The Big Picture | What Is It? | Diagnosis | Understanding Risk | Treatment Options | Prostate Cancer Results Study Group
Treatment Options
Once the prostate cancer has been graded and staged, PSA performed and a risk group assigned, most patients have several good treatment options to consider. Take your time to carefully evaluate each. We often see patients who feel that a treatment is being sold to them. Note that, for most patents, the control of the cancer is very similar across treatments. However, it is essential you allow adequate time to educate yourself sufficiently to reach a well-informed decision regarding your options and their side effects. Please ask us as many questions as you need. A second opinion from a different type of prostate specialist (surgeon, brachytherapist*, radiation oncologist, medical oncologist specializing in prostate cancer) is worthwhile. Prostate cancer is a complex disease, and physicians often differ in their opinions and expertise.
Seed Brachytherapy (Seed Implantation)
The treatment of prostate cancer using modern seed brachytherapy was pioneered by the physicians at the Prostate Cancer Center of Seattle in the 1980’s as an alternative to surgery. Over 600 centers around the world now perform seed implantation for prostate cancer, and it is estimated over a third of patients with prostate cancer receive this treatment. The word brachytherapy is derived from the Greek prefix brachy, meaning “short” or “near”, because the seeds containing radioactive material are implanted directly into the prostate gland near the cancer.
Brachytherapy, or permanent seed implantation as it is often referred, is a minimally invasive procedure performed as a single outpatient treatment under spinal or light general anesthesia. The procedure itself involves the placement of tiny radioactive seeds inside via thin needles into the prostate using ultrasound guidance. In contrast to the biopsy, the needles do not go through the rectum, rather they are placed through the skin just above the anus and below the scrotum. Prior to the implant, seed placement is carefully planned and mapped out using sophisticated computer planning. Brachytherapy has the advantage of delivering substantially higher doses to the cancer than any type of external beam radiation or High Dose Rate (HDR). Seed Implantation delivers substantially less dose to the surrounding normal tissues and thus less risk of injury to the bladder, hips, small bowel and other organs far away from the prostate.
Radioactive material (Iodine-125**, Palladium 103***, or Cesium 131**** inside the titanium seeds emit radiation over a very short distance killing the malignant cells inside the prostate. Each isotope has its own characteristic short lifespan over which the radiation is delivered, which your physician can explain. The titanium is not allergenic therefore there is no rejection of the seed by the body. After the procedure, patients are taken to recovery and are typically discharged an hour or two later. Most patients resume normal activities within 24-48 hours. The risk of serious complications such as death, infections or pulmonary emboli are extremely rare (zero in our experience). The most common side effect of prostate brachytherapy is temporary urinary irritation including frequency and urgency. Typically, these symptoms will last from a few weeks to several months. Permanent incontinence is rare and 90% of patients return to near their normal function within 1 year.
Surgery
Radical Prostatectomy***** is the removal of the prostate and may be performed using an open abdominal, a perineal or robotic laparotomy approach. The success of each is dependent on the experience of the surgeon. Regardless of the approach, studies have demonstrated that the side effects of each type are very similar with similarly experienced surgeons. Despite ads to the contrary, the only improvement of robotic surgery over standard surgery has been that patients can leave the hospital a day or two earlier. A robot does not make a surgeon better and has not, to date, improved the cancer control or incontinence rates. Most men undergoing prostate surgery will be hospitalized for 1-4 days, require a catheter for 2-4 weeks and experience a recovery time of a least a month to resume normal activities. The risk of death, infections, pulmonary emboli, etc are low but not zero. Long term urinary incontinence (being unable to control urine) is fairly consistent amongst reports and techniques with at least 10% or higher risk of stress and frank incontinence. A recent report from Washington University St. Louis revealed a 22% long term rate of incontinence in obese men, 16% in non-obese, physically active men and 59% in obese, physically inactive men (Wolin et al Urol 2009 Dec 15). The success of the surgery is highly dependent on the risk group, with low patients doing reasonably well and high risk failing at least 50% of the time. Experience is an important factor on outcome. At least one study concluded that the rate of complications is higher for less experienced surgeons (as compared to highly experienced surgeons). Reference
External Beam
There are various forms of external beam radiation. Each is marketed to patients as improving the results of treatment, but, in reality, all of them give similar biological doses to the prostate and therefore the results are very similar. IMRT, Proton Beam, Tomotherapy and Cyberknife are all forms of external beam radiation. IMRT radiation is the most common and stands for Intensity Modulated Radiation Therapy. The treatment is given from multiple angles to reduce dose to adjacent normal structures such as the bladder, rectum and bowel. The treatments are given at a hospital or clinic, 5 days per week for 8 1/2 weeks for a full treatment, or, for shorter periods if it is combined with seed implantation or for post radical prostatectomy failure. Some machines give the treatment course over a very short period of time which is called hypofractionation (e.g. Cyberknife). However, the long term results for cancer control and side effects for these very short hypofractionated treatment courses are very preliminary, experimental and you should be very cautious about these unknown factors. Rectal side effects such as frequent bowel movements and rectal pain, can occur with external radiation. In the past, hypofractionated treatment courses have been associated with increased complication rates and lower cancer control rates. There is typically a substantial dose to the hips with high dose external beam schedules which may result in hip fracture later on, especially if combined with hormonal therapy. As with other forms of prostate cancer treatment, urinary and sexual side effects are possible and vary depending on the health of the patient, skill of the treating physician, dose of radiation received and the cancer itself. These side effects for the specific treatment and center results should be discussed with your physician.
Proton Beam Therapy
Proton beam therapy is a form of external beam radiation therapy in which the radiation is delivered from a machine which generates protons. Protons have the advantage of penetrating tissue and then slowing down at a particular depth in tissue. By placing the prostate in this area where the protons slow, the effect on the normal tissue around the prostate should be less. For areas where there is a short distance of penetration required, such as childhood tumors, protons work extremely well. For prostate cancer which is deep in the pelvis, the advantages of protons were pronounced when old external beam techniques were used but have not been proven to be substantially better than IMRT techniques used today. It is, however, effective in early stage prostate cancer and has similar side effects to other external beam techniques. Proton therapy is extremely expensive, typically more than double any other therapy. Without evidence of better cancer control than brachytherapy, for example, it is hard to justify for the majority of patients. While cancer control results have been satisfactory, they have not shown to be superior to IMRT or brachytherapy for the treatment of prostate cancer. Furthermore, there are no urethral or hip sparing techniques yet developed for proton beam therapy which can potentially mean more side effects.
HIFU
High Intensity Focused Ultrasound (HIFU) is exactly as it sounds. High frequency ultrasound energy is focally directed to the prostate to kill the prostate and cancer cells. Much like a magnifying glass, the energy is very pinpoint and therefore requires a rather long course of time (several hours) to deliver the energy to the entire gland. HIFU is a procedure performed under spinal or epidural anesthesia. It can be repeated if necessary.
Currently, there is very limited short term and no long-term data on the efficacy of this procedure. This procedure is currently not FDA-approved for use in the United States.
High Dose Rate Brachytherapy (HDR)
HDR brachytherapy involves the temporary placement of a radioactive seed throughout the prostate. Approximately 12-16 plastic catheters are placed, under anesthesia, into the prostate gland through a template which is then sutured to the perineal skin below the scrotum. The small radioactive seed which is emitting radiation at a high rate (high dose rate) is directed down the catheters to sites in the prostate as determined and directed by a computer. The computer controls the length of time the seed stays in its position and therefore the dose delivered. After sequentially delivering the seed at each position, the seed is removed, leaving no radioactive material in the gland. This may be repeated several times over a few days. This type of treatment sometimes requires an overnight stay but often can be done as an outpatient treatment. HDR is usually combined with several weeks of external beam radiation as well. The advantage of HDR is that the operator can adjust the dose to the gland. High dose rate does not mean a higher dose is received to the prostate. The biological dose is similar to IMRT and much lower than permanent seed implantation. The side effects are also similar.
Cryosurgery
Cryosurgery is freezing the prostate. It is performed under spinal or light general anesthesia as an outpatient treatment. Using ultrasound guidance similar to brachytherapy, probes are placed into 8-12 positions within the gland. Liquid nitrogen is directed into each probe which freezes the surrounding prostate tissue. After the procedure, a supra-pubic tube or catheter is often used to rest the bladder for up to two weeks. There is a possible risk of incontinence and impotence is very common as the freezing also freezes the nerve for the erection. Short term results have not demonstrated any superiority over other treatments. Long term results which satisfactorily stratify patients into risk groups are lacking. Patients should be cautious with this approach and seek treatment only from very experienced practioners.
Hormonal Therapy
Hormone therapy is a non-curative form of therapy but can be useful for some patients. Typically, it involves giving one or two drugs, such as Lupron or Casodex, to decrease the testosterone levels in the blood to castrate levels. Short term Hormonal therapy is given in some patients prior to seed implantation to shrink the gland or in high risk patients to improve the results of seeds and external beam radiation (IMRT). It has not been shown to improve the results of surgery. Hormonal therapy can kill some of the cancer cells or effectively stop the cancer from progressing for a long period of time. This type of therapy can be administered orally or via injection. Short-term side effects can include hot flashes, mood swings, fatigue and loss of sex drive. Hormonal therapy may also be used on a long term basis to control cancer progression. Long-term side effects can include weight gain, diabetes, osteoporosis, high cholesterol, breast tenderness and/or enlargement and possible cardiac complications.
Active Surveillance (Watchful Waiting)
Depending on the characteristics of the cancer, we may recommend an active surveillance or watchful waiting as a reasonable approach to managing the disease. Some patients have extremely slow growing cancers, have other medical issues that are more important than their cancer or have difficulty with the possible side effects of any treatment. Active surveillance requires closely monitoring the cancer with PSA readings, occasional biopsies and digital rectal exams. Treatments such as brachytherapy surgery or radiation therapy can still be given if the cancer advances. This option may be recommended if your cancer is not causing any symptoms, you have a very low PSA and grade, the cancer is expected to grow very slowly and is small and contained within one area of the prostate. This option, however, is not advisable for men of a life expectancy greater than 10 years. As with all treatments, there are risks involved which should be carefully explained to you. Additionally, you will need to be completely comfortable with this option, as knowledge of having a cancer and not receiving treatment, can cause some anxiety.