Prostate Cancer Treatment Options

Once the prostate cancer has been graded and staged, PSA performed, and a risk group assigned, most patients have several good treatment options to consider. Take your time to carefully evaluate each. Note that, for most patients, the control of the cancer is very similar across treatments. It is important you allow adequate time to educate yourself sufficiently to reach a well-informed decision regarding your options and their side effects.

Please ask us as many questions as you need. A second opinion from a different type of prostate specialist (e.g. urologist, or, radiation oncol-ogist specializing in prostate cancer) can be arranged. Prostate cancer is a complex disease, and physicians often differ in their opinions and expertise.

External Beam Radiation Therapy (EBRT)

There are various forms of external beam radiation. IMRT, Proton Beam, Tomotherapy and Cyberknife are all forms of external beam radiation. IMRT radiation is the most common and stands for Intensity Modulated Radiation Therapy. IMRT has, by far, the most published studies and largest experience of the various EBRT modalities. The treatment is given from multiple angles to reduce dose to the bladder, rectum, hips and bowel. The treatments are given at a hospital or clinic, 5 days per week for 8-9 weeks for a full treatment, or, for shorter periods if it is combined with seed implantation or for post radical prostatectomy patients.

Recent advances in IMRT include Image Guide Radiation Therapy (IGRT). IGRT can be done by way of ultrasound, x-ray, radiofrequency beacons or CT. At Lakewood Ranch Oncology Center we

use daily cone beam CT-IGRT. This allows us to precisely target the prostate on a consistent basis. CT-IGRT is the only way one can evaluate the anatomy of the normal surrounding tissues (bowel, bladder and rectum) in order to avoid delivering unnecessary radiation to these structures.

Another advance is the use of dose-volume-histogram analysis (DVH analysis). We now know what volume of tissue (e.g. rectum, bladder, and small bowel) can “safely” tolerate what dose of radiation. As with other forms of prostate cancer treatment, urinary and sexual side effects are possible and vary depending on the health of the patient, skill of the treating physician, and the dose of radiation received.

Seed Brachytherapy (Seed Implantation)

Dr. Sylvester helped pioneer the treatment of prostate cancer using modern seed brachytherapy in Seattle in the 1980's as an alternative to surgery. Over 600 centers around the world now perform seed implantation for prostate cancer, and it is estimated over a third of patients with prostate cancer receive this treatment.

Brachytherapy, or permanent seed implantation as it is often referred, is a minimally invasive procedure performed as a single outpatient treatment. Tiny radioactive seeds are placed into the prostate via thin needles using ultrasound guidance. Prior to the implant, seed placement is carefully planned and mapped out using sophisticated computer planning. Seed implant brachytherapy delivers higher radiation doses to the cancer than other types of radiation.

Radioactive material (I125, Pd103, or Cs131) inside the titanium seeds emit radiation over a very short distance killing the prostate cancer cells. Each isotope has its own characteristic short lifespan over which the radiation is delivered. Seed implants are often combined with a shortened course of IMRT. After the procedure, patients are taken to recovery and are typically discharged an hour or two later. Most patients resume normal activities within 24-48 hours.

The most common side effect of prostate brachytherapy is temporary frequent and urgent urination. These symptoms typically last a few weeks to several months. Permanent incontinence is rare (1%) and over 90% of patients return to near their normal urinary function within 1 year.

High Dose Rate Brachytherapy (HDR)

HDR brachytherapy involves the temporary placement of a radioactive seed throughout the prostate. Approximately 12-16 plastic catheters are placed, under anesthesia, into the prostate gland through a template which is then sutured to the perineal skin below the scrotum. A small radioactive seed which is emitting radiation at a high rate (high dose rate) is directed down the catheters to sites in the prostate as determined and directed by a computer. The computer controls the length of time the seed stays in its position and therefore the dose delivered.

After sequentially delivering the seed at each position, the seed is removed, leaving no radioactive material in the gland. This may be repeated several times over a few days. This type of treatment sometimes requires an overnight stay. HDR is usually combined with several weeks of external beam radiation. If HDR monotherapy is given, it usually requires 2 operative procedures on different weeks. High dose rate does not mean a higher dose is received to the prostate. It means that the rate the radiation is given is high. The biological dose is similar to IMRT and lower than permanent seed implantation.

Surgery

Radical Prostatectomy is the removal of the prostate and may be performed using an open abdominal, a perineal or robotic laparotomy approach. The success of each is dependent on the experience of the surgeon. Regardless of the approach, studies have demonstrated that the side effects of each of these procedures are very similar with similarly experienced surgeons.

Despite ads to the contrary, the main advantage of robotic surgery over standard surgery may be a slight improvement in recovery time. A robot does not make a surgeon better and has not, to date, improved cancer control, sexual function or incontinence rates.

Most men undergoing prostate surgery will be hospitalized for 1-4 days require a catheter for 2 weeks and experience a recovery time of a least a month. The risk of death, stroke, pulmonary emboli, etc is low but not zero.

Long term urinary incontinence (being unable to control urine) is fairly consistent amongst reports and techniques with a 10% or higher risk of stress or frank incontinence. A recent report from Washington University St. Louis revealed a 22% long term rate of incontinence in obese men, 16% in non-obese, physically active men and 59% in obese, physically inactive men (Wolin et al Urol 2009 Dec 15).

Cryosurgery

Cryosurgery is freezing the prostate. It is performed under spinal or light general anesthesia as an outpatient treatment. Using ultrasound guidance similar to brachytherapy, probes are placed into 6 positions to freeze the prostate. After the procedure, a catheter is used to rest the bladder for up to 10 days.

There is a <5% risk of incontinence. Impotence is common as the freezing also affects the nerves for erections. It is used both as primary treatment and to “salvage” patients who have a local recurrence after radiation therapy.

Proton Beam Therapy

Proton beam therapy is a form of external beam radiation therapy in which the radiation is delivered from a machine which generates protons. Protons penetrate tissue and then slow down at a particular depth in tissue. By placing the prostate in the area where the protons slow, the effect on the normal tissue around the prostate should be less. For areas where a short distance of penetration is required, such as childhood tumors, protons work extremely well. For prostate cancer (which is deep in the pelvis) protons have not been better than IMRT.

In fact a recent study showed that IMRT did a better job at limiting radiation dose to surrounding normal tissue and bladder than proton beam therapy (Trofimov IJROBP 69:444-453, 2007).

While cancer control results with proton therapy have been satisfactory, they have not shown to be superior to IMRT or brachytherapy for the treatment of prostate cancer. Furthermore, there are no IMRT techniques yet developed for proton beam therapy.

Hormonal Therapy

Hormone therapy is a non-curative form of therapy but can be useful for some patients. Typically, it involves giving an injectable drug, such as Trelstar™ or Lupron™ with or without oral Casodex™, to decrease the testosterone levels in the blood to castrate levels. Short term Hormonal therapy is given in some patients prior to radiation to shrink the gland or in high risk patients to improve the results of seeds and IMRT. It has not been shown to improve the results of surgery.

Hormonal therapy can kill some of the cancer cells or effectively stop the cancer from progressing for a long period of time. Short-term side effects can include hot flashes, mood swings, fatigue and loss of sex drive. Hormonal therapy may also be used on a long term basis to control cancer progression. Long-term side effects can include weight gain, diabetes, osteoporosis, high cholesterol, breast tenderness and/or enlargement and possible cardiac complications.

High Intensity Focused Ultrasound (HIFU)

High Intensity Focused Ultrasound (HIFU) uses high frequency ultrasound energy to kill prostate and cancer cells. Much like a magnifying glass, the energy is pinpoint and therefore may preserve the nerves for erections. HIFU is a procedure performed under general anesthesia. It can be repeated if necessary. Currently, there is limited short term and no long-term data on the effectiveness of this procedure.

Clinical trials will be performed, and then evaluated by the FDA to determine whether or not HIFU should be approved for use

in the United States. Only patients with small glands and minimal calcifications are candidates. Patients require a suprapubic catheter after treatment for up to 2 weeks.

A comparative health related quality of life and effectiveness study is being reviewed by FDA, if approved only a few centers will be involved. Dr Sylvester at Lakewood Ranch Oncology Center has been invited to participate in that study along with physicians at Cleveland Clinic and MD Anderson.

Active Surveillance (Watchful Waiting)

Depending on the characteristics of the cancer, we may recommend active surveillance or watchful waiting as a reasonable approach to managing the disease. Some patients have extremely slow growing cancers, have other medical issues that are more important than their cancer or have difficulty with the possible side effects of any treatment. Active surveillance requires closely monitoring the cancer with PSA readings, periodic (usually yearly) biopsies and digital rectal exams. Treatments such as brachytherapy, surgery or radiation therapy can still be given if the cancer advances.

This option may be recommended if your cancer is not causing any symptoms, you have a low PSA and grade, the cancer is small and contained within one area of the prostate. Surveillance is usually not recommended for men with a life expectancy greater than 10 years. As with all options, there are risks involved which should be carefully explained to you.

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