Treatment Options

If it is determined that the disease is truly organ confined, the cancer is almost invariably curable. Non-organ confined is a much more serious situation, which is why early detection is critical to diagnosing and treating prostate cancer. While the goal of organ-confined treatment is cure, the goal of non-organ-confined disease is to convert a seriously life-threatening condition into a chronic non-fatal disease.

Prostate cancer is the only cancer where treatment is withheld because of quality of life issues. Urinary incontinence, the inability to control urination and cause leakage, and impotence in which erectile function is impaired or completely destroyed, are the two main quality of life issues which can postpone the decision to treat prostate cancer.

There are currently four methods of treatment a patient can consider for curative prostate cancer therapy which have roughly the same level of efficacy. Generally if the cancer is found to be intra-capsular (fibrous capsule surrounding the prostate), the overall cure rates are 91% in five years and 87% in a seven-year period. If the cancer is found to be extra-capsular at the time of treatment, the likelihood of cure is lower and may require other treatment modalities such radiation for patients that have had failed radical prostatectomy or androgenablation therapy. Some patients that fail radiation therapy may be candidates for salvage surgery, salvage HIFU, or salvage cryosurgery.

1) Radiation – Radiation is delivered by several possible methods. They can be divided into radioactive implant surgery referred to as high-dose or low-dose brachytherapy or external beam therapies including IMRT, IGRT, proton beam therapy and cyberknife therapy.

IMRT is an external beam radiation therapy which is delivered in tiny conformal doses to the prostate in 30 and 50 daily treatments. The net result is that the entire prostate is radiated in an extremely tolerable manner. A variation of IMRT is IGRT where continuous 2 and 3-dimensional imaging of the prostate is carried out during the course of each treatment to account for any movement of the prostate during the treatment session.

Cyberknife is a stereotactic radiosurgery whereby a computer program is used to determine the precise shape, size, and location of the tumor, and a robotic arm helps deliver highly concentrated beams of radiation.

Proton Beam therapy is where a beam of protons is used to radiate cancerous tissue.

Unfortunately there are no controlled studies that indicate the results of cyberknife and proton beam therapy are superior to IMRT or IGRT. External beam radiation has a low incidence of incontinence but patients become impotent as the radiation changes the nature of the targeted tissues. Impotence and a moderately high level of incontinence is extremely common after cryotherapy.

Brachytherapy is a form of radiation through the implantation of iodine 125 radioactive seeds or palladium 103 seeds, which are placed in the prostate using ultrasound guidance. They are placed in such a way that the entire prostate is treated by radiation emitted by the seeds. Eventually the radiation is completely expended and the seeds become inert.

High Dose Rate (HDR) Brachytherapy is a process whereby instead of placing a large number of uniform strength seeds that are inserted into the prostate permanently, HDR uses a single high-intensity radiation source on the end of a thin cable that is inserted temporarily.

These therapies show no advantage over IMRT or IGRT with respect to cancer cure, but have a decidedly greater complication rate due to radiation damage to the prostate and urethral structures.

2) Cryosurgery– The goal of cryotherapy is to eradicate prostate cancer by freezing the prostate gland. During this procedure needles are inserted into the prostate gland through the perineum, the area between the scrotum and anus. The needles deliver freezing gases to the cancerous cells thereby destroying them. One advantage of this therapy is that the ability to destroy the cancer is independent of the degree of malignancy of the tumor meaning that cryosurgery destroys any tissue that it freezes regardless of the nature of the cells. Cryosurgery is somewhat indiscriminant in its ability to control competence and sexual potency.

3) Radical Prostatectomy – the removal of the prostate through surgery.

With surgery, a radical prostatectomy can be done in 4 ways:

a) Open surgical procedure where an incision is made in the lower abdomen and the prostate is removed.

b) Perineal prostatectomy where an incision is made between the scrotum and rectum and the prostate is removed.

c) Laparoscopic prostatectomy in which several tiny incisions are made in the lower abdomen to allow the placement of a camera, light source and working instrument to remove the prostate.

d) Laparoscopic prostatectomy in which robotic arms are substituted for the hand controlled instruments of a laparoscopic prostatectomy and the surgeon work from a remote console to control the robotic arms.

The outcomes of above surgeries are dependant on the expertise and the technical ability of the operator. HIgh grade tumors or extend beyond the capsule fo the prostate are not likely to be curable by any of the techniques. The incidence of incompetence and impotency is significantly higher in surgically treated patients than by other means.

4) High Intensity Focsued Ultrasound (HIFU) is the ultrasonic ablation of the prostate. It consists of a single treatment which lasts several hours during which ultrasound energy is used to heat the prostatic tissue and thereby coagulate and destroy it. The ability to destroy the prostatic tissue is independant of the degree of malignancy of the tissue.

5) Active Surveilance is a process by which instead of immediately treating the cancer, the patient is closely monitored by periodic PSA levels and follow-up prostate biopsies. This form of management is limited to patients with small low-grade tumors who have great concerns about their quality of life. It is well known that most localized prostate cancer treatment has a negative impact on quality of life and therefore the patient is hesitant to proceed with curative localized therapy. It should be noted however that 80% of patients who enter an active surveillance program result in being treated with localized therapy within several years. It is also likely that a few patients will progress from localized disease to extra prostatic disease during this timeframe.

Of the above methods of treatment, only HIFU invariably preserves continence and potency. The reason for this is because HIFU excludes the sphincters that control continence and the nerves that control potency from the tissue destruction.

Click here to view our Decision Tree that can provide help with guidance toward choosing the right path of treatment that may help in the cure of your prostate cancer.