Sometime after being diagnosed with prostate cancer you and your doctor will start to discuss your medical management options. Knowing your tumor aggressiveness is critical for understanding if you are safe to pursue active surveillance or if you should pursue one or multiple forms of treatment. Each of the below treatments has pros and cons, so make sure to talk with your doctor, family, and friends to gather as much information as possible to create a plan that is best for you.
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Prostate Cancer Symptoms
There are other prostate conditions which can mirror symptoms related to prostate cancer. It is important that you meet with your doctor if you are experiencing any of the symptoms listed below in order to determine what might be causing those symptoms.
Early prostate cancer generally does not exhibit any symptoms. Oftentimes, an initial diagnosis is made by a doctor during an annual exam of the prostate. Men who do experience symptoms will generally notice changes in urinary and/or sexual function. These types of changes warrant a visit with your physician to determine the cause. Prostate cancer symptoms may include:
- A frequent urge to urinate, including nighttime frequency or urgency
- Difficulty initiating urination
- A weak or interrupted urine flow
- Pain or burning while urinating (from cancer pressing on the spinal cord)
- Loss of bladder or bowel control
- Difficulty achieving/maintaining an erection
- Painful ejaculation
- Blood in the semen or urine
- Pain in the hips, back or chest (indicating metastasis to the bones)
- Weakness, numbness, or swelling in legs and feet
Be Confident with Your Treatment Decision
What is Active Surveillance?
Some prostate tumors grow very slowly and never cause health problems. Active surveillance or watchful waiting involves regular testing and monitoring. Additional or definitive treatment can be started if cancer shows signs of progression.
Listen as two Urologists discuss everything you need to know about Active Surveillance.
Advantages of Active Surveillance:
- Avoid or delay treatment side effects including erectile dysfunction (chronic inability to achieve or maintain an erection satisfactory for sexual intercourse) and urinary incontinence (partial or complete loss of bladder control)
- Less impact on quality of life/normal activities
- Less risk of unnecessary treatment of small, slow-growing cancers
Disadvantages of Active Surveillance:
- Low chance of missed opportunity for cure
- Periodic follow-up MRI and/or prostate biopsies may be necessary
What Happens on Active Surveillance?
According to prostate cancer treatment guidelines you doctor may suggest the following:
- PSA (blood test) > every 3-6 months unless clinically indicated
- DRE (digital rectal exam) no more often than every 12 months unless clinically indicated
- Repeat prostate biopsy no more often than every 6-12 months unless clinically indicated
- MRI Imaging of the prostate may be recommended
Single-Modal or One Form of Treatment
Men with more aggressive tumors should undergo treatment. The type and intensity (magnitude) of the treatment is usually tailored to the potential risk of the disease. The most common forms of treatment include surgical removal of the prostate, radiation therapy and hormonal therapy. When single modality therapy is chosen, additional therapies may be considered later if the cancer should return.
Dual-Modal or Two Forms of Treatment
Men with very aggressive cancer may be offered multimodal therapy. Multimodality therapy employs two or more therapies planned at the treatment onset. National cancer guidelines offer suggestions as to which may be a more appropriate treatment option based on the patient’s risk and potential outcomes of the treatment. However, appropriate risk classification is very important in this decision and this actual risk assessment can be very difficult to make.
The final decision on whether to use a single or a multimodality therapy is a shared decision between the patient and the physician and is based on the perceived aggressiveness of the disease, the outcomes of the treatment, potential side effects of treatment or treatments and, of course, how the patient and his family want to proceed.
Surgical treatment is an option for some patients with prostate cancer. Before deciding on this treatment, a doctor will evaluate if the patient is healthy enough for an operation. The goal of surgery is to remove all cancerous tissue. During this process, normal prostate tissue will also be removed. Most surgeries can be divided into three types:
- Radical Prostatectomy without pelvic lymph node dissection
- Radical Prostatectomy with limited pelvic lymph node dissection
- Radical Prostatectomy with extended lymph node dissection
What is Radical Prostatectomy?
Radical Prostatectomy (RP) is an operation in which the entire prostate, and sometimes other tissue is removed. This procedure is used when the tumor appears to be contained within the prostate. There are several types of RP including; open, laparoscopic, and robotic-assisted.
Open approaches to prostatectomy
This option is the more traditional approach to doing a prostatectomy. Surgeons operate through a single cut to remove the prostate and nearby tissues. There are typically two methods used for open radical prostatectomy.
1. Radical retropubic prostatectomy
During this operation, the surgeon will make a single incision from below the belly button down to the pubic bone. The patient will be placed under general anesthesia or be given spinal or epidural anesthesia along with sedation during the surgery.
2. Radical perineal prostatectomy
During this operation, the surgeon will make an incision in the skin between the anus and scrotum (the perineum). This approach is used less often because the nerves that control erections cannot easily be spared and lymph nodes cannot be removed. However, it is often a shorter operation and might be an option if the patient does not prefer the nerve-sparing procedure, has had multiple previous abdominal or pelvic surgeries, or does not require lymph node removal.
Listen as two Urologists discuss what you should know before scheduling your surgery.
Laparoscopic radical prostatectomy
For a laparoscopic radical prostatectomy (LRP), the surgeon makes several small incisions through which special instruments are inserted into the pelvis to remove the prostate. One of the instruments has a small video camera on the end, which allows the surgeon to see inside the abdomen.
Robotic-assisted radical prostatectomy
A laparoscopic prostatectomy can be completed with the assistance of a “robot.” During the operation, the surgeon sits at a control panel near the operating table and uses this to control robotic arms to operate through several small incisions in the abdomen. Many physicians believe the robot allows for making more precise cuts compared to the surgeon’s hands. Surgeons who perform robotic-assisted surgery go through intensive, specialized training.
What is Pelvic Lymph Node Dissection?
Additional procedures may be performed on men with advanced disease. One of these procedures are removal of lymph nodes. Pelvic Lymph Node Dissection (PLND) is an operation that removes lymph nodes from the pelvis. PLND is advised when there is a 2% or higher risk of cancer within the lymph nodes. Nearly half of men will have a PLND with their radical prostatectomy.
What are the potential side effects of surgical treatment?
The potential side effects of surgical treatment can include but are not limited to:
During the operation:
- Bleeding requiring a blood transfusion
- Heart attack
- Blood clot formation
After the operation:
- Pain and swelling
- Urinary incontinence
- Erectile dysfunction
- Dry orgasms
Radiation is a procedure used in cancer treatment that uses high-energy rays to kill cancer cells. Radiation treatment damages the cancer cells DNA, leaving them unable to survive, grow, and spread. Specialized doctors, called radiation oncologists, specialize in the treatment of prostate cancer and currently use two common forms of radiation treatment, External Beam Radiation Therapy (EBRT) and Bracytherapy. Please consult your urologist or radiation oncologist when seeking more information on radiation treatments.
Prostate Cancer Radiation Basics
- External Beam Radiation Therapy (EBRT)
What is External Beam Radiation?
External Beam Radiation Therapy (EBRT) delivers radiation from outside the body using a large machine. The radiation passes through the skin and other tissue and targeted on the tumor. The treatment requires a number of sessions per week for several weeks.
What is Brachytherapy?
Brachytherapy delivers radiation therapy by placing radioactive seeds inside the prostate. The seeds are about the size of an uncooked grain of rice. They remain in the prostate to give a low dose of radiation to a specific area for weeks or months. After about 90 days, the radiation is completely gone.
What are the potential side effects of radiation treatment?
Potential side effects of radiation therapy can include but are not limited to1:
- Erectile dysfunction – over time
- Urinary problems
- Rectal problems
Prostate cancer cells need hormones called androgens to grow. Hormone therapy can slow tumor growth or shrink the tumor for a period of time. Hormone therapy is often given together with radiation therapy.
There are multiple types of hormone therapy. Speak to your doctor for a full list of hormone therapies.
Removal of the testicles can reduce the level of testosterone in the blood by 90 to 95 percent. This type of treatment, called surgical castration, is permanent and irreversible.
LHRH (Luteinizing hormone-releasing hormone) agonists or antagonists:
Drugs that are used to stop the testicles from making testosterone. It can either be injected into a muscle, injected under the skin or implanted under the skin every 1,3,4,6, or 12 months.
These drugs block receptors on cancer cells from receiving testosterone. These drugs are often used in combination with orchiectomy or other forms of ADT. This combination can also be called combined androgen blockade, complete androgen blockade, or total androgen blockade
This form of treatment can stop the adrenal glands and other tissues from making testosterone.
What are the potential side effects of hormone therapy?
Side effects vary by type and include but are not limited to:
- Erectile dysfunction
- Reduced desire for sex
- Weakening bones
- Weight gain
- Loss of muscle mass
- Heart disease
- Hot flashes
- Mood changes
All medical information in this section is from the 2018 National Comprehensive Cancer Network Guidelines for Patient. https://www.nccn.org/patients/guidelines/prostate/