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Prostate Cancer: A Range of Treatment Options

If your health care provider has told you that you have prostate cancer, you may soon face a difficult choice of treatment options.

Men will often find that the specialists performing one treatment usually espouse that treatment over others. A survey of urologists and oncologists published in the Journal of the American Medical Association (JAMA) found that although urologists and radiation oncologists agree on a variety of issues regarding detection and treatment of prostate cancer, they usually recommend the therapy that they offer.

Ironically, almost all the specialists may be right in many cases, according to the study, which said that no conclusive evidence currently backs any particular treatment over another.

So how can you know which treatment is best for you?

Before you pick a treatment

The first thing you should do, according to the American Cancer Society (ACS), is ask your health care provider about the extent (stage) and grade (aggressiveness) of your cancer. The medical field has a letter and number system for different stages and grades of prostate cancer, identifying everything from one splotch that is likely to grow slowly to out-of-control spreading.

Ask about the chances of treating it effectively, what is likely to happen if it is not treated right away, and what will be the likely side effects of any surgery or other treatments.

Then ACS recommends that you consider other factors, such as your age, what lifestyle you wish to have, whether you can live with potential incontinence or impotence, and what chances you're willing to take comfortably. For example, some older men choose to have no treatment at all because of operation dangers and lifespan issues. Younger men may be more concerned about curing the cancer than the side effects treatment might cause. 

Treatments

The two primary treatments for early-stage prostate cancer are prostatectomy, in which the prostate and in some cases tissues that surround it are removed, and radiation therapy, in which radiation is beamed into the prostate or inserted with a "seed" pellet (called brachytherapy) to kill the cancer cells.

The JAMA survey found that urologists and radiation oncologists agree that prostatectomy, radiation therapy, and brachytherapy are all effective treatments for localized prostate cancer in men expected to live at least 10 more years.

Expectant therapy (also known as active surveillance or watchful waiting) is often a reasonable choice for older men with other medical problems and early-stage disease. Watchful waiting means closely monitoring the condition, but not starting treatment unless the cancer begins to grow more rapidly or symptoms appear.

Other treatments such as hormone therapy, vaccine therapy, and chemotherapy are usually used in men with more advanced prostate cancer. 

Radical prostatectomy

This operation removes the entire prostate gland and some tissue around it and is used most often when the cancer is believed to have not spread past the prostate.

Conventional prostatectomies require incisions near the rectum or in the abdomen and can lead to incontinence (inability to control the bladder) and impotence (inability to get the penis erect because nerves were cut during surgery). Normal bladder control usually returns within several weeks or months after a radical prostatectomy but persists in some men. Impotence is a problem in 25 to 30 percent of men under 60 when surgery does not remove nerves on either side of the prostate, but rates can be much higher in older men or if the nerves cannot be spared. Many factors affect the risk of impotence, including a man's age and his ability to have erections before surgery.

A newer "keyhole," or laparoscopic, prostatectomy uses a thin, lighted tube with a camera on the end and several other long, thin instruments. They are inserted through several small incisions in the abdomen to remove the prostate. Men usually recover more quickly from this operation than they do from standard prostatectomy, although it is not yet clear how this approach compares with conventional prostatectomy in long-term results or in terms of side effects.

An even newer technique is robotic-assisted laparoscopic prostatectomy. In this approach, the surgeon sits at a control panel and precisely maneuvers long, thin surgical instruments with robotically controlled arms. Again, surgical recovery tends to be shorter, although there are no results comparing long-term side effects or results with older, more established treatments.

Radiation therapy

High-energy rays (such as X-rays) and particles (such as electrons and protons) are used to kill cancer cells. This therapy 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.

The two main types are external beam radiation and brachytherapy (internal radiation).

External radiation focuses a beam from outside the body onto specific spots. A small percentage of men experience permanent incontinence, and the percentage of men who have some impotence afterward is similar to the rate from surgery. Unlike surgery, where the side effects appear right away and may get better over time, the side effects from radiation therapy tend to come on gradually over months or even years. 

Brachytherapy uses thin, hollow needles to insert many radioactive pellets about the size of a grain of rice into the prostate. The radiation dies out after several weeks or months, and the pellets are allowed to harmlessly remain in the prostate.  Brachytherapy tends to have lower rates of incontinence than other treatments, although it can cause other problems, such as frequent urination. Some studies have found that impotence rates may be slightly lower, but other studies have found the rates to be the same as with other treatments.

Expectant therapy (watchful waiting or active surveillance)

The best strategy for some men may be to simply "watch and wait," with careful observation and monitoring of the cancer but no immediate treatment. 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 or expected to grow slowly. Also, if a man is older or frail, or has some serious health problems, this treatment may be an option. Some men may decide that the side effects of more aggressive treatments may outweigh the benefits. If at some point it becomes clear that the cancer is growing or it starts to cause symptoms, more active treatment can be considered. 

Hormone therapy

This treatment is often used for men whose cancer has spread beyond the prostate or has recurred after treatment. Its aim is to prevent the cancer cells from using androgens (male hormones), such as testosterone, which cause the cells to grow.

Side effects of this therapy include reduced or absent sexual desire, impotence, and hot flashes. Some men also have breast tenderness and growth of breast tissue.

To greatly reduce androgen levels, some doctors recommend an orchiectomy, which is the removal of the testicles. But more often, this is done using medicines that are injected monthly or even less often.

Chemotherapy

This is an option for men whose cancer has spread outside the prostate and for whom hormone therapy is no longer working. Chemotherapy doesn't destroy all the cancer cells, but it may slow tumor growth, reduce pain, and help men live longer. It can cause side effects, such as nausea, vomiting, loss of appetite, low blood counts (with increased risks of infections, bleeding, and fatigue), and hair loss.

Vaccine therapy

A prostate cancer vaccine, made by removing a man's own immune cells and exposing them in a lab to proteins found on prostate cells, may be used for advanced cancer if hormones are no longer working. The side effects of the vaccine are minimal in most men and include allergic-type reactions. While the vaccine isn't a cure, it may help men live longer.