Which treatment is best?

Deciding which prostate cancer treatment option is best can be very confusing. There are a number of options available. It is a huge shock to receive a prostate cancer diagnosis, but it is important not to rush into a treatment decision. Your doctor can talk you through your options and give you advice on which treatments are best for you depending on your particular situation so you can make an informed decision.

There are several important factors that should be taken into consideration when deciding on a prostate cancer treatment program. The main factors include the form of prostate cancer, the individual characteristics of a man’s prostate, life priorities and the expertise of a urologist.

Prostate cancer differs from other cancers because its behaviour can range from slow growing to aggressive. You and your urologist will determine the risk group (type of cancer) of your case using 3 tests: your PSA, Gleason score (this is what the cancer looked like under the microscope) and how the prostate gland felt when examined.

There are 3 risk groups involved. The following table highlights the characteristics of each risk group:

Low risk Intermediate Risk High Risk
PSA < 10ng/ml PSA 10-20ng/ml PSA > 20ng/ml
Gleason < 7 Gleason 7 Gleason 8-10
Clinical Stage < T2b Clinical Stage T2b/2c Clinical Stage T3

Determining which risk group the diagnosis falls into will serve as a rough guide to which treatments are possible and most appropriate. From here it is up to the patient, with guidance from a health care specialist, to decide which treatment option is most suitable for them.

1. Active surveillance

Men diagnosed with low risk prostate cancer in its early stages may be able to have the disease safely monitored through regular testing. In this case your doctor will perform a series of blood tests to measure PSA and periodic prostate biopsies to check for any changes.

Advantages

  • Avoids immediate potential for treatment related complications.
  • Defers treatment until necessary (i.e. if changes are detected).

Disadvantages

  • Regular review, blood tests and prostate biopsies.
  • Potential anxiety as a result of living with prostate cancer.
  • Although some surgical literature presents evidence that this approach is safe in some cases, there is no guarantee that the prostate cancer will still be curable when definitive treatment is undertaken.

2. Surgery (Radical Prostatectomy)

Surgery for prostate cancer involves the complete removal of the prostate gland and is called radical prostatectomy (RP). This operation can be performed various ways, including open, perineal,laparoscopically (LRP), radical retropubic prostatectomy or robotically. The cure rate for localised prostate cancer using this treatment varies with risk group but is generally around 95%.

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In open RP the surgeon makes an incision in either the lower belly or the perineum between the anus and the scrotum. The former is called the retropubic approach while the latter is called the perineal approach. Open RP is the traditional surgical approach to prostate removal and has a proven track record.

Advantages

  • Proven track record.

Disadvantages

  • Incision size
  • Longer hospital admission
  • Increased post-operative pain
  • Longer recovery period
  • Higher risk of complication compared to keyhole prostate cancer treatments (e.g. leaks and scar tissue)

3. Laparoscopic and Robotic Prostatectomy

Laparoscopic surgery involves several small incisions made in the belly of the patient by a surgeon. A viewing instrument called a laparoscope is then inserted through one of the incisions and the surgeon uses special instruments to remove the prostate through the other incisions.

Robotic-assisted laparoscopic radical prostatectomy (RALRP) is a surgical method where surgery is done through small incisions in the belly by using robotic arms. Thin tubes are inserted into the small incisions and the specialised instruments are placed through these tubes. The surgeon sits at a console adjacent to the operating table and controls the robotic arms. The robotic arms allow the surgeon’s hand motions to be much finer and precise when operating.

This type of surgery is suitable for men who have a low or intermediate and high risk disease and have a life expectancy of at least 10 years.

Advantages

  • Improved magnification
  • Less blood loss
  • Quicker recovery period
  • Shorter hospital admission
  • Reduced convalescence

Disadvantages

  • The RALRP procedure requires doctors with specialist training.
  • The RALRP equipment is very expensive and is not widely available in Australia yet.

Side effects from surgical treatments
Unfortunately men will experience side effects with all prostate cancer treatments. The main functional side effects men experience after surgery include urinary incontinence and erectile dysfunction (ED).

4. Radiotherapy

Radiotherapy, also known as radiation therapy, can be delivered using a number of methods. It can be given as an external source (EBRT), an internal source (LDR) or a combination of both internal and external radiation which is called high dose rate therapy (HDR). The suitability of these varying forms of radiotherapy depends on the stage and risk level of a man’s prostate cancer.

Low Dose Radiotherapy
Low dose radiotherapy (LDR) involves the insertion of radioactive seeds into the prostate. This treatment is used for men who have a low risk cancer, a small prostate, minimal symptoms and a life expectancy of at least 10 years.

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1. Placement of seeds during LDR Brachytherapy

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2. CT scan confirming placement of seeds

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3. Xray after seed insertion confirming position

Advantages

  • Shorter hospital stay
  • Avoidance of incisions

Disadvantages

Can worsen urinary function for 12-18 months in the following ways:

  • Pain during urination
  • Increase in urination frequency and urgency

High Dose Radiotherapy
High dose radiotherapy (HDR) involves needles placement into the prostate and behind the scrotum of the patient. Radioactive material is inserted through these needles to treat the prostate cancer with high doses of radiation.This internal treatment will usually be given in hospital and after the patient is discharged they will complete a course of external beam radiotherapy over several weeks. This treatment is combined with a 6 month course of hormone therapy and is most commonly delivered in 1-3 monthly injections that aim to lower the man’s testosterone levels. HDR is suitable for older men with intermediate or high risk prostate cancer.

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Intra-operative image of HDR Brachytherapy

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CT image showing placement of needles