Prostate cancer: a detailed review (Part 2)

We learn about the available treatment offered for localised and locally advanced prostate cancer.

Localised prostate cancer

Several treatment options are available. The choice is based on:

• Risk category of the prostate cancer
• Patient preference 
• General health and life expectancy of patient
• Affordability and treatment options available at different facilities

1. Active surveillance 

This is for low-risk disease. Curative treatments, such as radiotherapy or surgery, are delayed until disease progression. Patients are closely monitored with regular prostate specific antigen (PSA) tests and digital rectal examinations. A repeat biopsy may be performed six to 12 months after diagnosis or if cancer growth is suspected. 

Many men with low-risk prostate cancer can benefit as the cancer never progresses and they avoid side effects of treatment.

2. Radical prostatectomy

This involves surgical removal of the prostate, seminal vesicles and a margin of surrounding tissue. Options include: traditional open surgery, laparoscopic (key hole surgery) and robotic-assisted surgery. 

The advantage is that all prostatic tissue is removed and can be analysed, allowing more accurate staging. 

Radiotherapy is also available as an additional treatment after surgery if the PSA rises or the cancer has spread outside of the prostate. The most common side effects are urinary incontinence and erectile dysfunction. 

3. Radiotherapy

Radiotherapy options include:

External beam radiation (EBR)

High-energy X-rays are aimed at the prostate using a special machine, called a linear accelerator. The treatment is administered by a radiation oncologist at an oncology centre. The prostate cells including cells affected by cancer are destroyed. 

Patients are required to undergo treatment daily for five days for around six to seven weeks. Short-term side effects include a need to urinate frequently, burning pain when urinating, diarrhoea and tiredness. 

The long-term side effects may include increased urinary frequency and bleeding. The rectum may also be affected causing an urgent need to defecate, increased frequency, straining and bleeding. Erectile dysfunction can also occur. However, this generally develops over time rather than straight after treatment.

Brachytherapy

Radioactive seeds the size of rice grains are placed into the prostate. The seeds give off small amounts of radiation over months. The placement is planned before the procedure so that the specialist knows where to place the seeds and how many seeds are required. 

An ultrasound probe is inserted in the rectum to guide the seed placement which is done using thin needles that are inserted through the perineum (the area between the prostate and anus). 

A special grid is used to ensure accurate seed placement. Between 60-120 seeds are implanted, using about 20-30 needles which are inserted according to their planned positions. 

Side effects can include bowel problems, such as rectal pain, diarrhoea and bleeding. Urinary problems, such as increased urinary frequency and urgency, pain on urination and blood in the urine, can occur. Erectile dysfunction can also occur. 

Brachytherapy is a once-off treatment and is less invasive than surgery, so the hospital stay is short, and recovery time is quicker.

Locally advanced disease

This is cancer that has spread outside of the prostate to surrounding areas. Treatment can include:

• EBR combined with long-term hormone therapy
• Radical prostatectomy +/- adjuvant or salvage radiotherapy
• Watchful waiting
• Long-term hormone therapy alone

If a radical prostatectomy is done, it may include removal of the pelvic lymph nodes. It may not be possible to remove all the cancer in which additional post-operative treatment may be required. This can include EBR and/or hormone therapy.

1. Watchful waiting

This option is for older men or men who have a short-expected lifespan due to other diseases. 

The cancer is monitored by PSA testing and clinical examination. 

If it progresses, then androgen deprivation treatments (ADTs) are used to slow disease progression.  

2. Hormone therapy

Testosterone is essential for prostate cancer growth. By stopping testosterone production, cancer can be halted or slowed for a period. This can be done by removing the testes where most testosterone is produced (surgical castration), or by using medication to block testosterone production. This is called hormone therapy or ADT.

Hormone therapy can be used as stand-alone treatment or can be combined with EBR. It can also be used after a prostatectomy if all the cancerous tissue couldn’t be removed or if the PSA begins to rise. 

Removing testosterone has several side effects including: fatigue, loss of sex drive, erectile dysfunction, hot flushes, loss of muscle mass and strength, osteoporosis, increased risk for cardiovascular disease and Type 2 diabetes, and cognitive decline. 

To limit side effects, intermittent ADT may be used. This involves cycles of active treatment and cycles when no treatment is given.

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