Prostate cancer is the most common type of cancer affecting men. Rates of detection of prostate cancers vary widely across the world, with South and East Asia detecting less frequently than in Europe, and especially the United States. Prostate cancer tends to develop in men over the age of fifty and although it is one of the most prevalent types of cancer in men, many never have symptoms, undergo no therapy, and eventually die of other causes. This is because cancer of the prostate is, in most cases, slow-growing, symptom-free, and since men with the condition are older they often die of causes unrelated to the prostate cancer, such as heart/circulatory disease, pneumonia, other unconnected cancers, or old age. About 2/3 of cases are slow growing, the other third more aggressive and fast developing. Chances are either you or someone you know will develop the disease. The Prostate Cancer Treatment Guide’s information can help guide your visits with your physician as you formulate a plan for treatment.
Brachytherapy is a minimally invasive radiation therapy that plants small radioactive seeds inside the prostatic tissue. There are two types: permanent LDR and temporary HDR. There are two types of brachytherapy that are used in the treatment of prostate cancer: permanent low dose radiation (LDR) and temporary high dose radiation (HDR). LDR brachytherapy is uses iodine-125 and palladium-103 stored in titanium cases usually referred to as brachytherapy seeds. As the name permanent brachytherapy suggest, the seeds are permanently left inside the prostate gland. Over the course of their radioactive lives, the seeds will continuously emit low levels of radiation.
HDR brachytherapy uses a single radioactive seed made of iridium-194 which is sometimes referred to as an iridium wire. Soft flexible plastic catheters are inserted through the perineum and into the prostate gland. HDR brachytherapy entails an overnight stay in the hospital during which a patient undergoes two or three treatments with the wire through each catheter.
Chemotherapy works by destroying quickly-dividing cells and is usually reserved for patients with advanced or metastatic prostate cancer. Like radiation therapies, chemotherapy does not destroy the entire body because only cells that divide soon after being treated will die. Unfortunately, chemotherapy cannot be focused to any particular area of the body. All quickly-dividing cells of the body therefore are affected, including, those in the hair follicles, skin, gastrointestinal tract, and bone marrow. The severe and sometimes dangerous side effects of chemotherapy drugs have often outweighed their benefits as an early prostate cancer treatment. However, for patients with advanced disease, chemotherapy can be beneficial in both extending the life and decreasing pain.
Cryotherapy is a revolutionary minimally invasive therapy that uses ultrathin needles and freezing gases to destroy the cancerous tissue. Cryotherapy is an effective primary treatment for those who are in the early stages of prostate cancer with low risk for tumor extension. This treatment may also be an excellent alternative for those who are not good candidates for radical prostatectomy. Cryotherapy may be used if EBRT fails and the cancerous prostate cells are deemed radioresistant. Some advantages of include the one day in-hospital treatment, though some patients will stay overnight depending on their general health. Cryotherapy can also be repeated if it fails to ablate the cancerous tissue during the first round of treatment. Patients for whom treatments fail can also pursue alternatives such as radiation therapy or prostatectomy. Because cryotherapy is minimally invasive, patients experience only minimal, if any, blood loss. One disadvantage is that the long-term data on cryotherapy is limited, due to its newness as mainstream prostate cancer treatment.
Hormone Therapy prevents testosterone from spurring the growth of prostatic tissue and the prostatic tumor. There are 4 types: castration (surgical and chemical), combined, estrogen, and anti-androgen. Hormones are substances produced by glands in the body and circulated in the bloodstream. In prostate cancer, male sex hormones can cause prostate cancer to grow. Drugs, surgery, or other hormones are used to reduce the production of male hormones or block them from working. Hormone therapy used in the treatment of prostate cancer may include the following:
- Luteinizing hormone-releasing hormone agonists can prevent the testicles from producing testosterone. Examples are leuprolide, goserelin, and buserelin.
- Antiandrogens can block the action of androgens (hormones that promote male sex characteristics). Two examples are flutamide and nilutamide.
- Drugs that can prevent the adrenal glands from making androgens include ketoconazole and aminoglutethimide.
- Orchiectomy is a surgical procedure to remove one or both testicles, the main source of male hormones, to decrease hormone production.
- Estrogens (hormones that promote female sex characteristics) can prevent the testicles from producing testosterone. However, estrogens are seldom used today in the treatment of prostate cancer because of the risk of serious side effects.
Radiation Therapy refers to non-invasive beam therapy using electron, proton, or neutron beams. An example is intensity modulated radiation therapy (IMRT). The most common prostate cancer treatment, radiation therapy’s oldest form is electron beam; newer versions are intensity modulated, 3D-CRT, and proton beam therapy. Experimental treatment uses neutron beams. External beam radiation is sometimes called fractionated, meaning that small doses are given over a long period of time. Patients receive radiotherapy once a day, Monday through Friday over 5-9 weeks, depending on the patient. Normal prostate cells can repair the damage of a small amount of radiation fairly quickly. Cancerous cells cannot. Receiving a small dose everyday helps to minimize the damage sustained by the healthy cells of the surrounding organs. Giving patients the weekend off helps their body to recover enough to withstand the next five days of treatment.
Prostatectomy is prostate surgery and removes part of or the entire prostate gland. The radical perineal approach has been in use since the early 20th century. Not the until the 1940’s did doctors begin to uses the radical retropubic approach. Both of these approaches, however, engaged an unrefined surgical technique which resulted in significant blood loss for the patient. Once surgeons began clamping veins and refining surgical technique, patients immediately fared better. Until the 1980’s, the retropubic approach was the most commonly used. Today, the laparoscopic and robotic procedures are quickly becoming popular. Partly because many doctors PLND is can be diagnosed with other testing. In this procedure however conversion to the abdominal incision may be used if complications arise during a laparoscope-assisted procedure.
Robotic-Assisted Prostatectomy is the latest advancement in minimally invasive technology that deploys the use of robotic instrumentation and 3D imagery of the operating site when removing a cancerous prostate gland through a series of small incisions. In general, robotic prostatectomy surgery yields a shorter recovery period for the patient, and thus a quicker return to everyday activities when compared to traditional open surgical procedures.
Biologic therapy/ or Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy. The FDA has approved a new therapy for certain men with advanced prostate cancer called Provenge (sipuleucel-T). Provenge, an autologous cellular immunotherapy, is manufactured by Dendreon Corporation. It is intended for men with asymptomatic or minimally symptomatic prostate cancer that has metastasized and is resistant to standard hormone treatment.
High-intensity focused ultrasound (HIFU) is a treatment that uses ultrasound (high-energy sound waves) to destroy cancer cells. To treat prostate cancer, an endorectal probe is used to make the sound waves. As an acoustic wave propagates through the tissue, part of it is absorbed and converted to heat. With focused beams, a very small focus can be achieved deep in tissues. When hot enough, the tissue is thermally coagulated. By focusing at more than one place or by scanning the focus, a volume can be thermally ablated. At high enough acoustic intensities, cavitation (microbubbles forming and interacting with the ultrasound field) can occur. Microbubbles produced in the field oscillate and grow (due to factors including rectified diffusion), and eventually implode (inertial or transient cavitation). During inertial cavitation, very high temperatures inside the bubbles occur, and the collapse is associated with a shock wave and jets that can mechanically damage tissue. Because the onset of cavitation and the resulting tissue damage can be unpredictable, it has generally been avoided in clinical applications. However, cavitation is currently being investigated as a means to enhance HIFU ablation and for other applications.
Watchful waiting is not a euphemism for doing nothing, but rather it is the decision to delay treatment in favor of careful monitoring for the progression of prostate cancer. Watchful waiting may also be referred to as expectant management, conservative management, observation, or surveillance.
The theory behind watchful waiting treatment is that most prostate cancers, specifically prostate adenocarcinomas, usually grow very slowly. Patients who have low Gleason scores, other medical complications, or low grade tumors may wish to postpone treatment due to the side effects. The standard that most doctors use when recommending watchful waiting is a ten years life expectancy. If a patient can reasonably expect to benefit from a more aggressive treatment for a period of ten years or more, doctors may recommend pursuing other treatments now. Patients who are older or who wish to avoid the side effects of incontinence and impotence that usually come with other treatments may opt for watchful waiting.
Watchful waiting will tell you and your doctor how quickly your prostate cancer is progressing, or if the disease is progressing at all. PSA tests are usually taken every three months to monitor a change in PSA velocity. Doctors usually recommend that patients receive biopsies in a year. Patients also receive regular DRE’s which will detect any new regularities that may indicate the progression of prostate cancer.
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