With around 37,000 men in the UK diagnosed with prostate cancer each year, it is the most commonly occurring male cancer. For some, the cancer may be slow-growing and particularly for the elderly, not life-threatening. Nonetheless for others, it may only be picked up at a stage when curative treatment is not possible. Around 10,000 men die from the disease each year.
For those diagnosed with early stage prostate cancer, there are more treatment options than any other type of cancer. Indeed, many find the range of choice bewildering and difficult. Unlike, for example, breast cancer, where treatment is to a large extent mapped out according to clinical need, with prostate cancer, there is a much greater degree of personal choice.
About one third of patients opt for surgical treatment for prostate cancer, called a prostatectomy. This involves removing the prostate and may be carried out as open, laparoscopic (keyhole) or robot-assisted surgery. Men who choose this option normally do so because they want the cancerous prostate to be removed and surgery provides a high degree of assurance. Levels of PSA (prostate specific antigen) are measured after surgery and if at three months, PSA levels are 0.01ng, the operation is considered to have been curative. If there are any signs of residual cancer cells, having surgery leaves open the option of then having radiotherapy, although the same is not true vice versa.
Traditionally, the main disadvantage to a prostatectomy is the widely occurring complications of erectile dysfunction and incontinence. Nerve bundles which control erections and continence lie very close to the prostate and the standard prostatectomy involves using wide margins and causes irreparable damage to these nerves. Ten to twenty years ago, almost all men undergoing a prostatectomy would have been left with long term impotence.
Specialist prostate surgeons have developed a procedure called the nerve-sparing prostatectomy. It requires a high level of skill to ensure all cancer cells are safely cleared while also carefully dissecting the nerve bundles and minimising damage. If this is an option which you are interested in, you should ask your surgeon how many procedures he or she has carried out and request the results of these procedures, so you can understand exactly what to expect.
Another large group of patients opt for different forms of radiotherapy. There are three different approaches €” external beam radiation delivered by a machine called a linear accelerator (LINAC), conformal radiotherapy, sometimes referred to as Intensity Modulated Radiotherapy IMRT and brachytherapy, when radioactive seeds are inserted directly into the prostate.
Radiotherapy is generally used for localised prostate cancer, the term used when the cancer cells are confined to the prostate. It may also be used for what is called locally advanced prostate cancer, when cancer cells have started to breach the boundary of the prostate but have not yet spread into the lymph nodes. Radiotherapy is also used in palliative care for men whose prostate cancer has spread to the bones (metastatic cancer). Sadly for this group, curative treatment is no longer possible but radiotherapy can help improve survival time and pain control. There are side-effects with radiotherapy, ranging from short term symptoms during treatment of irritation and longer term problems such as incontinence and erectile dysfunction. The new technology has much reduced the overall risk of long term complications however.
There are two other types of treatments which are both offered in established NHS services but are not yet as established as the other approaches in terms of their overall effectiveness and long term results. HIFU uses a beam of high intensity sound waves (a form of ultrasound) to destroy the cancer cells in the prostate. Cryotherapy applies the same principle of destroying cancer cells with the opposite extreme, using cold and freezing cancer cells, rather than heating them up. The advantages to both types of treatment for prostate cancer are fairly minimal side-effects but there is still debate over their overall effectiveness and there is a lack of large scale long term results.
Finally, many men opt for what is referred to as €watchful waiting’ or €active monitoring’. This may be appropriate if the cancer is confined within the prostate and judged to be slow-growing. Your urologist will carry out tests called staging and grading in order to make this judgement. If you choose this option, you will need to have your PSA test repeated at regular interviews to keep a close eye on how the cancer is behaving over time. This may be combined with a new test called the PCA3 and MRI prostate mapping. There may be the need to have a prostate biopsy. For many men, active surveillance can be a very good option, particularly if they are elderly and it is likely that a slow-growing prostate cancer will not develop during their lifetime sufficiently to spread and cause any significant problems for overall well being.