This post was written by Adam Thomas, MD, PPG – Urology.
As Prostate Cancer Awareness Month comes to a close, we have one more aspect to cover. We’ve discussed prevalence, screening and the diagnosis of prostate cancer, which brings us to the treatment for prostate cancer.
Staging
The first step toward treatment is meeting with your doctor to stage the prostate cancer and determine how aggressive it may be. I often give my patients a “nomogram,” which gives a good idea of whether or not the prostate cancer has spread.
Very early, low-stage prostate cancer may not need any treatment, whereas metastatic aggressive prostate cancer may need chemotherapy and androgen deprivation (lowering the patient’s testosterone). This article focuses on non-metastatic prostate cancer, which is prostate cancer that has not spread beyond the prostate.
Treatment strategies
There are currently three main management or treatment strategies for localized prostate cancer: active surveillance, radical prostatectomy and radiation therapy.
Active surveillance is the current management strategy for men who choose to not treat their prostate cancer. Formerly called “watchful waiting,” which was simply following prostate-specific antigens (PSA), active surveillance is now a more intensive plan of following a man’s prostate cancer. In addition to PSA checks, an MRI of the prostate and repeat prostate biopsies are typical. Active surveillance can span several years, and with very low-risk prostate cancer, patients may be able to safely avoid treatment of their prostate cancer.
Radical prostatectomy is the surgical removal of the entire prostate and sometimes the lymph glands which drain the prostate. It is most commonly done robotically, which is an advanced laparoscopic technique that involves making several small incisions to safely remove the prostate. Recovery from this surgery is quite good, and patients can often return to normal activity within weeks. Patients may experience incontinence and wear pads initially, which can be stressful, but with physical therapy, most men recover their continence and are dry except for heavy lifting. The other risk is impotence. Fortunately, surgeons have learned over the past 20 years where the nerves to the penis are in relation to the prostate. As long as the cancer has not compromised the nerves, avoiding damage to the nerves can help a man to keep having good erections. That said, men often need medication to achieve a good erection.
There are several advantages to radical prostatectomy over other treatments. First, removing the entire prostate allows for better staging of the man’s prostate cancer and may reveal if there is more prostate cancer than previously thought or if it has spread beyond the prostate. Second, removing the entire prostate allows the urologist to more easily measure and evaluate a patient’s progress after surgery as a patient’s PSA should immediately trend to 0.0 or 0.1 and stay low. Third, if a patient needs further treatment to address cancer which may remain post-surgery, radiation can be given to try to cure the patient.
Radiation therapy is the non-surgical option for cure. Radiation for prostate cancer is painless with few side effects, in contrast to the radiation given for other cancers or even for prostate cancer 15-20 years ago. Side effects of prostate cancer develop from the surrounding tissues being damaged. Radiation oncologists apply focused radiation on the prostate, using two markers placed on each side of the prostate as their guide. Depending on factors specific to the patient, a special jelly (SpaceOAR) may be injected to create a separation between the rectum and the prostate to lower the risk of injury to the rectum. Radiation is typically given over five days and up to about 40 days depending on the patient’s individual needs.
The advantage that radiation has over radical prostatectomy is that a patient avoids surgical risk and associated complications, although these are rare. A patient will also retain his prostate (although it is scarred), so the risk of serious incontinence is very low. Impotence is still a risk over time as the nerves can be damaged and patients will often develop weaker erections several years after the treatment.
There are also some disadvantages with radiation. First, a urologist’s ability to measure and evaluate a patient’s progress can be more complex following radiation versus radical prostatectomy. The PSA should decrease after radiation, but the trend may vary over the first two years with the goal to have a PSA of 0.5 or less after two years. Second, if the PSA is higher than expected after radiation, surgery is not recommended as it can be very difficult. Third, patients can sometimes have irritation of their bowels causing blood.
Additional treatments for prostate cancer exist beyond these three primary options, which should be discussed between a patient and his urologist to determine the best course of action to address his specific needs.
Final thoughts
Prostate Cancer Awareness Month is an important observance that helps men better understand their prostate and encourage diligence around having regular prostate checks, but prostate health should always be a priority. Early detection helps to ensure better long-term outcomes. For any man who receives a diagnosis of prostate cancer, know that there are excellent options for care to help you and your loved ones get through this challenging experience.
