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Best Treatment For Localized Prostate Cancer

Considering Complementary And Alternative Methods

Treatment Options for Localized Prostate Cancer

You may hear about alternative or complementary methods that your doctor hasnt mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctors medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be harmful.

Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known about the method, which can help you make an informed decision.

What Is The Outlook For Patients Who Receive Focal Therapy

While the use of focal therapy for localized prostate cancer appears to be a promising development in a number of ways, it is still considered investigational and not yet part of standard therapy. There are a number of reasons for this, as follows:

  • The criteria for selecting ideal candidates havent been fully agreed on. This is an important question because mistakenly using focal therapy in place of a more traditional treatment could allow a cancer to go under-treated.
  • The criteria for defining an index lesion still need to be agreed on.
  • The idea that the index lesion determines how the cancer will develop hasnt yet been proven.
  • The factors that define treatment success or failure, and the triggers for re-treatment still need to be determined.
  • The long-term effectiveness of focal therapy is unknown.
  • It isnt clear that all side effects are eliminated by using focal therapy.
  • Focal therapy doesnt allow for firsthand pathologic and biologic study of cancerous tissue, as can be done when using surgical treatment.
  • Focal therapy sometimes leaves behind untreated cancer, which could possibly raise the risk of more serious problems in the future.
  • The overall cost to the healthcare system may be greater for focal therapy than for standard treatments.

Remission And The Chance Of Recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.

A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someone’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.

When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA-only or biochemical recurrence.

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How To Decide Between Radiation And Surgery For Localized Prostate Cancer

If youre like most men whove been diagnosed with prostate cancer, youve been told you have early-stage, localized prostate cancer, meaning the disease hasnt spread beyond the prostate. You may have also been told that you have choices about what you want to do next.

Unless your cancer is aggressive, youve probably been presented with three treatment options: active surveillance, radiation therapy or surgery. If you arent comfortable with active surveillance, or if its not an advisable option for you, you may have to decide between radiation therapy and surgery to treat your cancer.

Many men want to know whats the best treatment for their localized prostate cancer. But its a misconception that you have only one better or safer choice. In most cases, either radiation therapy or surgery is an equally good choice when we look at long-term survival.

Weve heard of some physicians telling men of their prostate cancer diagnosis and asking them to make a treatment decision at the same appointment. But prostate cancer progresses slowly, so most men have time to think about their options and shouldnt feel pressured into making an immediate decision.

How you feel about the big three possible side effects of treatmenturinary incontinence, sexual dysfunction and bowel healthmay be the deciding factor for you.

To help you through the process of making this decision, this article covers:

Effectiveness And Toxicity: Reviewing The Literature

Prostate Cancer Testing &  Surgical Options

Although PBT has generated much enthusiasm, its utility can be best confirmed by clinical trials. Unfortunately, there are no randomized trials completed that directly compare 3D-CRT or IMRT with PBT, and thus we must rely mainly on single-arm studies.

Loma Linda University Medical Center was the first center to open a hospital-based proton facility in 1990, and reported the first large single-arm experience. The authors analyzed 1255 patients, 731 of whom received 3D-CRT plus a boost with PBT and 524 of whom received PBT only. Included were patients with low-, intermediate-, and high-risk prostate cancer. Using American Society for Therapeutic Radiology Oncology consensus criteria, the 5- and 8-year biochemical failure free survival was 75% and 73%, respectively. More importantly, there were very low rates of Radiation Therapy Oncology Group grade 3 or higher morbidity: 1% genitourinary and 0.2% GI. To put these numbers in perspective, patients treated with IMRT at our institution had 6% GU and 1% GI grade 3 or higher morbidity.

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Standard Treatment Options For Stage Iv Prostate Cancer

Standard treatment options for patients with stage IV prostate cancer include the following:

  • Watchful waiting or active surveillance/active monitoring.
  • Hormonal manipulations

    Hormonal treatment is the mainstay of therapy for metastatic prostate cancer. Cure is rarely, if ever, possible, but striking subjective or objective responses to treatment occur in most patients. The cornerstone of hormonal therapy for prostate cancer is medical or surgical castration to stop the production of testosterone by the testes. This is commonly referred to as androgen deprivation therapy and can be achieved with bilateral orchiectomy or with administration of gonadotropin-releasing hormone agonists or antagonists. The most effective purely hormonal approach employs a combination of ADT and one of the following agents:

    • Abiraterone acetate, an inhibitor of cytochrome P450c17, a critical enzyme in androgen biosynthesis.
    • Apalutamide, an androgen receptor antagonist.
    • Enzalutamide, an androgen receptor antagonist.

    Randomized controlled trials have reported that combination therapy with any one of these drugs plus ADT results in longer overall survival than does ADT alone.

  • After a median follow-up of 30.4 months, the trial was stopped because of a clear overall survival benefit in the abiraterone study group: median survival not reached versus 34.7 months OS .
  • The 2-year OS rate was 82.4% in the apalutamide group and 73.5% in the placebo group .
  • Immediate versus deferred hormonal therapy

    Evidence :

    Barriers To Shared Decision Making

    Few studies have compared outcomes of different treatments for localized prostate cancer. A survey found that for the same hypothetical patient, 93% of urologists would recommend surgery, and 72% of radiation oncologists would recommend radiation therapy.11 In a survey of men with newly diagnosed prostate cancer, more than one-half significantly overestimated the survival benefit of treatment patient education, income, and health literacy did not affect the results.12 Although these patients had been counseled by their urologists and had already elected treatment or observation, more than one-half incorrectly answered most of an 18-item questionnaire designed to test knowledge about treatment options. This questionnaire can be used to identify patients who need further counseling.13

    With help from clinical guidelines, primary care physicians, with urologists and oncologists, can counsel patients about choosing treatment or surveillance for localized prostate cancer. Figure 1 presents guidelines from the National Comprehensive Cancer Network based on high-level evidence or expert consensus.14,15

    FIGURE 1.

    Algorithm for selecting localized prostate cancer treatment based on National Comprehensive Cancer Network guidelines.

    Adapted with permission from Mohan R, Schellhammer PF. Treatment options for localized prostate cancer. Am Fam Physician. 2011 84:416, with additional information from reference 15.

    FIGURE 1.

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    Treatment Options Under Clinical Evaluation For Stage I Prostate Cancer

    Treatment options under clinical evaluation for patients with stage I prostate cancer include the following:

  • High-intensity focused ultrasound therapy.
  • Vascular-targeted photodynamic therapy using a photosensitizing agent has been tested in men with low-risk prostate cancer. In the CLIN1001 PCM301 randomized trial, 413 men with low-risk cancer were randomly assigned in an open-label trial to receive either the photosensitizing agent, padeliporfin , or active surveillance. Median time to local disease progression was 28.3 months for patients receiving padeliporfin and 14.1 months for patients who were assigned to active surveillance . However, the appropriate population for photodynamic therapy may be quite narrow, as it may overtreat men with very low-risk disease and undertreat men with higher-risk disease.

    Thinking About Taking Part In A Clinical Trial

    Treatment Options for Localized Prostate Cancer

    Clinical trials are carefully controlled research studies that are done to get a closer look at promising new treatments or procedures. Clinical trials are one way to get state-of-the art cancer treatment. In some cases they may be the only way to get access to newer treatments. They are also the best way for doctors to learn better methods to treat cancer. Still, they’re not right for everyone.

    If you would like to learn more about clinical trials that might be right for you, start by asking your doctor if your clinic or hospital conducts clinical trials.

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    Active Surveillance And Watchful Waiting

    If prostate cancer is in an early stage, is growing slowly, and treating the cancer would cause more problems than the disease itself, a doctor may recommend active surveillance or watchful waiting.

    Active surveillance. Prostate cancer treatments may seriously affect a person’s quality of life. These treatments can cause side effects, such as erectile dysfunction, which is when someone is unable to get and maintain an erection, and incontinence, which is when a person cannot control their urine flow or bowel function. In addition, many prostate cancers grow slowly and cause no symptoms or problems. For this reason, many people may consider delaying cancer treatment rather than starting treatment right away. This is called active surveillance. During active surveillance, the cancer is closely monitored for signs that it is worsening. If the cancer is found to be worsening, treatment will begin.

    ASCO encourages the following testing schedule for active surveillance:

    • A PSA test every 3 to 6 months

    • A DRE at least once every year

    • Another prostate biopsy within 6 to 12 months, then a biopsy at least every 2 to 5 years

    Treatment should begin if the results of the tests done during active surveillance show signs of the cancer becoming more aggressive or spreading, if the cancer causes pain, or if the cancer blocks the urinary tract.

    Deterrence And Patient Education

    The majority of risk factors for prostate cancer are not modifiable. As such, patients should be educated about inherent risk factors such as age, ethnicity, and family history to ensure the correct groups present for PSA testing. It is important to educate patients requesting PSA screening about the risks of over-diagnosis and to reassure those who do not meet the criteria for testing.

    Lifestyle factors do not affect the risk of developing prostate cancer but may influence the risk of progression. Patients already diagnosed with prostate cancer should be encouraged to lead a healthy lifestyle, including diet and exercise, to reduce the risk of developing advanced disease. Obesity is a risk factor for prostate cancer progression and advanced disease.

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    Immediate Versus Deferred Hormonal Therapy

    Refer to the Treatment Option Overview for Prostate Cancer section for information on the use of immediate hormonal therapy plus radiation in the setting of locally recurrent prostate cancer after radical prostatectomy.

    PSA is often used to monitor patients after initial therapy with curative intent, and elevated or rising PSA is a common trigger for additional therapy even in asymptomatic men. Despite how common the situation is, it is not clear whether additional treatments given because of rising PSA in asymptomatic men with prostate cancer increase OS. The quality of evidence is limited.

  • After radical prostatectomy, detectable PSA levels identify patients at elevated risk of local treatment failure or metastatic disease however, a substantial proportion of patients with elevated or rising PSA levels after initial therapy with curative intent may remain clinically free of symptoms for extended periods. In a retrospective analysis of nearly 2,000 men who had undergone radical prostatectomy with curative intent and who were followed for a mean of 5.3 years, 315 men demonstrated an abnormal PSA of 0.2 ng/mL or higher, which is evidence of biochemical recurrence.
  • Of these 315 men, 103 men developed clinical evidence of recurrence.
  • The median time to development of clinical metastasis after biochemical recurrence was 8 years.
  • After the men developed metastatic disease, the median time to death was an additional 5 years.
  • What Treatments Are Used In Focal Therapy For Localized Prostate Cancer

    (PDF) Economic evaluation of treatments for patients with ...

    Focal therapy uses ablation, which is the use of extreme temperatures to destroy tissue. In focal ablation, the area of the prostate that contains the index lesion is targeted, rather than treating the entire prostate gland. Focal ablation techniques include:

    • Cryotherapy: The use of very cold gases passed through needles to freeze and destroy cancer tissue.
    • HIFU : The use of high-frequency sound waves directed at the tumor through an ultrasound probe inserted into the rectum. The high intensity waves cause the diseased tissue to heat up and die.
    • : A drug called a photosensitizer is injected into the bloodstream. This drug then absorbs light rays directed at the tumor, and produces an active form of oxygen that destroys cancer cells.
    • Laser ablation: The use of laser radiation energy pinpointed to a very small area to burn away cancerous tissue. Some laser ablation has the advantage of being able to be performed at the same time as magnetic resonance imaging , allowing very specific targeting and also real-time views of results.

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    Watchful Waiting Or Active Surveillance/active Monitoring

    Asymptomatic patients of advanced age or with concomitant illness may warrantconsideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent.

    Watchful waiting and active surveillance/active monitoring are the most commonly used terms, and the literature does not always clearly distinguish them, making the interpretation of results difficult. The general concept of watchful waiting is patient follow-up with the application of palliative care as needed to alleviate symptoms of tumor progression. There is no planned attempt at curative therapy at any point in follow-up. For example, transurethral resection of the prostate or hormonal therapy may be used to alleviate tumor-related urethral obstruction should there be local tumor growth hormonal therapy or bone radiation might be used to alleviate pain from metastases. Radical prostatectomy has been compared with watchful waiting or active surveillance/active monitoring in men with early-stage disease .

    • Regular patient visits.
    • Transrectal ultrasound .
    • Transrectal needle biopsies .

    Patient selection, testing intervals, and specific tests, as well as criteria for intervention, are arbitrary and not established in controlled trials.

    Comparison Of Curative Treatments

    Active surveillance, radiation therapy, and surgery all have advantages and disadvantages .13,2427 A randomized controlled trial of 1,643 men in Great Britain compared active surveillance, radical prostatectomy, and external beam radiation therapy for treatment of clinically localized prostate cancer over a median of 10 years.24 There were 17 prostate cancerspecific deaths overall: eight in the active-surveillance group , five in the radical prostatectomy group , and four in the EBRT group . There were no significant differences among groups in prostate cancerspecific mortality or all-cause mortality. Surgery and radiation therapy were associated with lower incidences of disease progression than active surveillance. No trials have compared treatment outcomes by race or ethnicity.

    Summary of Curative Treatment Options for Localized Prostate Cancer

    Radical prostatectomy

    EBRT = external beam radiation therapy.

    Information from references 13, and 24 through 27.

    Summary of Curative Treatment Options for Localized Prostate Cancer

    Radical prostatectomy

    EBRT = external beam radiation therapy.

    Information from references 13, and 24 through 27.

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    Ajcc Stage Groupings And Tnm Definitions

    The AJCC has designated staging by TNM classification.

    Table 1. Definition of Histologic Grade Groupa

    Grade GroupGleason ScoreGleason Pattern
    aAdapted from AJCC: Prostate. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp. 71526.
    1
    4+4, 3+5, or 5+3
    54+5, 5+4, or 5+5
    Table 2. Definitions of TNM Stage Ia

    StageGleason Score Gleason Pattern gIllustration
    T = primary tumor N = regional lymph nodes M = distant metastasis cT = clinical T PSA = prostate-specific antigen pT = pathological T.
    aAdapted from AJCC: Prostate. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp. 71526.
    The explanations for superscripts b through g are at the end of Table 5.
    IcT1ac, cT2a, N0, M0cT1 = Clinically inapparent tumor that is not palpable.< 10
    cT1a = Tumor incidental histologic finding in 5% of tissue resected.
    cT1b = Tumor incidental histologic finding in > 5% of tissue resected.
    cT1c = Tumor identified by needle biopsy found in one or both sides, but not palpable.
    cT2 = Tumor is palpable and confined within prostate.
    cT2a = Tumor involves 1/2 of one side or less.
    N0 = No positive regional nodes.
    M0 = No distant metastasis.
    Gleason Score, 6 Gleason Pattern, 3+3 .
    N0 = No positive regional nodes.
    M0 = No distant metastasis.
    References

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