Prostate Cancer Treatment: Do Your Homework, Know Your Options
According to the American Cancer Society, prostate cancer is the most common cancer among men, after skin cancer, and an anticipated 174,650 new cases will have been diagnosed by the end of 2019. While this is not welcome news, men diagnosed with prostate cancer can find assurance in understanding the stage of their disease and treatment options, which can actually bring comfort since most prostate cancers are curable if detected early. In addition, there are treatment options available today that lower the risks of unwanted side effects, such as urinary incontinence and erectile dysfunction.
Three choices have dominated treatment plans — active surveillance, radical prostatectomy and/or radiation. However, there are noninvasive treatments, such as high-intensity focused ultrasound (HIFU) and cryotherapy that are appropriate for prostate cancer patients who meet certain criteria.
Following is an overview of diagnosis and treatment options, which include potential side effects.
Here is what patients can expect from a follow up visit with a urologist following the results of an MRI (if done) and a biopsy indicating the presence of cancer:
The Grade of Your Prostate Cancer
The urologist will first discuss the grade and stage of the patient’s cancer. The grade is a number that is assigned by a pathologist, who looks at the tissue sample and assigns a grade using the Gleason grading system, which measures how aggressive the cancer is. Gleason grades go from 1 (least aggressive) to 5 (most aggressive). Grade 1 looks a lot like normal prostate tissue but has distinguishing features that make it identifiable as cancer. Grade 5, on the other hand, looks unlike normal prostate tissue and is almost not identifiable as such.
Oftentimes because of subtleties in the Gleason system it is possible for the pathologist to see more than one grade. Dr. Gleason’s score, which is used to solve this problem, is the sum of the two most common grades, with the primary grade being the most common and the secondary grade being the next most common. The order of the grades is significant. For instance, a score of 4 + 3, where 4 is more predominant than 3 tends to be a more aggressive cancer than 3+4.
However, not every patient has multiple grades. It is possible for the patient to have only one grade, but the Gleason score always has two numbers. So in this case the grade number is repeated. For instance if the cancer is all grade 4 and no other grade is seen, the Gleason score would be 4+4. Grades go from 1 to 5, but scores go from 2 to 10 and we start to talk about cancer for scores 6 (3+3) and higher.
The Stage of Your Prostate Cancer
Staging allows doctors to tell how advanced the cancer is at the time of diagnosis. Most cancers are clinically localized to the prostate. That is, there is no evidence, by different tests that the cancer has spread beyond the prostate. Common tests used to identify this might include a bone scan and a CT or MRI scan of the pelvis. Most cancers are T1c, meaning that the cancer is not palpable and was only identified because a patient presented with an elevated PSA. If the cancer can be felt it’s a T2 tumor.
· T2a: the tumor is small and localized to one side.
· T2b: it’s either a big tumor or palpable on both sides.
· T3: the tumor is palpable and has progressed beyond the limits of the prostate.
· T3 or T4: the cancer is clearly outside the prostate and has gone to a pelvic sidewall or to the base of the bladder.
Prognosis is largely based on your Gleason score, PSA and stage. Most prostate cancers are very curable. Only a minority of patients present with disease that is already incurable.
It’s important that men diagnosed with prostate cancer understand their treatment options and the side effects associated with each, so they make an informed decision with a full understanding of what’s behind their doctor’s recommendation.
More than 90 percent of men diagnosed with prostate cancer, have localized disease, defined as cancer that hasn’t spread outside of the prostate. These patients are typically given the options of active surveillance, radical (complete removal) prostatectomy or radiation therapy. For men with localized prostate cancer other treatment options are available. Here is an overview of all potential treatments:
High Intensity Focused Ultrasound (HIFU)
HIFU, which stands for High Intensity Focused Ultrasound, is a noninvasive option for patients with localized prostate cancer. HIFU combines magnetic resonance imaging and biopsy data with ultrasound guided imaging to enable doctors to precisely target and destroy only the diseased portion of the prostate, and spare surrounding structures. HIFU is significant because of the degree of precision with which the cancer can be treated in the prostate; sparing healthy tissue and thereby minimizing the risk of urinary continence and erectile dysfunction.
The most advanced HIFU system today is Focal One, which is being used at hospitals across the country, including Houston Methodist Hospital. Unlike radiation therapy or surgery, it is possible to repeat a HIFU procedure because it does not remove the prostate altogether.
Risks and side effects:
· Short term catheter required following treatment
· Potential inability to ejaculate
· Low rate of urinary incontinence and erectile dysfunction
Prostatectomy is a surgical approach to treating prostate cancer involving the removal of the entire prostate and seminal vesicles. It requires one-to-two night stay in a hospital.
Risks and side effects include:
· Urinary incontinence (inability to control the flow of urine from the bladder)
· Erectile dysfunction
Recovery after a prostatectomy usually occurs slowly over time. One study showed 60 percent of patients remained impotent at 18 months or more. And, as men age, incontinence becomes more prevalent after radical prostatectomy. The same study showed that over 40 percent of men, ages 75 to 79, were incontinent 24 months after this procedure
Each patient’s situation is different, so the doctor’s success rates and his/her personal evaluation is the best way to predict recovery outcomes.
Radiation therapy uses high-energy rays or particles to kill cancer cells. Radiation is common, and often used as the initial treatment for cancer that is still in the prostate gland. Cure rates for men with these types of cancers are about the same as those for men treated with prostatectomy.
Risks and side effects:
Side effects include:
· Bowel problems
- Radiation can irritate the rectum and cause a condition called radiation proctitis (leading to diarrhea, sometimes with blood in the stool and rectal leakage)
· Urinary problems
- Radiation can irritate the bladder and lead to a condition called radiation cystitis (urinating more often, burning sensation while urinating and/or blood in urine)
· Urinary incontinence (no control of urine)
· Erection problems, including impotence
- Problems with erections usually do not occur right after radiation, but slowly develop over time
- After a few years, the impotence rate after radiation is about the same as that after surgery
- However some studies report that rates of erectile dysfunction after this procedure have been as high as 50 percent within six years after treatment.
- If the lymph nodes around the prostate are damaged by radiation, fluid may collect in the legs or genital region over time, causing swelling and pain
Most of these problems go away over time, but in rare cases normal functions do not return.
Cryotherapy is the use of very cold temperatures to freeze and kill prostate cancer cells. This treatment is sometimes used for early-stage prostate cancer, and is often an option if the cancer comes back after radiation therapy.
The doctor uses transrectal ultrasound (TRUS) that goes into the anus to guide hallow probes (needles) through the skin. Very cold gases are passed through the needles to freeze and destroy the prostate. A catheter is left in place for several weeks afterward to empty the bladder while recovering.
Risks and side effects:
For men who have already had radiation therapy, side effects from cryotherapy tend to be worse, as opposed to men who have it as the first form of treatment.
· Blood in urine
· Soreness in the area where the needles were placed
· Swelling of the penis or scrotum is common
· Freezing may affect the bladder and rectum, leading to pain, burning sensations and frequent bowel movements
· Erectile dysfunction
- Freezing often damages the nerves near the prostate
- More common after cryotherapy than after a prostatectomy. In fact, impotence is reported to be 49 percent to 93 percent at one year.
· Urinary incontinence (having problems controlling urine)
According the American Cancer Society, doctors have less of an understanding of cryotherapy’s long-term effectiveness. Compared to surgery or radiation therapy, cryotherapy is not as effective for advanced prostate tumors.
It is important that men take educating themselves seriously. Knowing the options allows patients to make more informed decisions, evaluate all possible treatment options and choose the one that allows them to maintain their quality of life.
Brian J. Miles, MD
Dr. Miles is a board-certified urologist and Professor of Urology at Weill Cornell Medical College of Cornell University and Baylor College of Medicine. He specializes in urologic oncology, especially cancer of the prostate. He is also a Medical Director of Robotic Surgery at Houston Methodist Hospital in Houston, TX, and the physician in charge of Surgical Robot Training. Having served as the Director of the Urology Residency Program at Baylor College of Medicine, Dr. Miles continues to educate and provide professional direction to medical students, urology residents, and fellow urologists.
His primary focus and interest in clinical practice and research is in the detection and surgical treatment of prostate cancer, bladder cancer and kidney cancer. He has authored over 175 peer-reviewed scientific papers and book chapters and is consistently listed in Best Cancer Doctors in America, America’s Top Doctors, Best Doctors in America and Texas Super Doctor in Texas Monthly.