Treating localised prostate cancer

Localised prostate cancer refers to cancer that is confined to the prostate and has not spread to any other parts of the body. Treatment options will vary depending on numerous factors including your age, health, risk category, stage and grade of the cancer as well as your preferences regarding adverse effects, long-term effects and treatment goals. Often, a combination of treatments is used together to provide optimal therapy.

1. Watchful waiting

Using the watchful waiting approach, no active treatment is anticipated. It is usually an option for older men who are at low risk of their cancer progressing and causing them harm. If the cancer does progress, you would usually be treated with hormone therapy rather than surgery or radiation.

2. Active surveillance

For patients that have a low risk of their cancer spreading, or intermediate risk patients who wish to delay treatment, active surveillance is a viable option. Research shows that low risk localised prostate cancer patients have the same chance of living for 10 years or more as those who choose the more aggressive treatment options.

Active surveillance involves close monitoring of signs of progression of the cancer such as a PSA blood test and digital rectal exam periodically, as well as a repeat biopsy after one year and at specific intervals thereafter. If tests indicate that the cancer is spreading, you will be offered other treatment options such as surgery.

Advantages of this option include the lack of adverse effects and minimal disruption to your everyday life. Disadvantages of this treatment may mean increased painful and uncomfortable biopsies. There is also the small possibility that the cancer may grow more quickly than anticipated and become harder to treat.

3. Surgery

This treatment option is called a radical prostatectomy and involves removal of the whole prostate gland as well as surrounding tissues. It can be performed using a number of methods such as open radical prostatectomy, laparascopic radical prostatectomy or robotic assisted radical prostatectomy.

Adverse post-surgery effects to consider may include:
⦁ long-term impotence
⦁ no ejaculation
⦁ infertility
⦁ incontinence of urine and defecation

Although surgery can remove the cancer in a day, it is essential to set aside sufficient time for recovery and the completion of the treatment plan. There will also be a rapid fall in your PSA and easy follow-up of PSA levels, as well as a lower incidence of bowel problems in comparison with radiotherapy.

4. Radiotherapy

Radiotherapy is divided into two main types, external beam radiotherapy and brachytherapy.

External beam radiation therapy (EBRT) involves high energy X-ray beams being targeted at the prostate and sometimes surrounding tissues, from outside the body. Treatment is usually five days a week for six to eight weeks. Some patients may have hormone therapy for up to six months prior to radiation therapy as this helps to shrink the prostate, making the cancer easier to treat. Potential side effects may include bowel and urinary problems, fatigue, skin changes, sexual difficulties and infertility.

Brachytherapy is the insertion of radioactive material directly into the prostate at a low dose (LDR) or high dose (HDR). LDR is given by inserting permanent radioactive seeds into the prostate, which give off a concentrated amount of radiation to kill off the cancer cells. HDR also inserts radioactive material into the prostate, although it is temporary and for shorter periods. Adverse effects may include soreness, problems urinating, fatigue, sexual and fertility issues.

The advantages of radiotherapy include a lesser chance of incontinence than surgery and the ability to kill cancer cells that have spread out of the prostate. The disadvantages include the regular visits to be made to the hospital over several weeks for EBRT, risk of infertility, a greater risk of bowel problems when compared to surgery and the potential for side effects to worsen over time.

5. Hormone therapy

As prostate cancer cells usually need the hormone testosterone to grow, reducing testosterone may slow down the growth of the cancer. Hormone therapy may be given before and during radiotherapy to reduce the risk of spreading. In high risk men, it may be given for some time after radiotherapy to improve their outcomes and overall survival. It may be administered in the form of tablets or injections, or a combination of both. There are several potential hormonal side effects to consider such as loss of libido and erectile difficulties, hot flushes, weight gain, osteoporosis, diabetes and breast enlargement and tenderness.

These are currently the standard options in South Africa for treating localised prostate cancer. There are also less mainstream options, which your doctor may consider such as cryotherapy. In addition, another treatment called High-Intensity Focused Ultrasound has also had success in South Africa, however is currently on hold due to funding issues.

The type and severity of side effects vary from person to person. Its duration often depends on your age and health before surgery. Some side effects are temporary and easily manageable, while others may require additional medical treatment. Most side effects are reversible when treatment stops, but some are permanent. Always discuss the side effects you experience with your healthcare team to discuss the best potential treatment plans.

Fortunately, prostate cancer has one of the higher rates of survival of any cancer. With treatment that is appropriate for you, most men with localised prostate cancer can expect a good long-term prognosis.

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