The three most common forms of treatment for localised cancer are surgery (radical prostatectomy), radiotherapy and active surveillance (a form of delayed treatment or observation only). Another type of treatment, hormone therapy, can be used with radiotherapy for high risk localised prostate cancer, or for cancer which has spread to other parts of the body.
You usually have plenty of time to make a treatment decision – don’t feel rushed!
Surgery: Radical prostatectomy
Surgery to remove the entire prostate and the seminal vesicles (glands that 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 done by open surgery or by a ‘keyhole’ (laparoscopic) approach. The keyhole approach involves making several small openings in the abdomen. The surgeon may control the instruments using a ‘robot’. Keyhole surgery can take longer, but blood loss is usually less and recovery time and hospital stay 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 energetic activities such as heavy lifting.
Open and keyhole approaches have similar results. The surgeon’s experience (number of operations performed) in using either approach is important for a good outcome.
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 that are important for erections, this operation carries a high risk of poor quality erections (70–90% of cases in an Australian study). If the cancer is small, and the nerves controlling erections can be spared, impotence rates are at the lower end of this range. A nerve-sparing operation is less likely to be possible if your cancer is high risk.
The prostate lies at the opening or ‘plug hole’ of the bladder and surrounds the urine outflow tube (urethra). Mild to moderate urine leakage can occur after the operation. Urinary incontinence occurred in 9–16% men in the Australian study1 with severe incontinence at the lower end of this range.
The effectiveness of radical prostatectomy in treating localised cancer is very good: up to 88% of men with localised cancer remaining cancer-free at 12 years compared with 54% of men who did not have surgery. For this reason, it is offered as a potentially curative treatment.
Radiotherapy, also a common treatment, uses x-ray energy to kill cancer cells. It can be delivered from an external source (called external beam radiotherapy or EBR) or internally, where the source of the radiation is placed in the prostate itself (called brachytherapy).
The treatment is carefully planned using scans and computer software to deliver the right dose to the areas needed. Planning usually involves two visits to a radiation oncology department.
External beam radiotherapy
This treatment uses a method called conformal radiotherapy. This allows the radiotherapist to follow the shape of the prostate in three dimensions and to target the prostate while limiting damage to surrounding tissues.
Intensity modulated radiotherapy (IMRT) uses technology to follow the contours of the prostate to deliver higher, more targeted doses of radiation to increase its effectiveness while reducing unwanted side effects.
Image guided radiotherapy (IGRT) is a common technique used to assist radiation targeting and involves placing three (non-radioactive) seeds into the prostate before treatment.
This means the doctor can better monitor the position of the prostate during the course of radiotherapy.
External beam radiotherapy is usually divided into small doses over some weeks (e.g. a few minutes of treatment on each of 5 days per week over 7–8 weeks).
Radiotherapy is a suitable treatment for men with low to high risk prostate cancer. It does not have a sudden stressful impact on the body as surgery does and so is appropriate for older people and those with other illnesses and who are not strong enough to undergo surgery. It is also useful to treat disease that has spread just outside the prostate, but is contained within the prostate region.
Side effects are different from surgery. Temporary bowel problems such as diarrhoea and bladder irritation (cystitis) occur in most men after radiotherapy but usually settle down in time. Some men may experience long term diarrhoea, however the incidence of severe, permanent urinary or bowel side effects is low (1–2%). Side effects of radiotherapy may be minimal initially but can increase over several years after treatment. In an Australian study, at 3 years, urine leakage occurred in 3% of men, 2 men out of 3 were impotent and 15% had bowel problems.
External beam radiotherapy alone is a successful treatment for men with low and intermediate risk cancer. For men with high risk cancer, it may be combined with hormone therapy (also called androgen deprivation treatment) to improve cancer control.
Brachytherapy involves introducing permanent radioactive seeds (low dose rate) or temporary wires (high dose rate) into the prostate. The latter may be delivered with a 4-week course of external beam radiation.
Low dose rate (LDR) brachytherapy
LDR is offered to men with low risk cancer: a small, slow-growing tumour and a PSA less than 10 ng/mL. Control of the cancer is comparable to external beam radiotherapy and surgery.
Erectile problems are usually fewer after LDR brachytherapy than after surgery, with 36% impotent at 3 years in the Australian study quoted earlier. Brachytherapy may have a greater risk of troublesome urinary symptoms (poor stream, frequent urination, etc.) than either surgery or external beam radiotherapy. For this reason, men’s lower urinary tract symptoms are assessed before this treatment is offered. There is a small risk of urinary retention (inability to urinate) and some men may need to wear a urinary catheter initially. Bowel problems were not experienced by men undergoing LDR brachytherapy in the Australian study.
High dose rate (HDR) brachytherapy
HDR can be used to deliver very high doses of radiation to the prostate. It involves the temporary insertion of needles with the radioactive source on two to four occasions. It is often supplemented with EBRT. This treatment is suitable for men with intermediate and high risk cancers.
Side effects are similar to other forms of radiotherapy, although erectile problems are higher than after LDR brachytherapy (72% impotence in the Australian study.
Hormone therapy: Removing the male hormone or its effects
If you have a medium or high risk cancer, your EBRT might be combined with androgen deprivation therapy or hormone therapy. This is treatment with drugs designed to remove or minimise the effect of the male hormone, testosterone, on the body. Hormone therapy may begin 3 to 8 months before radiotherapy and may continue for 2 or more years.
The lack of male hormone can cause cancer cell death, making the job of radiotherapy easier. Hormone therapy alone is never a curative treatment.
This type of combined therapy has been shown to improve cure rates and survival in men with medium and high risk prostate cancer. However as male hormones have many functions in the body, removing them will cause side effects. These include hot flushes, breast enlargement, loss of libido and loss of erectile function (impotence), lack of energy, mood changes (depression) and weight gain. Over the long term, osteoporosis (weakening of the bones) may be a concern. Many doctors now recommend a bone density scan every 1-2 years to monitor changes. Vitamin D and calcium supplements are advised for men on hormone therapy.
Hormone therapy used to increase the effectiveness of radiotherapy is usually temporary, and these side effects diminish with time.
Prostate cancer support groups may prove helpful in contacting other men with prostate cancer.
Some younger men with low risk cancer may prefer to delay their choice of treatment until it is clear that treatment is needed to cure the disease. This approach aims to maintain sexual function for longer and avoid side effects. It is only recommended for men with low risk cancer or men with other significant life-threatening health issues.
Men on active surveillance have a PSA test every 3–6 months and may have biopsies. Treatment is often recommended if the PSA increases significantly, the biopsy Gleason increases to 7 or more or the cancer grows significantly in size. If this occurs, it still may be possible to have surgery or radiotherapy.
The disadvantage of active surveillance is that no-one can be certain if or when the cancer has progressed to a point when cure is not possible. It is an option you can discuss with your doctor(s).
Observation but no active treatment (Watchful Waiting)
Some men with slow growing cancers will not have symptoms of the disease in their lifetime. Men over the age of 75 years or who have fewer than 10 years life expectancy may not be affected by their cancer even with no treatment and therefore will not benefit from having treatment. Men on a watchful waiting program can be offered hormone treatment to control the cancer if and when it progresses. This is an option for older men or those with other serious illnesses.
A number of newer treatments are currently being developed and assessed for localised prostate cancer. While some are available in Australia, most do not attract Medicare or private health insurance benefits and can be costly.
Cryosurgery or freezing of the tumour tissue with liquid nitrogen is available to treat low to intermediate risk cancer that has not spread outside the prostate. Ultrasound during the procedure is used to guide the extent of freezing. It is not suitable for large prostates. Side effects include impotence and urinary incontinence. We don’t have long term data on cancer control and for this reason it is not recommended as a primary therapy. It may be offered as ‘salvage’ therapy after radiotherapy that has failed to control the cancer.
High intensity focused ultrasound (HIFU) is heating of tissue using microwaves. It is being used for localised and more advanced prostate cancer, but is not widely used in Australia. Side effects may include urinary retention (blockage of urine flow) and a prolonged period wearing a catheter. Long term outcomes are hard to measure.
Focal therapy is the removal or ‘ablation’ of small areas of cancer within the prostate gland. Its success depends on cancers being low risk, very small (less than one-tenth of the prostate) and knowing the exact position of the cancer. Because the rest of the prostate is left intact, it is thought that this type of therapy may involve less disruption to the nerves and tissues involved in erections and so have fewer side effects. The disadvantages are that re-treatment may be necessary and it may miss some cancers. The approach is considered experimental. This technique was examined by ABC News in April 2103.