Treatment Options for Localized Prostate Cancer

Prostate cancer is the most common cancer in men and its treatment remains controversial. The good news is that the mortality from prostate cancer has decreased significantly in the past several years- presumably the result of early detection with PSA and effective treatment. Selection of the best treatment for an individual patient depends on many factors and is best done in direct consultation with your urologist. Here is a brief description of the treatments and the factors that play a role in selection of the best approach for individuals.

Watchful Waiting: There is concern that many patients diagnosed with prostate cancer may be over- treated. It is correctly said that many, many more patients die with prostate cancer than from prostate cancer. Watchful waiting is not the same as ignoring the diagnosis- patients are monitored on a regular basis with PSA so active treatment can be initiated if the cancer, which often lays dormant, becomes active. Optimal candidates for watchful waiting are those with small volume (focal disease on only one or two biopsy cores), low grade- Gleason 6 or less disease with a low, relatively stable PSA and a life expectancy of 10 years or less. The advantage of watchful waiting is the avoidance of the cost and side effects of treatment. The main disadvantage is the risk that the disease may progress or spread without treatment.

Brachytherapy (Prostate Seeds): Radioactive seeds can be placed in the prostate to destroy the cancer. In properly selected patients brachytherapy controls prostate cancer as well as the gold standard, surgical removal of the prostate (Radical Retropubic Prostatectomy or RRP), at least for 10 years. The advantage of brachytherapy is that it can be done as an outpatient, day procedure. Radiation kills prostate cancer cells (and normal cells) at the time of cell division, so immediate side effects are minimal. Continence and potency are generally not compromised, at least for the first two years, and bowel side effects are uncommon. The procedure is done under anesthesia with an ultrasound probe inserted in the rectum and Xray imaging to visualize the prostate. Using a template (grid) and ultrasound guidance radioactive iodine or palladium seeds are placed through needles inserted into the gland through the perineum (between the anus and scrotum). Some swelling of the prostate occurs, so a catheter may be needed for a time after the procedure. Optimal candidates for brachytherapy are men with low grade, Gleason 6 or less disease who have no difficulty voiding (prostate obstruction). Brachytherapy is particularly useful for men who have a life expectancy of 15 years or less or those who are not candidates for radical prostatectomy. It is relatively less effective for high grade disease, and is not recommended for those who may eventually require treatment for prostatic obstruction. Disadvantage: Radiation causes fibrosis (scaring) and markedly decreases blood supply, which makes surgery difficult and compromises healing. Incontinence and other complications are very common if surgery is required after radiation.

External Radiation (EBRT or IMRT -Intensity Modulated Radiation Therapy and Proton Beam Radiation Therapy): Gamma and proton beam irradiation are considered together because they both use particles to disrupt cellular DNA and kill cells. Standard external radiation, now improved by better regulating the beam to target the prostate and spare normal tissue using "intensity modulation" has been around longer and is therefore more established. The superiority of proton beam radiation has not been demonstrated. The advantage of EBRT is that it requires no hospitalization and can treat disease that has extended outside the capsule of the prostate. There is even some evidence that it may be helpful when cancer has spread to lymph nodes. EBRT can be combined with brachytherapy if needed, and, unlike surgery, is improved with the addition of hormone therapy when spread outside the gland is expected. The procedure often involves placement of gold seeds in the prostate to mark it's location. Treatments are generally given 5 days a week for 6 to 8 weeks and take less than an hour. Other than some fatigue, most patients have few side effects during treatment, but bleeding from the rectum and bladder, associated with pain and frequency can occur. Optimal Candidates for external radiation (EBRT, IMRT or proton irradiation) are men who have a life expectancy of 10 years or less, have medical conditions that make surgery dangerous, or have disease outside the capsule of the prostate. The advantage of external radiation is the avoidance of surgery, treatment of disease outside of the gland, and minimal short-term side effects. The disadvantage is the protracted treatment course and significant risk of late complications. Like brachytherapy, EBRT causes scarring and decreases blood supply. Late complications such as bladder bleeding and even bladder cancer occur with increased frequency.

Cryotherapy: Cryotherapy or cryoablation of the prostate is becoming an increasingly popular alternative to radiation therapy. Like brachytherapy (prostate seeds), cryotherapy is a "day procedure." Prostate cancer cells are killed by breaking the cell by twice freezing and thawing. Under anesthesia an ultrasound probe is placed in the rectum to image the prostate. Using a template or grid, fine needles are placed in gland and using argon and helium gas the gland is frozen and then thawed two times. Temperature probes are placed to monitor the freezing and protect vital structures- the rectum and bladder sphincter. With the rectal ultrasound the "ice ball" in the prostate is continuously observed as well to avoid injury. The urethra passes through the prostate and is protected from freezing by placing a special catheter that circulates warm water during the procedure. While listed as an "experimental" procedure in many out of date publications, cryotherapy is fully approved by the FDA and Medicare and long term (10 year) studies confirm that survival and freedom from failure are as good if not better than radiation. The advantage of cryotherapy is that it is effective against high as well as low grade prostate cancer, and effectively treats prostate obstruction from benign hypertrophy as well as prostate cancer. Optimal candidates for cryotherapy are men with prostate cancer confined to the gland who are not candidates for prostatectomy and either have pre-existing erectile dysfunction (ED) or have disease only on one side so the opposite neurovascular bundle can be spared. The main disadvantage of cryotherapy is the high risk of damage to the nerves that control erection and run on either side of the prostate.

For more information you can visit Galil Medical
Patient Brochure: Patient Brochure PDF

HIFU (High Intensity Focused Ultrasound): HIFU, like external beam radiation therapy (EBRT), uses external energy that passes through the skin, is focused on the prostate, and kills the cells. Unlike EBRT, which requires daily treatments for a month and a half, HIFU is a day procedure. Under anesthesia an ultrasound probe, similar to the one you had to guide your biopsy, is inserted into the rectum. The prostate is carefully imaged and measured. With a computer controlled robotic arm guided by the surgeon the prostate is destroyed by focusing intense acoustic waves repetitively on small portions of the gland. These focused sound waves work like a scalpel to remove the prostate; heat generated by the waves destroy the gland. These effects can be observed by the surgeon during the procedure as vaporization bubbles in the gland. While this is a surgical procedure that requires special training, it is done like by waves passed through the body, without an incision. It is analogous to shock wave lithotripsy (ESWL) used to break up kidney stones. ESWL revolutionized the treatment of stone disease; HIFU has the potential of doing the same for cancer treatment. Optimal candidates for HIFU are currently those with low to intermediate grade (Gleason 7 or less) prostate cancer confined to a gland that is not greatly enlarged (less than 50 cc in size) who are not candidates for or decline open or robotic surgery and, if they live in the US, are willing/able to travel to another country. The advantage of HIFU is that it is a non-invasive outpatient procedure that destroys the prostate with little risk of erectile dysfunction (ED) or incontinence. From my experience it is clearly the best tolerated procedure: patients walk out of the hospital feeling well. Narcotic pain medicine (codeine) is not required. The main disadvantages of HIFU are the lack of 15 year follow up (though PSA and biopsy results are good), the lack of FDA approval for non-study use in the US, and the need for a supra pubic catheter (a tube inserted directly into the bladder through the lower abdominal wall) for 3 to 4 weeks after the procedure. Like ESWL for stones, where the sand and gravel from the stone must be passed in the urine, with HIFU the destroyed prostate must be passed in the urine. The suprapubic tube provides a safety valve if the urethra becomes clogged with debris.

The Sonablate® 500 is a minimally invasive medical device developed by Focus Surgery, Inc. (Indianapolis, IN), that uses HIFU to treat prostate cancer and benign prostatic hyperplasia (BPH). The Sonablate® 500 may be an appropriate treatment for the thousands of men who will be diagnosed with the disease. More information is available in the Sonablate® 500 Brochure PDF.

For more information on Sonablate® 500 you can also visit International HIFU

Radical Prostatectomy (Open): Radical prostatectomy is the gold standard treatment- the treatment by which all others must be compared. Major progress in the surgery has been made over the decades. The procedure generally involves a small, 5 inch vertical incision above the pubic bone at the base of the penis. The muscles are separated rather than cut, and the abdominal cavity (peritoneum) is not opened, so bowel complications are rare. Lymph nodes, the first site of spread of the disease, are removed and biopsied. If tumor does not invade the area of the neurovascular bundles, nerves that control erection can be preserved. The entire prostate is removed and the bladder neck sewn to the urethra. It is rare that patients now require blood transfusion, and many are ready to go home with an indwelling urethral catheter on the second postoperative day.

No treatment has provided cure rates that are superior to radical prostatectomy. Removal of the disease is a sure cure if the cancer is confined to the prostate, and pathologic examination of the specimen provides important prognostic information. If the disease is confined to the prostate survival is equal to that of men of the same age who do not have cancer. Optimal candidates for radical prostatectomy are healthy men who have a life expectancy of 15 or more years. The advantages of prostatectomy include, in addition to an excellent chance of cure, the ability to know the risk of recurrence based on the pathologic examination of the prostate as well as the follow up PSA. Unlike treatments that leave the prostate in place, PSA after prostatectomy should be zero (or 0.2 or less, which is the lower limit of accuracy of many labs). A rise confirmed above 0.2 permits early treatment of recurrent or residual disease. Radiation therapy can used as salvage if disease recurs in the bed of the prostate. In contrast, surgery is generally not a good option if disease recurs after radiation because of the high risk of complications related to the scarring and poor blood supply after radiation. The disadvantages of prostatectomy include the risks of surgery, including urinary incontinence, which generally resolves with Kegel's exercises, erectile dysfunction, which generally improves if the nerves are spared.

Robotic Radical Prostatectomy: The daVinci robotic prostatectomy appears to offer all of the advantages of radical prostatectomy with significantly less pain, less blood loss and a quicker return to full activity. The procedure involves a very small incision (less inch) near the belly button and similar or even smaller incisions on either side of the abdomen that allow insertion of small instruments including robot arms that are controlled by the surgeon. The vision is superior to that of open surgery, and the tiny robot arms allow the surgeon to do delicate manipulations that are very difficult to perform with standard open surgery. Optimal candidates for robotic prostatectomy are the same as those for open prostatectomy above. The advantages of robotic prostatectomy include shortened (1 day) hospital stay, less blood loss and pain, and, depending on the surgeon's skill, quicker return of full continence and potency.

Created: 12/29/2007