations. One approach, known as maximum androgen blockade or complete hormonal therapy, combines castration (either surgical or medical) with an antiandrogen pill, taken daily, for months or years. However, studies show that single hormone treatments have similar effectiveness compared to maximum androgen blockade. Combining surgery with hormonal therapy appears to relieve symptoms.

Medical castration by hormonal therapy can be costly, but, unlike surgical castration, its effects can be reversed by stopping the drug. Moreover, halting hormone treatments will sometimes, paradoxically, temporarily interrupt the progress of an advanced and advancing cancer.

Unfortunately, hormonal therapy for metastatic disease works only for a limited time. Remissions typically last 2 to 3 years. Eventually, cancer cells that don't need testosterone begin to flourish, and cancer growth resumes. When that happens, a variety of other, second-line hormonal-typr drugs (for example, hydrocortisone or progesterone) may be tried.

Clinical Trials

Many techniques are being tried in investigational studies. They have not been used in enough patients or for a long enough time to prove themselves better than conventional treatments.

Cryosurgery
Cryosurgery uses liquid nitrogen to freeze and kill prostate cancer cells. Guided by TRUS, the doctor places needles in preselected locations in the prostate gland. The needle tracks are dilated for the thin metal cryo probes to be inserted through the skin of the perineum into the prostate. Liquid nitrogen in the cryo probes forms an ice ball that freezes the prostate cancer cells; as the cells thaw, they rupture. The procedure takes about 2 hours, requires anesthesia (either general or spinal), and requires 1 or 2 days in the hospital.

During cryosurgery, a warming catheter inserted through the penis protects the urethra, and incontinence is seldom a problem. However, the overlying nerve bundles usually freeze, so most men become impotent.

Early hormonal therapy

Early or neoadjuvant hormonal therapy is started as soon as prostate cancer is diagnosed, in hopes of slowing the growth of cancer that has spread into nearby tissues or of cancer that has invaded the lymph nodes. Given prior to surgery, neoadjuvant hormonal therapy often helps to shrink a tumor.

Chemotherapy
Chemotherapy, which kills fastgrowing cells, has not proven particularly effective against slow-growing prostate cancer cells. Several promising new anticancer drugs are under study, being added to either surgery or radiation therapy for men with Stage III prostate cancer. Chemotherapy is also being tried in conjunction with hormonal therapy for men whose advanced cancers are no longer responsive to hormonal therapy alone.

Conformal radiation therapy
A 3-dimensional conformal radiation therapy (3D-CRT) uses sophisticated computer software to conform or shape the distribution of radiation beams to the 3-dimensional shape of the diseased prostate, sparing damage to normal tissue in the vicinity of treatment.

Complementary Therapies

In addition to medical treatment, some cancer patients want to try complementary therapies. Complementary therapies include acupuncture, herbs, biofeedback, visualization, meditation, yoga, nutritional supplements, and vitamins. Some prostate cancer patients feel that they benefit from some of these therapies.

Before you try any of these therapies, you should discuss their possible value and side effects with your medical doctors. You should let them know if you are using any such therapies. Be aware that these therapies may be expensive, and some are not paid for by health insurance. As with any treatment, you should ask the therapist for evidence of how the therapy has helped others.

The Prostate Cancer Treatment Decision Is Yours

An important consideration to factor into your treatment decisions is that success is not guaranteed. As many as half of the apparently localized cancers turn out, at surgery, to have already spread. And up to one-fourth, despite apparently successful surgery, will produce a recurrence over the next several years. Thus, while aggressive treatment will be unnecessary for some men, it will prove inadequate for others.

In coming to a decision, you may find it helpful to thoroughly discuss your treatment options, including benefits and side effects, with your wife/partner. You may also consider contacting your local prostate cancer support group after consulting with your primary care physician and one or more specialists. Getting a second opinion and different perspectives can be very helpful.

Your decision does not need to be rushed. Take time to explore all your options. You may prefer a teaching hospital or a cancer center for treatment, choosing a surgeon or radiation oncologist who has extensive experience in the newest, least traumatizing techniques. You may want to take part in a clinical trial evaluating new approaches. You will also want to keep abreast of new developments, checking with reliable resources. Ultimately, the decision rests with each individual. Each man has his own priorities and knows best which choices feel most comfortable for him.