Treatment Options for Prostate Cancer

The management and treatment options include:

•  Watchful waiting
For some men, particularly older men with major health issues, various treatments may not be appropriate. They will be regularly monitored and if symptoms develop (e.g. bone pain), treatment will be offered to manage these symptoms. The intent is to treat symptoms as they arise.

•  Active surveillance
For men who have low–risk localised prostate cancer, active surveillance is an option. Men are regularly monitored by the prostate specific antigen (PSA) test, digital rectal examination (DRE) and occasional further biopsies. The results from these tests and procedures will show if the cancer had changed. If the disease progresses, they are offered treatment, usually by surgery or radiotherapy. The thinking behind this strategy is that because treatments have side effects that affect quality of life, it can be better to delay treatment for as long as possible. Men on active surveillance may remain well without treatment.

•  Surgery
Surgery aims to remove your cancer completely if it has not spread beyond the prostate gland at the time of treatment (localised prostate cancer). The prostate will be removed in a procedure called a radical prostatectomy, with the intent to cure. This involves the removal of the entire prostate gland, as well as some of the tissues surrounding it, to make sure the cancer is fully removed before it spreads. Surgery is generally offered to healthy men whose cancer has not spread to other parts of the body.

A radical prostatectomy can be done in different ways:

•  Open radical prostatectomy – A cut is made below the navel to the pubic bone, to get to the prostate gland.
•  Laparoscopic radical prostatectomy – This is also known as ‘keyhole surgery’. A number of small cuts are made to allow insertion of a camera and instruments. The actual procedure is the same as open surgery, but done through smaller incisions, so you recover faster.
•  Robotic–assisted radical prostatectomy – Similar to laparoscopic surgery, but performed with instruments that have greater range of movement than standard laparoscopic ones.
[Note: Recovery time may be quicker with laparoscopic or robotic prostate surgery, compared to open surgery, but all three forms of radical prostatectomy have similar rates of recovery and side effects. The choice of surgery is largely dependent on the particular technique your surgeon has expertise in. At this time, there is no high level evidence that one technique is better than the other.

Sometimes a procedure called nerve–sparing prostatectomy can be done when undergoing surgery for prostate cancer. This can reduce the risk of erectile problems by preserving the nerves needed for erections. These nerves are on either side of the prostate. This procedure is not always possible because the cancer can affect the areas around the nerves. Talk with your urologist to find out if this option is possible for you.

Sometimes men with locally advanced prostate cancer may be offered surgery, with or without radiotherapy after surgery (this is called adjuvant radiotherapy). Whether or not this treatment option is considered depends on how far the cancer has spread into the prostate region. You can talk to your treating doctor to find out if this option is suitable to you.

Further questions to ask:
The following questions may be useful for you to ask your healthcare team about the form of radical prostatectomy that is recommended to you.•Why are you recommending this particular option instead of radiotherapy?
•  What are the advantages and disadvantages of this form of surgery for my situation?

Other Surgery: ‘Turp’ (Transurethral Resection 0f the Prostate):
TURP surgery:  involves cutting away some of the tissue from inside the prostate while leaving the outside of the gland in place. This type of surgery is sometimes used to control urinary symptoms in men with advanced prostate cancer. A side effect is ‘retrograde ejaculation’, when semen is forced back into the bladder during ejaculation due to damage to the internal sphincter muscle (valve) located near the prostate. The valve cannot close shut, so semen flows back into the bladder. It is then passed out with urine the next time you go to the toilet; potentially giving your urine a cloudy appearance. This is a harmless effect which occurs in most men having this type of surgery.

Radiotherapy may be used to treat prostate cancer by using X–rays to destroy cancer cells. It may be used to treat localised prostate cancer with the intent to cure. In some cases, people may also be given radiotherapy with the intent to cure, even if the cancer has spread to other parts of the prostate region (locally advanced prostate cancer).

Radiotherapy can be also given after surgery if:•your cancer may have spread outside the prostate gland – this is called adjuvant radiotherapy
•  If your PSA level started to rise – this is called ‘salvage’ radiotherapy.

Types of radiotherapy:
There are two main types of radiotherapy – external beam radiotherapy (EBRT) and brachytherapy. The difference is whether radiotherapy is applied from outside the body (EBRT) or inserted directly into the prostate (brachytherapy). Not all cancer treatment centres offer brachytherapy. Talk with your healthcare team about the availability of treatment options in your area.

In some instances, both surgery and radiotherapy may be used in combination with the aim to eradicate all the cancer cells.
External beam radiotherapy (EBRT) uses high energy x–ray beams that are directed at the prostate from the outside. Generally people have this treatment in a hospital setting daily, Monday to Friday, for 7–8 weeks. During your EBRT treatment, you can continue to do what you would normally do if you’re able but it can interfere with some day–to–day activities as you may need to schedule multiple hospital visits, and there are side effects.
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Brachytherapy is when radioactive material is given directly into the prostate at either at a low dose rate (LDR) or high dose rate (HDR). LDR and HDR relate to the speed with which the dose is delivered, not the actual dose itself. Brachytherapy may not be available in your local public hospital.

•  LDR – It is given by implanting permanent radioactive seeds directly into the prostate. The seeds give off a focused amount of radiation to the prostate with the aim of destroying the cancer cells. LDR brachytherapy is generally a treatment for men with localised prostate cancer. Placement requires surgery that may take a few hours but you may be able to have the treatment as a ‘day–only patient’ or have an overnight stay.

•  HDR – It is also given by inserting radioactive material directly into the prostate but, unlike LDR seeds, the placement of the material is temporary and for shorter periods – usually for a day or two at a time. The procedure takes place at a hospital but may require a longer stay than LDR brachytherapy. It is usually given in combination with EBRT for locally advanced disease.

Brachytherapy can cause side effects such as soreness, frequent and difficult urination, and bowel discomfort. There is no reason not to have sex soon after brachytherapy but you may not feel like it for the first few weeks. You may be advised to take certain precautions initially like wearing a condom when having penetrative sex (e.g. anal sex).

Use of hormone therapy before and after radiotherapy:
Hormone therapy, also known as androgen deprivation therapy (ADT), may be given before radiotherapy, called neo–adjuvant therapy, because this may improve treatment outcome. It’s been shown that using hormone therapy before and during radiotherapy can reduce the chance of the cancer spreading and improve survival chances. For men with higher risk cancer, hormone therapy is also given after radiotherapy (adjuvant therapy) to improve treatment outcome and overall survival.

Medications:
Some medications in tablet and injectable form can be prescribed to manage erectile difficulties. These medicines do have some side effects, and may not suit everyone. Tablet medications will only work if you have had nerve sparing surgery, but the injections can work even if the nerve has not been spared.

Implants/devices:
If you don’t want to use medications, devices that draw blood into the penis (e.g. vacuum erection device) or the use of penile implants (e.g. flexible rods or inflatable tubes) could be ways of getting an erection.