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The Decision Is YoursAn important consideration to factor into your treatment decisions is that success is not guaranteed. As many as half of the apparently localized cancers turn out, at surgery, to have already spread. And up to one-fourth, despite apparently successful surgery, will produce a recurrence over the next several years. Thus, while aggressive treatment will be unnecessary for some men, it will prove inadequate for others. In coming to a decision, you may find it helpful to thoroughly discuss your treatment options, including benefits and side effects, with your wife/partner. You may also consider contacting your local prostate cancer support group after consulting with your primary care physician and one or more specialists. Getting a second opinion and different perspectives can be very helpful. Your decision does not need to be rushed. Take time to explore all your options. You may prefer a teaching hospital or a cancer center for treatment, choosing a surgeon or radiation oncologist who has extensive experience in the newest, least traumatizing techniques. You may want to take part in a clinical trial evaluating new approaches. Ultimately, the decision rests with each individual. Each man has his own priorities and knows best which choices feel most comfortable for him. Second and Third OpinionsOnce you receive your doctor's opinion about what treatments you need, it may be helpful to get more advice before you make up your mind. Other doctors' opinions can help you make one of the most important decisions of your life. Getting another doctor's advice is normal medical practice, and your doctor can help you with this effort. Many health insurance companies require and will pay for other opinions. Another opinion can help you:
You may also consider contacting a prostate cancer support group in your area. Talking with other men who have experienced the various procedures available may help you to understand better the treatment options described by your doctor. Making Treatment ChoicesIf you have been diagnosed with prostate cancer, you may be overwhelmed with an array of treatment options. Your course of action will, to some extent, be influenced by the character of your cancer. Your decisions should also reflect your personal priorities after weighing each potential benefit and possible harm for the treatment options available. Your age and health and lifestyle should also be considered. Treatment decisions are complicated by shortcomings in both prognosis and treatment. Although your Gleason score and PSA level provide good guidelines, there is still no way to know for sure how rapidly your prostate cancer will progress. Nor are there any results available from clinical trials that directly compared different types of treatment for similar stages of disease to help you evaluate possible options. Treatment Options for Localized DiseaseIf your prostate cancer is confined to the gland, or localized (Stage I or II/low Gleason score), you are a good candidate for treatments that can result in long-term survival. There are three main approaches to managing localized cancer: watchful waiting, surgery, and radiation therapy. Watchful WaitingWatchful waiting, also called, "Vigilance," in Malecare groups, is based on the premise that cases of localized prostate cancers may advance so slowly that they are unlikely to cause men -especially older men-any problems during their lifetimes. Some men who opt for watchful waiting, also known as "observation" or "surveillance," have no active treatment unless symptoms appear. They are often asked to schedule regular medical checkups and to report any new symptoms to the doctor immediately. Watchful waiting has the obvious advantage of sparing a man with clinically localized cancer- who typically has no symptoms- the pain and possible side effects of surgery or radiation. On the minus side, watchful waiting risks decreasing the chance to control disease before it spreads, or postponing treatment to an age when it may be more difficult to tolerate. Of course, treatments may also improve over time if watchful waiting is chosen. Another potential disadvantage is anxiety; some men don't want the worry of living with an untreated cancer. The most obvious candidates for watchful waiting are older men whose tumors are small and slow growing, as judged by low grade/ Gleason score and low stage. Many men who choose watchful waiting live for years with no signs of disease. A number of studies have found that, for at least 10 or even 15 years, the life expectancy of men treated with watchful waiting (primarily older men with less lethal forms of prostate cancer) is not substantially different from the life expectancy of men treated with surgery or radiation-or, for that matter, of the population at large. In the early 1990s, roughly 30 percent of prostate cancer patients in the United States were treated by surgery, 30 percent by radiation, and 20 percent by watchful waiting. (Most of the rest were treated with a combination of therapies.) In Europe, by contrast, watchful waiting constitutes the standard treatment for asymptomatic prostate cancer. The popularity of surgery in this country has grown tremendously in recent years. A study of Medicare patients' records found that the number of men nationwide receiving radical prostatectomy by 1990 was six times greater than the number recorded for 1984, and the increase was seen in all age groups, from the youngest (that is, age 65) to men in their eighties. Recent statistics, however, indicate that since 1993, the rate of prostatectomies has been dropping. The procedure Pelvic lymph node dissection is done routinely as part of a retropubic prostatectomy; with a perineal prostatectomy, lymph node dissection requires a separate incision. Possible problems Prostatectomy also carries the risk of serious long-term problems, notably urinary incontinence, stool incontinence, and sexual impotence. (The procedure also makes it very unlikely for a man to father children, since little ejaculate is produced without the prostate.) Most men experience urinary incontinence following surgery. Many continue to have intermittent problems with dribbling caused by coughing or exertion. A few men permanently lose all urinary control. Some men can be helped with an artificial urinary sphincter, surgically implanted, or with injections of collagen to narrow the bladder opening. Infrequently men may develop stool or fecal incontinence after radical prostatectomy. Fecal incontinence is the loss of normal muscle control of the bowels. Muscle damage can occur during rectal surgery. Stool incontinence may also be caused by a reduction in the elasticity of the rectum, which shortens the time between the sensation of the stool and the urgent need to have a bowel movement. Surgery or radiation injury can scar and stiffen the rectum. At one time, prostatectomy almost invariably resulted in sexual impotence. Today, the risk of impotence may be reduced by nerve-sparing surgery. This technique carefully avoids cutting or stretching two bundles of nerves and blood vessels that run closely along the surface of the prostate gland and are needed for an erection. However, nerve-sparing surgery is not possible for everyone. Sometimes the cancer is too large or is located too close to the nerves. Even with nerve-sparing surgery, many men-especially older men-become impotent. Most men will lose a degree of sexual function. (If a man has trouble with erections prior to treatment, nerve-sparing surgery is probably not indicated.) Depending on age, extent of disease, and type of surgery, the chances of impotence vary widely-somewhere between 20 and 90 percent. Radiation TherapyRadiation therapy uses high-energy x-rays, either beamed from a machine or emitted by radioactive seeds implanted in the prostate, to kill cancer cells. When prostate cancer is localized, radiation therapy serves as an alternative to surgery. External beam radiation therapy is also commonly used to treat men with regional disease, whose cancers have spread too widely in the pelvis to be removed surgically, but who have no evidence of spread to the lymph nodes. In men with advanced disease, radiation therapy can help to shrink tumors and relieve pain. Radiation therapy is the second most common treatment for early-stage prostate cancer. Radiation therapy uses high-energy rays to destroy cancer cells. For the treatment of prostate cancer, it can be delivered by two basic methods: external beam (similar to an x-ray) or brachytherapy (internal radiation delivered with implanted radioactive seeds). Some patients are treated using both methods. Physicians here have developed several techniques that allow them to deliver higher, more effective doses of each type of radiation to cancerous tissues, while also minimizing exposure and potential damage to nearby healthy tissues, thus lessening side effects. One such technique, a form of external-beam radiation, is called 3-D conformal radiation therapy. In this therapy, a computer builds a 3-D image of the prostate from multiple CT scans. This 3-D image is then used to shape the radiation beam so it exactly matches the contours of the prostate, using moveable leaves similar to the lens on a camera. The radiation beam is thus aimed much more precisely at prostate tissues, allowing for more effective, higher doses of radiation to be delivered while sparing surrounding tissues. Treatment sessions typically last about 15 to 20 minutes and take place every weekday for eight to nine weeks. Fatigue is a possible side effect of radiation therapy, but it gradually ceases after treatment is completed. Some men may also experience impotence, bowel problems, urinary problems, and rectal discomfort or bleeding. Studies of patients with early and more advanced prostate cancer who were treated with 3-D conformal radiation therapy show that those who received high radiotherapy doses were more likely to have PSA levels that dropped below 1.0 ng/ml and were less likely to have rising PSA levels five years later. Higher radiation therapy doses have also been associated with much lower rates of positive biopsies three years after therapy was completed. Side effects, too, have been much lower than with conventional radiotherapy techniques. About 60 percent of patients have few or no urinary symptoms, and 85 percent have few or no rectal problems. About 30 percent of men develop impotence from the treatments. A newer, even more advanced method of 3-D conformal radiation therapy, called intensity modulated radiation therapy, or IMRT, is now being used. This method uses the same leaves to shape the radiation beam to the exact contours of the prostate, but it goes a step further. Again using sophisticated computer software, the leaves that shape the beam are used to momentarily block the radiation beam from some tissues, resulting in a higher dosage of radiation to some tissues and a lower dosage to other tissues. In this manner, doctors are able to further reduce the dosage of radiation to healthy tissues, while maintaining a highly effective dosage to cancerous tissues in and near the prostate. Recent studies conducted here have shown this method results in a significant reduction of side effects such as rectal bleeding.
External beam radiation therapy Depending on how extensive the cancer is or how big the prostate has grown, hormone therapy may be used before radiation therapy to help shrink the size of the tumor, thereby making it easier to treat. Hormone therapy decreases the amount of the male hormone testosterone in the body, which can promote the growth of cancer cells. The primary target or External Beam Radiation is the prostate gland itself. In addition, the seminal vesicles may be irradiated (since they are a relatively common site of cancer spread). Radiating the lymph nodes in the pelvis, once common practice, has not proven to produce any long-term benefits for most patients, but it may be necessary in certain circumstances. Possible problems Radiation can also cause a variety of long-term problems. These include proctitis, inflammation of the rectum, with bleeding and bowel problems such as diarrhea, and cystitis, inflammation of the bladder, leading to problems with urination. In addition, some 40 to 50 percent of men treated with radiation therapy become impotent. With newer techniques, available at state-of-the-art radiation therapy centers, side effects may be fewer. Higher-energy radiation beams can be more precisely focused, while computer technology allows a radiation oncologist to tailor treatment to the anatomy of the individual patient. Internal radiation therapy As practiced today, internal radiation therapy relies on ultrasound or CT to guide the placement of thin-walled needles through the skin of the perineum. Seeds made of radioactive palladium or iodine are delivered through the needles into the prostate, according to a customized pattern-using sophisticated computer programs- to conform to the shape and size of each man's prostate. The implantation procedure can be completed in an hour or two under local anesthesia; the patient typically goes home the same day. The seeds emit radiation for several weeks, then remain permanently and harmlessly in place. Alternatively, some doctors use much more powerful radioactive seeds over a period of several days. Such temporary implants, which require hospitalization, may be combined with low doses of external beam radiation. Because the experience with modern internal radiation therapy techniques is relatively recent and limited to carefully selected patients, long-term results are not yet known. At 5 years, more than 90 percent of patients remain free of disease. Internal radiation therapy is not well suited for large or advanced tumors, or for men previously treated with transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), who run an increased risk for urinary complications. For men with small, well-differentiated tumors, it may provide an option that is less invasive, has fewer side effects, takes less time to do, requires less time in the hospital, and is less costly than either external radiation or surgery. Another form of brachytherapy, high-dose-rate (HDR) brachytherapy, may be used for patients who have somewhat more advanced or aggressive prostate cancer with an increased potential of microscopic extension beyond the prostate and the prostate capsule. In this procedure, the needles that guide the placement of the radioactive seeds are left in place for a day and a half. They are connected to a mobile radiation source that gives a brief, concentrated dosage of radiation at several intervals, allowing for a higher dosage in a brief period of time compared to permanent seeds. This form of treatment is also planned using the intraoperative computer program. It is sometimes combined with a five to six week course of 3-D conformal or IMRT radiation therapy. Possible problems Treatment Options for Disease That Has SpreadIf your cancer has grown beyond the prostate gland (Stage III), it cannot be stopped with local therapies -although radiation therapy can help to keep the tumor in check and hormonal therapy may slow its advance. If your prostate cancer is metastatic (Stage IV), it is usually treated with hormonal therapy, which can relieve painful or distressing symptoms and slow the progress of disease. Another option for metastatic disease is to enter clinical trials and accept new treatments that are being studied. Hormonal therapy combats prostate cancer by cutting off the supply of male hormones (androgens) such as testosterone that encourage prostate cancer growth. Hormonal control can be achieved by surgery to remove the testicles (the main source of testosterone) or by drugs. Hormonal therapy targets cancer that has spread beyond the prostate gland and is thus beyond the reach of local treatments such as surgery or radiation therapy. Hormonal therapy is also helpful in alleviating the painful and distressing symptoms of advanced disease. Further, it is being investigated as a way to arrest cancer before it has a chance to metastasize. Although hormonal therapy cannot cure, it will usually shrink or halt the advance of disease, often for years. Surgery to remove the testicles (orchiectomy or surgical castration) is usually an outpatient procedure. The testicles are removed through a small incision in the scrotum; the scrotum itself is left intact. To help offset the operation's psychological toll, some men opt for reconstructive surgery in which the surgeon replaces the testicles with prostheses shaped like testicles. A variety of hormonal drugs can produce a medical castration by cutting off supplies of male hormones. Female hormones (estrogens) block the release and activity of testosterone. Antiandrogens block the activity of any androgens circulating in the blood. Still another type of hormone, taken as periodic injections, prevents the brain from signaling the testicles to produce androgens. Possible problems Hormonal therapy has been tried in many combinations. One approach, known as maximum androgen blockade or complete hormonal therapy, combines castration (either surgical or medical) with an antiandrogen pill, taken daily, for months or years. However, studies show that single hormone treatments have similar effectiveness compared to maximum androgen blockade. Combining surgery with hormonal therapy appears to relieve symptoms. Medical castration by hormonal therapy can be costly, but, unlike surgical castration, its effects can be reversed by stopping the drug. Moreover, halting hormone treatments will sometimes, paradoxically, temporarily interrupt the progress of an advanced and advancing cancer. Unfortunately, hormonal therapy for metastatic disease works only for a limited time. Remissions typically last 2 to 3 years. Eventually, cancer cells that don't need testosterone begin to flourish, and cancer growth resumes. When that happens, a variety of other, second-line hormonal-type drugs (for example, hydrocortisone or progesterone) may be tried. There is hope around this problem, too, as some doctors are learning how to make hormone therapy effective longer than 2 to 3 years. Ask your doctor if s/he is familiar with this. Cryosurgery During cryosurgery, a warming catheter inserted through the penis protects the urethra, and incontinence is seldom a problem. However, the overlying nerve bundles usually freeze, so most men become impotent. Early hormonal therapy Complementary TherapiesIn addition to medical treatment, some cancer patients want to try complementary therapies. Complementary therapies include acupuncture, herbs, biofeedback, visualization, meditation, yoga, nutritional supplements, and vitamins. Some prostate cancer patients feel that they benefit from some of these therapies. Before you try any of these therapies, you should discuss their possible value and side effects with your medical doctors. You should let them know if you are using any such therapies. Be aware that these therapies may be expensive, and some are not paid for by health insurance. As with any treatment, you should ask the therapist for evidence of how the therapy has helped others.
Stage I and Stage IIIf your prostate cancer is limited to the prostate (Stages I or II) and it is well or moderately differentiated (Gleason score 7 or below), the 5- year outcome is considered excellent for all three treatment options: watchful waiting, surgery, or radiation therapy. Even at the end of 10 years, few men with Stage I or II and a low Gleason score will have succumbed to prostate cancer. With a median age of 72 at diagnosis, many men with prostate cancer die of a variety of other natural causes in the next 10 to 15 years. Few men with low-grade localized disease die of prostate cancer. The disease-specific survival rate-which excludes deaths from other causes-is close to 90 percent. In other words, regardless of treatment- watchful waiting, surgery, or radiation therapy-such a man can consider his cancer a chronic disease because he is much more likely to die of other causes than of prostate cancer. Men with localized tumors who opt for watchful waiting, if they live long enough, may run a greater risk of eventually developing metastatic disease. In one series of studies, the chance of developing metastases within 10 years was 19 percent for men with well-differentiated tumors and 42 percent for men with moderately differentiated tumors. Only one small study has directly compared watchful waiting with radical prostatectomy, and it found no significant differences in survival. More reliable answers should be forthcoming from ongoing trials. In a 15-year study known as PIVOT (Prostate Cancer Intervention versus Observation Trial), some 1,250 patients with clinically localized prostate cancer (Stage I or Stage II and low Gleason score) are being randomly assigned to either watchful waiting or radical prostatectomy. Similar trials comparing watchful waiting to surgery or to radiation therapy are under way in Europe. Surgery or radiation therapy is chosen typically by those men whose tumors, although apparently localized, are more extensive or poorly differentiated (Gleason score of 8 to 10). Without aggressive therapy, around three-quarters of such men will have developed metastatic disease in the following 10 years, and twothirds will have died from prostate cancer. Whether or not treatment can change these outcomes is under study. The reality is that not all seemingly localized cancers are, in fact, limited to the prostate gland. When examining excised biopsy tissue, pathologists find that as many as half show prostate cancer that has broken through the capsule, invaded the seminal vesicles, or spread into the surgical margins or lymph nodes. In other words, many cancers that are clinically Stage I or Stage II need to be reclassified as Stage III after the pathologist reports his findings. In other cases, even some cancers that are clinically staged and pathologically verified as Stage I or II apparently are still capable of spreading, since up to one-fourth of these patients will experience the recurrence of prostate cancer over the next few years. A review of Medicare records from around the country found that more than one-third of the men initially treated with radical prostatectomy needed additional cancer treatment in the next 5 years. Stage IIIIf your prostate cancer is Stage III, it is a regionalized tumor that has spread beyond the prostate-through the capsule that encloses the prostate and perhaps into the seminal vesicles. However, it has not yet, as far as can be determined, reached the lymph nodes or any more distant sites in the body. External beam radiation therapy is often used to treat Stage III cancers. Besides being less invasive than surgery, it is better suited for bulky tumors. A few men have surgery, while others rely on watchful waiting. Men whose tumors are reclassified as Stage III after surgery (because cancer is found to have spread through the capsule or into the lymph nodes) sometimes go on to have radiation therapy postoperatively. Studies are in progress to evaluate this approach. Stage III tumors are often large enough to create difficulties with urination. These may be treated in a variety of ways, including radiation therapy, surgery, TURP, and hormonal therapy. The long-term prospects for men with Stage III prostate cancer depend on the extent of disease. Once cancer has broken through the prostate capsule, chances that the disease will progress in the next 10 years are about 50-50. Spreading to the seminal vesicles further increases the likelihood of a recurrence. One study, following up on men who had been treated with radiation therapy 20 years earlier, found that close to half of them eventually died of prostate cancer, although nearly as many had died of some other cause with no sign of cancer recurrence. Stage IVIf your prostate cancer has spread to the nearby lymph nodes or to distant parts of the body, it is called metastatic prostate cancer. Hormonal therapy will generally improve symptoms and delay the progress of disease for another 2 to 3 years. If just the lymph nodes are involved, a man may use hormonal therapy to delay the progress of prostate cancer even longer. However, the vast majority of those with positive lymph nodes at the time of getting hormonal therapy will remain at risk of developing additional metastatic disease within 10 years after the treatment. Bone metastases tend to be less responsive to hormonal therapy. Pain ManagementOver time, metastatic prostate cancer often stops responding to hormonal therapy. Advancing disease may be accompanied by painful symptoms, usually involving the urinary tract or bones, along with weakness, fatigue, and weight loss. Doctors, including specialists in pain control, can offer a variety of ways to counteract such symptoms and help the patient achieve comfort. Radiation, with either external beam radiation therapy or periodic injections of bone-seeking radioactive chemicals (radionuclides), may ease pain caused by bone metastases, and it may also delay the progress of disease. Surgery can be helpful in opening a blocked urinary tract. Beneficial drugs include steroids and other "second-line" hormonal therapies, as well as painkillers. When pain cannot be entirely eliminated, it can be effectively relieved in the majority of patients. New DirectionsProstate cancer research is advancing on dozens of fronts. Scientists are probing the basic causes of disease, developing markers to distinguish slow-growing cancers from aggressive cancers, and testing drugs to control or reduce risk for prostate cancer. Most of the results are preliminary at present. Depending upon your choice of treatment for prostate cancer, your doctor will make some recommendations for followup care. These recommendations may include more tests, and the results will be used to make choices that should improve your quality of life as a prostate cancer survivor. For example, you may be asked to have more PSA tests, bone scans, or palliative treatment. If you find any unusual changes in your body such as bone pain or swollen lymph nodes, you should call your doctor as soon as possible. |
