Prostate Cancer: Treatment Options Explained

Hearing the words "You've got cancer" is never easy. When you're a man, and the diagnosis is prostate cancer, anxiety can run even higher.

One reason is that for many years treatment included serious side effects, including incontinence and impotency.

"In addition to fearing for their life because of the cancer, many men also feared the treatment process, and more specifically, the side effects," says Herbert Lepor, MD, chairman of urology and professor at the NYU School of Medicine in New York City.

While side effects of treatment still exist, experts say the risks of having them are far lower today than ever before. What's more, with many new twists on some of the traditional treatments, doctors say the cure rate is also better than ever.

At the same time, choosing a treatment isn't always easy. Although there are guidelines doctors follow, most experts say decisions are made on a case-by-case basis, with no two men having the same exact needs.

"There are so many factors that go into selecting the right treatment -- a man's age, his biopsy and other exam results, his general state of health, his emotional state of mind -- there are many variables that must be considered in order to find the right treatment for each patient," says Lepor.

There are also some general guidelines -- and some important information -- about each of the treatment options.

To help take you through the maze, four top prostate cancer experts have helped WebMD prepare the following guide. But they caution that it's important to discuss all your options with your personal doctor before making any treatment decisions.

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Prostate Cancer Option 1: Expectant Management

Some also call it "watchful waiting" or the "wait and see" approach. But the bottom line on expectant management is that no active treatment is given. Instead, the cancer's progress is closely monitored.

And while that may seem like a radical way of approaching cancer treatment, experts say that for many men it's the right choice, especially those who are older and have numerous other health problems.

"Because prostate cancer is frequently slow-growing and often nonaggressive, men who are diagnosed in their 60s, 70s, or 80s will likely succumb to other illnesses before the prostate cancer becomes an imminent threat. So in this respect treatment isn't always necessary," says Simon Hall, MD, chairman of the department of urology at Mt. Sinai Medical Center in New York City.

Indeed, Hall says he suspects many men actually don't need treatment for prostate cancer and that some are likely being overtreated for a disease that is not likely to kill them.

Moreover, in a study published in the journal Prostate Cancer and Prostatic Diseases, experts from the Brady Urological Institute of The Johns Hopkins School of Medicine report that although prostate cancer may be present in about one in three men over the age of 50, only one in six will see their condition worsen to the point of significant disease. Moreover, the lifetime risk of dying from prostate cancer is less than 4%.

However, a study published recently in The Journal of the American Medical Association reported that when questioning urologists and doctors who specialized in radiation treatment, none was particularly supportive of expectant management. The exception to this was in a small subgroup of men with life expectancies less than 10 years and very favorable, nonaggressive cancer.

So how do you know if expectant management is for you? In addition to considering age and general health status, the American Cancer Society says also consider your Gleason score, which is based on the biopsy of cancerous cells. The higher the score, the more likely that the cancer will quickly grow and spread. Also important: The size of your tumor and whether or not the cancer has spread outside your prostate gland.

Hall says a patient's state of mind also matters. "We know from limited data that about one-third of men who choose expectant management will drop out not because of disease progression, but because psychologically they can't deal with doing nothing about it," says Hall.

If you choose expectant management you will likely receive PSA tests and digital rectal exams every six months and sometimes additional biopsies. If symptoms develop, or the cancer becomes more aggressive, other treatment options remain.

Who should not opt for expectant management? Hall says any man in his 50s or younger, older men in exceedingly good health, any man experiencing symptoms (including back and leg pain), or those with an extremely aggressive cancer.

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Prostate Cancer Option 2: Radiation

In the event that treatment becomes necessary, a popular option is radiation therapy, a method of using high-energy rays to kill cancer cells or to shrink the size of the tumor. It is said to work equally well for prostate cancer that has not spread outside of the gland or has only spread to nearby tissue. Experts say almost any man with prostate cancer can benefit from radiation.

"Essentially the same men who would be candidates for a prostate surgery are also candidates for radiation therapy," says Paul Barrett, MD, director of radiation oncology at the University of Cincinnati.

There are two types available:

External beam radiation. This is similar to an X-ray, but with a longer exposure. Barrett says this noninvasive treatment uses radiation from an external source directed to the prostate gland. However, side effects can occur and include diarrhea, rectal leakage, and impotence.

One advance is called "3D conformal radiation therapy" (3DCRT), which uses computers to map the location of the prostate and may result in more precise treatment. Even newer is “intensity modulated radiation therapy (IMRT). Here radiation is focused from many directions using a moving source, with the capability of adjusting both the strength and the intensity of the beam.

In all instances, Barrett tells WebMD, “The normal course of treatment takes about seven-and-a-half weeks, with five treatments per week, approximately 15 minutes each."

Radiation seed implant therapy. Also known as brachytherapy, in this treatment, surgeons permanently implant tiny radioactive seeds into the prostate gland. These seeds deliver high-dose radiation directly to the prostate for a predetermined length of time. The implantation procedure takes about one hour, and Barrett says the patient frequently goes home the same day.

In a second approach, needles are used to temporarily place seeds within the prostate, releasing higher doses of radiation. This treatment takes several days, during which time needles are frequently left in the prostate overnight.

"Since both the external beam and the seed radiation yield similar results -- and occasionally they are used together -- for most men the choice boils down to convenience: Do you want an invasive treatment that is done in about an hour, or a noninvasive treatment that takes seven weeks," says Barrett.

He also says both forms of radiation can cause urinary tract and rectal irritation, as well as diarrhea and tiredness, usually starting in the fourth week. In most instances, he says, problems wear off within a few weeks after treatment is completed.

While studies show both approaches are comparable to surgery in terms of cure rates, you may be surprised to learn that so is the risk of side effects, including urinary incontinence and impotence.

There is a misconception that radiation does not cause impotence, but that's not true. Potency may be at 100 percent following surgery, but as time goes on, that can worsen, and impotence can set in," says Reva Ghavamian, MD director of urological oncology at Montefiore Medical Center in New York City.

Conversely, he says, if you do experience impotence following surgery, the impact is immediate but, “as time goes by, 18 to 24 months, there might be recovery," he says.

In the end, Barrett says both surgery and radiation "pretty much equal out in terms of how many men are affected by either incontinence or impotence." That said, he also reports that the older you are when treatment is rendered, the more likely you are to experience these problems.

The good news: Barrett says medications such as Viagra or Levitra can frequently help with impotence. Prostate Cancer Option 3: Radical Prostatectomy

For those men who won't feel comfortable unless they know their diseased tissue is gone, a procedure called a radical prostatectomy can help. Here, the entire prostate gland and sometimes the lymph nodes and nearby tissue are removed, with hopes of leaving the patient cancer-free. Radical prostatectomy is an option when prostate cancer is has not spread beyond the prostate gland.

Some doctors believe this is always the better approach, particularly for men under age 50.

"In my opinion, surgery is the more definitive way to cure this disease, and if you are very young, it is always the better choice, simply because we don't have any really solid long-term data on radiation therapy in younger men," says Lepor, a prostate surgeon.

Lepor tells WebMD older men can also be good candidates if they are in otherwise good health.

And while Lepor says radiation oncologists argue that surgery has a higher risk of complications, he believes that in the hands of skilled and experienced surgeons, the cure rates are equal, or "even better for surgery," he says.

Ghavamian, also a surgeon, agrees and adds, "Once you remove the prostate you can examine it, so both doctor and patient will have a precise Gleason score as well as full knowledge of the extent of the cancer, and that can help better predict recurrence and judge the need for additional therapy. And you won't get that with radiation," he says.

Once you've decided on surgery, there are a few approaches from which to choose.

Radical retropubic prostatectomy (open prostatectomy). This is the traditional operation that removes the prostate through a major incision in the lower abdomen.

Radical perineal prostatectomy. In this procedure, the prostate is removed through an incision that is made in an area between the scrotum and the anus.

Laparoscopic prostatectomy. Here the doctor removes the prostate through several small incisions using specialized surgical instruments.

Nerve-sparing radical prostatectomy. This procedure is similar to the radical perineal prostatectomy, but nerves that control erections are not removed.

Robotic laparoscopic prostatectomy. The newest approach, this technique calls for up to five tiny incisions through which doctors insert a tiny camera and specialized surgical instruments including computerized arms of a surgical robot. The doctor controls the robotic arms and instruments via a 3-D computer screen, offering a field of vision that some say is so pristine, it allows for surgical maneuvers that are simply not possible in another venue.

Ghavamian says this in turn may help preserve nerve function related to incontinence and sexual function.

He also says that when compared with open surgery, "The robotic approach causes far less blood loss and allows a faster recovery."

In at least one large study, published in the British Journal of Urology International, doctors found the robotic procedure generally was safer, less bloody, and required shorter hospitalization than open surgery.

The study also found that following robotic surgery, the average return of erections occurred in 180 days compared with 440 days for open surgery.

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Hormonal Therapies and Chemotherapy

Still another approach to controlling the growth of prostate cancer is the use of hormones designed to reduce levels of the male sex hormone testosterone or block its effect. How can this help?

"Under normal circumstances, testosterone is what stimulates prostate cancer to grow, so one form of hormone therapy stops production, while another blocks it from reaching prostate cells," says Barrett.

While on its own hormone therapy won't cure prostate cancer, it can slow the growth in men looking to put off surgery or radiation therapy. It is also frequently used to shrink tumors, which in turn helps make other treatments more effective. Occasionally it is also used as a follow-up treatment, or if cancer recurs.

Testosterone production can be stopped surgically by removal of the testicles. Drugs that hinder testosterone production include Lupron, Viadur, Eligard, Zoladex, and Trelstar. Drugs that block the body from using testosterone include Eulexin, Casodex, and Nilandron. A relatively new treatment known as Plenaxis is also available for men who don't respond to other forms of hormone therapy, though it does have up to 5 percent risk of allergic reaction.

In hormonal treatments, side effects can include hot flashes, breast tenderness, growth of breast tissue, osteoporosis, anemia, weight gain, fatigue, decrease in good HDL cholesterol, and depression.

For advanced cancer or in the event that hormonal therapy is not effective or stops working, chemotherapy drugs may be used.

According to the American Cancer Society, the chemotherapy drug Taxotere has been reported to extend the life of men with advanced prostate cancer, and together with prednisone it has been approved by the FDA for this use. Additionally, the chemotherapy drug mitoxantrone, used in combination with prednisone, has also been FDA-approved for prostate cancer.

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Published Feb. 27, 2006. SOURCES: Hebert Lepor, MD, chairman of urology, and professor, NYU Medical Center, New York. Simon Hall, MD, chairman, department of urology, Mt. Sinai Medical Center, New York. Paul Barrett, MD, director, Radiation Oncology, University of Cincinnati. Reva Ghavamian, MD, director, urological oncology, Montefiore Medical Center, New York. Khan, M., Prostate Cancer and Prostatic Diseases, December 2005; vol 8: pp 311–315. Fowler, F. The Journal of the American Medical Association, June 28, 2000; vol 283: pp 3217-3222. American Cancer Society. Tewari, A., British Journal of Urology International, 2003; vol 92: pp 205-210.