Deciding on the best treatment option for early prostate cancer

Deciding on the best treatment option for early prostate cancer

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One of the most confusing things about being diagnosed with early stage prostate cancer is choosing if and how to treat it. Unlike other cancers that have one or two standard treatment options, acceptable approaches for prostate cancer are more numerous. Each has different pros and cons and the decision about how to proceed needs to be customized to each man, depending on his age, his general health, and the severity of his early prostate cancer.

Treatment options

• Radical prostatectomy is the surgical procedure that removes the prostate gland. The operation is traditionally performed through a vertical incision made in the pelvis. The man needs to be admitted to the hospital and recover for several days.

The most worrisome potential long term side effects are urinary incontinence and impotence. A new technology is available: robotic laparoscopic prostatectomy. This method entails making five small incisions instead of one larger one. The recovery is expected to be faster and easier than with the traditional procedure.

• Radiation therapy has a cure rate comparable to that of surgery. The two forms of radiation therapy are external beam and brachytherapy, pronounced bray-kee-ther-uh-pee .

o External Beam Radiation Therapy entails the use of a radiation treatment machine, most commonly, a linear accelerator. Using sophisticated treatment planning computers and devices built into the linear accelerator, the radiation beams deliver a very precise dose of radiation to the intended area while sparing the normal surrounding structures, such as the rectum and bladder. By using 3-D conformal radiation therapy, the radiation beams conform to, or match the shape of the tumor. Intensity modulated radiation therapy, also known as IMRT, is a refinement of 3-D conformal radiation therapy.

It uses multiple, tiny beamlets, instead of a single radiation beam. IMRT beamlets can be understood by visualizing it as multiple, tiny mosaic tiles of different hues of blue; the tumor receives the dark blue beamlets, whereas the tissue near the rectum and bladder receives the beamlets of the palest shade of blue. This way, the intensity of each tiny beamlet is modulated. IMRT has enabled radiation oncologists to deliver much higher doses of radiation therapy to the prostate with fewer complications to the rectum, resulting in higher cure rates.

Temporary and early side effects include the need to urinate frequently, diarrhea, abdominal cramping, and fatigue, which is usually not severe. Side effects that can develop months to years later include urinary incontinence and erectile dysfunction, albeit a significantly lower incidence than with surgery. With the advent of IMRT, the risk of rectal injury that can cause rectal bleeding is uncommon.

o Prostate Seed Implants introduce multiple radioactive pellets smaller than grains of rice into the prostate gland. The prostate gland then receives a substantial dose of radiation, but the surrounding tissues receive virtually none. This option is very attractive to men who are concerned about maintaining potency. Also, for men who do not have a significant risk of the cancer penetrating through the capsule that envelopes the prostate, a prostate seed implant can serve as the only form of therapy. However, men whose tumors fall into a higher risk category cannot be treated solely with a prostate seed implant, and need to supplement it with external beam radiation therapy, albeit a briefer course of treatment than in men who receive only external beam radiation therapy.

The disadvantages of brachytherapy include the fact that the radioactive seeds take several weeks to decay to the level of background radiation; during this time, men need to refrain from getting close to pregnant women and small children. Also, there is a low risk of rectal irritation in the short and long run. Infrequently, the need to urinate frequently can persist. Incontinence and impotence are relatively rare. The risk of a channel forming between the urinary tract and the rectum, also known as a rectal fistula, can cause urine to leak through the rectum. This complication is rare, fortunately, and can be repaired surgically.

• Cryosurgery involves freezing the prostate tissue with liquid nitrogen. Via the guidance of an ultrasound probe inserted in the rectum, needles are guided into the prostate, by piercing the skin between the scrotum and the anus. Short term side effects include blood in the urine for several days, soreness of the surgical area, swelling of the penis and scrotum, urinary burning, and frequency of urine and bowel movements. Late complications include nerve damage that can result in impotence and rarely, the formation of a fistula. Also, the long-term success rate is not well known.

• Hormone Therapy is also known as androgen deprivation therapy (ADT). Prostate cancer thrives on testosterone. By depleting testosterone, prostate cancer cells die. ADT has never been demonstrated to be a curative modality, but it is useful in holding the disease at bay for some time. Its other role is in shrinking the prostate prior to surgery or radiation therapy. Side effects are those of “male menopause”, such as hot flashes, weight gain, decreased mental acuity and depression. Other potential adverse effects include osteoporosis, anemia, breast enlargement, fatigue, diminished good cholesterol and loss of muscle mass.

• Watchful waiting is a reasonable choice for men who have a short life expectancy, as well as for those men who have very slowly growing prostate cancer and will most likely not die from prostate cancer but rather, from some other more life threatening problem.

The down side of watchful waiting is the psychological implication that the man’s mortality is looming ahead of him. Although no active treatment is given, men are still followed with digital rectal exams, PSA levels and possibly, transrectal ultrasounds of the prostate. However, with low risk prostate cancer in an elderly man, this might be a fine option.

Apparently the spectrum of treatment options is vast, and ranges from doing nothing to undergoing radical surgery. To make the best decision for himself, a man should know his treatment options based on his individual situation and lifestyle. Then, he will be empowered by knowledge as he embarks on his journey into the world of medical opinions. Finally, he should choose an experienced specialist to ultimately treat and follow him.

By Carol L. Kornmehl, M.D., FACRO

For more information about radiation therapy, check out www.ASTRO.org , the official website of ASTRO, The American Society for Therapeutic Radiology and Oncology.

Dr. Kornmehl is Medical Director of Radiation Oncology at Passaic Beth Israel Medical Center, Passaic, NJ, and author of the critically acclaimed consumer health book, “The Best News About Radiation Therapy” (M. Evans, 2004). Her website is www.RTSupportDoc.com .

Copyright 2006 by Carol L. Kornmehl. All rights reserved. No part of this article may be reproduced without express written consent by the author.

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