Prostate Cancer

Description

Alternative Names

Treatment for Localized Prostate Cancer

Choosing the best treatment for localized prostate cancer (T1 or T2) is generally based on the patients age, the stage and grade of the cancer, and the patients knowledge and acceptance of the risks and benefits of each therapy.

Patients have three main options:

• Surgery (radical prostatectomy or cryosurgery) removes or destroys the prostate gland. The vessels that carry semen and surrounding tissue may also be removed. With cancer that has spread beyond the prostate, the pelvic lymph nodes are removed.
• Radiation is used to destroy tumors.
• Watchful waiting (for selected patients with lower-risk tumors) involves lifestyle change and careful monitoring for cancer progression. Treatment at that point may be hormonal agents, radiation, or surgery, depending on its extent.

Therapies to suppress androgen (male hormones) may be beneficial as additional treatment in some cases. Unfortunately, even the medical community is divided over the best treatment for localized prostate cancer. No treatment appears to have a survival advantage. The choice is often not an easy one, even for experts, for many reasons.

Lack of Data on Survival Rates. To date, neither any treatment nor watchful waiting has emerged with a survival advantage. For example, an important 2002 study reported that radical prostatectomy reduced deaths specifically from prostate cancer compared to watchful waiting but it had no advantage in terms of overall survival rates. The average age of the men was 65. Another 2002 study reported that survival rates were higher after radical prostatectomy than with radiation in men in low to moderate risk categories. However, some experts argued that the radiation used in the studies did not reflect new advances. There was no survival advantage from either approach in higher-risk patients.

Imperfection of Classification System. The classification systems are not perfect. For instance, even if tumors are rated in low stages and grades and are treated accordingly, undetected cancer cells may escape and spread beyond the prostate. Other factors, such as the mans age and medical condition, must be included in determining whether aggressive treatments or conservative measures are appropriate.

Specialty Bias. Patients should be aware that physicians may be biased to prefer a specific treatment depending on their specialty. For example, in one study the following treatments were favored for patients who were generally appropriate candidates for either surgery, radiation, or watchful waiting:

• 93% of urologists recommended radical prostatectomy.
• 72% of radiation oncologists recommended radiation. (And 82% thought that radical prostatectomy was overused.)
• Virtually none of the physicians recommended watchful waiting for higher-risk disease. When in doubt, patients should always seek a second opinion to help them make this important choice.

Quality of Life. Surgery and radiation both have potentially distressing side effects, including the possibility of impotence, incontinence, or both. A man must then weigh his own emotional responses to the possibility of these side effects versus the possible stress of watchful waiting.

In general, differences in quality of life after surgery or radiation treatment have to do with the specific effects of each type of treatment:

• Radiotherapy generally causes more bowel problems than surgery does, 30% to 35% versus 6% to 7%, according to a 2001 study. In a 2003 meta-analysis, the risk for impotence in radiotherapy varied from 25% with brachytherapy to 45% with external beam radiotherapy.
• Prostatectomy causes more urinary incontinence (39% to 49% versus 6% to 7% for radiotherapy patients) than radiotherapy. Risk for impotence, according to 2002 meta-analysis, ranges from 66% after nerve-sparing prostatectomy to 87% after cryotherapy. In spite of these adverse effects, a 2002 study reported no meaningful differences in well-being or quality of life during a four-year period in men who chose surgery versus those who chose watchful waiting.
• Watchful waiting could lead to cancer growth that eventually obstructs the urinary tract (which can happen with the treatments as well).It may also impose an emotional burden on men who live with the possibility of progressive cancer and its difficult treatments. Some who decide to wait become what some physicians refer to as the walking worried, men who are constantly concerned with their PSA levels. Because aggressive treatment reduces such anxiety, some studies reported that years after surgery, about three quarters of men say they would chose it again, in spite of significant side effects, which include impotence and incontinence in many of them.

Choosing Watchful Waiting

Watchful waiting involves lifestyle change and careful monitoring for cancer progression. Most patients should have a digital rectal exam and PSA blood test every six to 12 months. If PSA levels rise, more intensive tests are required to determine if the cancer has advanced to the point where treatment may be necessary. Patients should exercise and eat healthy foods. Symptoms such as weight loss, pain, urinary problems, fatigue, or impotence should be reported to the patients physician.

Candidates. Watchful waiting is a consideration for the following patients:

• Men in their late 70s and older. More aggressive therapies (surgery and radiation) are usually recommended for men in their 50s and younger. The choice for men in their 60s and early 70s is more problematic. The general recommendation is that aggressive therapy is suitable for those who have a life expectancy of more than 10 years and who have early and low-grade cancer. At this point the tumor grade is the best guide for determining the risks in choosing watchful waiting.
• Elderly men with early-stage (T0 to T2) low-grade tumors.
• Men with low to moderate (e.g., 3 to 13 ng/mL) PSA levels.

Because prostate cancer grows so slowly, it is likely that good candidates will die first from causes unrelated to the cancer. There is therefore little potential benefit from surgery or radiation, which both pose a risk for impotence and incontinence.

Choosing Surgery (Radical Prostatectomy)

In men whose cancer is confined to the prostate, surgical resection (radical prostatectomy) offers the potential for cure. Cure rates from initial surgery in men with localized cancer are about 70%, depending on tumor stage, tumor grade, and PSA levels. (Of note, a study in 2002 suggested that in men who have prostate cancer, PSA levels between 2 ng/mL and 9 ng/mL are not useful in predicting how aggressive the cancer is or in determining treatment.)

Candidates. Radical prostatectomy is a consideration for men who meet all of the following criteria:

• In good health and with a life expectancy of 10 years or more. As average life expectancy in men has increased, more older men are becoming candidates for surgery. Complication rates are higher the older a man is, however.
• The cancer has not spread beyond the prostate gland.
• The cancer is potentially life threatening. (In general, a life-threatening tumor is indicated by volumes more than 0.2 cc and Gleason grade scores greater than 5.)

The procedure is more likely to cause incontinence (up to 50%) than radiation treatment but has fewer bowel complications. Impotence rates are about the same. Surgery for prostate cancer may be particularly difficult in men who have had transurethral resection of the prostate (TURP).

Choosing Radiation

Radiation therapy (or radiotherapy) is administered as external-beam radiation or as brachytherapy (radiation implants). It may be used as the sole primary treatment for localized prostate cancer, and has five-year survival rates similar to those of surgery.

Candidates. Radiation is a consideration for men with one or more of the following characteristics:

• Being older and, particularly, having other medical problems.
• The cancer may have extended beyond the prostate capsule but has not spread to the lymph nodes or further.
• Being a good surgical candidate, but having decided against an operation.
• The risk for incontinence (less than 10%) is much lower than with surgery, although bowel problems occur in about a third of patients. Impotence rates are about the same.

Choosing Hormonal Treatments

Hormonal treatment in prostate cancer uses drugs or surgery (orchiectomy) to suppress or block male hormones (androgen), particularly testosterone and dihydrotestosterone. Hormone therapy is used for advanced and metastatic cancer and may be used if treatment for localized prostate cancer has failed and cancer recurs (as indicated by rising PSA levels).

Hormonal Treatments for Local Cancer. Investigators are evaluating a hormonal approach called triple androgen blockade that might prove to be useful for local or locally advanced prostate cancer. There is some controversy to this approach, however, since androgen deprivation can significantly impair quality of life and survival benefits of the treatment at this stage is uncertain.

Hormonal Treatment Before or After Surgery. Some investigators are finding benefits from using hormone therapy before surgery (neoadjuvant therapy) to reduce the tumor size, although it is not clear yet if this approach has survival benefits. Hormonal treatment may be useful after surgery in men who have high-grade tumors or tumors that have invaded the semen-carrying vessels or lymph nodes. Such men have a risk for failure after surgery of 50% to 80%.

Hormonal Therapy Before or With Radiation. Hormonal drugs combined radiation therapy may improve survival rates in moderate- or high-risk groups. Patients may need to take these agents long-term (e.g., three years) to improve outcome. Hormonal agents used before radiation (neoadjuvant therapy) may be helpful in shrinking enlarged glands so that brachytherapy (radiation implants) can be used.