Most men diagnosed with prostate cancer are recommended to have treatment with curative intent. If the cancer is low-grade and localised, an active surveillance path may be followed. If the cancer is low grade and a man’s life expectancy (due to age or other medical conditions) is less than 10 years, a reasonable case for watchful waiting can be made.
The following list summarises treatment options for prostate cancer:
- Surgery: Radical Prostatectomy
- robotic assisted laparoscopic
- open
- laparoscopic
- Radiation (also called external beam radiation or EBR), with various acronyms for the techniques IMRT and VMAT
- Prostate Brachytherapy (low dose)
- High dose HDR
- Hormonal Treatment
- Chemotherapy – generally Taxol based
- New novel agents, which include:
- Abiraterone
- Enzalutamide
- Sipuleucel-T
- Cabazitaxel
(The role of high-intensity focused ultrasound and cryotherapy has not yet been established and their “long term” results are uncertain).
Which Treatment To Choose?
With Whom?
- Consult with a Urologist. Preferably one who has a special interest in prostate cancer and preferably someone who can offer all treatment options.
- Have a low threshold to obtain a second opinion (many Kiwis are reluctant to do this).
- Take your time. It may require two or three consultations over a few weeks to decide.
- Be aware of the costs involved; some insurance policies cover all surgical costs and some do not.
- Some surgeons are affiliated providers for some or all of their procedures. This does not mean they provide a superior level of care, but rather that they have entered into a financial arrangement with an insurance company.
How Your Surgeon Helps You Choose
This can be difficult! Some patients have several options with similar chance of cure, others have fewer options due to some of the reasons below:
Important factors:
- Stage and grade of cancer
- Size of prostate
- Presence of urinary symptoms
- Presence of bladder outflow obstruction (blockage)
- Age and life expectancy of the patient
- Access to private care (as brachytherapy and robotic prostatectomy are only available in the private health sector).
Clinical factors that may influence decision making:
If the prostate is large (greater than 60cc), brachytherapy is ruled out for anatomical reasons (pubic bone arch interference), which means it is not technically possible.
If there is significant bladder outflow obstruction, the prostate is large and the patient has no major comorbidity (other illness) then surgery is probably the most sensible approach.
Brachytherapy is effective for small low-grade cancers in men with small prostates.
The side-effects are generally mild, with rapid convalescence. Some patients who may have chosen brachytherapy may now decide to proceed with Robotic Assisted Prostatectomy because of its minimally invasive appeal.
External beam radiation (EBR) is more often used in men with locally advanced tumours when these have spread outside the prostate (“T3”).
Other Factors to Consider:
It is easier to monitor the control of the cancer after surgery, as the PSA should fall to undetectable levels.
In addition, the prostate once removed is examined by a pathologist, and the size of the tumour and margin status are reported (also the lymph nodes, if these are removed as part of the operation), this all provides valuable information about outcome / prognosis.
The PSA should fall to undetectable levels after surgery. The PSA normally drops below 2ug/L with brachytherapy, but in about 20% of men it can fluctuate. This “bounce” effect can be disconcerting.
Ten Questions to ask your Urologist about your Prostate Cancer
– these may help your understanding of prostate cancer and treatment
- What Stage is it? (T1, T2, T3, T4)
- What Grade is it? (Gleason score 6 -10)
- Do I need further tests to stage the cancer?
- What are the treatment options?
- What is your success with these treatments?
- What are the side effects of the treatments?
- Do you (the Urologist) perform these procedures?
- How do you monitor the effectiveness of treatment?
- What treatment is available if the primary treatment fails?
- What to tell the family? (treatment, prognosis, increased risk for siblings)