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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Modifying Risk Level Classification
The new millennium brought changes as 1) more epidemiological and demographic data accumulated, 2) the nature of PCa was better understood, and 3) sub-radical therapies such as focal ablation or hemi-ablation were developed to offer comparable cancer control but with far fewer side effect risks. A need was seen to add qualifiers to low risk PCa. Thus, the National Comprehensive Cancer Network subdivided this category into very-low and low-risk types to help doctors and patients determine for which men Active Surveillance or a sub-radical treatment would be safe choice.
The NCCN system did not qualify intermediate risk PCa. It differs a bit from DAmico, defining it as stage T2b or T2c, Gleason score of 7, and PSA level 10-20 ng/mL. However, by 2015 it was clear that this category was the largest group of PCa cases with the most heterogeneous disease characteristics. There was a wide range of PCa-specific mortality as well as biochemical or clinical recurrence after radical treatment by prostatectomy, beam radiation, and brachytherapy . Studies began to show that all Gleason 7 is not created equal men with Gleason 3+4=7 had better outcomes than those with Gleason 4+3=7, Therefore, In order to better understand this risk group, new classification systems have been proposed that help reduce its heterogeneity by subdividing men with intermediate-risk prostate cancer into favorable and unfavorable subgroups.
Focal Therapy For Prostate Cancer
With recent advances in MRI and targeted biopsy, we are better able to locate the exact area of prostate cancer. Men who do not have an enlarged prostate, who have prostate cancer that is detected only in a single region of the prostate and have intermediate grade cancer can be a candidate for focal therapy. This type of therapy treats only the cancerous tissue and spares the normal prostate, thereby preserving urinary and sexual function
Here at UCLA we commonly use cryotherapy or HIFU to focally treat prostate cancer. Given that this is a relatively new form of treatment, we have established rigorous post-treatment protocols using MRI and biopsies to ensure that the cancer has been adequately treated.
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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.
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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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.
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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Gene And Protein Tests For Prostate Cancer
For men with prostate cancer that is localized , a major issue is that its often hard to tell how quickly the cancer is likely to grow and spread. This can make it hard to decide if the cancer needs to be treated right away, as well as which types of treatment might be good options.
Some types of lab tests, known as genomic, molecular, or proteomic tests, can be used along with other information to help better predict how quickly a prostate cancer might grow or spread, and as a result, help decide what treatment options might be best and when they should be given. These tests look at which genes or proteins are active inside the prostate cancer cells. Examples of such tests include:
These tests continue to be studied to find more areas where they can be useful in prostate cancer risk and treatment decisions.
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 .
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Considering Prostate Cancer Treatment Options
For most men diagnosed with prostate cancer, the cancer is found while its still at an early stage its 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 youre 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.
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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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.
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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Matching Treatment For Favorable Risk Prostate Cancer
Today, the majority of PCa cases are diagnosed early thanks to PSA screening coupled with noninvasive multiparametric MRI tumor detection. It therefore makes sense that for those with Gleason 3+3 and some with Gleason 3+4, the conditions are favorable for a successful minimalist approach to managing the disease, including treatment and AS. These are considered favorable low-risk and favorable intermediate-risk prostate cancers. When carefully diagnosed and qualified, these patients may safely hold off on such aggressive radical treatments provided they protect themselves by adhering to monitoring protocols.
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 havent 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.
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Comparison Of Distribution Of Patient Characteristics Stratified By Whether Patient Was Upgraded To Prostatectomy Gleason 8 Or Higher
Clinicopathologic characteristics of the 136 included patients are presented in Table 1. The median age was 60.5 years, and the median pretreatment PSA was 5.8 ng/mL. Most men had clinical T1c disease. All of men had Gleason score 7, with 49.3% of these demonstrating Gleason 4 + 3 on biopsy. The median GPC was 70%. We observed that men who had pathologic upgrading at the time of RP were significantly older and had higher median GPC
Treatment Protocol At Each Institution
Some patients receiving SEED-BT at institution A in 2006 were treated using preplanning methods. Most other patients at the 3 institutions were treated using an intraoperative planning method with modified peripheral loading techniques using a Mick applicator,. The therapeutic planning and post-implant dosimetric evaluation were performed using the Interplant planning system or Variseed . 125I was used for all patients. Either Oncoseed 6711 or STM 1251 was used for SEED-BT. The doses were defined using the TG-43 criteria. At 1 month after treatment with SEED-BT alone, a computed tomography-based dosimetric analysis was performed to calculate the D90, V100, and V150 results. Prostate D90 is the minimum dose to 90% of the prostate gland at 1 month. Prostate V100 and V150 are the percentages of the prostate gland volume respectively receiving 100% and 150% of the prescribed dose at 1 month. These treatment protocols were used at each institution:
Institution A
Institution B
Institution C
All patients classed as intermediate-risk were candidates for treatment with SEED-BT alone. Patients receiving SEED-BT alone were treated at a prescribed dose of 145 Gy. Non patients were treated with a combination of SEED-BT and EBRT. The CTV for SEED-BT included the entire prostate. No PTV was created in SEED-BT.
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