Treatment

Starting treatment for prostate cancer can be daunting, but armed with the right knowledge, you’ll have a better idea of what to expect.

Your treatment will be determined by:

  • Age
  • Gleason Score given to your tumour
  • Stage of prostate cancer
  • Symptoms
  • Risks
  • General health
  • Patient preference

Treatment options for men diagnosed with prostate cancer include:

You, as the patient, are the most crucial part of the decision making process. It’s vital to ask questions and raise concerns with your doctors, so you know what to expect. Some of the questions you may want to ask about treatment options are:

  • What are my treatment options? Which ones do you recommend and why?
  • What are the benefits of each type of treatment?
  • What are the risks and possible adverse effects associated with each type of treatment?
  • How can I prepare for treatment?
  • Will I need to stay overnight or longer in the hospital or is there an outpatient procedure available?
  • What is the cost of my treatment? Bear in mind, your doctor might not know what the exact cost of the treatment is. It’s important to enquire with your medical aid about whether they cover the treatment and what you’ll have to pay for yourself.
  • Will the treatment affect my normal day to day life or my sex life?

Treatment options by stage

Your doctor will discuss with you the various treatment options that are available depending on the stage of prostate cancer that you are diagnosed with. The following is a guide to the treatment options that may be suggested.

STAGE 1

Standard treatments to control the prostate cancer.

  • Active surveillance.
  • Radical prostatectomy, usually with pelvic lymphadenectomy.
  • External beam radiotherapy.
  • Brachytherapy – interstitial implants of radioactive seeds.
  • Clinical trials of new therapies may be an option.
Read More

STAGE 2

Standard treatments to control the prostate cancer.

  • Active surveillance.
  • Radical prostatectomy, usually with pelvic lymphadenectomy. Radiotherapy may also be given after surgery.
  • External beam radiotherapy. Hormone therapy may be recommended after the radiotherapy.
  • Brachytherapy.
  • Clinical trials with new therapies may be an option.
Read More

STAGE 3

Treatments usually include a combination of brachytherapy,

radiotherapy, hormonal therapy and surgery to alleviate urinary symptoms.

Patients at stage III are at high risk for metastatic spread of prostate cancer. The treatment goal is to maximally destroy the cancer and reduce the possibility of further spread. Some patients may have untraceable metastatic spread which requires indefinite systemic hormonal treatment.

  • External radiotherapy. Hormone therapy is consistently recommended with and after the radiotherapy.
  • Hormone therapy, usually in conjunction with other treatment method and may be continued indefinitely.
  • Radical prostatectomy is uncommon and performed only in selected patients and typically followed by external radiation and hormone therapy.
  • Brachytherapy and external radiotherapy routinely together with hormone therapy.
  • Transurethral resection of the prostate (TURP) to alleviate urinary symptoms.
  • Watchful waiting (observation).
  • Clinical trials with new therapies may be an option.
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STAGE 4

The goals of treatment focus on slowing disease progression,

improving quality of life and increasing survival time.

  • Hormone therapy.
  • Chemotherapy in combination with hormone therapy.
  • Palliative external radiotherapy to control symptoms or prevent fracture of affected by cancer bones.
  • Palliative internal radiotherapy with Radium 223 or Strontium 89.
  • Transurethral resection of the prostate (TURP).
  • Watchful waiting (observation).
Read More

Note: In patients with prostate cancer which has spread to the bone, denosumab and bisphosphonates have been show to prevent cancer-related skeletal complications. These include fractures, the need for surgery or radiotherapy to bone or spinal cord compression. These drugs are also used for treatment of high calcium levels in bloodstream.

Other options to control or prevent damage of bones by cancer or pain in stage IV prostate cancer include: external or internal palliative radiotherapy, pain medication or additional supportive measures.

Active surveillance

Because prostate cancer often grows very slowly, some men (especially older men or those with other serious health problems) might never need treatment for the prostate cancer. Instead, their doctors may recommend approaches known as expectant management, watchful waiting, observation, or active surveillance.

Active surveillance means holding off treatment and monitoring the cancer closely with PSA blood tests, digital rectal exams, and ultrasounds at regular intervals to see if the cancer is growing. Prostate biopsies may be done as well to see if the cancer is becoming more aggressive. If there’s a change in your test results, your doctor would then talk to you about treatment options.

Watchful waiting (observation) is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a man’s symptoms to decide if treatment is needed.

If you choose the active surveillance option you are choosing to delay the side-effects and risks associated with surgery or other therapies. However, you run the risk of reducing your chances of controlling the cancer before it spreads.

It can be stressful for some men to know they’re living with an untreated cancer and it’s very important to discuss your feelings with your doctor. You can change your mind and opt for treatment at any time.

Questions to ask your doctor:

  • Is putting off treatment a safe option? Will I live longer if I choose treatment rather than active surveillance?
  • What happens if I change my mind?
  • How often will I need to have tests? What tests will I need to have?
  • How will we know when the cancer gets worse or starts spreading?
  • Are there certain symptoms I need to look out for between doctor visits?

Surgery

If you are diagnosed with early-stage prostate cancer, found only in the prostate, surgery may be recommended. Surgery may also be an option in advanced prostate cancer, to control symptoms.

There are many types of surgery, all of which involve the surgeon removing the entire prostate gland, seminal vesicles and the lymph nodes close to the prostate.

Types of surgery to remove the prostate:

  • Radical retropubic prostatectomy. This involves the surgeon making a large cut in your abdomen, below the belly button. The surgeon then removes the prostate through your open abdomen.
  • Laparoscopic prostatectomy. The surgeon will make several small cuts in your abdomen and insert surgical tools through these cuts. Then, using a laparoscope, which is a long, thin tube with a camera on the end, the surgeon can see the prostate and will remove it through the small cuts using the surgical tools (often called keyhole surgery).
  • Radical perineal prostatectomy. The prostate is removed through a cut that is made between the scrotum and the anus.
  • Robotic laparoscopic surgery. Small cuts are made in the abdomen and the surgeon uses a laparoscope and a robot to remove the prostate through the cuts. The surgeon operates the robotic arms using a computer.

Types of surgery used to treat prostate cancer or relieve symptoms include:

  • Multiple tubes inserted transperineally and used to freeze and kill prostate tissue.
  • Transurethral Resection of the Prostate (TURP). A long thin scope is inserted through the urethra. The end of the scope has a cutting tool which is used to remove tissue from the prostate. A TURP does not remove all of the cancer from the prostate but it can help to relieve a blockage of urine flow.

Be sure to discuss pain relief with your doctor prior to surgery. You’ll be given medication to control any pain you may experience and you’ll be able to adjust your pain relief after surgery, on discussion with your doctor.

You’ll probably have to stay in hospital after the surgery and a tube will be put through the penis into your bladder to drain urine whilst you are healing. The tube will stay in for about 5 to 14 days.

You might experience urinary incontinence after surgery. This means you may lose control of your bladder. In most men, this is only temporary and you’ll be given advice on exercises to help you regain bladder control. However, in some men this may be permanent and a team of doctors and nurses will help you to deal with the problem.

Another side effect of surgery can be erectile dysfunction. This means the nerves around your prostate may be damaged, resulting in loss of sexual function. Whilst sexual function can return in some men, permanent erectile dysfunction will occur if the nerves are severed. Again doctors and nurses can help you manage the problem.

Once your prostate is removed you will have dry orgasms. This means there’ll be no semen released when you have an orgasm. Sperm banking is recommended if you still wish to father children.

Questions to ask your doctor:

  • If I need surgery, which surgery is recommended and why?
  • How long will I have to stay in hospital? How will I feel after the surgery?
  • Will I have pain after surgery and how will it be managed?
  • What are the chances that I will have permanent urinary incontinence or erectile dysfunction?

Therapies

Radiotherapy

There are 2 main types of radiotherapy – external and internal. They can be used to treat any stage of prostate cancer. In early stage prostate cancer, radiotherapy can be used either in place of surgery or after surgery to destroy any remaining cancer cells. Radiotherapy may also be recommended in advanced stage prostate cancer to help with pain relief.

External radiotherapy. This means a sophisticated machine is used to deliver the radiation and a computer is used to pinpoint the radiation to target the prostate. Treatment is usually given 5 times a week over a number of weeks. Each radiotherapy session only lasts a few minutes.

Brachytherapy. This form of treatment involves inserting either dozens of radioactive seeds into the prostate using needles or several tubes into the prostate which are loaded with radioactive material.

There are two types of brachytherapy. Low Dose Rate (LDR), which is the insertion of radioactive seeds via a day/overnight procedure, and HDR (High Dose Rate), which means tubes are temporarily placed in the body, and loaded with radioactive therapy for up to five treatment sessions. HDR is not conducted in South Africa as yet.

The seeds give off radiation for a few weeks or months and then remain in the prostate permanently once the radiation wears off. The seeds can be implanted as an outpatient procedure, meaning you will not need to stay in hospital and you will probably be able to resume normal activities within a few days. You may be concerned about how the radioactive material in your body could affect you or those around you. Although the majority of the radiation seeds only emit radioactivity within 2.5cm of the seed it’s worth taking note of the following precautions:

  • You should limit prolonged close contact (less than 2 metres) with pregnant women, those who may be pregnant, or children, for 2 months after the seeds have been implanted
  • If you have seeds implanted you must avoid allowing children to sit on your lap for prolonged periods, for 2 months after the seeds have been implanted
  • You’ll be given a lead container in which to place any seeds you might pass in your urine. You should pick these up with a spoon or a pair of tweezers, place them in the lead box and return them to your radiation oncologist who dispose of them safely.
  • You should avoid sexual intercourse for 2 weeks after the seeds have been implanted as you may pass a seed when you have an orgasm
  • You should wear a condom when you have sex for 2 months after the seeds have been implanted

The tubes are loaded with radioactive material during a treatment session that lasts a few minutes and then the radioactive material is removed. This process can be repeated up to 5 times and you’ll have to stay in hospital for about 1 to 2 days. The tubes will be removed before you leave the hospital.

You may experience side-effects such as diarrhoea, rectal pain, urinating more often and a burning pain when you empty your bladder. These side-effects should go away gradually.

Questions to ask your doctor:

  • What radiation options are available to me?
  • When can I start treatment and how long will it last?
  • How often will I need to have treatments?
  • How will I feel when I receive the radiotherapy? Will I need to stay overnight in hospital? Can I drive myself to and from the hospital or outpatient clinic?
  • How should I take care of myself during treatment?
  • How will you check if the treatment is working?
  • Will I have side-effects directly after the radiotherapy?
  • Will there be long-lasting side-effects from the radiotherapy?

Hormone Suppression Therapy
Prostate cancer cells rely on testosterone to help them grow. Therefore, hormone or anti-androgen therapy is used to stop your body from producing testosterone in the hope that cancer cells will die or grow more slowly.

Hormone therapy can be used in a number of scenarios:

  • For advanced prostate cancer, to shrink or slow the growth of tumours
  • For early-stage prostate cancer to shrink tumours before radiotherapy and to ensure radiotherapy is a success
  • After surgery or radiotherapy to slow the growth of any cancer cells left behind

If you are to have hormone therapy to treat your prostate cancer the following options may be available to you:

  • Luteinising hormone-releasing hormone (LH-RH) agonists. These drugs prevent the testicles from making testosterone. Examples include: leuprolide, goserelin. These types of drugs are usually given by an injection into a muscle or under the skin.
  • Anti-androgens. This group of drugs blocks the action of male hormones on cancer cells. Examples include: bicalutamide and flutamide. You’ll probably be given an anti-androgen along with an LH-RH agonist or before starting on an LH-RH agonist. Anti-androgens are available in tablet form.
  • Abiraterone acetate. This drug is taken by mouth and works by reducing levels of testosterone in the body. It’s been shown to reduce the size of prostate cancer tumours, which helps improve quality of life in patients suffering from CRPC. Clinical trials have also shown that abiraterone can improve survival times in CRPC that’s progressed after treatment with LH-RH agonists, anti-androgens and/or docetaxel chemotherapy.
  • The testicles may be surgically removed as they are the main source of testosterone in the body.
  • Other drugs may be given to prevent the adrenal gland from making testosterone. Examples include: ketoconazole and aminoglutethimide.

Side-effects associated with hormonal therapies include: erectile dysfunction, hot flushes, weakened bones, reduced sex drive and weight gain.

Questions to ask your doctor:

  • What hormone therapy options are available to me? Is there a particular option that is better for me?
  • How often will I need to have treatment, what will it involve and how long will it last?
  • Will I need to stay in hospital or will I be treated as an out-patient?
  • How will I feel during treatment?
  • How will we know if the treatment is working? How often will I need to come for check-ups?
  • What are the chances of me having side-effects and what are the long- and short-term side-effects?

Chemotherapy
Chemotherapy is reserved for patients with stage IV prostate cancer. The effectiveness of this treatment method depends on specific medical circumstances of men affected by prostate cancer.

The greatest benefit of chemotherapy has been noted in patients with newly diagnosed prostate cancer with extensive metastatic spread. The addition of docetaxel chemotherapy to androgen-deprivation hormone therapy extended survival for men with newly diagnosed metastatic hormone-sensitive prostate cancer by more than 13 months.

Other chemotherapeutics like carbazitaxel prolonged survival of patients with castrate/hormone resistant prostate cancer who failed earlier lines of therapy. Mitoxantrone hasn’t demonstrated a survival improvement but remains a palliative therapeutic option when other methods of therapy failed or are not available.

Chemotherapy is a very effective method of cancer treatment that’s helped save millions of lives, but it does cause side effects. The medicines used in chemotherapy can’t distinguish between fast-growing cancer cells and other types of fast-growing cells, such as blood cells, skin cells and the cells inside the stomach.

This means most chemotherapy medications have an effect on the body’s cells and tissues causing problems including:

  • Fatige and weakness
  • Feeling and being sick
  • Diarrhoea
  • Hair loss

Some chemotherapy side effects are mild and treatable, while others can cause serious complications if not recognised immediately and corrected. Frequently, people only have minimal side effects, but for some people, a course of chemotherapy can be unpleasant and upsetting.

Living with and adapting to the side effects of chemotherapy can be challenging. However, it’s important to realise that most, if not all, side effects will disappear once the treatment is complete. There’s no risk of the side effects of chemotherapy being passed to other people, including children and pregnant women, if they’re in close contact with someone having chemotherapy.

You’ll be monitored regularly to check for side-effects and to check on your general health. It’s possible for some of your side-effects e.g. nausea or diarrhea, to be managed with other medications.

New developments
New treatment options are becoming available that can be used in men whose cancer has failed to be managed by radiotherapy, surgery and hormonal therapy. This type of advanced stage prostate cancer is known as castration-resistant prostate cancer and, until now, there have been very few available treatment options for use at this stage.

Discussed below are some of the newer treatments available, however, you’ll need to discuss with your doctor which options are available in South Africa, or the country in which you are being treated.

Radium 223. This is a radiopharmaceutical agent that binds with minerals in the bone to deliver radiation directly to bone tumours, thereby limiting the damage to the surrounding normal tissues. The U.S. Food and Drug Administration (FDA) approved the drug in May 2013. Radium 223 significantly improves overall survival in men with metastatic, hormone-refractory prostate cancer that’s spread to bones (but no other organs), according to the results of a study published in the New England Journal of Medicine.

Cabazitaxel. This is a chemotherapy drug that’s currently being studied in many clinical trials. This describes the testing process of a new drug before it reaches the market and becomes widely available. It’s been approved in the U.S.A for the treatment of CRPC that has not responded to other treatments including other chemotherapy with docetaxel, and is approved for use in South Africa.

Enzalutamide. This works by more effectively blocking the action of male hormones on cancer cells than other anti-androgens. Clinical trials have shown that Enzalutamine can improve survival in CRPC that’s progressed after treatment with LH-RH agonists, anti-androgens and/or chemotherapy with docetaxel. This product is soon to be registered for use in South Africa.

Sipuleucel-T. This is a vaccine that stimulates the patient’s defenses to respond against the cancer. It’s the first of this type of treatment to be approved in the U.S.A but is not yet available in South Africa.

In addition to these therapies approved in the U.S.A and that are available, or should become available in South Africa in the future, other therapies are under investigation which offer more promise in the treatment of prostate cancer.