Prostate cancer is the growth of abnormal cells in the prostate. Cancer cells slowly progress to become a mass called a tumor. Tumors can metastasize, meaning spread beyond the prostate, which is a sign of advanced disease. Metastatic tumors may eventually be fatal.
The goal of prostate cancer therapies is to cure the cancer or to manage the symptoms of the disease.
Physicians may recommend not actively treating slow-growing cancers to avoid the risks and side effects of treatment. This approach is called watchful waiting.
The active treatments for prostate cancer include:
- Surgery;
- Cryotherapy;
- Radiation therapy;
- Hormone therapy; and
- Chemotherapy.
It is possible to cure prostate cancer. The likelihood of a cure depends on the grade and stage of cancer and a man’s pretreatment level of prostate specific antigen (PSA).
WHEN IS IT INDICATED?
Physicians must know the grade and stage of cancer before selecting treatment. Grade refers to how much of the cancerous prostate tissue resembles normal prostate tissue. The process of determining where the prostate cancer is and how far it has spread is called staging.
PRE-TREATMENT GUIDELINES
Surgery
To establish whether a patient’s cancer is localized, a surgeon will remove the pelvic lymph nodes. Lymph node removal requires hospitalization.
The patient is instructed not to eat anything after midnight the night before prostatectomy surgery. On the day before the surgery, the patient is instructed to self-administer a special medical enema. The patient may also be instructed to stop taking aspirin and any other anticoagulants.
WHAT TO EXPECT
Surgery
The physician and the patient usually choose surgery when the patient is in good health, younger than 65 years, and the cancer has not spread.
Radical prostatectomy. Radical prostatectomy is the removal of the prostate and is intended for patients whose cancer is confined to the prostate. Radical prostatectomy offers the best chance for a cure. The surgery is performed while the patient is either under general or spinal anesthesia. A surgeon removes the entire prostate, the seminal vesicles, and the nerves that help the penis become erect.
The procedure takes between 3 and 4 hours and requires a 2- to 3-day hospital stay.
Nerve-sparing radical prostatectomy. Nerve-sparing prostatectomy is similar to radical prostatectomy except that the physician spares the nerves that cause a man to have an erection if the nerves are cancer free. Nerve-sparing prostatectomy is limited to men in the early stages of prostate cancer.
Robot-assisted laparoscopic prostatectomy. Robot-assisted laparoscopic prostatectomy (RLP) removes the prostate and seminal vesicles. The robotic surgical system includes a tiny, lighted telescope, mini camera, and highly maneuverable “hand.” The incisions necessary to insert the camera and hands are smaller than those in traditional RP.
To perform the procedure, a surgeon sits at a console near the patient and looks at a screen that displays the patient’s pelvis, including the prostate. The surgeon uses hand devices on the console to move the robotic fingers that hold the surgical instruments and perform the surgery.
Surgeons who have training and experience with RLP can perform the procedure in approximately 3 to 7 hours. Patients usually can leave the hospital in 1 to 2 days.
Cryosurgery. This type of surgery treats localized cancer by freezing cancer cells until they die. After the patient receives spinal or general anesthesia, the surgeon inserts between 6 and 8 long, thin metal probes through the skin between the anus and scrotum and guides them to the cancerous prostate tissue. Once activated, the probes send a freezing agent to destroy the cancerous tissue.
Non-surgical treatments
Radiation therapy. Radiation may be recommended as a separate treatment or in conjunction with surgery.
Radiation, or high-energy x rays used to kill cancer cells, can either be internal or external, meaning the radiation source is positioned outside of the body or is implanted into the cancerous prostate area.
Patients must be treated with external radiation at least 5 days per week for 7 to 8 weeks.
Brachytherapy is a type of internal radiation, or the implantation of small radioactive pellets into the prostate. Like cryosurgery, brachytherapy uses probes that insert into the skin between the anus and the scrotum to deliver the radioactive pellets. Another form of brachytherapy uses hollow needles that contain iridium, a radioactive source.
Often brachytherapy is combined with external beam radiation to intensify treatment.
Hormone therapy. When cancer has spread outside of the prostate, hormone therapy may be recommended. Sometimes it is used in addition to surgery or radiation.
The goal of hormone therapy is to reduce the production of androgens. Androgens are the hormones that help develop and maintain the sexual characteristics that form after puberty. It is believed that the androgens, one of which is testosterone, help prostate cancer cells to grow.
Orchiectomy, the surgery to remove the testicles, is considered hormone therapy because it dramatically reduces the production of androgens. The procedure takes from 30 minutes to 1 hour with the patient under general anesthesia.
The following drugs can reduce androgen levels without the need of an orchiectomy:
- Luteinizing hormone-releasing hormone (LHRH) analogs;
- Implant medications, such as leuprolide (Viadur); and
- Anti-androgens.
Medications don’t cure prostate cancer but temporarily slow the growth of cancer cells. Some patients will undergo hormone therapy for 2 to 3 years; others may remain on hormone therapy for the rest of their lives.
Chemotherapy. When hormone therapy isn’t working and prostate cancer has spread beyond the prostate, chemotherapy may be recommended. It is not recommended for early stage prostate cancer.
During chemotherapy, anticancer drugs are injected or taken by mouth so that they circulate through the bloodstream and destroy cancers that have spread throughout the body. Chemotherapy usually does not kill all cancer cells but does slow cancer growth and reduce pain.
POST-PROCEDURE GUIDELINES
All therapies require follow-up PSA tests.
Surgery
Following surgery, the physician will instruct the patient on how to take care of the incisions and change the dressing.
Radical or nerve-sparing prostatectomy. Following surgery, a flexible tube to drain urine from the bladder is implanted into the patient’s urethra for approximately 7 to 14 days. Showers are not permitted for 2 to 3 days after the surgery.
Many men feel weak and tired for weeks after surgery. Within 1 month, patients can resume normal activities.
Men who undergo prostatectomies no longer produce semen and have dry orgasm, meaning they cannot ejaculate. If a man wants to father children, he must consider having some of his sperm retrieved, frozen, and stored before undergoing a prostatectomy.
Robot-assisted laparoscopic prostatectomy. After an RLP, the Foley catheter is removed after 5 days. Most men who have had an RLP resume their normal activities 7 to 10 days after surgery.
Radiation therapy. The physician will schedule the patient for a follow-up visit at 4 to 6 weeks after the end of therapy.
POSSIBLE SIDE EFFECTS AND COMPLICATIONS
Surgery
Radical prostatectomy. Impotence still occurs in about 30 percent of men, and it takes up to 2 years for function to return.
Robot-assisted laparoscopic prostatectomy. Patients usually have less pain and recover faster than those who undergo a traditional prostatectomy. In addition, the risk of postoperative incontinence and erectile dysfunction is low.
Cryosurgery. The major side effect of cryosurgery is impotence.
Non-surgical techniques
Radiation therapy. Side effects from external radiation exposure include:
- Temporary bowel problems;
- Frequent urination;
- Impotence in 20 to 40 percent of men; and
- Prolonged periods of difficulty emptying the bladder
Hormone therapy. Side effects may include:
- Hot flashes;
- Loss of libido and sexual function;
- Enlargement of breast tissue; and
- Appetite stimulation and consequent weight gain.
Chemotherapy. Because chemotherapy can kill many healthy cells, it can cause a variety of side effects, including:
- Fatigue;
- Nausea and vomiting;
- Loss of appetite;
- Loss of hair;
- Mouth sores; and
- Susceptibility to infection and to bruising or bleeding after minor cuts or injuries.
LIFESTYLE ADJUSTMENT
Prostate cancer patients should seek emotional support from family, friends, and community services before, during, and after treatment. In addition, patients need to take optimal care of their bodies by exercising, getting plenty of rest, quitting smoking, limiting alcohol consumption to 1 to 2 drinks per day, and eating nutritious meals.
Some researchers feel that diet may help to prevent prostate cancer. Antioxidants and other natural compounds in food have shown anti-tumor properties in scientific studies. Foods that are high in these substances include:
- Tomatoes (because of an element called lycopene);
- Broccoli;
- Oranges;
- Garlic;
- Onions;
- Red wine and red grapes; and
- The spice turmeric.
Soy protein has also been associated with reduced risk for prostate cancer.
