If prostate cancer has been diagnosed, graded and staged, there is much to consider before reaching a prostate cancer treatment decision. Patients often feel that they must make a decision quickly. However, it is essential that a patient allows adequate time to educate himself, and reaches a well-informed decision regarding his options. A patient should ask questions of his cancer care team.
Ideally, seeking a second opinion is worthwhile. Prostate cancer is a complex disease, and physicians may differ in their opinions.
Treatment of prostate cancer using seed brachytherapy was pioneered in the 1960s as an effective alternative to surgery. The word brachytherapy is derived from the Greek prefix brachy, meaning “short” or “close”, because the seeds containing radioactive material are implanted directly into the cancerous prostate gland.
Also referred to as seed implants or seeds, brachytherapy is a one-time, minimally invasive procedure usually performed in an outpatient setting under general anesthesia. The procedure itself involves the placement of tiny radioactive seeds inside the prostate using ultrasound equipment.
The seed implants immediately emit radiation and kill the malignant cells inside the prostate. The time it takes for the radiation to deliver its total dose depends on the seed (isotope) used. There are currently 3 isotopes commonly used in prostate brachytherapy: Cesium131, Iodine125, and Palladium103. Brachytherapy seeds themselves are compatible with human tissue. After the procedure, patients are taken to recovery and are typically discharged a few hours later. Most patients resume normal activities within 24-48 hours. The most common side effect of brachytherapy is temporary urinary irritation including frequency and urgency. These symptoms will last from a few weeks to a few months.
There are several different types of surgical procedures for prostate cancer, each with different benefits and risks. What is important to understand is that the risks associated with surgical removal of the prostate are much like those of any major surgery, including risks from anesthesia. In addition, most men undergoing prostate surgery will be hospitalized, require a catheter for 2 weeks and experience a lengthy recovery time. Potential side effects of radical prostatectomy or robotic prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). Both incontinence and impotence can affect a man, not only physically, but emotionally and socially. These side effects are also possible with other forms of therapy, although with varying degrees of frequency and severity. At least one study concluded that the rate of complications is higher for less experienced surgeons (as compared to highly experienced surgeons) (Catalona, WJ, et al., “Potency, continence, and complication rates in 1870 consecutive radical retropubic prostatectomies”. J. Urol., 1999.)
External beam radiation is often referred to as IMRT (intensity modulated radiation therapy). The radiation is produced by a large machine outside the body. Men go to a hospital or clinic for the treatment. On average, treatments are given 5 days per week for 8 1/2 weeks, requiring ongoing trips to the clinic. Rectal side effects such as frequent bowel movements and rectal pain can occur with external radiation. As with other forms of prostate cancer treatment, urinary and sexual side effects are common and vary depending on the health of the patient, skill of the treating physician, dose of radiation received and the cancer itself.
Proton Beam Therapy
Proton beam therapy is a form of external beam radiation therapy. In many ways proton therapy is much like X-ray treatment. Using powerful magnets and other machines, protons, which are small particles, are accelerated to near the speed of light and aimed at cancerous tissues. The nature of these proton particles allows physicians to aim them more precisely, causing the radiation to dissipate soon after reaching the cancerous cells. This precision, however, has the downside of requiring treatments to take twenty to thirty minutes, which is longer than standard radiation therapy. Like IMRT, proton beam therapy also requires approximately 8 weeks of daily treatments.
Results evaluating the efficacy of proton beam therapy have only recently been reported. Only several thousand prostate cancer patients have been treated with this therapy. Results have been satisfactory; however, they have not shown to be superior to IMRT or brachytherapy for the treatment of prostate cancer. Furthermore, there are no urethral sparing techniques yet developed for proton beam therapy, which can potentially mean more urinary side effects. Finally, when compared to proton beam therapy, brachytherapy has a lower incidence of injury to the bladder and rectum, while still being capable of delivering the ultimate dose of radiation.
High intensity focused ultrasound (HIFU) is another form of treatment for prostate cancer. It is delivered through the rectum, using focused sound waves in a targeted area, which increases the temperature in the prostate to cause tissue destruction. HIFU is a 2-3 hour, one-time procedure performed under spinal or epidural anesthesia. It can be repeated if necessary.
Currently, there is no long-term data on the efficacy of this procedure. There are also some limitations; for example, the prostate gland must be of a certain size to perform the treatment effectively. Furthermore, side effects can include incontinence and impotence. Finally, this procedure is currently not FDA-approved for use in the United States.
High Dose Rate Brachytherapy
HDR brachytherapy involves the temporary placement of tiny plastic catheters into the prostate gland through a template that is sutured to the perineal skin below the scrotum. Once in place, a tiny radioactive seed is inserted on a temporary basis into the catheters in a sequential pattern. A computer controls the length of time the seed delivers its radiation through the catheter. After the radiation has been given, the catheters are removed, leaving no radioactive material in the gland. This type of treatment requires an overnight stay in the hospital and is usually combined with several weeks of external beam radiation.
Cryosurgery, or freezing the prostate, is another treatment option for prostate cancer. Using ultrasound guidance, an urologist inserts a probe filled with liquid nitrogen through the skin into the prostate, which freezes the prostate tissue. Cryosurgery may require a hospital stay. After the procedure, a supra-pubic tube or catheter is often used to rest the bladder for up to two weeks. Damage to the nerves and blood vessels around the prostate can cause complications. There is a possible risk of incontinence and impotence is very common.
Hormone therapy is a non-curative form of therapy. The end result is a decrease in testosterone level. This stops the cancer from progressing for a temporary time. Hormone therapy is often used in combination with IMRT or seed brachytherapy in high risk patients. It can also be used to reduce the size of the prostate gland prior to seed implant in a low risk patient. This type of therapy can be administered orally or via injection. Short-term side effects can include hot flashes, mood swings, fatigue and loss of sex drive. Long-term side effects can include weight gain, diabetes, osteoporosis, high cholesterol, breast tenderness and/or enlargement and possible cardiac complications.
Expectant Management (Watchful Waiting)
Depending on the characteristics of the cancer, some doctors may recommend an approach known as expectant management, or “watchful waiting.” This approach involves closely monitoring the cancer without active treatment such as surgery or radiation therapy. This option may be recommended if your cancer is not causing any symptoms, is expected to grow very slowly, or is small and contained within one area of the prostate. This option, however, is not advisable for men of a life expectancy greater than 10 years. Finally, patients need to be of the correct mindset for this option as knowledge of having a cancer, but not treating it, can cause anxiety.
“What you need to know about Prostate Cancer”. National Institute of Health, 2005.
“Understanding Prostate Changes”. National Institute of Health, 2004.