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Cancer Types Prostate Cancer

 
Prostate Cancer: Treatment
Men with prostate cancer have many treatment options. The treatment that’s best for one man may not be best for another. The options include active surveillance (also called watchful waiting), surgery, radiation therapy, hormone therapy, and chemotherapy. You may have a combination of treatments.

The treatment that’s right for you depends mainly on your age, the grade of the tumor (the Gleason score), the number of biopsy tissue samples that contain cancer cells, the stage of the cancer, your symptoms, and your general health. It is best to consider all your treatment choices, the expected results of each, and the possible side effects to develop a treatment plan that meets your medical and personal needs.

Your urologist specializes in treating problems in the urinary or male sex organs and is a surgeon. Other specialists who treat prostate cancer include urologic oncologists, medical oncologists, and radiation oncologists. You may also see an oncology nurse and/or a registered dietitian.

Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You may want to discuss with your doctor the possible effects on bowel function, urinary function, sexual activity, and fertility.

At any stage of the disease, supportive care is available to relieve the side effects of treatment, to control pain and other symptoms, and to help you cope with the feelings that a diagnosis of cancer can bring.

You may want to ask your doctor these questions before choosing your treatment:

  • What is the grade of the tumor?
  • What is the stage of the disease? Has the cancer spread? Do any lymph nodes show signs of cancer?
  • What is the goal of treatment? What are my treatment choices? Which do you recommend for me? Why?
  • What are the expected benefits of each type of treatment?
  • What are the risks and possible side effects of each treatment? How can side effects be managed?
  • What can I do to prepare for treatment?
  • Will I need to stay in the hospital? If so, for how long?
  • How will treatment affect my normal activities? Will it affect my sex life? Will I have urinary problems? Will I have bowel problems?
  • What will the treatment cost? Will my insurance cover it?
  • Would a clinical trial (research study) be appropriate for me?


Active Surveillance

You may choose active surveillance if the risks and possible side effects of treatment outweigh the possible benefits. Your doctor may suggest active surveillance if you’re diagnosed with early stage prostate cancer that seems to be slowly growing. Your doctor may also offer this option if you are older or have other serious health problems.

Choosing active surveillance means you’re putting off the side effects of surgery or radiation therapy. If you and your doctor agree that active surveillance is a good idea, your doctor will check you regularly (such as every 3 to 6 months, at first). After about one year, your doctor may order another biopsy to check the Gleason score. You may begin treatment if your Gleason score rises, your PSA level starts to rise, or you develop symptoms. You’ll receive surgery, radiation therapy, or another approach.

The advantage of active surveillance is the avoidance or delay of side effects of treatment, but this choice has risks. The cancer may grow undetected in between doctor visits or the tumor may be larger or more aggressive than thought, which could lead to more intense subsequent treatment. Also, it may be harder to cope with surgery or radiation therapy when you’re older.

You may want to ask your doctor these questions before choosing active surveillance:

  • If I choose active surveillance, can I change my mind later on?
  • Is it safe for me to put off treatment?
  • How often will I have checkups? Which tests will I need? Will I need a repeat biopsy?
  • How will we know if the prostate cancer is getting worse?
  • Between checkups, what problems should I tell you about?


Surgery

Surgery is an option for men with early (Stage I or II) prostate cancer. It’s sometimes an option for men with Stage III or IV prostate cancer.

Before the surgeon removes the prostate, the lymph nodes in the pelvis may be removed. If prostate cancer cells are found in the lymph nodes, the disease may have spread to other parts of the body. If cancer has spread to the lymph nodes, the surgeon does not always remove the prostate and may suggest other types of treatment.

Removing the entire prostate is a highly effective treatment for localized prostate cancer. It is an option for men with intermediate risk, or young men at low risk who have many more years to live and want to ensure that the cancer does not come back.

The urethra, a narrow tube that runs the length of the penis and carries urine from the bladder out of the body, runs directly through the prostate on its way out of the bladder. After removing the prostate, the surgeon stitches the urethra directly to the bladder so that urine is able to flow.

The pelvic lymph nodes may also be removed during surgery to determine if the cancer has spread outside of the prostate.

There are several types of surgery for prostate cancer. Each type has benefits and risks. You and your doctor can talk about the types of surgery and which may be right for you.

  • Open Surgery: The surgeon makes an incision (cut) into your body to and removes the entire prostate through the abdomen. This is called a radical retropubic prostatectomy. Very rarely the surgeon will remove the prostate through a cut between the scrotum and the anus, a procedure called a radical perineal prostatectomy.
  • Laparoscopic prostatectomy: The surgeon removes the entire prostate through 4 or 5 tiny incisions, rather than a single long cut in the abdomen. A thin, lighted tube (a laparoscope) helps the surgeon remove the prostate and affected tissues. Smaller incisions often lead to less blood loss and shorter hospital stays.
  • Robotic laparoscopic surgery: The Davinci robot includes a laparoscope and two robot arms. Robotic arms can make very precise movements with delicate instruments. Such precise manipulation creates less trauma to surrounding tissue and may more reliably leave the nerves intact that control erections.
  • TURP: A man with advanced prostate cancer may choose TURP (transurethral resection of the prostate) to relieve symptoms. The surgeon inserts a long, thin scope through the urethra. A cutting tool at the end of the scope removes tissue from the inside of the prostate. TURP may not remove all of the cancer, but it can remove tissue that blocks the flow of urine.

The advantage of removing the prostate is that it prevents the spread of cancer and cures the cancer if the cancer cells have not spread outside the prostate.

There are disadvantages. Prostatectomy, by any method, is major surgery. If you have a health issues such as heart disease, breathing difficulties such as asthma or emphysema, and/or blood clotting problems, surgery may not be the best option for you.

You may be uncomfortable for the first few days or weeks after surgery. However, medicine can help control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

The time it takes to heal after surgery is different for each man and depends on the type of surgery. You may be in the hospital for one to three days.

After surgery, the urethra needs time to heal. You’ll have a catheter. A catheter is a tube put through the urethra into the bladder to drain urine. You’ll have the catheter for 5 days to 3 weeks. Your nurse will show you how to care for it.

After surgery, some men may lose control of the flow of urine (urinary incontinence). Most men regain at least some bladder control after a few weeks.

Surgery can damage the nerves around the prostate. Damaging these nerves can make a man impotent (unable to have an erection). In some cases, your surgeon can protect the nerves that control erection. But if you have a large tumor or a tumor that’s very close to the nerves, surgery may cause impotence. Impotence can be permanent. You can talk with your doctor about medicine and other ways to help manage the sexual side effects of cancer treatment.

If your prostate is removed, you will no longer produce semen. You’ll have dry orgasms. If you wish to father children, you may consider sperm banking or a sperm retrieval procedure before surgery.

You may want to ask your doctor these questions before choosing surgery:

  • What kinds of surgery can I consider? Which operation do you recommend for me? Why?
  • How long will I be in the hospital after surgery?
  • How will I feel after the operation?
  • If I have pain, how can we control it?
  • Will I have any lasting side effects?
  • What is the chance that the surgery will cause incontinence or impotence?
  • Is there someone that I can talk with who has had the same surgery that I’ll be having?
  • How often will I need checkups?


Radiation Therapy

Radiation therapy is an option for men with any stage of prostate cancer. Men with early stage prostate cancer may choose radiation therapy instead of surgery. It also may be used after surgery to destroy any cancer cells that remain in the area. In later stages of prostate cancer, radiation treatment may be used to help relieve pain.

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area.

Doctors use two types of radiation therapy to treat prostate cancer. Some men receive both types:

External radiation: The radiation comes from a large machine outside the body. You will go to a hospital or clinic for treatment. Treatments are usually 4 to 5 days a week for about 7 or 8 weeks.

Radiation oncologists have developed two techniques to minimize bladder and rectum damage:

With 3D conformal radiotherapy, a computerized program maps out the exact location of the prostate tumors so that the highest dose of radiation can reach the cancer cells within the gland and there is less chance of damaging surrounding tissue.

Intensity-modulated radiation therapy (IMRT) allows oncologists to change (modulate) the intensity of the doses and radiation beams to better target the radiation to the prostate, and deliver lower does to tumor cells immediately adjacent to the bladder and rectal tissue.

External beam radiation therapy may be given in combination with androgen deprivation therapy for patients with advanced prostate cancer that has not spread to a distant organ.

Internal radiation (brachytherapy): In this therapy, tiny metal pellets, each smaller than a grain of rice, containing radioactive iodine or palladium are surgically implanted into the prostate with careful mapping to place the seeds in the proper place in the prostate. Over the course of several months the seeds give off radiation and kill the prostate cancer cells. By the end of a year, the radioactive material degrades, and the seeds that remain are harmless.

Brachytherapy alone is an option for men at low risk of a cancer recurrence, as the therapy delivers a low dose of radiation. Brachytherapy doesn’t require daily visits as external beam therapy does.

High-dose rate brachytherapy involves inserting hollow tubes into the prostate through which high doses of radioactive iridium are delivered to carefully mapped out locations in the prostates. Doses are delivered for 2 to 3 days. After the final dose the tubes are removed. This is an inpatient procedure and is usually followed by a short course of external radiation therapy.

The advantage of external beam radiation is the possibility of a cure. The advantages of brachytherapy include a short recovery time and low rates of erectile dysfunction (impotence).

There are disadvantages. Side effects depend not only on your health status before treatment, but also on the dose and type of radiation. You’re likely to be very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay active, unless it leads to pain or other problems.

If you have external radiation, you may have diarrhea or frequent and uncomfortable urination. Some men have lasting bowel or urinary problems. Your skin in the treated area may become red, dry, and tender. You may lose hair in the treated area. The hair may not grow back.

Internal radiation therapy may cause incontinence. This side effect usually goes away.

Both internal and external radiation can cause impotence. You can talk with your doctor about ways to help cop with this side effect.

You may want to ask your doctor these questions before choosing radiation therapy:

  • Which type of radiation therapy can I consider? Are both types an option for me?
  • When will treatment start? When will it end? How often will I have treatments?
  • Will I need to stay in the hospital?
  • What can I do to take care of myself before, during, and after treatment?
  • How will I feel during treatment? Will I be able to drive myself to and from treatment?
  • How will we know the treatment is working?
  • How will I feel after the radiation therapy?
  • Are there any lasting effects?
  • What is the chance that the cancer will come back in my prostate?
  • How often will I need checkups?


Hormone Therapy

A man with prostate cancer may have hormone therapy (also called Androgen deprivation therapy) before, during, or after radiation therapy. Hormone therapy is also used alone for prostate cancer that has returned after treatment.

Male hormones (androgens) can cause prostate cancer to grow. Hormone therapy keeps prostate cancer cells from getting the male hormones they need to grow. The testicles are the body’s main source of the male hormone testosterone. The adrenal gland makes other male hormones and a small amount of testosterone.

Hormone therapy uses drugs or surgery:

  • Drugs: Your doctor may suggest a drug that can block natural hormones:

    Luteinizing hormone-releasing hormone (LH-RH) agonists: These drugs can prevent the testicles from making testosterone. Examples are leuprolide, goserelin, and triptorelin. The testosterone level falls slowly. Without testosterone, the tumor shrinks, or its growth slows. These drugs are also called gonadotropin-releasing hormone (GnRH) agonists.

    Antiandrogens: These drugs can block the action of male hormones. Examples are flutamide, bicalutamide, and nilutamide.

    Other drugs: Some drugs can prevent the adrenal gland from making testosterone. Examples are ketoconazole and aminoglutethimide.

  • Surgery: Surgery to remove the testicles is called orchiectomy.

After orchiectomy or treatment with an LH-RH agonist, your body no longer gets testosterone from the testicles, the major source of male hormones. Because the adrenal gland makes small amounts of male hormones, you may receive an antiandrogen to block the action of the male hormones that remain. This combination of treatments is known as total androgen blockade (also called combined androgen blockade).

Hormone therapy can be given short-term (4 to 6 months) or long-term (2 to 3 years), sometimes in combination with external beam radiation therapy. Short courses of androgen deprivation therapy can be used to shrink larger tumors, making it easier to localize radiation needed to kill the tumor cells.

The main advantage of hormone therapy is that tumor growth can be slowed. There are disadvantages.

Testosterone is the primary male hormone, and plays an important role in establishing and maintaining the typical male characteristics, such as body hair growth, muscle mass, sexual desire, and erectile function and contributes to many other physiologic processes in the body.

Other potential side effects include osteoporosis, anemia, fatigue, memory loss, and risks of diabetes and cardiovascular disease. Any treatment that lowers hormone levels can weaken your bones. Your doctor may evaluate you for osteoporosis and suggest you take vitamin D supplements and boost your calcium intake to 1,200 mg per day. S/he may suggest medicines such as biophosponates that may reduce your risk of bone fractures.

An LH-RH agonist may make your symptoms worse for a short time at first. This temporary problem is called “flare.” To prevent flare, your doctor may give you an antiandrogen for a few weeks along with the LH-RH agonist.

An LH-RH agonist such as leuprolide can increase body fat, especially around the waist. The levels of sugar and cholesterol in your blood may increase too. Because these changes increase the risk of diabetes and heart disease, your health care team will monitor you for these side effects.

Antiandrogens (such as nilutamide) can cause nausea, diarrhea, or breast growth or tenderness. Rarely, they may cause liver problems (pain in the abdomen, yellow eyes, or dark urine). Some men who use nilutamide may have shortness of breath or develop heart failure. Some may have trouble adjusting to sudden changes in light.

If you receive total androgen blockade, you may have more side effects than if you have just one type of hormone treatment.

If used for a long time, ketoconazole may cause liver problems, and aminoglutethimide can cause skin rashes.

Doctors usually treat prostate cancer that has spread to other parts of the body with hormone therapy. For some men, the cancer will be controlled for two or three years, but others will have a much shorter response to hormone therapy. In time, most prostate cancers can grow with very little or no male hormones, and hormone therapy alone is no longer helpful. At that time, your doctor may suggest chemotherapy or other forms of treatment that are under study. In many cases, the doctor may suggest continuing with hormone therapy because it may still be effective against some of the cancer cells.

You may want to ask your doctor these questions before choosing hormone therapy:

  • Which kind of hormone therapy can I consider? Would you recommend drugs or surgery? Why?
  • If I have drugs, when will treatment start? How often will I have treatments? When will treatment end?
  • If I have surgery, how long will I need to stay in the hospital?
  • How will I feel during treatment?
  • What can I do to take care of myself during treatment?
  • How will we know the treatment is working?
  • Which side effects should I tell you about?
  • Will there be lasting side effects?
  • How often will I need checkups?


Chemotherapy

Chemotherapy may be used for prostate cancer that has spread and no longer responds to hormone therapy. Chemotherapy uses drugs to kill cancer cells. The drugs for prostate cancer are usually given through a vein (intravenous). Some men need to stay in the hospital during treatment.

The side effects depend mainly on which drugs are given and how much. No two people are the same and no two cancers are the same, which means that no two people will react to the drugs in the same way. Dosage, the combination of drugs, and the response to the drugs might be completely different. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

  • Blood cells: When chemotherapy lowers the levels of healthy blood cells, you’re more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of drug. There are also medicines that can help your body make new blood cells.
  • Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may change in color and texture.
  • Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, or diarrhea. Your health care team can give you medicines and suggest other ways to help with these problems.

You may want to ask your doctor these questions before choosing chemotherapy:

  • Why do I need this treatment?
  • Which drug or drugs will I have?
  • How do the drugs work?
  • What are the expected benefits of the treatment?
  • What are the risks and possible side effects of treatment? What can we do about them?
  • When will treatment start? When will it end?
  • How will treatment affect my normal activities?


Nutrition and Physical Activity

It’s important for you to take care of yourself by eating well and staying as active as you can.

You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy. Your doctor, a registered dietitian, or another health care provider can suggest a healthy diet.

To improve your diet Prevent Cancer Foundation suggests you consider reducing dietary fat intake, especially animal fat as your first step. Then try to make your diet rich in fruits, vegetables, nuts, beans and whole grains. Add a few servings of fruits and vegetables to your diet each day. Mix some dark, leafy greens like spinach in with your salad. Eat a peach, or other brightly colored fruit for a snack. Alcohol consumption is linked to increased risk of mouth, esophagus, pharynx, larynx, liver and breast cancers. Men should try to drink no more than 2 drinks a day. Women should try to drink no more than one drink a day.

Research shows that people with cancer feel better when they are active. Walking, yoga, swimming, and other activities can increase your energy. Exercise may reduce pain and make treatment easier to handle. It also can help relieve stress. Whatever physical activity you choose, be sure to talk to your doctor before you start. Also, if your activity causes you pain or other problems, be sure to let your doctor or nurses know about it. You shouldn’t try to exercise to the point of exhaustion.


Follow-up Care

You’ll need regular checkups after treatment for prostate cancer. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, you should contact your doctor.

Your doctor will check for return of cancer. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment.

Checkups may include a digital rectal exam and a PSA test.

  • Digital rectal exam: Your doctor inserts a lubricated, gloved finger into the rectum and feels your prostate through the rectal wall. Your prostate is checked for hard or lumpy areas.
  • Blood test for prostate-specific antigen (PSA): A lab checks the level of PSA in your blood sample. The prostate makes PSA. Prostate cancer may cause a high prostate level.

The DRE and PSA tests can detect a problem in the prostate. A rise in PSA level can mean that cancer has returned after treatment or there could be a less serious condition. Your doctor may also order a urine test to check for blood or infection, or a biopsy, a bone scan, CT scans, an MRI, or other tests.

You may want to ask your doctor these questions after you have finished treatment:

  • How often will I need checkups?
  • Which follow-up tests do you suggest for me?
  • Between checkups, what health problems or symptoms should I tell you about?

Tell your doctor about any side effect of treatment, most get better with time. As they persist, there are management strategies to help as well.