Prostate Cancer: Weighing Options

   August 16, 2012   


You’ve been diagnosed with prostate cancer and after the shock comes confusion.
Should you treat it fast with surgery but face an immediate risk of sexual and urinary problems? Or should you opt for weeks of daily radiation treatments and side effects that set in more slowly? Should you also use hormone therapy that may shrink the cancer — and your sex drive along with it? Or should you just monitor your cancer and hope you’ll catch it if it starts to spread out of control?

Some 185,000 men will be diagnosed with prostate cancer this year in the U.S., and many will get conflicting advice. There’s little consensus on how or even whether to treat prostate cancer, which can be slow-growing and harmless or aggressive and lethal.

But every man’s cancer is different, as is his general health, family history, life situation and mindset. Make sure you understand your own priorities. Some men want the cancer out as fast as possible; others want to avoid surgery at all costs. Some want the best chance for a long-term cure; some care as much or more about avoiding incontinence or erectile dysfunction.

Here’s a look at the options:

Surgery:

Men diagnosed with prostate cancer in their 40s and 50s are often steered toward surgery (called a radical prostatectomy), since it’s thought to offer the best chance for long-term survival. What’s more, removing the prostate and examining it in a lab is the only way to know for sure how much cancer was there and how likely it is to return.

Surgeries using the daVinci Robotic System now account for over 50% of prostatectomies. The surgeon sits at a console about six feet from the patient and, while watching on a video screen, manipulates miniature, flexible tools that perform the surgery through small incisions. It’s minimally invasive, which reduces pain, recovery time and blood loss. Most patients go home the next day.
“If you have a well-trained robotic surgeon, there’s absolutely no reason to filet patients open and go through all the mess we used to have,” says David Samadi, chief of robotic and minimally invasive surgery at Mount Sinai Medical Center in New York City who has performed over 1,800 robotic prostatectomies.

Radiation:

Men over 70, those with other health problems or those whose cancer has spread beyond the prostate are usually counseled to have radiation. External-beam radiation therapy, or EBRT, requires no incisions, no hospitalization and no anesthesia. But it can be inconvenient: Patients generally undergo 40 or more treatments over six to eight weeks. High-energy beams damage the ability of cancer cells to replicate. The entire prostate slowly withers as well.

Radiation has fewer immediate side effects than surgery, but urinary discomfort and loss of sexual potency often set in gradually.

In one form of radiation called bracytherapy, doctors insert 70 to 80 tiny radioactive pellets into the prostate that gradually dissolve and destroy cancer cells internally. Many patients like the convenience: Itrequires just one minimally invasive procedure that lasts about an hour.

One downside is that patients are advised to avoid prolonged contact with pregnant women and children to minimize a slight risk of radiation exposure to them. In high-dose bracytherapy, a radioactive source is placed in the prostate only temporarily, with no risk to others. Studies have shown that bracytherapy carries a higher risk of urinary problems than other therapies.

Lumpectomy:

About 20% of prostate cancer patients have very small localized tumors. One new option for them is focal ablation, in which doctors destroy the individual tumor while leaving the rest of the gland intact, much like a lumpectomy for breast cancer.

Of several ablation techniques, cryotherapy has been in use the longest. Doctors insert metal prongs into the prostate to surround the tumor and freeze it with liquid nitrogen.

Critics argue that prostate tumors that are small and localized enough for focal therapy could be safely watched instead.

Watchful Waiting:

At least 50% of men diagnosed with prostate cancer in the U.S. have a low-grade form of the disease that experts say doesn’t need immediate treatment and may never. But less than 10% opt to put treatment off and just monitor their cancer. That’s in part because it can be psychologically difficult to live with untreated cancer, and in part because the medical system is geared toward active treatment.

The big risk with watchful waiting is that a cancer will spread from a highly curable early stage to a more advanced stage, growing outside the prostate, that is far more difficult to treat. Some tumors that have been stable for years can suddenly start to spread.

That’s why patients and doctors alike need to do active monitoring, with PSA tests every three to six months, digital rectal exams annually, and repeat biopsies if the PSA starts to rise. “You can’t have a patient who will disappear on you. If the guy moves to Florida and five or six years from now his PSA hits 90, then it’s over,” Dr. Samadi says.

WDiet and Exercise:

Besides being conscientious about followup exams, patients can help their own cause by maintaining a healthy diet and lifestyle. Getting exercise and minimizing stress can go a long way as well. Stress hormones epinephrine and norepinephrine help prostate-cancer cells grow and impair the immune system.

Late-Stage Cancer:

Not all prostate-cancer patients can control their cancer with diet and exercise. For those whose cancer has metastasized, a variety of hormone therapies that block testosterone can often stop the progression very successfully, at least for a while. The downside is a high risk of osteoporosis, hot flashes, depression, breast enlargement, diabetes, obesity and high blood pressure. Using hormone therapy intermittently can help reduce such side effects.

Conclusion:

Experts urge men with prostate cancer — at any stage — to join clinical trials if possible. “That’s how we made all the progress in breast and colon cancer,” says Jonathan Simons, president of the Prostate Cancer Foundation, which funds clinical research. “We have some very important ideas to test that might lengthen your life.”

How Prostate-Cancer Treatments Compare

TREATMENTRECOMMENDED FORPROSCONS
Active Surveillance: Also known as watchful waiting; no treatment, but continued monitoring via PSA, biopsies, scanningGleason score below seven, PSA below 10; small, localized tumors; men with less than 10 years’ life expectancy85% of prostate cancers don’t cause problems; no surgery, no hospitalization, no side effects; new imaging techniques allow close monitoring15% of prostate cancers do spread, requiring more aggressive treatment later; requires regular follow-ups; psychological stress
Robotic Prostatectomy: removal of the prostate gland using da vinci robotic surgeryCancer confined to the prostate, men under 65 and healthy enough for surgeryHigh cancer cure rate with minimal post operative complications when performed by a skilled robotic surgeon; nerve sparing procedure that preserves sexual function and continence; one-two day post operative hospitalization with removal of catheter in 5-7 daysPotential erectile and urinary side post operative effects when the procedure is performed by an inexperienced robotic surgeon
External-Beam Radiation: Prostate is bombarded from outside the body with X-rays or proton beamsCancer outside the prostate; men over 70 and those who can’t have surgeryNo incisions, hospitalization or anesthesia; few immediate side effectsRequires multiple treatments that are uncomfortable and inconvenient; high probability of erectile and urinary problems that develop and worsen over time; can cause rectal soreness
Brachytherapy: Tiny radioactive seeds are implanted in prostate and kill the cancer cells graduallyLow and medium-grade cancersOne-time, minimally invasive procedure; no hospital stayHigh probability of urinary and erectile problems that develop and worse over time
Drug Therapies: Hormone medications block androgens that fuel cancers; can be combined with radiation or chemotherapyAdvanced, high-grade or recurrent cancersCan help halt spread of cancer, shrink enlarged prostateLoss of libido and erectile function; osteoporosis; decreased muscle mass; hot flashes; breast enlargement; diminished mental acuity
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