Management and Treatment
Treatment options
A number of factors will determine treatment options available to you including your age and the stage and grade of your cancer. In 2014, NICE recommended three curative treatment options, (radical surgery, brachytherapy and external beam radiotherapy). These seem to offer patients the same chance of cure but individuals may be better suited to one treatment over another. For those patients with advanced cancer, where complete cure is not an option, the treatment and support regime will be designed to keep the disease in check, alleviate symptoms, maintain quality of life and maximise the period over which you can lead a normal and productive life.
New treatments and enhancements of existing treatments are coming on stream on a regular basis. Often these are designed to target the cancer more accurately while minimising damage to healthy tissue, so reducing side effects. Inevitably new developments will continue to take place and it is important that you are made aware of all the options by your consultant.
Management and treatment of Early Prostate Cancer
Active surveillance
Do not be surprised if your consultant recommends having no immediate treatment and embarking on a regime of active surveillance. This is suitable for men with small localised and less aggressive cancers that are unlikely to spread. In such cases a slow growing cancer may not cause any problems during your lifetime and active surveillance can mean avoiding or at least delaying treatment with its possible associated side effects. It is important that the prostate has been accurately and extensively assessed before you undertake this option. Patients under active surveillance are closely monitored with PSA tests, digital rectal examinations and MRI scans at appropriate intervals. If the cancer shows signs of progressing your consultant will discuss with you the options for curative treatment.
Watchful waiting
This option is usually offered to older men in cases where the disease may grow so slowly that it will not cause significant symptoms or to men whose health does not allow them to undergo invasive treatment. The aim is to keep an eye on the cancer over the long term and offer palliative (as opposed to curative) treatment if problems do develop. Monitoring activity through PSA tests and digital rectal examinations may not be as frequent as in the case of active surveillance. Should symptoms start to occur or if the disease starts to spread more quickly than expected, then hormone treatment (see page 13) is a likely option.
Radical surgery
This involves the total removal of the prostate gland under general anaesthetic in an operation called a Radical Prostatectomy. It is done where diagnostic tests suggest that all of the cancer can be completely removed along with the prostate gland. This may involve conventional open surgery but most surgeons are now using laparascopic (keyhole) or robotic surgery (both of which involve cutting and manipulating tissue through tiny incisions). Recovery from keyhole surgery is much faster than is the case when the area being operated on is completely opened up and less time is therefore spent in hospital and convalescence.
During surgery you will be fitted with a temporary catheter through which your urine will drain. This will normally be removed 10-14 days after the operation. Tissue that has been removed will be sent to pathology for analysis to check whether the cancer has been completely removed. If any cancer is found outside the prostate or a significant risk of recurrence is identified, then you may be offered further treatment such as radiotherapy or hormone treatment.
Here’s Mr Matthew Perry, leading surgeon and Clinical Director of Urology at The Royal Surrey, and one of our Prostate Project Trustees, live in theatre, showing how innovative robots are helping surgeons perform laparoscopic surgery for prostate cancer.
Radiotherapy: 2 options
1. Brachytherapy
This is a one-stage treatment for early prostate cancer in which tiny radioactive seeds are implanted directly into the cancerous prostate gland through delivery needles under ultrasound control. The needles are passed through the skin behind the scrotum. A real time planning computer monitors the procedure to ensure that the desired radiation dose is given to the cancerous parts of the gland while the surrounding structures are spared. By delivering radiation directly into the prostate, the side effects can be minimised and patients rapidly return to their normal activities. The procedure is performed under general anaesthetic and may be a day case or involve an overnight stay in hospital.
This short film by Prof Stephen Langley explains brachytherapy for localised prostate cancer; inserting tiny radioactive seeds directly into the prostate. The radiation damages the cancer cells, causing them to die, with minimal side effects.
2. External beam therapy
This involves directing high-energy radiation at the tumour from outside the body. Modern technology (Conformal 3D or Intensity Modulated Radiotherapy) uses a computer to ‘shape’ the radiotherapy beams to a more exact shape of the prostate, minimising the amount of healthy tissue that receives radiation. Fiduciary markers (tiny pieces of metal) may be inserted into the prostate under local anaesthetic. These markers, along with the planning (CT) scan that takes place before treatment, help ensure that the radiotherapy beams are precisely focused on the area needing treatment. External beam radiotherapy may also be used if the cancer has spread outside the gland. Hormone therapy (see page 13) is usually given to men undergoing this treatment.
Treatment is usually daily (Monday-Friday) for 4-8 weeks. To maximise effectiveness and reduce side effects, you are likely to be asked to ensure that your bowels have moved and that your bladder is full before each treatment. This will be explained to you by a radiographer at the planning stage. If anything about the process is unclear, do not hesitate to ask for further explanation and advice at any stage in the process.
Side Effects
All radical/curative treatments carry the risk of side effects. These include impotence (loss of erections), incontinence (leakage of urine) and bothersome urinary symptoms. Some of these will wear off but some may be long term. It is important that you discuss the relative risks of these with your urologist, and/or members of the multi-disciplinary team looking after you (which will include a clinical nurse specialist, oncologist, etc.). It is very important not to rush into any form of treatment (seek a second opinion if need be) and to consider the pros and cons of each procedure.
Although your consultant(s) may recommend a course of treatment, the final decision remains YOURS, with help and support from spouse or partner and those closest to you. It is important to ensure you are told about and understand all available treatment options so that you can make an informed decision based on the benefits and risks associated with each.
Recurrence
Recurrence is usually indicated by a rising PSA or, for the minority of prostate cancers that do not affect PSA levels, other tests or symptoms. Tests such as MRI, CT, bone scan and/or a further biopsy will indicate if the recurrence is local or distant from the pelvis or prostate. It may not be necessary to initiate further treatment straightaway and this will depend on the results of the tests and speed of change in the PSA.
Should the prostate cancer recur after curative treatments there are several options available. For example, recurrence after external beam radiotherapy may be treated by cryotherapy or HIFU, after brachytherapy by radical prostatectomy or cryotherapy and recurrence after surgery can be treated by external beam radiotherapy. These treatments can only be used if the recurrence is localised to the prostate and has not spread elsewhere. If the recurrence is not localised to the prostate, hormone therapy is usually used.