Prostate Cancer: Understanding All the Options
March 04, 2019
One in seven men will be diagnosed with prostate cancer. Hopefully, it will be diagnosed at an early stage, when it is curable. Hopefully, a yearly PSA (the blood test for prostate specific antigen) and a DRE (digital rectal exam, also known as a “finger wave”) are being followed. When the DRE is suspicious, or the PSA is elevated, or rises more than 0.75 per year, then a prostate biopsy must be discussed with that man.
There are no symptoms of early prostate cancer. By the time a man develops symptoms from the cancer, it is usually at an advanced stage. That is why a yearly check up is so critical.
When localized, or “early” prostate cancer is found, a complete discussion of the options for treatment is the first step in deciding upon the appropriate treatment for each individual. What are the options?
Here is a list of the things to ask your urologist, radiation oncologist, or oncologist about treatment.
- Active Surveillance. That means to follow closely the PSA and DRE, and monitor for changes that might indicate a need for repeat biopsy and/or further treatment. Men chosen for Active Surveillance generally have a small prostate cancer (less than 3 positive biopsies, and a Gleason grade (the pathologist’s assessment of the aggressiveness of the prostate cancer) of 3+3 or less. A recent study from a large number of men, in Denmark, who were followed on Active Surveillance for 20 years showed that 60% required treatment due to advancing prostate cancer. About 1/3 of those men had progression of the disease, some developing metastatic disease which was not curable.
- Radiation. This can be done by either “external beam” (usually 40 or so small doses given over a 7-8 week period) or by brachytherapy, where small radioactive “seeds” are placed into the prostate in one procedure. There is also a quicker “external beam” called Cyber-Knife, which can provide bigger doses over a shorter period of time. All radiation works the same way: it kills the cancer by injuring the DNA of the cancer cell. The next time that cell divides, it dies, because it is unable to reproduce. Complications from radiation occur because of all the normal tissue that also gets radiated in the process. The prostate is located deep in the pelvis, surrounded by the bladder, the rectum, the pelvic muscles and urinary sphincter, and the pubic bone. Radiation damage to any of these tissues is frequent, and may result in a lifelong complication that is incurable. Radiation can also lead to erectile dysfunction and urinary incontinence.
- Surgery. Most prostates are now removed with the assistance of the DaVinci surgical system, or “robot.” It is a device which, using laparoscopic instruments, replicates the surgeons hand movements on a remote console, to dissect tissue and to completely remove the prostate. In some men, sparing of the “nerves of erection” can preserve erectile abilities. The risk of “nerve sparing” includes leaving cancer behind, requiring follow-up radiation. After surgery, a urinary catheter through the penis is left in place for at least one week. Open radical prostatectomy, neither laparoscopic nor using the robot, requires a catheter for 3 weeks. After removal of the catheter, in either robotic or open prostatectomy, nearly all men are incontinent, and must wear a pad or diaper until they regain control over the urine. Most men will regain control within a year of surgery, but around 15% will continue to leak, and require pads or diapers. The incidence of erectile dysfunction (ED) after surgery is significant, and gets worse with age. As men enter their 60’s and 70’s, the incidence of ED with radical prostatectomy is more than 50% or higher, depending on the individual.
- Cryoablation. This is freezing and thawing the prostate twice, in one session, to kill the prostate cancer. It is performed by inserting long trocars through the perineum, that area between the scrotum and the anus (the “bicycle seat” area). Several long needle probes are also inserted to monitor the temperatures of the prostate and nearby structures. The procedure is labor intensive and requires multiple large canisters of argon and neon gases to be brought to the operative suite. The laws of thermodynamics are utilized to freeze the whole prostate into an ice ball, monitored by ultrasound, and then thawed by reversing the process. The incidence of ED with cryoablation is 100%, as it is not possible to spare the nerves of erection. The risk of incontinence is less than with surgery or radiation, but a catheter must still be worn for a time, after the procedure.
- HIFU. This is High Intensity Focused Ultrasound, which can be delivered to the prostate in one outpatient session lasting 2-3 hours. An ultrasound probe is inserted via the rectum, under general anesthesia, and the ultrasound waves are focused on solely prostate tissue, passing innocently through the rectal wall to their target. The energy delivered immediately destroys the targeted tissue, in a very exact fashion. The prostate is continuously imaged with ultrasound, and the neurovascular bundles, containing the nerves of erection, are clearly visible, and can be spared. In no other therapy can the surrounding structures be carefully visualized and spared, while still achieving successful cancer control. In HIFU, both the urinary sphincter, the bladder, and the nerves of erection can be routinely safeguarded, resulting in an extremely low incidence of incontinence, and an impressively higher rate of preserving erections. HIFU has been in continuous use in Europe and most of the world since 1994. More than 100 papers in peer-reviewed journals attest to the success of cancer control. In the three largest studies from groups in France and Germany, the 5 and 10 year cancer-specific morbidity and mortality was similar to radical prostatectomy. That means that the cancer control was as good as surgery, and better than radiation. HIFU was approved by the FDA for prostate ablation in October 2015. There are applications to treat other organs, including the brain, which are under investigation.
- Transrectal MRI guided focal laser ablation of the prostate. This treatment is investigational and offered at a few locations in the US. The idea is to place a laser fiber into a prostate cancer visible on MRI, and to burn the tissue using the conductive energy of the laser, sort of like a hot skewer inserted into a piece of meat. The heat burns the tissue immediately around the skewer, and the energy fades out within a few millimeters. Another MRI is done to confirm treatment of the lesion. Unfortunately, most prostate cancers extend further out from the visible lesion. Therefore, a high percentage of prostate cancer remains untreated. This fact accounts for the relatively high failure rate of focal laser ablation.
If you are considering treatment of your prostate cancer, please be sure to speak to you doctor about all the options. Every man has a unique situation, and no one treatment is right for everybody. If you have further questions, please feel free to explore my website here at cliffordgluckmd.com. If you would like to speak with me regarding your prostate cancer, you may leave your information in the inquiry section of the website or call the Wellness Center directly at (781) 337-6737 to make an appointment.
We look forward to treating you.
Clifford D Gluck, MD FACS