Mark Scholz, MD and Richard Lam, MD
Edited with permission (November 2008)
From Prostate Oncology Specialists
In the past, prostate cancer was generally diagnosed at an advanced stage. As a result there was a much higher risk of dying from the disease. Since the advent of PSA testing in 1988, men are being diagnosed with prostate cancer at an earlier stage thereby reducing their risk of dying. Unfortunately, the risk of dying from prostate cancer has not been totally eliminated; a small percentage of newly-diagnosed patients have high-grade variants that are still dangerous. We also still see men who fail to do PSA screening; these men may present with advanced disease at the time of their first check-up. Fortunately these sad circumstances become less common every year as more and more men get PSA testing. However, even though some forms of prostate cancer can indeed be dangerous, for most men, the danger of dying is very low.
Now that prostate cancer has become a treatable disease, like hypertension or diabetes, new problems have surfaced. One problem is that selecting effective treatment has become complicated by a plethora of treatment options. Here is a very brief introduction to the types of therapy available for men with newly-diagnosed prostate cancer:
No Treatment – It is now becoming clear that thousands of men undergo aggressive treatment every year for a type of prostate cancer that will never be life-threatening. Active Surveillance, with treatment only administered if the cancer grows, is becoming more and more popular for men with the low grade form of prostate cancer.
Local treatment options refer to strategies directed at eradicating the prostate gland and the cancer it contains. Examples of local treatments are surgery (radical prostatectomy), radioactive seed implantation, beam radiation therapy, and cryosurgery. All these “local” treatments, when administered by accomplished experts, can be expected to eradicate the cancer within the prostate with a high degree of consistency. However, there are two potential drawbacks. First, the treatment can cause irreversible side effects to adjoining structures such as nerves that control erections, urinary, and rectal function. Second, the treatment may not cure the cancer; sometimes the cancer has already spread outside of the prostate.
Systemic treatment options are designed to stop cancer in the whole body, not just the prostate. These options include herbal, hormonal, and chemotherapy treatments. The disadvantage of systemic treatments is that the treatment suppresses the cancer rather than eradicating it. Effective systemic treatment aims to convert prostate cancer into a chronic, non-progressive condition which may be controlled for many years. Systemic treatments are also associated with side effects. Fortunately with systemic treatments the side effects are almost always reversible.
Combination options (systemic plus local treatment) are used for selected patients who have a high risk of relapse with local therapy alone. Combination treatment offers the best chance for cure in patients with disease that is at greater risk of being outside the prostate. Combination options are reserved for high-risk situations because using two treatments together can cause an accumulation of side effects.
Selecting the best treatment means choosing the right intensity of treatment to achieve control of the cancer without applying excessive treatment that could result unnecessary side effects. Since the more dangerous types of prostate cancer warrant combination therapy, a determination of the cancer’s aggressiveness is the first order of business. The aggressiveness of the cancer is determined by a process called staging. Staging is accomplished by gathering important information about the type and extent of the cancer by reviewing specific blood tests, biopsy information, and scan results. After staging is completed, the cancer specialist can meld this information into a prediction about whether or not the cancer is still contained in the prostate gland. Once these risks are understood patients can then be counseled about which treatment options are most appropriate for their specific situation.
Selecting treatment for men with prostate cancer is unusual because the patients themselves select the treatment! This is because with early stage disease, the best choice can not be determined simply by selecting the treatment with the best cure rates; there are multiple options all with comparable cure rates! Therefore only by examining the potential side effects of each treatment option and comparing it with the other choices can important distinctions be made among all the different alternatives. After all, if the patient himself is going to bear the brunt of any treatment-related side effects; isn’t it only sensible for them to help choose the type of treatment they will undergo?
Even though a patient’s involvement in the treatment selection process is an absolute requirement, there are potential pitfalls. Clear and objective reasoning may be difficult during a time of shock and grief brought on by the diagnosis of cancer. Strong emotions are also stirred up as one is forced to face the possibility of treatment-related, life-altering, side effects affecting sexual, rectal, and urinary function. Forced by circumstances to act as “amateur doctors,” patients can be prone to hurried treatment decisions instead of waiting until they have a full understanding of all the information; despite reassurances, it is hard for patients to escape the lingering fear that “times a wasting” while the cancer is growing and spreading.
Recommendations for Selecting Treatment:
1. Don’t rush into immediate treatment!
2. Obtain thorough and proper staging to determine the percent likelihood of the cancers spread to a location in the body distant to the prostate.
3. Educate yourself thoroughly about this disease via sources such as the internet, books, and support groups focused on prostate cancer.
4. Seek advice and treatment from doctors who specialize in treating prostate cancer.
5. If you have questions, contact the PCRI helpline.
See related PCRI Paper