Considering Prostate Cancer Treatment Options
For most men diagnosed with prostate cancer, the cancer is found while it’s still at an early stage — it’s small and has not spread beyond the prostate gland. These men often have several treatment options to consider.
Not every man with prostate cancer needs to be treated right away. If you have early-stage prostate cancer, there are many factors such as your age and general health, and the likelihood that the cancer will cause problems for you to consider before deciding what to do. You should also think about the possible side effects of treatment and how likely they are to bother you. Some men, for example, may want to avoid possible side effects such as incontinence or erection problems for as long as possible. Other men are less concerned about these side effects and more concerned about removing or destroying the cancer.
If you’re older or have other serious health problems and your cancer is slow growing , you might find it helpful to think of prostate cancer as a chronic disease that will probably not lead to your death but may cause symptoms you want to avoid. You may think more about watchful waiting or active surveillance, and less about treatments that are likely to cause major side effects, such as radiation and surgery. Of course, age itself is not necessarily the best reason for your choice. Many men are in good mental and physical shape at age 70, while some younger men may not be as healthy.
The Risks Of Active Surveillance For Men With Intermediate
- By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Men diagnosed with slow-growing prostate tumors that likely wont be harmful during their lifetimes can often avoid immediate treatment. Instead, they can have their tumor monitored using a strategy called active surveillance. With this approach, doctors perform periodic checks for tumor progression and start treatment only if the cancer begins to metastasize, or spread. Active surveillance has become popular worldwide, but doctors still debate which groups of men can safely use this strategy. Some doctors offer it only to men with the lowest risk of cancer progression. Others say that men with intermediate-risk prostate cancer can also make good candidates.
A new study now shows that intermediate-risk tumors are more likely to metastasize on active surveillance than initially expected. Most men do fine on surveillance, but we have detected a higher risk of metastasis among intermediate-risk patients over the long term, said Dr. Laurence Klotz, director of the active surveillance program at the University of Torontos Sunnybrook Health Sciences Centre, where the study was based.
Side Effects Of Surgery For Prostate Cancer
The most commonly experienced side effects of surgery for prostate cancer are urinary incontinence and erectile dysfunction.
According to the patient-reported outcomes from men who participated in the ProtecT trial, men who undergo a radical prostatectomy experience more sexual dysfunction and urinary problems than those treated with radiation therapy.
While many reported an improvement in the severity of their symptoms six months after surgery, these men continued to report poorer sexual quality of life six years after surgery compared to those who had radiation therapy.
While men treated with radiation reported experiencing bowel function problems after treatment, the men who had a prostatectomy were generally able to undergo the procedure without experiencing any changes in bowel function after surgery.
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Radiation Therapy Oncology Group 94
This multi-institutional study was conducted to evaluate the effect of the addition of AST to RT on overall survival, freedom from biochemical failure, freedom from clinical progression, and disease-free survival in patients with localized prostate cancer in response to the positive effect on these parameters seen in RTOG 86-10. To this end, 1979 patients with T1bT2b prostate cancer and PSA less than 20 ng/ml were randomized to receive EBRT alone or in conjunction with 2 months of neoadjuvant and 2 months of concurrent goserelin and flutamide.
Some Things To Consider When Choosing Among Treatments
Before deciding on treatment, here are some questions you may want to ask yourself:
- Are you the type of person who needs to do something about your cancer, even if it might result in serious side effects?
- Would you be comfortable with watchful waiting or active surveillance, even if it means you might have more anxiety and need more frequent follow-up appointments in the future?
- Do you need to know right away whether your doctor was able to get all of the cancer out ? Or are you comfortable with not knowing the results of treatment for a while if it means not having to have surgery?
- Do you prefer to go with the newest technology , which might have some advantages? Or do you prefer to go with better proven treatments that doctors might have more experience with?
- Which potential treatment side effects might be most distressing to you?
- How important for you are issues like the amount of time spent in treatment or recovery?
- If your initial treatment is not successful, what would your options be at that point?
Many men find it very stressful to have to choose between treatment options, and are very fearful they will choose the âwrongâ one. In many cases, there is no single best option, so itâs important to take your time and decide which option is right for you.
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What Affects My Treatment Options
Your treatment options will depend on whether your cancer is contained within the prostate gland , has spread just outside of the prostate or had spread to other parts of the body .
You may have a choice of treatments. Your doctor or specialist nurse will explain all your treatment options, and help you to choose the right treatment for you.
Your treatment options and which treatment you choose may depend on several things, including:
- how far your cancer has spread
- how quickly your cancer may be growing
- the advantages and disadvantages of each treatment
- what each treatment involves
- the possible side effects of each treatment
- practical things, such as how often you would need to go to hospital, or how far away your nearest hospital is
- your own thoughts about different treatments
- how the treatment you choose now could affect your treatment options later if your cancer comes back or spreads
- your general health
- how long youre expected to live for.
The first treatment you have may affect which treatments you can have in the future, if you need further treatment. Speak to your doctor or nurse about this.
It can help to write down any questions you want to ask at your next appointment. And to take someone to appointments, such as your partner, friend or family member.
Listen to a summary of this page
The Staging Guide Video Series
Hi, Im Dr. Scholz. Lets talk about prostate cancer.
Weve been going through a series of short videos about the management of Teal otherwise known as intermediate risk prostate cancer. In this video were going to cover the comparison of all the different treatment options for Teal, and try to give you a little hierarchygive you a kind of number 1, 2, 3 in terms of options that I would be thinking of if I was in this situation.
First, when youre talking about Teal you have to realize there are three subtypes, the Teal subtype we divide at PCRI into Low, Basic, and High. So when we talk about many options for treating teal, were really talking about Basic-Teal. Why is that? Well, Low-Teal those men are candidates for active surveillance. High-Teal are going to get better cure rates with combination therapythat is a seed implant plus IMRT and a short course of hormone blockade . For Basic-Teal were really talking about having a broad selection of therapy amongst surgery, radiation therapy which could be IMRT, proton therapy, SBRT stereotactic body radiation CyberKnife, two different types of seed implants, and even primary hormone blockade , or just TIP alone which was very popular before radiation technology got a lot better. So the remainder of the video is really going to be talking about options or Basic-Teal, comparing the pros and cons of all these different treatments.
So lets move on and talk about that, lets talk about discomfort and inconvenience.
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Initial Treatment Of Prostate Cancer By Stage
The stage of your cancer is one of the most important factors in choosing the best way to treat it. Prostate cancer is staged based on the extent of the cancer and the PSA level and Gleason score when it is first diagnosed.
For prostate cancers that haven’t spread , doctors also use risk groups to help determine treatment options. Risk groups range from very low risk to very high risk, with lower risk group cancers having a smaller chance of growing and spreading compared to those in higher risk groups.
Other factors, such as your age, overall health, life expectancy, and personal preferences are also taken into account when looking at treatment options. In fact, many doctors determine a mans possible treatment options based not just on the stage, but on the risk of cancer coming back after the initial treatment and on the mans life expectancy.
You might want to ask your doctor what factors he or she is considering when discussing your treatment options. Some doctors might recommend options that are different from those listed here.
When Is Brachytherapy Alone The Right Choice
For a patient with disease that is confined to the prostate and not too aggressive, brachytherapy alone is a good option. With the use of sophisticated real-time computer-based planning, we can use brachytherapy to deliver radiation in an extraordinarily precise way, with minimal exposure to the surrounding normal tissues. It is also convenient for the patient as it is done in an outpatient setting and most people are able to get back to work the next day.
But brachytherapy is not right for everyone. For some patients with less-aggressive disease, a watch-and-wait approach would also be very reasonable. At MSK, our philosophy is that when the disease is caught very early meaning a low PSA level, or nonaggressive disease as reflected by a Gleason score of 6 with evidence of cancer in only a few of the biopsy samples and no evidence from the MRI of a significant amount of disease then it would be very appropriate to do active surveillance and hold off on treatment.
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Dana Farber Cancer Institute Trial
This trial sought to evaluate the effect of the addition of androgen deprivation therapy to RT on survival, disease-specific mortality, survival free from salvage hormonal therapy, and all-cause mortality. To this end, 206 men with T1bT2b, N0, M0 adenocarcinoma of the prostate and either a Gleason score of at least 7 , a serum PSA of at least 10 ng/ml, or, in patients with low-risk cancer, MRI evidence of extra-prostatic disease or seminal vesicle invasion, were randomized to receive 70 Gy via 3DCRT alone or in combination with 6 months of androgen suppression therapy . All patients received an initial 45 Gy to the prostate and seminal vesicles followed by an additional 25.35 Gy boost to the prostate plus a 1.5 cm margin via a four-field 3DCRT technique. Leuprolide or goserelin were used in combination with flutamide to achieve androgen blockade. At a median 4.52 years of follow up, patients randomized to receive combined modality therapy had significantly higher survival, lower prostate-cancer-specific mortality, and higher survival free of salvage hormonal therapy. Five-year survival rates favored CMT by 10 percentage points . At 7.6 years of follow up, the KaplanMeier 8-year survival estimates were 74% and 61% respectively for patients receiving AST versus those receiving RT alone. The increased risk in all-cause mortality was significant only in those patients randomized to RT with or without minimal comorbid pretreatment disease .
Who Remained Prostate Cancer Free
Intermediate Risk patients experience a wider range of results and approaches due to the risk of disease beyond the prostate. When selecting a course of action, consultations are recommended with a urologist or surgeon, radiation oncologist and medical oncologist. Different treatments have different results and side effects. It is important to understand the potential impact each treatment can have on your quality of life after treatment.
Intermediate Risk patients are at a higher risk for cancer relapse or recurrence than Low Risk patients. That means patients in this risk group are more likely to have their cancer return following initial treatment, which may require additional treatment. To understand how effective the treatment or combination of treatments, are in keeping patients in remission, Doctors perform periodic monitoring or testing PSA levels, following treatment. It is very unlikely that the cancer will ever return, if you remain in remission for 10-15 years after prostate cancer treatment. Click on ‘Get the Study’, to obtain your copy of Foundation’s work. Share this Study with your Doctor as you select your treatment plan.
Intermediate Risk is any of the following:
PSA greater than 10 less than 20
Gleason Score is 7
LOW | HIGH
How to Use the Graph
About the Data
For More Information:
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The Staging Grading And Prognosis Of Prostate Cancer
The tests completed by your specialist help work out whether you have prostate cancer and if it has spread to other parts of your body. This process is called staging. It helps you and your health care team decide which management or treatment option is best for you.
The most common staging system for prostate cancer is the TNM system. In this system, letters and numbers are used to describe the size of the tumour , whether the cancer has spread to nearby lymph nodes , and whether the cancer has spread to the bones or other organs, i.e. whether it has metastasised . The TNM scores are combined to work out the overall stage of the cancer, with higher numbers indicating larger size or spread.
|localised – stages 12||The cancer is contained inside the prostate.|
|locally advanced – stage 3||The cancer is larger and has spread outside the prostate to nearby tissues or nearby organs such as the bladder, rectum or pelvic wall.|
|advanced – stage 4||The cancer has spread to distant parts of the body such as the lymph glands or bone. This is called prostate cancer even if the tumour is in a different part of the body.|
Grade and risk category
The biopsy results will show the grade of the cancer. This is a score that describes how quickly the cancer may grow or spread.
Risk of progression
Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for anyone to predict the exact course of the disease.
Brachytherapy For Prostate Cancer
Brachytherapy is a form of internal radiation therapy. With this type of therapy, radiation is delivered to the prostate tumor inside the body via a catheter or another implantable device.
High-dose rate brachytherapy uses radioactive Iridium-192 to deliver high doses of radiation to the prostate tumor. Treatments are short, sometimes requiring as few as five sessions. Brachytherapy radiation more tightly surrounds the tissues were targeting, which may help spare normal tissues.
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Why Is Risk Level Important
Risk level is all about matching the right treatment to the right patient, so its very important!
The idea of classifying PCa according to risk was originally based on the relative risk of PSA failure after prostatectomy or radiation. Until the late 1990s, the only conceivable treatment options were either whole gland surgery or radiation, and watchful waiting . The standard risk classification was the DAmico system:
- Low risk defined as stage T1c, T2a and PSA level 10 ng/mL and Gleason score 6
- Intermediate risk defined as stage T2b or Gleason score of 7 or PSA level > 10 and 20 ng/mL
- High risk defined as stage T2c or PSA level > 20 ng/mL or Gleason score 8.
Treatment For Intermediate Risk Prostate Cancer
Intermediate risk prostate cancers are the most frequently treated prostate cancers. They are cancers that are confined to the prostate, often are Gleason 7 and have a PSA of less than 20. These cancers are treated in men with life expectancy greater than 10 years to prevent spread of the cancer in the long-term. There are a number of different effective treatment options for intermediate risk prostate cancer and the decision is often a personal one. Here at UCLA we recommend consultation with both Urologist and Radiation Oncologist to help men decide which treatment option is best for them.
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Can Adt Compensate For Dose Escalation
The Prostate Cancer Study III examined the addition of ADT to SDRT and DERT in intermediate-risk patients . The preliminary results of this trial have now been published in abstract form. A total of 600 patients were enrolled. Intermediate-risk prostate cancer was defined as T1/T2 disease, GS 6, PSA level 1020 ng/mL or T1/T2 disease, GS of 7, PSA level 20 ng/mL. Patients were randomly assigned to one of three arms: 6 months of ADT plus 70 Gy to the prostate , 6 months of ADT plus 76 Gy , or 76 Gy alone . ADT consisted of bicalutamide and goserelin for 6 months. RT was delivered using a 3D conformal technique and started 4 months after the beginning of ADT. Median follow-up was 6.75 years. Primary endpoints were biochemical failure and disease-free survival . Secondary endpoints included OS, as well as hormonal and radiation-related toxicities. Biochemical failure was defined as 2 ng/mL above the PSA nadir.