Treatment of stage -c- prostate cancer -- current thoughts

TREATMENT OF STAGE -C- PROSTATE CANCER -- CURRENT THOUGHTS

Stage C cancer means that the cancer remains in and around the prostate but has not spread to
other organs, such as lymph nodes or bones. The areas that might be involved include:
the tissues and muscles of the pelvis around the prostate
the seminal vesicles, which are glands that also make semen and are connected to the prostate
gland
the bladder neck (where the prostate and bladder join)
The following are the choices that are available to us in the treatment of Stage C prostate cancer.
NO TREATMENT
This option consists merely of close observation of the cancer, looking for any signs of
progression with blood tests, scans and physical examinations. Specific cancer treatment will be
undertaken only when problems arise from the cancer growth. While this approach may seem
out of the question in some cases, withholding treatment is appropriate and justifiable in many
circumstances. The treatments might be more risky than the disease. For instance, a very
elderly male with Stage C cancer, and with no symptoms, might be better left alone. The same
goes for someone with other significant medical problems such as emphysema or heart disease.
In the absence of symptoms, and in the presence of other medical situations which are more
threatening, observation may be appropriate.
In some medical environments, such as Sweden, no treatment or observation has become a fairly
standard approach to prostate cancer. They believe that in some patients, the disease will grow
so slowly that radical treatment is unneeded because patients will die of other diseases. In
patients whose prostate cancers grow quickly, they feel comfortable that treating the spread with
medical or hormonal treatment is all that is required or needed, even if not curative.
Observation has many supporters and must be considered.
HORMONE THERAPY
The prostate gland is uniquely male. Its very existence is due to the presence of male hormones,
which the prostate, and most prostate cancers require to grow. This observation led urologists to
the use of hormone reduction to treat prostate cancer in the 1940s. Except for newer drugs, the
principles of hormone reduction still stand today.
Most male hormone, or testosterone, is made in the testes. The usual way of effecting hormone
reduction is either a monthly shot (Lupron or Zolodex) or surgical removal of the testicles
(orchiectomy). The shots are temporary and the effects are reversible when the shots are
stopped. Removal of the testicles is a permanent treatment that cannot be reversed. Medication
taken in pill form, referred to as antiandrogens such as flutamide or bicalutamide, may be added
to either of these treatments to further reduce male hormone activity.
Seven out of ten men will have an initial reduction in the tumor present. Unfortunately this
response is usually not permanent. In most patients the response to hormone therapy will last 2-
3 years. In most cases the first sign of the cancer growing once again is a rise in the prostate
specific antigen (PSA). Other treatments may then have to be used.
In some patients, reversible hormone treatments with shots and pills (Lupron, Zolodex,
flutamide, bicalutamide) can also be used to temporarily shrink the cancers, so that the cancer
might then respond better to surgery or radiation treatments. Adding hormone treatment to
radiation or surgery is still experimental, but some of the preliminary studies have shown good
respones. Hormones may be given for three to eight months before surgery and then usually
stopped after the prostate has been removed. Hormones are usually given at the same time as
radiation treatments (external therapy or implants) and then stopped after the treatments are
completed.
SURGERY
Surgical removal of the prostate, or 'Radical Prostatectomy', is felt to be a standard therapy for
localized prostate cancer or Stage B. The use of surgery for locally extensive cancer (Stage C) is
more controversial. With the addition of pre-surgery hormone treatments, many inoperable
patients can be successfully treated with removal of the prostate. The possibility of lymph node
involvement that cannot be seen on CAT scan or MRI is very high, perhaps 50% or more. The
lymph nodes are usually carefully examined in patients with Stage C disease before the prostate
is removed. If the nodes are involved, most surgeons feel that removal of the prostate should not
be done and the surgery is stopped.
In some situations, when the PSA is very high (over 20) and the tumor is very aggressive
(Grade is > 7), we may consider laparoscopy to look at the lymph nodes. This is a telescopic
examination of the internal structures done with a general anesthetic. Laparoscopy allows us to
remove suspicious lymph nodes without a big incision in the abdomen. If the nodes are not
involved, surgery or radiation can then be done.
Radical prostatectomy involves removal of the entire prostate gland. The bladder is reconnected
to the urethra (channel through the penis). Removal of part of the prostate or just the cancer is
not done. Too many prostate cancers have multiple areas of involvement within the gland that
are undetected, making partial removal a poor choice. Also, partial prostatectomy is not
technically feasible.
The major advantage of total prostate removal is the simple fact that IF the cancer is localized to
the prostate then removal of the prostate will potentially cure the cancer.
The major disadvantages are:
There is no guarantee of cure of the cancer
Incontinence--2-4% of men will have permanent problems with urinary control-- they will
require some form of protection (diapers). In those rare cases, a surgical appliance can be
implanted to control incontinence if it does remain a problem.
Impotence--The nerves that stimulate erections run adjacent to the prostate on their way to the
penis. If all of these nerves are removed during total prostatectomy, impotence (inability to
achieve an adequate erection) will result. In certain circumstances, some of the nerves that
create erections can be spared with a success rate between 40-70%. Not every man is a good
candidate for nerve sparing because of the extent of disease, particularly Stage C cancers.
Patients who develop impotence, and even those whose erections were not adequate before the
surgery can be treated with a variety of modalities. Treatment of impotence in post-prostate
surgery includes vacuum pumps, self-injections of medications and placement of prostheses --
all of which work, and work well in selected patients.
Blood loss--Radical prostatectomy carries with it an average blood loss of greater that one unit of
blood. On occasion, the blood loss can be more than three or even four units. To prevent the use
of bank blood we sometimes ask patients to store their own blood for subsequent use, if needed.
Easy to do, and clearly the safest way to receive blood.
Surgical complications--pain, infection, anesthetic problems, pneumonia, blood clots, and heart
problems can occur with any major operation. Unique to prostatectomy are injury to the rectum
(adjacent to the prostate), and scarring of the new connection between the bladder and urethra,
which might require stretching, performed in the office or in day surgery.
Recovery Time: The operation lasts two to three hours and the hospitalization usually lasts 2 to
3 days. All patients go home with a catheter in place, continually draining the urine into a
special leg bag. You will be seen three weeks after surgery to have the catheter removed. Most
men have poor urinary control at the beginning and will require some form of protection, such
as a diaper. Within three weeks, most men have achieved reasonably good control and require
minimum protection and have resumed their normal activities. Sometimes, the recovery is
slower, but rarely more than three to six months.
RADIATION THERAPY -- EXTERNAL BEAM
External beam radiation therapy is one of the simplest of therapies trying to cure the cancer.
Over a six to seven-week period, the patient will receive a radiation treatment lasting about 15
minutes, 5 days a week. The radiation is aimed at the prostate from many different angles in an
attempt to reduce the dosage to the surrounding tissues while maximizing the dosage to the
prostate and the cancer. As mentioned above, we may give temporary hormone shots and pills
during the radiation treatment.
The advantages of external radiation therapy are its ease of administration, requiring no surgery,
no anesthesia, and no blood loss. The biggest disadvantage is that the cancer is left in place and
one must hope that the amount of radiation delivered is enough to cure the cancer.
Unfortunately, the surrounding structures being sensitive to overdoses of radiation, namely,
bladder and rectum, limit the amount of radiation that can be given safely. Hence the dose given
may not be enough to kill all the prostate cancer cells. The recurrence rates of the cancer at later
times is in the range of 70% or more, as measured by rising of the tumor marker, PSA.
During the last two to three weeks of treatment, diarrhea and urinary urgency and frequency are
quite common and on occasion so severe that the treatments need to be temporarily halted.
These symptoms usually resolve two to three weeks after the radiation treatments have ceased.
Permanent radiation injury to the bladder or rectum occurs in a small percent of patients creating
chronic pain and/or bleeding. Difficulty with erections (impotence) occurs in 50% of patients
who were having no problems prior to treatment.
IMPLANT THERAPY
Implants are forms of radiation therapy that can be used with localized cancer. Stage C cancer
usually involves areas that the implant will not treat. Most radiation therapists will not consider
implants for Stage C disease.
CHEMOTHERAPY
Chemotherapy is the use of medicines or drugs to stop the growth of cancers. Chemotherapy is
used for the most part in patients whose disease has spread to other parts of the body
(metastases) and is resistant to other forms of treatment.
The drugs are very powerful and work by killing cells that tend to grow quickly. Cancers tend to
grow quickly, but, unfortunately, so do cells in bone marrow, gut and other areas. Anemia,
weakness, nausea, vomiting, diarrhea and other side-effects can occur. Unfortunately,
chemotherapy rarely cures prostate cancer, but merely palliates or temporizes the cancer growth.
Because of the poor track record with prostate cancer, chemotherapy tends to be used only
when all other avenues of treatment have been exhausted.
CRYOTHERAPY
Cryotherapy or 'freezing' the prostate has been around for 40 years. The original technique
involved open surgery and placement of liquid nitrogen directly into the prostate cancer. The
overall success rate was marginal and the technique was abandoned in the early 60's. More
recently, cryotherapy using ultrasound as a guide to place needles has returned. To date,
insufficient data exists to know how effective cryotherapy might be. The frozen tissue dies and
is then either urinated out or re-absorbed into the body. Whether all of the cancer is killed is
unknown at this time.
Follow-up to Treatment.
After your treatment is rendered, regardless of which treatment is undertaken, we will be
following your progress very closely. If surgery or observation is chosen, the follow-up will be
through our office. If radiation or implants are used, the follow-up will be shared by our office
and the radiation therapists.
The keys to follow-up in most circumstances will be the rectal exam of the prostate, or, in the
case of surgery, the area where the prostate was. We will be looking for evidence of recurrence
or regrowth of the tumor. If suspicious areas occur, ultrasound and biopsies of these areas may
be indicated.
In addition, the PSA blood test can be used as a marker for the effectiveness of treatment. If the
prostate gland is removed (Radical Prostatectomy) we expect the PSA level to be unmeasurable
(reported by the laboratories as less than 0.1, 0.05, or 0.02, depending on the specific assay that
is used). If any PSA is measured after Radical Prostatectomy, then the presence of prostate
cancer cells somewhere in the body has to be suspected. Prostate cancer cells that have spread to
other areas also leak PSA. Even if we cannot find the areas of spread with scans or other tests,
the presence of PSA means that the cancer is present. IF the treatment of the cancer was with
any form of radiation, chemotherapy or hormone therapy, the PSA level will not necessarily
become unmeasurable. The normal prostate cells may not be destroyed and may still leak
normal amounts of PSA. However, the PSA level should be stable if the treatment is working.
That means a rising PSA level suggests growth of the cancer.
In summary, all the treatments discussed above are appropriate and acceptable. This handout is
an outline of the important points of each treatment. More than likely you will have other
questions to be answered. Some of the terminology may not be clear or understandable to you
or your family. You may have heard of other treatments for cancer that might be applicable. We
expect to be able to discuss all these questions with you in further detail.

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