How To Pick The Best Treatment For Prostate Cancer
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Read the pamphlet text below or click here to download a PDF of this 3-fold pamphlet.

 

For picking prostate cancer treatment, the most important consideration is quality-of-life. Long term survival is the norm so lingering side effects from treatment are a leading concern. Treatment selection starts by segregating men into Low, Intermediate or High-Risk categories.1 How to determine a man’s risk group is outlined in the PCRI brochure, “What’s Your Type” available at www.pcri.org.

Low-Risk Prostate Cancer

For men in the Low-Risk category, the decision is simple – active surveillance. Active surveillance avoids the toxic side effects of immediate treatment without sacrificing the chance for cure or impairing long term survival.

Active Surveillance Protocol
1. PSA every 3 months
2. PCA-3 and digital rectal examination every 6 months
3. Biopsy after one year and every two to three years thereafter
4. Annual imaging with color Doppler ultrasound or endorectal MRI can be considered though neither is widely available

Intermediate-Risk Disease

Intermediate-Risk disease is complicated because there are so many options. Again, Quality-of life is the most important issue.2,3,4,5,6,7 Decisions about treatment are based on the risk of side effects, not the misguided idea that one type of treatment cures cancer better. There are multiple “local” treatment options – surgery, seed implants, radiation and cryotherapy with variable side effects (see table). There is one “systemic” option – Testosterone Inactivating Pharmaceuticals (TIP). Local treatments ablate the prostate; TIP affects the whole body.
pamphlet_pick_table

Radical Prostatectomy
The mortality rate from surgery is 1 out of 200 operations.9,10 When potency is defined as having erections identical to before surgery, studies indicate that only 5-15%11,12 of men have complete recovery.

Cancer is left behind after surgery (a positive margin) from 10-50% of the time depending on the skill of the surgeon and the extent of the cancer.13 Microscopic examination of the surgically-removed prostate gland provides helpful information about the extent and grade of the cancer which informs about the likelihood of future relapse. The removal of the prostate also creates a “clean slate” by removing all non-cancerous PSA producing prostate tissue. This simplifies PSA monitoring so that even slight elevations of PSA (above 0.2) accurately indicate relapsing cancer. After the operation, urinary control takes several months to be restored. The side effects and risks of robotic surgery are not much different from the older, open procedure except that the scars are smaller, and the hospital stay is shorter.

Radioactive Seed Implantation (Brachytherapy)
Brachytherapy is a 60-minute outpatient procedure under spinal anesthesia. About two-thirds of patients encounter short-term urethritis. Patients who have enlarged prostate glands or preexisting urinary symptoms from BPH are more prone to develop urethritis. A non-cancerous rise in PSA called a PSA “bump” occurs in up to 30% of men. The bump engenders anxiety because a PSA increase can also signal cancer recurrence.

Intensity Modulated Radiation Therapy (IMRT)
Side effects from IMRT – diarrhea, urethritis and fatigue– tend to be mild, lasting for only a couple of months. As with seeds, if impotence occurs, onset is usually delayed (rather than immediate as with surgery). Two to four percent of men treated with IMRT will develop long term proctitis which in most cases will never heal completely and can lead to rectal leakage, loss of normal sensation and an inability to sense the difference between gas and stool. Other serious problems caused by proctitis include bleeding, urgency, and pain.

Testosterone Inactivating Pharmaceuticals (TIP)
Testosterone blockade for 9-12 months results in a negative biopsy 80% of the time. Men with a positive biopsy are generally given local treatment. After TIP, men are monitored as if they are on active surveillance. Approximately 50% of men will need retreatment with TIP or local therapy within 5 years.

Loss of Libido and Muscle Mass
With TIP, libido is completely lost in 90% of men over age 70, 80% of men in their 60s and in two-thirds of men in their 50s. Libido returns when testosterone recovers. However, even after recovery, some men describe their libido as less intense. Shrinkage of the penis can also occur. Loss of skeletal muscle mass causes easy fatigability. Weight training improves muscle mass and quality-of-life.14

Weight Gain, Hot Flashes and Breast Growth
Loss of testosterone slows body metabolism. Failing to follow a good diet easily leads to a ten or twenty pound weight gain. Hot flashes occur in two-thirds and require treatment in about 20% of men. An estrogen patch dramatically reduces hot flashes in most. Other options are Depo-Provera®, Effexor®, Neurontin® or acupuncture.15 If preventative measures such as Femara® are not used, breast enlargement will occur in about a third of men. Established breast enlargement is only reversible with cosmetic surgery or liposuction.

Osteoporosis, Arthritis and Mood Swings
TIP causes accelerated calcium loss that is preventable with Boniva® or Actonel®. Joint aches, particularly in the hands responds to Glucosamine, Motrin® and Celebrex®. In men with excessive mood swings, small doses of Zoloft® or Paxil® restore the intensity of feeling back to the normal range.

High-Risk Disease

Randomized prospective studies in men with High-Risk disease show that radiation combined with TIP is superior to either radiation alone or TIP alone.16,17,18 The optimal duration of TIP, however, is controversial. TIP for 30 months gives better survival than 6 months.19 The unanswered question is whether 12 to 18 months is sufficient.
Some physicians argue for doing surgery first so there is a second chance for cure with radiation. However, surgery for High-Risk disease frequently results in a positive margin with the need for eventual radiation and TIP, an undesirable triple whammy of treatments.

Final Thoughts

Men quickly discover that everyone is bursting to share their opinion. Run from these “experts” – doctors, friends or family – who preach simplistic answers. In their minds all prostate cancer is life-threatening. They have no idea of what they don’t know. The treatment options should be carefully weighed from a quality-of-life perspective. To summarize, TIP is attractive because the side effects are reversible. However, at best, TIP only leads to active surveillance (after TIP is stopped). Further treatment with surgery, radiation or TIP may eventually be required. On the other hand, local treatments are appealing because they often lead to a cure – not a longer life – but an improved quality-of-life by achieving closure. However, surgery and radiation involve betting all your chips on one roll of the dice. If no major side effects like impotence or incontinence occur, you win big. Conversely, when side effects occur, they can be permanent. In reality, all the options are bad. Men finally reach a decision about what to do when they finally decide which treatments they don’t want to do. What is leftover, even though undesirable, is what they end up doing.

For more information, see NEWLY DIAGNOSED

References
1. Stephen Boorjian, Mayo Clinic validation of the D’Amico risk group classification for predicting survival following radical prostatectomy. The Journal of Urology, April 2008.
2. John Davis, Quality of life after treatment for localized prostate cancer: Differences based on treatment modality. The Journal of Urology, September 2001.
3. John Wei, Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. Journal of Clinical Oncology, January 2002.
4. James Talcott, Time course and predictor of symptoms after primary prostate cancer therapy. Journal of Clinical Oncology, November 2003.
5. David Miller, Long-term outcomes among localized prostate cancer survivors: Health-related quality-of life changes after radical prostatectomy, external radiation, and brachytherapy. Journal of Clinical Oncology, April 2005.
6. Stephen Frank, An assessment of quality of life following radical prostatectomy, high dose external beam radiation therapy and brachytherapy iodine implantation as monotherapies for localized prostate cancer. The Journal of Urology, June 2007.
7. Martin Sanda, Quality of life and satisfaction with outcome among prostate-cancer survivors. The New England Journal of Medicine, March 2008.
8. Paolo Gontero, New insights into the pathogenesis of penile shortening after radical prostatectomy and the role of postoperative sexual function. The Journal of Urology, August 2007.
9. Colin Begg, Variations in morbidity after radical prostatectomy. The New England Journal of Medicine, April 2002.
10. Pierre Karakiewicz, Thirty-day mortality rates and cumulative survival after radical retropubic prostatectomy. UROLOGY, December 1998.
11. Harin Padma-Nathan, Postoperative nightly administration of sildenafil citrate significantly improves the return of normal spontaneous erectile function after bilateral nerve-sparing radical prostatectomy. The Journal of Urology Abstract 1402, 2003.
12. John Mulhall, Defining and reporting erectile function outcomes after radical prostatectomy: Challenges and misconceptions. The Journal of Urology, February 2009.
13. Peter Scardino, Continuing refinements in radical prostatectomy: More evidence that technique matters. The Journal of Urology, February 2005.
14. Roanne Segal, Resistance exercise in men receiving androgen deprivation therapy for prostate cancer. Journal of Clinical Oncology, May 2003.
15. M. Hammar, Acupuncture treatment of vasomotor symptoms in men with prostate cancer: A pilot study. The Journal of Urology, March 1999.
16. Michel Bolla, Long-term results with immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase II randomized trial. The Lancet, July 2002.
17. Anthony D’amico, 6-month androgen suppression plus radiation therapy vs radiation therapy alone for patient with clinically localized prostate cancer. The Journal of the American Medical Association, August 2004.
18. Miljenko Pilepich, Androgen deprivation with radiation therapy compared with radiation therapy alone for locally advanced prostatic carcinoma: A randomized comparative trial of the radiation therapy oncology group. Urology, April 1995.
19. Michel Bolla, Duration of Androgen Suppression in the Treatment of Prostate Cancer. New England Journal of Medicine, June 2009.