Many treatment options exist for prostate cancer. If you have prostate cancer, consider your age and general health before making a decision about treatment. You also need to think about which side effects you can live with. Some men, for example, cannot imagine living with side effects such as incontinence or impotence. Other men are less concerned about these and more concerned about survival.
Treatment decisions are often hard to make by yourself. No written information can take the place of talking directly with your health care professionals. In addition,talk with your family and friends and consider getting more than one opinion. It is natural for surgical specialists such as urologists to recommend surgery and for radiation oncologists to recommend radiation. Primary care doctors can help you choose the treatment that is best for you.You might find that speaking with others who have faced or are currently facing the same issues is useful.
Watchful waiting is based on the premise that cases of localized prostate cancers may advance so slowly that they are unlikely to cause men–especially older men–any problems during their lifetimes. Some men who opt for watchful waiting, also known as "observation" or "surveillance," have no active treatment unless symptoms appear. They are often asked to schedule regular medical checkups and to report any new symptoms to the doctor immediately.
Watchful waiting has the obvious advantage of sparing a man with clinically localized cancer, who typically has no symptoms, the pain and possible side effects of surgery or radiation. On the minus side, watchful waiting risks decreasing the chance to control disease before it spreads, or postponing treatment to an age when it may be more difficult to tolerate. Of course, treatments may also improve over time if watchful waiting is chosen. Another potential disadvantage is anxiety; some men don't want the worry of living with an untreated cancer.
The most obvious candidates for watchful waiting are older men whose tumors are small and slow-growing, as judged by low grade Gleason score and low stage.
Many men who choose watchful waiting live for years with no signs of disease. A number of studies have found that, for at least 10 or even 15 years, the life expectancy of men treated with watchful waiting (primarily older men with less lethal forms of prostate cancer) is not substantially different from the life expectancy of men treated with surgery or radiation–or, for that matter, of the population at large.
An operation called radical prostatectomy completely removes the prostate and nearby tissues. A radical prostatectomy is further described in terms of the incisions used by the surgeon to reach the gland. In a retropubic prostatectomy, the prostate is reached through an incision in the lower abdomen; in a perineal prostatectomy, the approach is through the perineum, the space between the scrotum and the anus.
In radical prostatectomy, the surgeon excises the entire prostate gland, along with both seminal vesicles, both ampullae (the enlarged lower sections of the vas deferens), and other surrounding tissues. The section of urethra that runs through the prostate is cut away (and with it some of the sphincter muscle that controls the flow of urine). Pelvic lymph node dissection is done routinely as part of a retropubic prostatectomy; with a perineal prostatectomy, lymph node dissection requires a separate incision.
CryoAblation, also known as cryosurgery or cryotherapy, is a medicare-approved, minimally invasive procedure that kills prostate cancer by freezing the cancerous cells.
With CryoAblation, the physician inserts 6-8 slender probes into the prostate gland. Contained within each probe is argon gas cold enough to freeze the entire prostate. A warming catheter protects the urethra from the very cold temperatures.
Recent advances have made cryosurgery extremely safe and highly effective. Ultrasound images allow your doctor to guide the probes to the best possible positions for killing the cancer. Temperature sensors carefully monitor the process and precisely determine when target temperatures have been reached.
The benefits of the procedure include a choice of general or local anesthesia, a fast recovery and lower risk of potential side effects, such as incontinence. In fact, incontinence affects just five percent of cryosurgery patients -- far less than with other procedures. On the other hand, this procedure carries a high risk of impotence.
Brachytherapy kills cancer cells through the use of high-energy x-rays that are delivered to the prostate from dozens of tiny radioactive seeds implanted directly into the prostate gland. This approach, known as interstitial implantation or internal radiation therapy, has the advantage of delivering a high dose of radiation to tissues in the immediate area, while minimizing damage to healthy tissues such as the rectum and bladder. When the cancer is localized, brachytherapy serves as an alternative to surgery.
As practiced today, internal radiation therapy relies on ultrasound or CT to guide the placement of thin-walled needles through the skin of the perineum. Seeds made of radioactive palladium or iodine are delivered through the needles into the prostate, according to a customized pattern—using sophisticated computer programs—to conform to the shape and size of each man's prostate.
External beam radiation therapy uses high-energy x-rays beamed from a machine called a linear accelerator to kill cancer cells. Intensity modulated radiation therapy (IMRT) is a type of external beam cancer treatment that conforms the radiation beam to the size, shape and location of a tumor. With conventional external beam radiation, directing the beam at the cancerous tissue without damaging surrounding healthy tissue is difficult. With IMRT technology, sophisticated algorithms are used to determine the optimal dose of radiation for each area of the prostate. Then the radiation is delivered according to the treatment plan by a computer-controlled collimator mounted on the end of a linear accelerator. As the collimator rotates around the patient, its shutter leaves shift to form specific patterns that regulate the amount of radiation administered to the healthy tissue while delivering intense radiation to the cancerous tumor. This type of therapy generally involves treatments five days a week for eight or nine weeks. In many cases, if the tumor is large, hormone therapy may be started at the time of radiation therapy and continued for several years.
External beam radiation therapy is commonly used to treat men whose cancers have spread too widely in the pelvis to be removed surgically, but have no evidence of spreading to the lymph nodes.
Hormonal therapy combats prostate cancer by cutting off the supply of male hormones (androgens) such as testosterone that encourage prostate cancer growth. Hormonal control can be achieved by surgery to remove the testicles (the main source of testosterone) or by drugs.
Hormonal therapy targets cancer that has spread beyond the prostate gland and is thus beyond the reach of local treatments such as surgery or radiation therapy. Hormonal therapy is also helpful in alleviating the painful and distressing symptoms of advanced disease. Further, it is being investigated as a way to arrest cancer before it has a chance to metastasize. Although hormonal therapy cannot cure, it will usually shrink or halt the advance of disease, often for years.
Surgery to remove the testicles (orchiectomy or surgical castration) is usually an outpatient procedure. The testicles are removed through a small incision in the scrotum; the scrotum itself is left intact. To help offset the operation's psychological toll, some men opt for reconstructive surgery in which the surgeon replaces the testicles with prostheses shaped like testicles.
A variety of hormonal drugs can produce a medical castration by cutting off supplies of male hormones. Female hormones (estrogens) block the release and activity of testosterone. Antiandrogens block the activity of any androgens circulating in the blood. Still another type of hormone, taken as periodic injections, prevents the brain from signaling the testicles to produce androgens.