Types of Treatments for Prostate Cancer

Depending on the stage of their disease, men often have more than one treatment option to consider. Several factors should be taken into account when choosing between these options, including both the potential benefits and risks. The side effects associated with each of type of prostate cancer treatment are discussed in the next section.

Radical Prostatectomy

In a radical prostatectomy, the surgeon removes the entire prostate gland plus some tissue around it. This operation is used most often if the cancer appears not to have spread outside the gland. During the surgery the patient is either under general anesthesia (asleep and totally unconscious) or under spinal or epidural anesthesia (the same type of anesthesia often given to women during childbirth to numb the lower half of the body) with sedation.

Retropubic approach	Perineal approach

Fig 3. Radical Prostatectomy

There are 2 main types of radical prosta­tectomy: radical retropubic prostatectomy and radical perineal prostatectomy. In the retropubic operation, the surgeon makes a skin incision in the lower abdomen. The surgeon may remove lymph nodes during this operation through the same incision. A nerve-sparing radical retropubic prostatectomy is a modification of this operation. During this procedure, the surgeon carefully examines the small bundles of nerves on either side of the prostate gland. If it appears that the cancer has not spread to these nerves, the surgeon will try to not remove or damage them. Because these are the nerves that are needed for erections, leaving them intact lowers (but does not eliminate) the risk of impotence (not being able to have an erection) following surgery.

A newer approach to surgery is laparoscopic radical prostatectomy (LRP). The surgery begins with the urologist making several small incisions in the patient’s abdomen. (The incisions are one-fourth to one-half inch long, compared to a single 5- to 6-inch long incision for traditional surgery.) A laparoscope – a long, thin, lighted video camera – is then inserted through one of the incisions. Tiny surgical instruments are inserted into the other incisions. The surgeon sometimes uses a robotic system (called the da Vinci system) to control the movement of the instruments. Mini-cameras on the instruments send images to video monitors. These images are larger than life, magnified many times, allowing the surgery to be extremely precise. The magnified view also helps the surgeon avoid damaging the delicate structures and nerves surrounding the prostate. LRP has been used in the United States since 1999. Robotic LRP was developed in the United States in 2000. Both are more frequently being done in university centers, are relatively new procedures, and require skilled and experienced surgeons.

In the radical perineal prostatectomy, the prostate is removed through an incision in the skin between the scrotum and anus. Nerve-sparing operations are more difficult with this approach, and lymph nodes cannot be removed through this incision. If men having a radical perineal prostatectomy need lymph nodes examined, the surgeon can remove some nodes through a very small skin incision in the abdomen or by using a laparoscope (discussed earlier).

Open operations are followed by an average hospital stay of 2–3 days and the average time away from work is 3 to 6 weeks. A catheter (a thin, flexible tube) is usually inserted through the penis and into the bladder after surgery while the patient is still asleep. The catheter is kept in place for 7 to 10 days to help patients urinate easily while they heal. With the laparoscopic prostatectomy, patients generally go home the day after surgery.

Radiation Therapy

Radiation therapy (RT) uses high-energy rays (such as x-rays) or particles (such as electrons or protons) to kill cancer cells. Radiation is sometimes used to treat prostate cancer that is still confined to the prostate gland or has spread to nearby tissue. If the disease is more advanced, radiation may be used to reduce the size of the tumor or to provide pain relief when cancer has spread to the bones. The 2 main types of radiation therapy are external beam radiation and brachytherapy (internal radiation).

External beam radiation
External beam radiation is focused from a source outside the body on the area affected by the cancer. It is much like getting a diagnostic x-ray but for a longer time. Before treatments start, imaging studies are done to find the exact location of the cancer. The radiation team will then make ink marks on the patient’s skin that they will use later as a guide for focusing the radiation in the right area. Patients are usually treated 5 days per week in an outpatient center over a period of 7 to 9 weeks. Each treatment lasts only a few minutes and is painless.

Three-dimensional conformal radiation therapy (3D-CRT) can more accurately target the prostate. This can reduce side effects, particularly damage to the rectum. It uses sophisticated computers to precisely map the location of the cancer within the prostate. The patient may be fitted with a plastic mold resembling a body cast to keep him still and in one position so that the radiation can be more accurately aimed. Since the prostate can move, it may be imaged daily so that the radiation beam targets it more precisely. Radiation beams are then aimed from several directions. Short-term results suggest that by aiming the radiation more accurately, it is possible to reduce radiation damage to tissues near the prostate and improve effectiveness by increasing the radiation dose to the cancer. For this reason, 3D-CRT is now the preferred method when using external beam radiation for the initial treatment of prostate cancer.

An advanced type of 3D-CRT is called intensity modulated radiation therapy (IMRT). IMRT can even more precisely map the location of cancer and focus high doses of radiation on it and not the surrounding normal tissue.

External beam radiation can also be used at specific sites to relieve bone pain from prostate cancer metastasis.

Internal radiation therapy (brachytherapy)
Internal radiation therapy uses small radioactive pellets (each about the size of a grain of rice) that are placed directly into the prostate. They can be left in place permanently or temporarily. Imaging tests such as transrectal ultrasound, CT scans, or MRI are used to accurately guide placement of the radioactive material into the cancer.

The permanent pellets are sometimes called seeds. The radioactive seeds (made of isotopes such as iodine-125 or palladium-103) are placed inside thin needles, which are inserted through the skin of the perineum (area between the scrotum and anus) into the prostate. The seeds are left in place as the needles are removed and give off low doses of radiation for weeks or months. Radiation from the seeds travels a very short distance, so the seeds can put out a very large amount of radiation to a very small area. This decreases the amount of damage done to the healthy tissues that are close to the prostate. Usually, anywhere from 40 to 100 seeds are placed. Because they are so small, their presence causes little discomfort. They are left in place after their radioactive material is used up. This type of radiation therapy requires spinal anesthesia (where the lower half of your body is numbed) or general anesthesia (where you are asleep) and may require 1 day in the hospital.

Alternatively, more radioactive material can be placed for less than a day. This approach is called high-dose rate (HDR) brachytherapy, and it is usually combined with low-dose external beam radiation. Hollow needles are placed through the perineum into the prostate. Soft nylon tubes (catheters) are placed in these needles. The needles are then removed but the catheters stay in place. Radioactive iridium-192 or cesium-137 is then placed in the catheters, usually for 5 to 15 minutes. Generally, about 3 brief treatments are given, and the radioactive substance is removed each time. The treatments are usually given over a couple of days. After the last treatment the catheters are removed. For about a week following insertion of the needles, patients may have some pain in the perineal area and may have red-brown discoloration of their urine.

Systemic radiation therapy
Strontium-89 and samarium-153 are radio­active substances used to treat bone pain caused by metastatic prostate cancer. They are injected into a vein and settle in areas of bone that contain cancer. The radiation given off kills the cancer cells and relieves some of the pain caused by bone metastases. The majority of prostate cancer patients with painful bone metastases are helped by these treatments. If prostate cancer has spread to many bones, this approach is better than trying to aim external beam radiation at each affected bone.

Hormone Therapy (Androgen Deprivation Therapy)

Hormone therapy is often used for patients whose prostate cancer has spread beyond the prostate or has come back (recurred) after treatment. It can also be combined with radiation therapy for certain stage T3 cancers. The goal of hormone therapy is to block the effect of the male hormones, called androgens, which is why this treatment is often referred to as androgen deprivation therapy or ADT. The main androgens are testosterone and dihydro­testosterone (DHT). Androgens are produced mainly in the testicles and cause prostate cancer cells to grow. Lowering androgen levels or blocking their action can make prostate cancers shrink or grow more slowly. But hormone therapy alone does not cure the cancer.

Some prostate cancers do not respond to hormone therapy. These are called androgen-independent cancers. Often prostate cancers respond to hormone therapy for a few years before becoming androgen-independent. Less often, prostate cancers may be androgen-independent at the time they are diagnosed. Prostate cancer that starts off being androgen-independent may be a different kind of prostate cancer called small cell or neuroendocrine (See Less Common Types of Prostate Cancer).

There are several methods used for hormone therapy:

Orchiectomy
Orchiectomy is the removal of the testicles (male reproductive glands found in the scrotum). Although it is a surgical treatment, orchiectomy is considered hormone therapy because it works by removing the main source of male hormones. By lowering androgen levels, orchiectomy is able to shrink or slow the growth of most prostate cancers for a period of time.

Luteinizing hormone-releasing hormone agonists
These drugs can decrease the amount of testosterone produced by the testicles as effectively as surgically removing the testicles. Luteinizing hormone-releasing hormone (LHRH) agonists are injected or placed as small implants under the skin either monthly or every 3, 4, or 12 months. The LHRH agonists currently available in the United States are goserelin, leuprolide, and triptorelin. All are about equally effective. They work by actually stimulating the pituitary gland to release hormones that cause testosterone production. After about 3 weeks, the pituitary gland “runs out” of these hormones and testosterone production drops.

Understanding this action is important because early in the treatment there can be a surge of testosterone production. This can cause the cancer to temporarily grow. If the cancer is in the bones, a patient may feel more bone pain. This is called a “flare” reaction. Flare often can be avoided by giving drugs called anti-androgens for a few weeks when starting treatment with LHRH agonists.

Luteinizing hormone-releasing hormone (LHRH) antagonists
So far, only one drug of this class, Plenaxis (abarelix), has been approved for use in the United States. This drug blocks the release of the release of hormones from the pituitary gland that stimulates testosterone production. It has the advantage of not causing a “flare” reaction but can cause allergic reactions.

Antiandrogens
Anti-androgens block the body’s ability to use androgens. Drugs of this type, such as bicalutamide, flutamide, and nilutamide, are taken as pills, up to 3 times a day. Anti-androgens can be used alone, but are often combined with LHRH agonists. This is called combination hormone therapy, or total androgen blockade. Combination hormone therapy probably offers no advantage over LHRH agonists or orchiectomy when used alone. These drugs are also used early in the course of treatment with LHRH agonists to block the flare reaction. Finally, anti-androgens may be tried when hormone therapy for advanced prostate cancer has failed. In this setting, anti-androgens are called second-line hormone therapy.

Other hormone drugs
The female hormone estrogen (diethylstil­besterol or DES) is sometimes effective after other hormone treatments have stopped working. Ketoconazole, initially used for treating fungal infections and later found to block androgen production, is another drug for second-line hormone therapy.

Chemotherapy

Chemotherapy or chemo is an option for patients whose prostate cancer has spread outside of the prostate gland and for whom hormone therapy is no longer working. It is not expected to destroy all of the cancer cells, but it may shrink the cancer or slow its growth and reduce pain.

Chemotherapy uses anti-cancer drugs that are injected into a vein, injected into a muscle, or taken by mouth. These drugs kill cancer cells, but they also damage some normal cells. The doctor must maintain a delicate balance of chemo doses, making them high enough to kill the cancer cells, but not high enough to destroy too many healthy cells.

Docetaxel is a chemo drug that is used to treat prostate cancer that has returned or continued to grow and spread after treatment with hormone therapy. The NCCN experts state that the first chemo regimen a patient receives should include docetaxel. Docetaxel may be combined with other drugs to reduce the chances of the cancer cells becoming resistant to chemo.

Small cell prostate carcinoma or neuroendocrine cancer is a rare type of prostate cancer that is more likely to respond to chemotherapy than to hormone therapy. Small cell carcinoma develops most often in the lungs. Because small cell lung cancer often responds to chemo­therapy with cisplatin and etoposide, these drugs are recommended for treating small cell cancers that develop in the prostate.

Expectant Management (Watchful Waiting or Observation)

One strategy for some patients with prostate cancer may be to “watch and wait” with no immediate active treatment. The cancer is regularly and carefully observed and monitored.

This approach may be recommended if a prostate cancer is not causing any symptoms (especially if it is very small and contained to one area of the prostate), if it is expected to grow very slowly, or if the patient is older or has other serious health problems. Because prostate cancer often grows very slowly, many older men who have the disease never need treatment. Some men may decide that the side effects of active treatment outweigh the benefits they hope to achieve. In these instances, the man may opt for expectant management (watchful waiting). Choosing expectant management does not mean that active treatment cannot be used if the cancer begins to grow more quickly or causes symptoms.

Treatment of Pain and Other Symptoms

Most of this document discusses ways to remove or destroy prostate cancer cells or to slow their growth. But it is important to realize that maintaining your quality of life is a very important goal. Don’t hesitate to discuss your symptoms or any other quality-of-life concerns with your cancer care team.

As discussed before, radiation therapy (either external beam therapy or medicines such as strontium-89 or samarium-153) can be used to relieve bone pain caused by prostate cancer metastasis.

Bisphosphonates are a group of medicines that can be used to slow the damage caused by the spread of cancer within bones and prevent fractures. These drugs may relieve pain caused by bone metastases and may slow growth of these metastases. They also may have the added benefit of strengthening bones in men who are receiving hormone therapy. The bisphosphonates most commonly used are pamidronate and zoledronic acid. Both are given by intravenous (IV) injection, but the time of infusion is much shorter for zoledronic acid.

There are other effective and safe ways to treat pain, most other symptoms of prostate cancer, and most of the side effects caused by prostate cancer treatments. When properly prescribed, drugs can effectively relieve pain without risk of addiction, dependence, or becoming too drowsy to continue most of your usual activities. Enduring unnecessary pain has no benefit whatsoever. Pain medication does not interfere with anti-cancer treatments. In fact, getting effective pain relief can help some patients be more active and may, indirectly, help them live longer.

Alternative or Complementary Therapies

Complementary and alternative medicines are a group of different types of health care practices, systems, and products that are not part of your usual medical treatment. They may include Chinese herbs, special supplements, acupuncture, massage, and a host of other types of treatment.

The American Cancer Society defines complementary treatment methods as those that are used along with your regular medical care. Some methods that can be used in a complementary way are meditation to reduce stress, acupuncture to relieve pain, or peppermint tea to relieve nausea. There are many others. Some of these methods are known to help and may add to your comfort and well being, while others have not been tested. Some have been proven not to be helpful. A few have even been found harmful.

Alternative treatments are defined as those that are used instead of your regular medical care. These treatments have not been proven to be safe and effective in clinical trials. Some may even be dangerous or have life-threatening side effects. The most common danger is that you may lose the chance to be helped by standard treatment. Delays or interruptions in your standard medical treatment may give the cancer more time to grow.

Deciding What to Do: It is easy to see why people with cancer may consider alternative treatments. You want to do all you can to fight the cancer. Sometimes mainstream treatments such as chemo can be hard to take. And sometimes they stop working.

At times like this, when people suggest that their treatment can cure your cancer without serious side effects, it’s normal to want to believe them. But the truth is that most non-standard treatments have not been tested and proven to be effective for treating cancer. As you consider your options, talk to your doctor or nurse about any treatment you are thinking about using. Call the American Cancer Society at 1-800-ACS-2345 or visit www.cancer.org to learn more about the specific treatments you are considering.

With reliable information and the support of your health care team, you may be able to safely use methods that can help you while avoiding those that could be harmful.

STAGES

SIDE EFFECTS

For more information on these treatment guidelines, or on cancer in general, call the NCCN at 1-888-909-NCCN or the American Cancer Society at 1-800-ACS-2345. Or you can visit these organizations’ web sites at www.cancer.org (ACS) and www.nccn.org (NCCN).

© 2007 by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reproduced in any form for commercial purposes or downloaded and stored in any information-retrieval system without the express written permission of the NCCN and the ACS. Single copies of each page may be printed out for personal, noncommercial use only.