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There are many different aspects that needed to be considered in assessing a patient’s suitability of a particular prostate cancer treatment and patients frequently feel unqualified to make such an important decision.
All too often patients can be confused and given seemingly conflicting advice regarding the benefits of the different treats available.
At the Prostate Cancer Centre, three leading experts work closely together in a combined clinical team helping patients select the best treatment for them. By using their large experience based on having treated over 1000 patients by these different therapies they can help you decide upon the optimal treatment for you and your prostate cancer.
At present, there is no definite evidence as to which is the best treatment for prostate cancer, especially for early stage T1 or T2 tumours, and different Urologists may have differing views.
One of the reasons for this is that some patients with early stage disease will often live 10 years or more if no treatment at all is used.Therefore, more involved therapies have a hard act to beat. However, in other patients, the disease can be much more serious. Unfortunately, whilst it is possible to give broad figures, it can be difficult to predict what course the prostate cancer will take in any individual. Also, the side-effects of treatment, which can be severe, must be balanced against the overall benefit of therapy. For example, there is little point in undergoing major surgery to take out the prostate if the tumour has spread to areas where it cannot be removed.
The treatment of prostate cancer is determined by the stage and the grade of the disease as well as the PSA. There are a number of treatment options for every stage, each with their own advantages and disadvantages.Thus, the therapy needs to be tailored to suit each individual patient. It is possible to cure patients with prostate cancer at an early stage, but even if cure is not a possibility, the disease can normally be kept in check for a number of years.
Prostate cancers treatment should be undertaken by a specialist who regularly perform large number of such procedures and who work in a team approach with other clinicians. Several studies have demonstrated a link between the number of procedures performed by a specialist and the likelihood of their success. Furthermore for many of the complex procedures listed below there is a lengthy learning curve which first needs to be overcome before good results can be obtained.
At the Prostate Cancer Centre we have the largest collective experience in the treatment of early prostate cancer using the latest techniques in Europe. Our published and presented results match the best that have been achieved by any institution in the World.
The different treatment options available to patients diagnosed with prostate cancer are described below.
It is important that any patient with such a diagnosis is aware of the different treatments and they should feel free to discuss these with their specialist. The Prostate Cancer Centre can help you to make an informed decision tailored to you as an individual. Patients may find the the PCC’s “treatment selector” helpful in comparing the different treatments and assessing their suitability for them
If you would like help in beginning the process of selecting the right treatment for you select this link to view the Prostate Cancer Centre treatment selector
If their cancer has been diagnosed accidentally, during an operation to remove prostatic tissue blocking the urinary stream or by a PSA blood test and biopsy, and the patient has no symptoms, a “wait and see”policy may be chosen. This does not mean “do nothing”, but the patient will be regularly monitored by the doctor and if problems develop, appropriate action taken. During this observation period, seeing how quickly the PSA rises can assess the severity of the condition.
Frequently, patients opting for such a treatment strategy will be offered a repeat prostate biopsy 2 years after diagnosis, to ensure the grade of the cancer has not worsened. If treatment is ultimately required, curative therapies may still be offered, although often hormone therapy (see page 21) is the treatment of choice. With such a regimen, patients commonly live for a number of years and this option is frequently chosen by patients with low grade cancers and/or who are elderly.
Whilst normally there is no rush to undergo a particular treatment option for prostate cancer, work is on going to examine whether deferring treatment after diagnosis with an Active surveillance approach will affect the chances of cure should a curative therapy be ultimately used.
Radical prostatectomy is an operation performed to remove the entire prostate and is only done for cancer which is thought not to have spread beyond the prostate (organ-confined). It should not be confused with transurethral (performed through the penis, using a telescope) prostatectomy (TURP), which removes only the inner two-thirds of the prostate and is performed for a prostate obstructing the flow of urine from the bladder. It is a major operation with an excellent safety record when done by an expert.
For more information on radical prostatectomy please read A Patient’s Guide to Radical Prostatectomy which can be downloaded by selecting this link. Alternatively, you can read more about Laparoscopic radical prostatectomy by selecting this link.
External beam radiotherapy involves directing high-energy rays at the tumour. the aim of the treatment is to destroy the cancerous cells and leave the healthy ones intact.
This procedure may be used in two situations: firstly to treat early cancers confined to the gland and the surrounding tissues (so called radical radiotherapy). Secondly, it can be used to treat tumours that have spread to the bone and which are causing pain.
Radiotherapy is a painless procedure, like having an X-ray, although there can be troublesome side effects associated with the treatment. Radical radiotherapy for a tumour localised to the prostate may be given in two ways. Conventionally the radiation is directed by a machine (linear accelerator) through the body to reach the prostate, as with an X-ray. The treatment can also be delivered via prostate brachytherapy (for more information see Prostate Brachytherapy below).
Conventional treatment is given on an out patient basis for five days a week for approximately 6-8 weeks. However, when the radiotherapy is being used to treat the bones only a few treatment sessions are necessary.
Brachytherapy is a technique for treating prostate cancer, using tiny radioactive seeds of Iodine-125 (I125) that are inserted permanently into the prostate gland. 'Brachy' means close and, in this treatment, the radioactivity is inserted directly into the cancerous organ. This is unlike conventional external beam radiotherapy, where it travels through the body tissues before reaching the prostate gland. Brachytherapy provides a higher, more localised radiation close to the prostate and minimises the effects on the surrounding tissues, such as the rectum and bladder.For more information on brachytherapy, please read A Patient’s Guide to Prostate Brachytherapy which can be downloaded by selecting this link. Alternatively, you can read more about Prostate Brachytherapy by selecting this link
When cancer has spread beyond the prostate, going to either the lymph nodes or bones, hormonal therapy may be very effective at shrinking the tumour and reducing the side effects of the disease.
It does not provide a cure, but will often keep the cancer in check for a number of years. Some patients are given a course of hormone therapy before having radical radiotherapy. This is useful if the cancer has spread outside the confines of the gland but has not yet reached the lymph nodes or bone.
As mentioned above, the prostate gland and prostate cancer are under the influence of testosterone, the male sex hormone, which drives the tumour to grow and spread. By blocking the body's production of testosterone, or blocking its action, the growth of the tumour may be greatly reduced. There are a number of ways to administer such hormone therapy and these are listed below.
Whatever technique is chosen by the patient, certain side effects are common such as hot flushes, a loss of sexual desire, impotence and occasionally breast tenderness or, rarely, breast enlargement.
The parts of the testicle that produce testosterone may be surgically removed by a small operation called an orchidectomy, which can be performed as a day case procedure. This has the advantage of being a ‘one off’ treatment, which does not rely on the patient remembering their medication, and tends to cause less breast problems. However, the operation is irreversible and an option that some men find unacceptable.
Injection of an agent, known as an LH/RH analogue has a similar effect to removing the testicles but is reversible and does not involve an operation. A doctor or nurse gives the injection every one or three months. Because there can be an initial rise in testosterone after the first injection, a two week course of anti-androgen tablets (see below) are normally prescribed to stop this effect.
Hot flushes, breast tenderness and impotence are common side effects with this form of treatment.
This therapy involves taking daily tablets to block the action of testosterone. Some types of this drug have a second action also; they reduce the production of testosterone by the testicles. Drugs that have this dual action (e.g. cyproterone acetate) can be used alone to treat prostate cancer, although they tend to cause impotence and a lack of sexual desire more commonly than those drugs that act only on blocking testosterone (e.g. bicalutamide). However this later drug can frequently cause breast tenderness and slight enlargement.
Cyro-surgery uses extreme cold to destroy the prostate tissue. Using transrectal ultrasound in a fashion similar to brachytherapy, fine cryo-needles are inserted into the prostate gland. Under anaesthetic, argon and helium gases are used to freeze then thaw the prostate, causing destruction of the tumour. Temperature can be as low as -140°C. A warming device and temperature sensors protect vital neighbouring structures such as the rectum, bladder and sphincter muscles.
Patients typically stay in hospital overnight and are discharged home with a urinary catheter for two weeks, to allow the swelling of the prostate to go down. Cryo-surgery is a newer technique being investigated in only a small number of specialist centres in the UK. The impotence rate is higher than with other treatments and incontinence can occasionally occur. Although it has been used to treat men with newly-diagnosed prostate cancers, it is currently primarily reserved for patients with recurrent prostate cancer after treatment by radiotherapy.
For more information on cryotherapy, please read A Patient’s Guide to Prostate Cryotherapy which can be downloaded by selecting this link. Alternatively, you can read more about Targeted cryoablation by selecting this link
HIFU is a treatment designed to treat localized prostate cancer using high intensity focused ultrasound (HIFU). A rectal probe generates high intensity ultrasound waves which travel through the rectal wall and are focused in the prostate. This focusing produces intense heat and provokes the destruction of the tissue inside the targeted zone with minimal effect to surrounding tissues. The treatment typically takes 3 hours to perform, usually under a under general aesthetic. The technique is very new in the field of prostate cancer treatments and is still under research with little long term data to verify its effectiveness, However, for some patients especially with recurrent localised prostate cancer following radiotherapy it may offer use second line option.
Studies show that the strongest environmental risk factor for developing prostate cancer is our diet. Men can and should manipulate their diet to reduce this risk. Interestingly, patients who have been treated for prostate cancer also seem to benefit from altering their diet as it reduces their risk of cancer recurrence (Schroeder, 2000).
- Vitamins A, C and D reduce the rate of cell division
- Vitamin E is an antioxidant
- Selenium (found in nuts) reduces the rate of cell division
- Lycopene (found in tomatoes) reduces the rate of cell division
- Green tea reduces the effect of testosterone on the prostate
- Soy reduces the effect of testosterone on the prostate
- Weight loss
Natural hormonal therapy
Hormone therapy blocks the production or effect of testosterone on prostate cells, leading to a reduction of their size and number. All of the compounds listed below can artificially lower PSA, so it is important that you tell your doctor if you take any of them. Oestrogen is an active component of each of them and can also cause breast swelling and tenderness, reduced libido and erections and deep vein thrombosis. Unfortunately, these treatments are effective against prostate cancer cells for only 2-3 years, after which they become ‘hormone-resistant’, just as bacteria can become resistant to antibiotics with time. They are palliative, rather than curative.
This extract from berries of the saw palm tree (Serenoa repens) acts like oestrogen to lower testosterone and reduce both benign and cancerous prostate growth.
The name combines “PC” for prostate cancer and the Latin world “spes” which means hope. It contains the oestrogen component, diethylstilbestrol, and Chinese herbs, including the anti-inflammatory drug indomethacin, which also has anti-cancer properties. Unfortunately, it contains warfarin, which can cause prolonged bleeding.
This is PC-SPES compounded with sterolins, which have anti-cancer properties, and quercetin, which blocks the effect of testosterone on prostate cells.
There are a wide range of sophisticated treatments available to patients with prostate cancer. Each treatment has benefits and drawbacks but you can be guaranteed that the Prostate Cancer Centre will help you to choose the right treatment for you. For help and support dealing with a diagnosis of prostate cancer visit the coping section of the website for videos, contact information for support groups and other pertinent information.