3. Prostate Cancer: After the diagnosis

• Introduction and Overview
• Learning that it's cancer
• Choosing a treatment?
• Treatment options
• Which treatment is right for me?
• How do we know when the cancer is controlled?
• For More Information

Introduction and Overview

The time immediately following diagnosis of prostate cancer is a difficult one for most men, their families and friends. This is partly because at the same time as coming to terms with the meaning of a potentially life threatening disease, a choice about treatment is being made.

This information sheet describes ways men can work through this, and gives an outline of the main treatment options for localised prostate cancer (cancer which has not spread beyond the prostate region). Treatment options for more advanced cancer (including hormonal therapy) are given in Mr PHIP no. 4 and 5 in this series. For more information, also consult the resource list at the end of this information sheet.

Some key points to consider:

• Prostate cancer is usually slow growing compared to other cancers and when caught early, it can be cured, usually by surgery or radiotherapy.
• Cancer stage or how far the cancer extends is important in making a treatment choice.
• For localised cancer, the three most common treatment strategies are surgery, radiotherapy and observation only (also called active surveillance or watchful waiting)
• Each treatment has pros and cons which you need to weigh up.
• It is important for you to take your time and talk to a range of people before making a decision. Decisions can be changed as time passes.

Learning that it's Cancer

Hearing the word cancer is usually a shock. Men often say that after that word was mentioned, they felt in a daze - ’didn’t hear anything the doctor said’. A man’s response to a diagnosis of cancer may be shaped by his experience of a father, uncle or friend who was diagnosed before current improvements in knowledge and treatment. The following suggestions may be helpful at this stage:

• Take your time. Prostate cancer is normally slow growing. Most men have time to talk to others before making a decision.
• Talking to your GP, he/she may answer some of your questions.
• A second appointment with your Urologist - write a few questions down before the appointment as a reminder, or have a support person present.
• A second opinion. This can be arranged through your GP or specialist. Men with localised cancer are often encouraged to talk to a radiation oncologist - a doctor who specialises in radiotherapy for the treatment of cancer.
• Talking to other men with prostate cancer can be helpful in learning about the experience of treatment, and life after diagnosis.
• Partners of men with prostate cancer also feel shock and distress at a diagnosis of prostate cancer. Men and women look for support in different ways, and often have different concerns. The booklet ‘Coping with a Diagnosis of Prostate Cancer’ and other resources at the end of this information sheet may be helpful.

Choosing a treatment?

The choice of treatment depends on the stage of the cancer (how far it has spread), and the particular benefits and side effects of each treatment. Surgery and radiotherapy are offered as treatments for cancer which has not spread beyond the prostate (localised prostate cancer). Some of the side effects will have implications for your lifestyle, and so it is important that you explore all your treatment options.

How is stage determined?

Information about cancer stage comes from the rectal examination (the doctor feels the prostate with a gloved finger in the rectum) and radiology tests such as rectal ultrasound, CT (Computed Tomography), MRI (Magnetic Resonance Imaging) and bone scans. The PSA (Prostatic Specific Antigen) blood test is a guide to tumour extent also. The biopsy indicates cancer grade (see below). From these investigations, estimates of the tumour’s size, where it is located and how aggressive it is (see grade) can be made. For example, if a man has a moderate PSA level (say less than 10ng/ml) and the tumour is not aggressive and cannot be felt by the doctor at the rectal exam, it is highly likely to be contained within the prostate (localised). The most common system used to describe cancer stage is the TNM system (see below).

Figure 1 - Prostate Cancer Stages

TNM System

You usually have plenty of time to make a treatment decision - don't feel rushed!

If the patient has surgery, further indication of the extent of the cancer comes from the pathologist who examines the tissue removed. Small, undetectable amounts of cancer can sometimes extend beyond the prostate into surrounding tissues, or lodge in the lymph nodes near the bladder in the pelvis.

What is cancer grade?

Tumour grade is a measure of how abnormal the tumour tissue looks (seen under the microscope) and reflects how fast it is likely to grow (its aggressiveness). The most common system for Grade is called the Gleason score. To decide a Gleason score, the pathologist examines tissue from the biopsy or operation. The pathologist scores the appearance of the two most common cell patterns out of 5 and adds them. The total score ranges from 2 to 10. Intermediate to high grade cancers (those with a score of 7-10) are the greatest threat because they are growing more rapidly and tend to spread earlier from the prostate.

The three factors, PSA level, clinical stage (from the rectal exam) and Gleason grade, can be combined in a prediction tool called a ‘nomogram’ which estimates the probability of cancer spread or later recurrence. These tools are based on the outcome of thousands of patients undergoing treatment¹.

A nomogram called the ‘Partin Tables'² gives the probability of spread beyond the prostate region at the time of operation (Internet address given at end of this issue). It should be remembered however, that these tools can only give estimates. The 'Kattan' Nomogram gives the likelihood of cancer recurrence following surgery or radiotherapy.

Treatment Options

The three most common forms of treatment for localised cancer are surgery (radical prostatectomy), radiotherapy and observation only (watchful waiting). Another form of treatment, hormonal therapy, is often used in combination with radiotherapy for locally advanced prostate cancer (refer Mr PHIP no. 5 of this series).

Radical prostatectomy

Surgery to remove the entire prostate and the seminal vesicles (glands which secrete part of the ejaculate) is called a radical prostatectomy. Like any major surgery, it has risks, and is usually offered to healthy men who have at least a 10 year life expectancy. The operation can be performed by open surgery (the traditional way), or by a ‘keyhole’ (laparoscopic) approach. This ‘keyhole’ approach is recent and involves making several small openings in the abdomen. In this case, the surgeon may control the instruments using a machine called a ‘robot’. Laparoscopic surgery takes longer, but blood loss is usually less and hospital stay is shorter. Depending on whether the surgery is open or ‘keyhole’, hospital stay is 1 - 6 days with a recovery period of 3 - 6 weeks before returning to work or activities such as heavy lifting.

Potential long term side effects of a radical prostatectomy are poor erections (impotence) and urinary leakage (incontinence). Because the prostate lies next to nerves and blood vessels which are important for erections, this operation carries a high risk of poorer quality erection (30 to 80% of cases³). If the cancer is small, and the nerves controlling erections can be spared, impotence rates are lower – around 35%⁴. Likewise, the prostate lies at the base of the bladder and surrounds the urine outflow tube (urethra), and so mild to moderate incontinence can also occur (in about 16% cases⁴).

The results of radical prostatectomy for localised cancer are very good: up to 86% of men with localised cancer live for at least 10 years, and up to 78% are recurrence-free during that time⁵. For this reason, it is offered as a potentially curative treatment.

Radiation Therapy

Radiotherapy, also a widely offered treatment, uses X-ray energy to kill cancer cells. It can be delivered from an external source (called external beam radiotherapy or EBRT) or internally, where the source of the radiation is placed in the prostate itself (called brachytherapy). Either way, the treatment is carefully planned, with the aid of scans and computer software, to deliver the right dose to the areas needed. This planning process usually involves two visits to a radiation oncology department. Conformal radiotherapy allows the radiotherapist to follow the shape of the prostate in three dimensions and is standard care for EBRT. The treatment is divided into small doses over an extended period of time, eg. a few minutes treatment on each of 5 days per week over a period of 7 - 8 weeks.

Radiotherapy does not have a sudden stressful impact on the body as surgery does, and so it is often offered to older people, and those with other illnesses who are not strong enough to undergo surgery. It is also useful to treat disease which has spread just outside the prostate, but is contained within the prostate region. The different types of patients make comparison of treatment outcomes with surgery difficult, but the results are similar with 70% free of recurrence after 8 years⁶.

Brachytherapy involves introduction of radio-active seeds (low dose rate) or wires (high does rate) into the prostate and is sometimes delivered prior to, or following external beam radiation. Low dose rate is most likely to succeed in patients with a small, slow-growing tumour and a PSA less than 10ng/ml. Control of the cancer is comparable to EBRT and surgery⁷. Hormone therapy may be advised, in combination with EBRT or brachytherapy.

Erectile problems are usually fewer after brachytherapy than after surgery (4 - 14%⁸). Erectile problems may vary depending on the age of the patient, the radiation technique used and the patient’s potency prior to treatment. Temporary bowel problems such as diarrhoea and cystitis occur in most men but usually settle down shortly after treatment. Up to one-third of patients, especially those treated with EBRT may experience long-term diarrhoea⁹. The incidence of severe, permanent urinary or bowel side effects is low 1 - 2%.

Brachytherapy has a greater risk of troublesome urinary symptoms (poor stream, frequent urination etc) than either surgery or EBRT - about 25%). For this reason, men’s lower urinary tract symptoms are assessed before this type of treatment is offered¹⁰. There is a small risk of urinary retention (inability to urinate) and some men may need to wear a urinary catheter initially. Surgery to relieve bladder blockage may be advised prior to brachytherapy .

According to early reports, men with relatively slow growing cancers lived for about the same length of time with or without treatment. Because treatment carries risks, has side effects and can affect quality of life, the option of no treatment at all is one that can be considered. This is particularly true for men over 75 years, or who have other illnesses and whose life expectancy is reduced.

Recent reports suggest that, particularly for men in their 50s and 60s, slow growing cancers can ultimately progress and cause death. Active surveillance by a specialist is therefore recommended. This doctor will review the need for treatment at intervals and in discussion with yourself. This decision will depend on the change in PSA levels over time and results of other investigations, including repeat biopsy on occasions.

New Treatments

A number of newer treatments are currently being developed and assessed for localised prostate cancer. While some are available in Australia, in the main they do not attract Medicare or private health insurance benefits and so can be costly.

Cryosurgery or freezing of the tumour tissue with liquid nitrogen is available to treat localised cancer. Ultrasound during the procedure is used to guide the extent of freezing. Side effects include impotence and incontinence as with other treatments. The long term effectiveness of this treatment is not thought to be as reliable as either surgery or radiotherapy.

Hyperthermia or heating of tissue using microwaves (High Intensity Focussed Ultrasound or HIFU) is being used for localised and more advanced prostate cancer. It is not widely practised, and long term outcomes are still awaited.

Additional Therapies

Many men have written about the positive experiences they have had with other therapies such as meditation and dietary changes. Anything which supports and maintains your physical health and state of mind is potentially helpful. If you are considering additional therapies it is sensible to discuss these with your doctor.

Which treatment is right for me?

Choice of treatment depends very much on your particular cancer – whether it presents a low risk, moderate or high risk of recurrence. Many doctors use the PSA level and cancer grade to decide which are the ‘risky cancers’. Refer Table 1 (below).

For low risk cancers, treatments include brachytherapy, EBRT, radical prostatectomy and watchful waiting. For moderate risk cancers, radical prostatectomy and EBRT with or without brachytherapy are options. For higher risk cancers, and where an aggressive approach is needed, hormone therapy may be offered in combination with radiotherapy. For an older man, with less than 10 years life expectancy, and low to intermediate risk cancer, watchful waiting (active surveillance) is an option.

How do we know when the cancer is controlled?

After surgery or radiotherapy, the only sure answer as to whether the treatment has removed or destroyed all of the cancer comes from PSA tests. The PSA level will drop rapidly (within weeks) after surgery, but may take from 12-18 months to reach its lowest point after radiotherapy. PSA levels are expected to remain low in the long term: undetectable levels after surgery and ideally, less than 1.0 ng/ml after radiotherapy. If the PSA starts and continues to rise again, it typically means that there is continued growth of the cancer.

Sometimes after radiotherapy, in particular brachytherapy, the PSA can reduce, bounce upwards for a few months, then settle back down. The reason for this ‘bounce’ is not known.

If the cancer recurs or has spread beyond the prostate region, your options include hormonal therapy. Hormonal therapy can control the cancer successfully for many years. Issues surrounding this treatment are discussed in Mr PHIP no. 4 and 5.

Although the time after a diagnosis can be difficult for many, it is important to remember that for most men, after treatment for prostate cancer, there are many good years of life ahead.

Footnotes

1. Han, M and A.W. Partin, Sem Urol Onc, 2002. 20, 123-30.
2. Partin, A.W. et al. JAMA, 1997. 277,1445-51.
3. Steineck, G. et al. New Engl J Med, 2002. 347, 790-6.
4. Roumeguere, T. et al. World J Urol, 2003. 20, 360-6.
5. Evidence-based recommendations for the management of localised prostate cancer. 2003, Canberra: NHMRC.
6. Kupelian, P.A. et al. J Clin Oncol, 2002. 20, 3376-85.
7. Doust, J. et al. Aust Fam Phys, 2004. 33, 525-9.
8. Crook, J. et al, CMAJ, 2001. 164, 975-81.
9. Perez, C. Prostate, in Principles and Practice of Radiation Oncology, 1997, Lippincott-Raven: Philadelphia. p.1583-1694.
10. Terk, M.D et al. J Urol, 1998; 160, 1379-82.;

This information sheet is not intended to take the place of medical advice. Information on prostate disease is constantly being upated. We have made every effort to ensure that information was current at the time of production, however your GP or specialist may provide you with new or different information which is more appropriate to your needs.

© Repatriation General Hospital, Daw Park 2000-2004