Prostate Cancer (cont.)
What are Treatments of Prostate Cancer?
- Treatments for prostate cancer are generally effective in most men. Different treatment options are indicated depending on the severity of the disease.
- Treatment for localized prostate cancer include:
- Active surveillance
- Radical prostatectomy
- Radiation therapy
- Cryotherapy and HIFU
- Treatment for advanced disease includes:
- A combination of factors defines the severity of the disease or the prognosis (including the chances of dying of the disease).
- Specifically these factors include:
- Tumor stage, defined by the extent of the disease (localized vs advanced) given by TNM staging.
- Tumor grade, defined by the pathologists report on the biopsies or surgical specimen given by the Gleason score.
- PSA value (Prostate Specific Antigen blood test).
- In addition, the therapeutic plan takes into consideration potential benefits vs. side effects of the treatment but also individual factors including the patient's biological -- as opposed to their chronological -- age as well as the presence or absence of comorbidities (other diseases).
- A man's treatment plan should be tailored to his individual case and it may be adjusted according to his expectations, specific needs, and feelings about the different options available.
- It is important that a man understands and discusses his treatment plan with his medical team and specifically with his urologist and/or oncologist (cancer specialist).
What is Active Surveillance (Deferred Treatment)?
Active surveillance is an appropriate management for selected patients with localized disease. This involves monitoring one's cancer to see if it gets worse and how quickly, while not doing anything else to treat it at the present time.
- Often, many PSA-detected prostate cancers are small, well differentiated, and thought to have a relatively low risk of progression. For this reason, many men will receive no active treatment or they will postpone it for some time without significantly decreasing the chance of cure.
- The goal of active surveillance is to avoid treatment-related complications for men whose cancers are not likely to progress while maintaining an opportunity for cure in those who show evidence of progression.
- Active surveillance is a conservative regimen that includes regular visits to the urologist for digital rectal exams, PSA measurements, and, if necessary, imaging tests and/or repeated prostate biopsies to assess if the cancer is becoming more aggressive over time.
- One benefit of active surveillance is that one does not experience the side effects of treatment. On the other hand, symptoms (if any) will continue. In some cases, symptoms can be at least partly relieved with medication.
- Active surveillance is most often used for men who have very early-stage cancers and for men who are not candidates for surgery and other aggressive therapies.
- If the cancer starts to grow, the urologist may recommend treatment.
- Active surveillance should be distinguished from "watchful waiting," which is based upon the premise that some men will not benefit from definitive treatment of localized prostate cancer.
- For patients managed with watchful waiting, the decision is made at the outset to forego definitive treatment and to provide palliative treatment (typically androgen-deprivation therapy) for symptomatic local or metastatic progression.
- Watchful waiting may be an acceptable alternative for elderly men or those with substantial comorbidities.
What is Radical Prostatectomy?
Radical prostatectomy is the surgical removal of the entire prostate. This operation is indicated for cancer that is limited to the prostate and has not invaded the capsule of the prostate, any other nearby structures or lymph nodes, or distant organs.
- The entire prostate, seminal vesicles, and ampulla of the vas deferens are removed, and the bladder is connected to the membranous urethra to allow free urination.
- Radical prostatectomy is used to treat men with clinically-localized prostate cancer who have a life expectancy of at least 5 years. Although there are not specific or universally accepted age limits for radical prostatectomy, the life expectancy of men above 70 to 75 years of age is low enough that few men in this age range undergo radical prostatectomy.
- Anesthesia for radical prostate surgery has been provided using general, spinal, and epidural approaches; however, most surgeons today prefer regional anesthesia, which has been reported to be associated with less blood loss and a lower risk for pulmonary emboli.
- Complications of this procedure include urinary incontinence and impotence. Newer techniques spare the nerves that controls urination and erection. Of men who undergo these newer techniques, most are continent, and a majority are able to have an erection.
- Radical prostatectomy can be combined with radiation therapy in men with cancer for whom the surgery showed positive margins and which is likely still isolates in the prostate surgical bed. There is an excellent survival rate if cancer has not spread further than this.
- A man should be certain to understand the risks and benefits of this procedure before deciding to go ahead.
- Surgical techniques include open retropubic radical prostatectomy, open perineal radical prostatectomy, and minimally invasive radical prostatectomy (laparoscopic radical prostatectomy and robotic-assisted radical prostatectomy [RARP]).
- Both retropubic and perineal radical prostatectomy techniques are widely used “open” surgical approaches. They both include skin incisions.
- Minimally-invasive techniques have become popular over the past decade and are largely replacing open prostatectomy in most large U.S. centers.
- Laparoscopic radical prostatectomy: This type of surgery follows the same oncological principles as "open" radical prostatectomy. Rather than a large incision, laparoscopic methods make use of abdominal distention with air that allows a working space using surgical instruments that are introduced through small abdominal incisions.
- Robot-assisted radical prostatectomy (RARP): This technique gives the surgeon better operative site visualization and more natural hand motions to control the surgical instruments. Currently, many radical prostatectomy surgeries in the U.S. are performed with the help of the da Vinci robotic system. For robot-assisted surgery, five small incisions are made in the abdomen through which the surgeon inserts tube-like instruments, including a small camera. This creates a magnified three-dimensional view of the surgical area. The instruments are attached to a mechanical device, and the surgeon sits at a console and guides the instruments through a viewing device to perform the surgery. The instrument tips can be moved in a variety of ways under the control of the surgeon to achieve greater precision in surgery. So far, studies show that traditional open prostatectomy and robotic prostatectomy have had similar outcomes related to cancer-free survival rates, urinary continence, and sexual function. However, in terms of blood loss during surgery and pain and recovery after the procedure, robotic surgery has been shown to have a significant advantage. Robotic procedures, however, are usually more expensive and the extra cost may not be covered by insurance.
- Quality of life after radical prostatectomy:
- The complications of most concern to men who undergo these procedures are urinary incontinence and impotence, which are due to operative damage to the urinary sphincter and penile nerves. The frequency of incontinence and erectile dysfunction depends in part upon the experience and expertise of the surgeon.
Transurethral resection of the prostate (TURP) is an alternative to radical prostatectomy.
- Only part of the prostate is removed by an instrument inserted through the urethra.
- An electric current passes through a small wire loop at the end of the instrument. The electrical current cuts away a piece of the prostate.
- This procedure is used to remove tissue that is blocking urine flow in patients with extensive disease or those that are not fit enough to undergo radical prostatectomy. It is not considered a procedure for cure.
Medically Reviewed by a Doctor on 11/22/2016
Pierre-Alain Hueber, MD, PhD
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