Over the past 20 years, overall survival rates for all stages of prostate cancer combined have increased from 67% to 89% Some of the possible reasons for the increase in survival rates include public education, new techniques of early detection, and aggressive therapy. The major treatment options for prostate cancer include surgery, radiation, medical therapy and watchful waiting. A patient's treatment options will depend upon his age, the stage of the disease, and the advice of a physician.
Surgery for Prostate Cancer
The goal of surgery is to remove the entire prostate gland and all of the cancer. What follows is a description of a number of techniques used by surgeons when operating on the prostate.
The Complete (Radical) Prostatectomy
Surgical removal of the entire prostate gland is called radical prostatectomy. Radical prostatectomy is usually performed to remove early-stage prostate cancer before it can spread to other parts of the body. Often, the pelvic lymph nodes are also sampled for a biopsy as a precautionary measure. In most cases, taking out the prostate takes out the cancerous tumor as well. If the cancer spreads outside of the prostate, it cannot be cured with surgery. Patients who undergo radical prostatectomy should expect at least a 2- to 4-day stay in the hospital, while full recovery can sometimes take up to 12 weeks. As with all major surgeries, prostatectomy patients may require a blood transfusion. Hormonal therapy is sometimes used before surgery to shrink the prostate cancer tumor so it can be removed more effectively. Radical prostatectomy has become safer and less likely to leave men impotent or incontinent, although results vary from surgeon to surgeon. The risk of impotence, which is the inability to achieve or maintain an erect penis, often depends on a patient’s age, health, and the stage of his cancer. Incontinence, which is involuntary urination, appears to occur less often than impotence in patients after radical prostatectomy.
A transurethral resection of the prostate (TURP) involves removing tissue from the prostate by inserting an instrument through the urethra into the penis. At the end of the instrument, called a resectoscope, is an electrically heated wire loop, which is used to scoop out the unwanted prostate tissue. This procedure is sometimes necessary to relieve the symptoms of prostate cancer and make urinating easier. It is also performed on men who cannot have a radical prostatectomy due to age or other illnesses. This type of surgery has several advantages. Because no surgical incision is required, hospital stays are brief and recovery is usually uneventful. In a vast majority of cases, urinary function returns to normal after a TURP. In most cases, the ability to have sexual relations is also not affected by the procedure.
Orchiectomy is a surgical procedure that completely removes the testicles. It is considered hormonal therapy because, like certain prescription drugs, orchiectomy also reduces hormone levels. In fact, LH-RH analog therapy has been shown to be comparable to orchiectomy in decreasing the body’s supply of testosterone. Most patients prefer LH-RH analog therapy over orchiectomy to treat their prostate cancer. Orchiectomy is a routine surgical procedure that usually has no long-term complications. It gives an immediate and permanent reduction in testosterone. However, orchiectomy may require being hospitalized for approximately 2 days or more. Many patients respond favorably to orchiectomy, but for those patients for whom this surgical procedure fails, the operation is often viewed as unnecessary, expensive, and possibly psychologically damaging. Hot flashes, impotence, and loss of sexual desire are common side effects with orchiectomy.
Cryosurgery treats localized prostate cancer by freezing and destroying the prostate. There is renewed interest in this procedure due to improved technology, and the fact that the Health Care Financing Administration (HCFA) has authorized reimbursement for the procedure in men with newly diagnosed T1-T3 stage prostate cancer as of July 1, 1999. HCFA made this decision because 5-year follow-up results with cryosurgery appear to be the same as those of radiation treatment. Cryosurgery is currently being investigated for use following radiation. One of the main side effects appears to be incontinence. A five-pronged probe filled with nitrogen is guided through a skin incision into the cancer using transrectal ultrasound (TRUS). TRUS allows your physician to monitor the freezing process of the prostate, which can get as low as -195° Celsius. A warming catheter is placed in the urethra to prevent damage. Cryosurgery has several benefits: low morbidity, minimal blood loss, and a short hospital stay. Complications such as impotence and incontinence can arise if the freezing damages nerves near the prostate. Some patients may also experience penile numbness or swelling, or develop obstructions from dead prostate tissue.
Radiation therapy involves exposing cancer cells to high doses of radiation in the hope of killing the tumor. The most widely used types are external beam radiation therapy and internal radiation therapy. External beam radiation therapy treats the prostate and other selected tissues with a carefully targeted beam of radiation administered from machines outside the body. In internal radiation therapy, often referred to as brachytherapy, tiny radioactive seeds are implanted in the prostate through a surgical procedure. Compared with external beam radiation, brachytherapy may offer certain advantages: the seeds can be implanted precisely in the tumor. A higher dose can be used with potentially less damage to surrounding tissue. Implanting the seeds takes less time than a full course of external beam radiation treatment. Hormonal therapy is sometimes used before radiation therapy to shrink the prostate and the tumor. The smaller prostate may allow the radiation to be more tightly focused, concentrating the dose so that the tumor receives more rays. Hormonal therapy is often prescribed prior to brachytherapy to shrink the prostate to allow more effective seed placement and distribution. Impotence and incontinence occur slightly less often with radiation therapy than with surgery. Other side effects with radiation therapy include fatigue, skin reaction in treated areas, frequent and painful urination, upset stomach, diarrhea, and rectal irritation or bleeding. Most of these side effects disappear once treatment is stopped.
Medical Treatment of Prostate Cancer
The goal of medical therapy for prostate cancer is to shut down the production of the male hormone testosterone. The reason for this is that testosterone, which is produced almost entirely by the testicles, can stimulate the growth of hormone-dependent prostate cancer cells the same way kerosene fuels a fire.
Hormonal therapy is used to decrease the production of testosterone, which, in turn, slows cancer cell growth. There are various types of hormonal therapy:
- Drugs that reduce testosterone to castrate levels (i.e., LH-RH analogs)
- Surgical removal of the testicles, which produce the male hormones
- Antiandrogens, estrogens
Hormonal therapy is sometimes used before radiation therapy or before surgery to shrink the prostate cancer tumor. The smaller tumor may allow the radiation to be more tightly focused, concentrating the beam so that the tumor receives more rays. Before surgery, shrinking the tumor may allow it to be removed more effectively.
LH-RH analogs are used to shut down the testosterone produced by the testicles, thus slowing the spread of prostate cancer. LH-RH stands for luteinizing hormone-releasing hormone. One example of this class of drugs is Lupron Depot® (leuprolide acetate for depot suspension, TAP Pharmaceuticals Inc.). The most common side effect associated with Lupron Depot is hot flashes. Like other treatment options, LH-RH analogs may cause impotence. Symptoms may worsen over the first few weeks of treatment. Periodic monitoring of PSA and testosterone is recommended.
Another treatment alternative for advanced prostate cancer involves the use of a hormone-blocking drug called an antiandrogen, often taken in combination with an LH-RH analog. The antiandrogen may be administered to counteract the small amount of testosterone produced by the adrenal glands. Examples of antiandrogens are Eulexin® (flutamide, Schering Corporation), Casodex® (bicalutamide tablets, Zeneca Pharmaceuticals), and Nilandron® (nilutamide tablets, Hoechst Marion Roussel Inc.).
Lycopene is the antioxidant that gives tomatoes and other fruits their red color. Cooking the tomatoes breaks down the cell walls, allowing your body to access the lycopene much easier than from fresh tomatoes. Some studies have suggested a health benefit with respect to the development of prostate cancer. Be sure to consult your physician about any changes you make to your diet.
VITAMIN E AND SELENIUM
Recent studies have shown that vitamin E and selenium supplements may have some health benefits with respect to the development of prostate cancer. Be sure to consult your physician about any changes you make to your diet.
PC-SPES is a combination herbal preparation of eight different substances. The Food and Drug Administration (FDA) do not regulate it because it is considered a food supplement and not a medication. It contains chrysanthemum, isatis, licorice, Ganoderma lucidum, Panex-pseudo-ginseng, Rabdosia rubescens, saw palmetto, and scutellaria. There is evidence that some of these compounds have similar activity to the female hormone, estrogen. Licorice appears to stick to the estrogen receptor sites on cells. Ginseng induces the expression of gene products classically stimulated by estrogen. PC-SPES may cause loss of libido, breast swelling, and breast tenderness. These same side effects are found when males are treated with medical doses of estrogen. Laboratory analysis of PC-SPES showed the herbal combination has potent activity similar to estrogen in yeast cells, mice, and humans. PC-SPES does seem to have important effects on the prostate gland that are not totally understood to date. Clinical studies are currently ongoing and more information is needed before PC-SPES can be recommended in the treatment of prostate cancer. Because many treatment decisions are based on the PSA blood test and PC-SPES can cause a decrease in its level, physicians must know when patients are using this therapy. It is important that physicians ask patients about the utilization of PC-SPES and patients inform their healthcare provider about their utilization. No one wants the wrong treatment recommendation because the physician was not informed of all herbal therapies used by the patient.
CHEMOTHERAPY FOR PROSTATE CANCER
Chemotherapy is the use of drugs to destroy cancer cells & abnormal cells that keep dividing and growing without control. Chemotherapy drugs work by destroying very active cells that divide rapidly. Unfortunately, chemotherapy also can affect normal cells that actively divide, such as blood cells forming in bone marrow, in hair follicles, in the mouth, and in the intestines. When that occurs, it causes side effects. Different chemotherapy drugs cause different side effects. The most common side effects are feeling tired, nausea and vomiting, diarrhea, mouth sores, hair loss, and a low white blood cell count. To minimize the side effects, chemotherapy drugs are carefully monitored according to the amount and number of times that they are administered by your physician. Supportive medication may also be given to further help offset the side effects caused by the chemotherapy drugs.
Watchful waiting or active surveillance is another option involving careful observation without immediate treatment for prostate cancer. This may be an appropriate therapeutic course for men who:
- Are found to have less aggressive tumors, which often tend to grow slowly
- Are older than 70 years of age
- Have significant coexisting illnesses
- Are fearful of the side effects of more aggressive therapies
WHAT TO ASK YOUR DOCTOR
Talking to your doctor is one of the best ways to help you understand your medical condition. When sitting in your doctor's office, it can be hard to remember all the questions that you may have. Sometimes it is helpful to write down a list of concerns to discuss with your physician.