The appropriate treatment of prostate cancer is often controversial. Treatment options vary based on the stage of the tumor. In the early stages, surgical removal of the prostate (prostatectomy) and radiation therapy may be used to eradicate the tumor. Metastatic cancer of the prostate may be treated by hormonal manipulation (reducing the levels of testosterone by drugs or removal of the testes) or chemotherapy.

SURGERY:
Surgical treatment is usually only recommended after thorough evaluation and discussion of treatment options. A man considering surgery should be aware of the expected benefit of the procedure, as well as its potential risks.

• Removal of prostate gland (radical prostatectomy) -- often recommended for treatment of localized stage A and B prostate cancers. This is a lengthy procedure, usually performed using general or spinal anesthesia. An incision is made through the abdomen or perineal area. You may remain in the hospital for 5 to 7 days. Possible complications include impotence and urinary incontinence, although nerve-sparing procedures can reduce the risk of these complications. This surgery should be performed by a urologist with extensive experience doing this specific procedure.

• Removal of the testes (orchiectomy, castration). This alters hormone production and may be recommended for metastatic cancer. There may be some bruising and swelling initially after surgery, but this will gradually subside. The loss of testosterone (hormone) production may lead to problems with sexual function, osteoporosis (thining of the bones), and loss of muscle mass.

RADIATION THERAPY:
Radiation therapy is used primarily to treat prostate cancers classified as stages A, B, or C. Whether radiation is as good as prostate removal is a debatable topic, and the decision about which to choose can be difficult. In patients whose health makes the risk of surgery unacceptably high, radiation therapy is often the preferred alternative. Radiation therapy to the prostate gland may be performed in a number of ways:

• External beam radiation therapy is performed in a radiation oncology center by specially trained radiation oncologists, usually on an outpatient basis. Prior to treatment, a therapist will mark the location that is to be radiated with a special semi-permanent marking pen. The radiation is delivered to the prostate gland using a device that resembles a normal X-ray machine. The treatment itself is generally painless. However, there are several side effects associated with radiation therapy -- loss of appetite, fatigue, skin reactions such as redness and irritation, rectal burning or injury, diarrhea, cystitis (inflamed bladder), and blood in urine. External beam radiation therapy is usually performed five days a week for six to eight weeks.

• Another method consists of implanting small pellets of radioactive iodine, gold, or iridium directly into the prostate tissue through a small incision. The advantage of this form of radiation therapy is that the radiation is directed at the prostate with less damage to the surrounding tissues.

MEDICATIONS:

• Hormonal manipulation -- aims at lowering testosterone levels. Since prostate tumors require testosterone, reducing the testosterone level is often very effective in preventing further growth and spread of the cancer. This can be done either through surgical removal of the testes or by using medications. Hormone manipulation is mainly used to relieve symptoms without curing the prostate cancer, such as in people whose cancer has spread. Preliminary evidence suggests that it may improve cure rates when combined with radiation or surgery; however this is still under investigation.

Synthetic drugs like Lupron or Zoladex that mimic the function of LHRH (luteinizing hormone releasing hormone) are being used increasingly to treat advanced prostate cancer. These medications suppress testostorone production. The procedure is often called "chemical castration" because it has the same result as surgical removal of the testes, although it is reversible, unlike surgery. The drugs must be given by injection, usually every three months. Possible side effects include nausea and vomiting, hot flashes, anemia, lethargy, osteoporosis, reduced sexual desire, and erectile dysfunction (impotence).

Other medications used for hormonal therapy include androgen blocking agents (such as flutamide) which prevent testosterone from attaching to prostate cells. Possible side effects include erectile dysfunction, loss of sexual desire, liver problems, diarrhea, and enlarged breasts.

• Chemotherapy is often used to treat prostate cancers that are resistant to hormonal treatments. An oncology specialist will usually recommend a single drug or a combination of drugs aimed at destroying the cancer cells. Medications that may be used to treat prostate cancer include:
  • mitoxantrone
  • prednisone
  • paclitaxel
  • docetaxel
  • estramustine
  • adriamycin

  Most people receive their chemotherapy (after the initial dose) on an outpatient basis at a clinic or physician's office. Possible side effects are numerous and specific to a given chemotherapy drug.

• Serial prostatic-specific antigen (PSA) blood test (usually every 3 months to 1 year)
• Bone scan and/or CT scan to evaluate for metastasis
• Complete blood count (CBC) to monitor for signs and symptoms of anemia
• Monitor for other signs and symptoms indicating disease progression, such as fatigue, weight loss, increased pain, decreased bowel and bladder function, and weakness

Impotence is a potential complication after prostatectomy or radiation therapy. Recent improvements in surgical procedures have made this complication occur less often. Urinary incontinence is another possible complication. Medications can have side effects, including hot flashes and loss of sexual desire.

Call for an appointment if you are a man older than 50 and have:

• Never been screened for prostate cancer (by rectal exam and PSA level determination)
• Not maintained annual evaluations
• A family history of prostate cancer

You should discuss the advantages and disadvantages to PSA screening with your physician.