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Prostate Cancer 101

Understanding My Treatment Options?

There is no one size fits all approach to prostate cancer. Every man faces a wide array of options on how to treat their disease and the course of care they choose can vary greatly. Understanding your unique diagnosis will help you and your healthcare team determine which options work best for you.

For each man, the potential benefits versus risks and side effects of treatment should be considered. If you are diagnosed with prostate cancer, it is important to determine whether the clinical data is an accurate reflection of the actual cancer and whether or not there is a possibility of more aggressive disease.


Treatment Options for Prostate Cancer

Dr. Arthur Burnett, Patrick C. Walsh Distinguished Professor of Urology, Director, Basic Science Laboratory in Neurourology and Director, Male Consultation Clinic at Johns Hopkins Medical Institutions reviews options available to men based on their disease and risk level.



NCCN Guidelines®
Risk Category Initial Treatment Recommendations
Very Low
Low
Intermediate
High
Very High

ObservationObservation (also called watchful waiting) is a strategy of choosing not to treat or monitor the prostate cancer. It is an option for men who are not likely to benefit from treatments such as surgery or radiation therapy (e.g. older men or men with serious health problems) AND/OR men who do not want either of those options. If men who go on observation later experience metastasis or urinary symptoms, they may choose to be treated but typically these treatments are geared towards managing symptoms, not curing the cancer.

Men who choose observation should still schedule regular appointments with their doctor although they may elect not to have additional prostate biopsies.


Active Surveillance Prostate CancerActive surveillance (AS) is a management option for patients with prostate cancer that is unlikely to spread or progress in the near term. AS consists of strict, regular monitoring of the cancer by your doctor. AS allows men to avoid potentially life-altering side effects of treatment while retaining the option to treat the cancer with curative intent if the tumor shows signs of progression.

AS monitoring generally includes the following:

  • PSA test
  • Digital Rectal Examination (DRE)
  • Ultrasound
  • Scheduled Prostate Biopsy

The frequency of these tests will be determined by your doctor. If the results of any of these tests suggest that your cancer status has changed, your doctor will discuss whether a change from AS to treatment makes sense.

Active Surveillance should be based on your type of prostate cancer and personal preferences, along with the guidance and recommendations of your doctor.


Prostate Cancer Treatment Options: Active Surveillance

Many men with prostate cancer are confused by the difference between treatment options active surveillance, watchful waiting and observation. Dr. Arthur Burnett, Patrick C. Walsh Distinguished Professor of Urology, Director, Basic Science Laboratory in Neurourology and Director, Male Consultation Clinic at Johns Hopkins Medical Institutions discusses these individual options and how they can play a role in prostate cancer treatment.


Radiation therapy involves directing high-energy radiation to the prostate, with the aim of destroying cancer cells. Two main types of radiation therapy are available, depending on the stage and grade of prostate cancer:

  • External beam radiation therapy (EBRT): For EBRT, the radiation comes from an instrument located outside the body, similar to an x-ray machine. Treatment is typically given 5 days/week, either once or twice a day, for 2-10 weeks.
  • Brachytherapy: Brachytherapy involves placement of radiation-containing “seeds,” which are about the size of a grain of rice and contain radioactive material, into the prostate using thin needles. The radiation may either remain there permanently or may be removed after a few days.

Common side effects of both EBRT and brachytherapy are urinary problems, which usually disappears with time. This can include issues such as increased frequency, blood in the urine, burning sensation, and/or weak stream. Erectile dysfunction, or difficulty attaining and/or maintaining an erection for sexual activity, may also develop, even years after radiation therapy.

Patients who undergo EBRT may experience skin issues such as itchiness, discomfort, and darkening of the skin. Additionally, the effect of radiation on the lining of the rectum and bowels may lead to some abdominal discomfort as well as diarrhea and excessive gas. Patients may also experience at least a mild degree of fatigue during and shortly after their EBRT.

Brachytherapy may cause pain and bruising in the perineum and testicles. Although it is rare, there is a slight increase in the likelihood of new cancers forming in the pelvis years after radiation therapy for prostate cancer.


Surgery involves removal of the prostate and surrounding tissues. The most commonly performed procedure is a radical prostatectomy, which removes the entire prostate, seminal vesicles, and sometimes other tissue. In the modern era this procedure is often done laparoscopically with the assistance of robotic arms; in some cases it may be performed as a standard open surgical procedure.

Short term risks of prostate cancer surgery include the risks of an operation under anesthesia including but not limited to blood loss, infection, nerve injury, heart attacks, and blood clot formation. Prostatectomy also carries long term risks of urinary incontinence (trouble controlling urination leading to urinary leakage) and erectile dysfunction (difficulty attaining and/or maintaining an erection for sexual activity). It is also possible to form scar tissue at the surgical site, leading to difficulty emptying the bladder.


Cryosurgery Prostate CancerCryosurgery consists of freezing prostate tumors to kill the cancer cells. This procedure involves applying cold argon gas via a thin needle into the tumor in the prostate. Cryosurgery is FDA-approved but not widely used at this time. It is also sometimes used as salvage therapy for patients who have failed primary radiation therapy and have residual disease that is still confined to the prostate.

Known short-term side effects may include the inability to empty the bladder, painful swelling, and a “pins and needles” feeling in the penis. Long-term side effects may include erectile dysfunction, incontinence, fistulas, and urethral blockage resulting from scar tissue.


High Intensity Focused UltrasoundHIFU is a treatment designed to destroy prostate tissue using focused ultrasonic waves administered via a probe inserted through the rectum while the patient is under anesthesia. HIFU is FDA-approved for the destruction of prostate tissue but not specifically for the management of prostate cancer. It is not widely used at this time and is somewhat controversial; some doctors believe HIFU is an effective way to treat select prostate cancers with minimal side effects whereas others believe it is not a sufficient treatment to adequately control prostate cancer.

Possible side effects of HIFU include erectile dysfunction, urinary urgency, and urinary incontinence.


Hormonal TherapyThe goal of hormonal therapy is to eliminate and/or inhibit the activity of any male hormones (primarily testosterone) that may fuel the growth of cancer from within the body. Hormonal therapies are classified as either androgen deprivation therapy (ADT) or secondary hormonal therapy.

Androgen Deprivation Therapy (ADT)

There are three types of ADT:

  • Surgical castration (orchiectomy): This involves surgical removal of the testicles, which secrete testosterone, a hormone that can potentially stimulate prostate cancer growth. This is the simplest form of ADT.
  • Medical castration (LHRH agonist and LHRH antagonist): This involves the use of medications that block your body from making testosterone, which may encourage growth of prostate cancer. These agents are given by injection on a scheduled basis.
  • Antiandrogens: Medications used to augment the effects of surgical or medical castration. These agents are provided as oral tablets and block the activity of testosterone in the body.

The most common side effects associated with androgen deprivation therapy include hot flashes, decreased libido, erectile dysfunction, and increased bone fracture risk. Additional, less specific effects include fatigue, increased risk of diabetes and heart attacks/strokes, weight gain, cholesterol increase, decreased muscle mass, anemia, and memory loss.

 

Secondary Hormonal Therapy

Secondary hormonal therapy is a different type of hormonal therapy, used in patients who experience a cancer relapse despite being on primary ADT. These medications may be given orally, injected, or infused. Patients who receive secondary hormonal therapy generally continue their primary ADT as well. Examples of secondary hormonal therapy include estrogens (diethylstilbestrol), ketoconazole, and androgen receptor signaling inhibitors (abiraterone acetate and enzalutamide).

Use of diethylstilbestrol (DES) is associated with cardiovascular complications, including blood clots and heart attack. Ketoconazole is associated with fatigue, abdominal pain, hepatotoxicity, and nausea; abiraterone may cause shortness of breath, low potassium, and edema; enzalutamide may cause muscle pain, diarrhea, and edema.


The goal of chemotherapy is to rid your body of cancer cells that have spread from the prostate to other locations. The medications used for prostate cancer chemotherapy are generally given as intravenous (IV) injections every 3 weeks. Generally, chemotherapy is advised when the cancer appears to have stopped responding to initial hormonal therapy. While you are receiving chemotherapy, you will continue to take ADT, as well as bone-targeted therapy if the cancer has spread to your bones.

It is important to note that the chemotherapy you might receive for prostate cancer is likely to be very different than the chemotherapies your friends and family members may have gotten for other cancers. In fact, while there are over 50 chemotherapy medications for cancer treatment, only 3 are used in prostate cancer patients. Thus, you will likely get the best information about possible side effects from your doctors and nurses.

Potential side effects of chemotherapy include anemia, neutropenia, fatigue, nausea/vomiting, diarrhea, and pain.


Genetic TestSipuleucel-T (Provenge®1) is a vaccine given to some patients with metastatic prostate cancer who have no or very minor symptoms. Administration of this vaccine involves a blood draw. Immune cells are extracted from the blood sample and trained to recognize a foreign protein frequently found on prostate cancer cells. About 2 days later, these cells are reinfused into your body where they will hopefully attack existing cancer cells.

The side effects of the prostate cancer vaccine is mostly limited to infusion reactions, which include chills, fatigue, back pain, nausea, joint aches, and headache. These effects are not long lasting but can often be prevented with careful monitoring during infusion.


Bone Targeted TherapyBone-targeted therapy, such as Xofigo®2 (radium 223 dichloride), is used to specifically treat prostate cancer that has spread to the bone. These medications are given as an infusion every 3-4 weeks, and may be given at the same time as ADT and chemotherapy. Bone-targeted therapy may be associated with fatigue, nausea, anemia, and pain.

 

Mens Health NetworkVisit Men’s Health Network’s Prostate Health Guide to learn more about your prostate cancer treatment options.

 

REFERENCES
1. Provenge® is a registered trademark of Dendreon Corporation.
2. Xofigo® is a registered trademark of Bayer.

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