Prostate Cancer: Treatment

Overview

 

Receiving a diagnosis of prostate cancer is a very stressful event. After the initial shock has passed, a decision on the best course of action should be made. To say that most men find this a very confusing process would be an understatement. There are many reasons for this confusion but the three primary ones are that (1) each prostate tumor is unique, (2) each man is unique and (3) there is honest, genuine controversy regarding the best management in some instances.

 

Newspapers and magazines often talk about prostate cancer as if it is a single condition - that a prostate cancer in one man is the same in another. Nothing could be further from the truth. Each prostate cancer is different and can be defined by its own:

 

  • Stage
  • PSA
  • Grade
  •  

    There are literally thousands of different variations based on these parameters - and the management of these tumors may vary markedly. This is one reason why the advice and treatment given to one man with prostate cancer may not be relevant to another man.

     

    In order to simplify discussion and management, prostate cancer diagnoses can be grouped into different 'disease states'. Disease states are groups of cancers which share similar characteristics and whose management can be approached in a similar manner. Please keep in mind that there can be significant differences in how different cancers within each disesae state are managed.

     

    Disease States in Prostate Cancer
    1. Localized prostate cancer
    2. Rising PSA after primary therapy
    3. Advanced prostate cancer
      1. Metastatic disease responsive to testosterone-reducing therapy
      2. Metastatic disease resistant to testosterone-reducing therapy

     

    Goals and Outcomes of Prostate Cancer Management

     

    The ultimate goal of prostate cancer treatment is to provide each man with the best quality and length of life possible as if the prostate cancer had never developed in the first place.

     

    In an ideal world, we would be able to cure 100% of prostate cancers with 100% success and without even the slightest inconvenience or adverse effect for the patient. While this is what we strive for, it is not currently possible. Even when the treatment results in the 'trifecta' of prostate cancer outcomes (cure, preservation of erectile and urinary function), there is inevitably at least some recovery time and inconvenience. In addtion, while many cancers are curable, some are not despite our best efforts. Each treatment has at least the potential to produce lasting side-effects.

     

    Therefore, when deciding on the best management for your own prostate cancer, it is important to keep in mind what the potential outcome of the different management options are in terms of BENEFITS and RISKS. These will change based on the tumor, the individual and the treatment.

     

    Goals of Prostate Cancer Treatment

    Cure Palliation

    Cure is the eradication of cancer.

     

    While cure is possible in many men with localized proste cancer, cure is neither always necessary nor is it always possible.

     

    As of 2011, cure can only be achieved for localized prostate cancers. Advanced prostate cancers can, however, be put into remission for long periods of time.

    Palliation is providing the best quality of life for men who cannot be cured.

     

    This is the primary goal in men with advanced prostate cancer.

     

    Treatment for localized prostate cancer (which is not typically associated with any symptoms) usually does not improve on what a patient already has in terms of function, whether it be sexual, urinary or bowel function. Therefore, the goal is typically preservation of pre-existing function and avoidance introducing side-effects or adverse events. There are exceptions to this - for example, men who have outflow obstruction from prostate cancer can have a much stronger stream with less urinary urgency and frequency after removal of the prostate.

     

    Palliative treatments for advanced prostate cancer, by definition, are aimed at improving symptoms which are a direct result of the prostate cancer. Unlike localized prostate cancer which rarely causes symptoms, advanced prostate cancer commonly causes symptoms or is highly likely to cause symptoms in the near future if none are yet present.

     

    Types of Treatment Related Toxicity - please note

    1. The probability of each type of potential adverse event is different - some are quite rare and therefore not all potential adverse events should be given the same weight when making a decision on which treatment is best for you.
    2. The different treatments are associated with different types of adverse events. For example, bowel problems are much less common with surgery than radiation. Conversely, there are no issues related to incision for radiation (since there is none).
    Short Term/Acute Toxicity Long Term Toxicity:

    Short term toxicity includes those things which tend to be short lived for weeks to a few months

    Most short term toxicity is a direct result of treatment rather than from the disesae itself

    Long term toxcity includes those things which tend to be either long lived or may appear long after treatment is completed

    Long term toxicity can result from progress of the cancer OR from the treatment itself

    Treatment-Related Cancer-related Treatment-Related Cancer-Related

    These will depend on the procedure.

    For surgery, these include things such as operative time, duration of hospital stay, bleeding, pain, recovery time, risk of anesthetic, duration of catheterization, bladder and erectile dysfunction, etc.

    For brachytherapy, these include things such as procedure time, anesthetic risks, bleeding, pain, duration of catheterization, bowel, bladder and erectile dysfunction, etc

    For external beam radiation, these include things such as fatigue, skin changes, bowel, bladder and erectile dysfunction, etc.

     

    For hormonal treatments: hot flushes, loss of erectile function and sex drive, weight gain, loss of strength, etc.

     

    Often the multiple treatments are combined. For example, hormone therapy can introduce additional toxicity to radiation treatments.

    This is usually only an issue with advanced prostate cancers. This includes pain in the bones, blood in the urine, urinary retention, etc.

    Urinary (surgery and radiation): incontinence (leakage), retention, pain, bleeding

     

    Sexual (surgery and radiation): loss of ejaculation, loss of erections

     

    Bowel (radiation only): diarrhea, loose stool, loss of stool (fecal incontinence), bleeding, fistulae

     

    Other: hormonal treatments used on a long term basis can have a number of health effects, including osteoporosis

    Blockage of the bladder by urethral obstruction


    Bleeding in the urine


    Blockage of the tubes draining the kidneys into the bladder (ureters)


    Pelvic pain


    Bony pain


    Fatigue


    Death

     

    All of these goals are important, but each man will place a different emphasis on one goal over another. It is, unfortunately, impossible to guarantee with absolute certainty that each goal will be met with success for any given approach but some approaches are more likely to deliver than others. This is despite our best intentions and executing a plan as best as possible. In hindsight, some decisions will appear good and some bad. In reality, it is only possible to make a decision based on the information which is present at that time and no one can predict the future perfectly.

     

    Where does this leave the man with prostate cancer trying to make a decision on how to manage their disease? It starts with knowing what he has, identifying what the available options are, taking a look at the what can be expected with each option and then choosing a course of action which best suits your own goals. Having a framework for a discussion with your physician is the critical starting point for being a participant in your care. The decision is ultimately yours and your physician's job is to discuss the options and make recommendations where possible.

     

    Here are questions to consider regarding each course of action or treatment:

    1. How likely is a particular outcome?
    2. How important is that particular outcome to me?
    3. How does this compare with the alternatives?

     

    If you decide that surgery is the best option for you, the information on how to make a decision on choosing the type of surgery and your surgeon can be found here.

     

    Investigational Treatments

     

    It is inevitable and completely understandable that many patients will seek information for available treatments on the internet. Some general advice and commentary on using the internet as a resource can be found here. We are aware of these sorts of investigational treatments but do not routinely discuss any treatment with a patient unless it has a verifiable, reliable track record in terms of helping patients with their cancer. There have been numerous treatments put forward as viable alternatives or adjuncts to radiation and surgery but which after thourough evaluation have been found either lacking in efficacy or harmful to patients (or both) - sometimes side-effects are devastating (rectourethral fistula, for example). As always, the internet is not a substitute for expert opinion from a specialist surgeon who deals with these issues every day and is able to interpret the evidence. Here are some investigational treatments with some information.

     

    High-intensity Focussed Ultrasound (HIFU)

     

     

    Recommended Web Resources


    Localized/Early Stage Prostate Cancer
    NCI Early Stage Brochure
    Overview of staging, anatomy and all treatment options. Caveats: the US medical system is very different than the Canadian one. Medical Oncologists in Canada in general treat advanced prostate cancer only - i.e. those requiring chemotherapy. Urologists (surgeons) and Radiation Oncologists are responsible for the management of men with localized prostate cancer in Canada. Urologists may manage advanced prostate cancer also.

    General Prostate Cancer Web-Resources

    Memorial Sloan-Kettering Cancer Center in New York is an excellent resource for information on prostate cancer. Balanced, unbiased discussions of the disease, including discussion regarding some of the controversies in prostate cancer.

    General Information on Cancer

    UNDERSTANDING CANCER - Metrovan Urology info on the principles of diagnosis, staging, prognosis and more.

    American Cancer Society

    BC Cancer Agency: Good general website from the British Columbia Cancer Agency. Has contact information on locations.

    National Cancer Institute: Excellent source of understandable and mainly unbiased information. Several very good brochures on every stage of prostate cancer.

    National Comprehensive Cancer Network: peer-reviewed expert content/prostate cancer guidance on evidence-based cancer diagnosis and management. Best for Prostate and Kidney Cancer. The most in-depth information is located in the physician section and requires registration.