Every year, roughly 190,000 American men learn they have prostate cancer. It's bad news, but it isn't likely to be a death sentence. Thanks to widespread screening, nearly 90 percent of prostate cancers are detected before they spread beyond the gland. At this point, the disease is highly curable, meaning that after five years men who have undergone treatment remain cancer-free.
Men with early-stage prostate cancer have more options than ever before, enough to present many patients and their doctors with a dilemma: Every treatment has potential benefits and drawbacks, so which is the right course of action? The answer depends on many factors, including the size and aggressiveness of the tumor, the age and health of the patient, and the patient's personal preferences.
Before deciding on a specific treatment, the Prostate Cancer Foundation urges men to consult with three different types of prostate cancer specialists -- a urologist (a doctor who specializes in the urinary tract and male reproductive organs), a radiation oncologist (a doctor who specializes in the treatment of cancer patients using radiology), and a medical oncologist (a doctor who specializes in the overall treatment and management of cancer).
Here's a look at the three most common treatment options for early-stage prostate cancer -- watchful waiting, surgery, and radiation therapy. If you've recently been diagnosed with the disease, this overview can help you and your doctor choose the therapy that's right for you.
One thing to remember is that screening tests, such as the prostate-specific antigen blood testing (PSA), may be complex and the resulting treatment may vary according to age. In 2008, the American College of Preventive Medicine issued a statement saying there is not enough evidence to recommend for or against routine screening using the PSA test. You should discuss all the uncertainties of screening tests with your doctor before moving forward. Not all men decide to go forward with screening.
Prostate cancer is often a very slow-growing disease. It can take 10 years or more for small tumors to spread beyond the gland and pose a serious threat to health. Screening tests can find prostate cancer, but the problem is that most tumors are so slow-growing that it is hard to tell whether finding it early makes a big difference, especially for older men whose life expectancy is already less than 10 years.
For this reason, the best course of action may be no action at all. The treatments for prostate cancer are serious and may have lasting side effects, so deciding when -- and if -- to begin treatment is a decision to be considered carefully. Some factors that may make watchful waiting a better option are:
- Age. Men over 65 are likely to have fewer symptoms, according to the Prostate Cancer Foundation, and so may not need serious intervention.
- Overall health. Treatment like surgery or radiation will likely take a harder toll on the bodies of men who have conditions including heart disease, high blood pressure, or poorly controlled diabetes.
- Type of tumors. Treatment may not make sense for men with small tumors that have not spread to areas outside the prostate, those who have very early-stage cancers, or men with slow-growing tumors.
Watchful waiting doesn't mean the cancer will be ignored. A doctor will conduct regular PSA tests, which can sometimes be a sign of tumor growth. Your doctor will probably also do regular DRE tests (digital rectal exams) and may want to use ultrasound, CT scans, bone scans, or MRI scans to detect any cancer growth. If the cancer starts growing faster than expected, treatment may be warranted after all. The American Joint Committee on Cancer uses a system to determine the seriousness of a tumor:
Stage 1 or 2 tumors: Tumors that are detectable or nondetectable through touch and confined to the prostate.
Stage 3 tumors: Tumors that have reached the membrane covering the prostate.
Stage 4 tumors: tumors that invade adjacent tissue and organs or have spread to lymph nodes or other organs.
One size does not fit all when it comes to treatment for prostate cancer. According to the American Cancer Society, most doctors today agree that surgical removal of the prostate gland -- called radical prostatectomy -- and radiation have about the same cure rates for early stage prostate cancer. Each treatment has several different methods, and each has its own risks and side effects.
Unlike some cancers that grow from a single tumor, prostate cancer consists of a number of small tumors scattered throughout the prostate, which explains why the entire prostate gland must be removed. Because the urethra, the narrow tube that carries urine out from the bladder, runs through the prostate gland, it must be reattached directly to the bladder after the prostate is removed.
Most men can expect normal bladder control to return within weeks or sometimes months of the surgery, but some men continue to have problems with incontinence and are unable to completely control their urine flow. According to the American Cancer Society, one large study found that five years after undergoing radical prostatectomy, 15 percent of men had either no bladder control or experienced frequent urine leaks.
Another big concern for some men is impotence, the inability to achieve an erection after prostate surgery. The nerves that control erections lie very close to the prostate gland. If they are damaged during surgery, or need to be removed because the cancer has spread to them, your brain may send an arousal signal to your penis, but it won't get the message. If you're concerned about the possibility of becoming impotent, talk to your surgeon to see whether you'd be a good candidate for nerve-sparing surgery. This is a very precise surgical method that can often preserve sexual function.
Even if the nerves must be severed, a highly skilled surgeon may be able to graft nerves from other areas of the body (usually the side of the foot) onto them. About a third of men receiving this type of surgery are able to have erections after six months or so of recovery. However, this surgery requires doctors to have highly specialized skills and is not widely available.
Some men can still have normal feeling in their penises and can still have orgasms after nerves have been damaged, although there will be no ejaculation since semen is not produced. Several medications and devices can help such men achieve erections and enjoy a complete sex life.
Whatever type of surgery you have, don't be afraid to ask your surgeon how many times he or she has performed it. Although there's no guarantee that a very skilled surgeon will cure you and a lesser skilled surgeon won't, it's reasonable to want the best possible person on the job. According to the American Cancer Society, large cancer treatment centers where there are more surgeons who do this type of surgery regularly generally have fewer problems with side effects like incontinence.
Radical prostatectomy works best for relatively healthy patients under age 65 whose cancer hasn't spread outside the prostate gland. For one thing, such men generally have the strength to handle a major operation. Most patients have to stay in the hospital for two to three days, and usually have to recuperate for about a month before returning to work.
A technique called laparoscopic surgery, which uses the same type of small incisions that are used to remove the appendix, has been used to perform laparoscopic radical prostatectomy, or LRP, since 1999.Laparoscopic surgery is considered minimally invasive surgery. That is, it doesn't cause as much trauma to the body as a traditional radical prostatectomy. There are several different types of laparoscopic surgery -- one type even uses robotic arms to assist the surgeon. Because these procedures are relatively new and technically more challenging, it's especially important to find a doctor who is well experienced. A study reported in the May 2008 issue of the Journal of Clinical Oncology found that such minimally invasive surgery usually results in quicker recovery times and fewer complications, though there can be problems if the surgeon is less experienced.
Instead of removing the entire gland, healthy tissue and all, doctors can use radiation to target and kill the cancer cells. There are two ways to deliver the radiation. In a process called external beam radiation, a machine produces a highly focused beam of energy aimed directly at the tumor. It usually takes about five sessions a week over seven to nine weeks to treat the tumor. Alternatively, a doctor can implant radioactive pellets or "seeds" in the tumor. This is called seed therapy or brachytherapy. It's a minor procedure, and most patients go home the same day it is performed. The seeds give off radiation to the surrounding tissue over several months, killing the prostate cancer cells. After about a year, the seeds lose their radioactivity.
A different type of brachytherapy uses small tubes to deliver higher-dose radiation to the cancer site. The tubes are left in place for just two or three days, and the patient must stay in the hospital for that time.
Radiation therapy has some obvious advantages over radical prostatectomy. First and foremost, the patient avoids major surgery. The recovery time is minimal, and there's less risk of serious complications.
Radiation, however, can be hard on the body. Patients often feel exhausted at the end of their treatment. And roughly half of all radiation patients become impotent within two years, according to the American Academy of Family Physicians. Also, up to 30 percent of all patients will briefly suffer other unpleasant side effects such as rectal bleeding, burning during urination, frequent urination, and diarrhea.
Perhaps the biggest drawback to radiation treatment is uncertainty. Unless a surgeon cuts open a patient and physically removes the tumor, there's no way to be sure that every single cancer cell has been destroyed. Any remaining cells may eventually form new tumors 10 or 15 years later. For this reason, radiation isn't usually recommended for young patients.
What other treatments are available? Cryosurgery
In recent years a new treatment has been developed that destroys prostate cells through freezing. Called cryosurgery or cryotherapy, this treatment is sometimes used when cancer is limited to the prostate gland. In this procedure, the doctor uses hollow needles to transmit liquid nitrogen to the targeted area, using ultrasound images to guide the way. The "ice ball" of liquid nitrogen freezes the entire gland and kills the cancer. Cryosurgery is less invasive than a radical prostatectomy, but not much is known about its long-term effectiveness. For this reason, it isn't usually considered a first line of treatment. It is sometimes recommended when cancer returns after surgery or other treatment.
Since freezing also damages nerve cells near the prostate, most men who undergo cryosurgery will be impotent. Other side effects may include blood in the urine, soreness, and swelling for a few days after surgery. Sometimes cryosurgery affects the bladder and bowels, causing pain and the urge to go to the bathroom frequently, but this usually goes away in time.
High-intensity focused ultrasound
This technique is the exact opposite of cryotherapy -- it uses ultrasound waves to kill the prostate cells with heat. The patient is given a general or local anesthetic and then a probe is inserted into the rectum that emits high-intensity ultrasound waves to a targeted area. The probe is surrounded by a cooling balloon, so surrounding tissue isn't harmed. Although this technique is considered experimental in the United States, it has been used in Europe for several years with some success. Side effects can include urinary infections, incontinence, and impotence.
Prostate cancer that has spread beyond the prostate gland can no longer be cured, but it can be slowed down. Doctors can put the brakes on the disease by injecting the patient with drugs that block the supply of testosterone, a male hormone that helps fuel prostate cancer. In advanced cases, a surgeon can greatly reduce the flow of testosterone by removing the testicles.
When testosterone levels plummet, either because of testicle removal or the use of hormone drugs, prostate cancer tends to shrink or grow more slowly. Unfortunately, the cancer cells that do not respond to the reduction in testosterone will continue to grow, and over time, hormone therapies will have less of an effect on the growth of the tumor.
According to the Prostate Cancer Foundation, hormone therapy is also sometimes used in men with localized cancer as an interim step between watchful waiting and active treatment, though there is little data to show that it is effective in this role.
Not surprisingly, hormone therapy causes some unpleasant side effects. Many men develop enlarged, tender breasts. Other possible side effects include hot flashes, erectile dysfunction, and loss of interest in sex.
In cases where prostate cancer has spread and hormone therapy hasn't worked, a doctor may recommend chemotherapy, in which anticancer drugs are either injected or taken orally. Because the drugs are in the patient's bloodstream, they travel throughout the body to attack cancer cells wherever they may be. Although chemotherapy can't cure prostate cancer, it can often slow it down -- prolonging a patient's life and easing his symptoms.
Whatever approach your doctor recommends, be sure to ask about the potential risks and benefits. And be sure to stay positive. With so many options available, most patients have a good chance of beating the disease.
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