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Prostate Cancer Treatment Options

Prostate Cancer Treatment Options:

    • High Intensity Focused Ultrasound (HIFU)
    • Radical prostatectomy
    • Radiation therapy
    • Hormone therapy
    • Cryotherapy

Some patients are choosing no treatment at all, or active surveillance, because of the effects on quality of life after treatment. The treatment modalities are described below in more detail.

High Intensity Focused Ultrasound (HIFU)

HIFU with the Sonablate 500 is a non invasive treatment option for prostate cancer that uses a transrectal probe to focus ultrasound waves in the prostate. In the focal zone, the temperature is rapidly elevated which causes tissue destruction. During HIFU, the entire prostate is treated or ablated. The entire gland is ablated to make sure there is less chance for cancer to recur in tissue that might have been left in the area. HIFU with the Sonablate® 500 takes between one to three hours and is performed as an out-patient procedure under a general, spinal, or epidural anesthesia. Recovery is minimal. There is a catheter that is inserted during the procedure that is usually worn for one to four weeks as the body heals so the bladder can empty properly. People usually are up and walking around within hours after HIFU and can return to a normal lifestyle within a couple of days. HIFU with the Sonablate® 500 has very low rates of both impotence and incontinence. Focal HIFU for small cancers appears to be feasible, with an even further decreased risk of impotence and/or incontinence.

Radical Prostatectomy

A radical prostatectomy is surgery to remove the entire prostate gland and some of the tissue around it and may be done by open or (robotic) laparoscopic surgery. An open prostatectomy usually takes one to two hours and a laparoscopic prostatectomy can take up to eight hours. The procedure is usually preformed under general anesthesia, requires a one to seven day hospital stay and a catheter is worn after the procedure for up to three weeks. Full recovery and mobility can take up to eight weeks. Following a radical prostatectomy, impotence rates are as high as 50% to 80% and incontinence rates between 10% and 20%.

Radiation Therapy

There are two primary types of radiation therapy: External Beam Radiation Therapy (EBRT) and brachytherapy or seed implants. EBRT is usually recommended for men with a prostate volume less than 60 grams and involves eight weeks of radiation directed at the cancer from outside of the body. Brachytherapy is radiation therapy transmitted by tiny radioactive pellets placed inside the prostate.

Radiation therapy has improved greatly in recent years; however, often the area of radiation is not precisely controlled and the radioactivity can extend beyond the therapeutic field and affect the neuro-vascular bundles and urinary sphincter causing permanent damage that leads to impotence and incontinence. As many as 80% of men who receive radiation notice a change in their ability to have erections. This change most often develops slowly over the first year or so after radiotherapy. Approximately 10% to 20% of radiation patients suffer from incontinence.

There is also a chance for damage to the rectum and the bowels as a result of ionizing radiation including proctitis or a rectal fistula which in severe cases may require a colonoscopy. Recent studies also show that radiation for prostate cancer causes a greater risk for developing rectal or colon cancer. The radiation field may also extend to the bladder causing radiation cystitis, an irritation of the bladder, which may be severe enough to necessitate major surgery to divert the urine away from the bladder.

Hormone Therapy

Hormone therapy, which reduces the amount of testosterone in the bloodstream and thereby deprives a prostate tumor of a necessary stimulus, has been shown in clinical trials to extend life and delay time to disease progression. Nearly all prostate cancers treated with hormone therapy become resistant to this treatment over a period of months or years. Possible side effects of hormone therapy include: hot flashes, breast tenderness and growth of breast tissue, osteoporosis, anemia, decreased mental acuity, loss of muscle mass, weight gain, fatigue, decrease in HDL (”good”) cholesterol and depression.

Cryoablation

Cryoablation is a form of cryotherapy for the prostate that involves the controlled freezing of the prostate gland in order to destroy cancerous cells. The damage caused by freezing occurs at several levels: molecular, cellular and whole tissue structure. Important factors influencing freezing injury are the rate of temperature reduction after the initiation of freezing, the time cells remain frozen and the subsequent heating rate during thawing.

The cells are not the only structures damaged during freezing. During cryoablation of the prostate, the surrounding connective tissue (stroma) and the smallest blood vessels (capillaries) are damaged and subsequently have an inadequate blood supply that is believed to slow the growth of cancer.

Cryoablation begins with placing hollow needles at predetermined locations in the prostate under ultrasound guidance. Through the needles Argon gas is injected that results in deep sub-zero temperatures causing cellular destruction of the prostate in a controlled fashion. This cycle is repeated at least twice to achieve cancer cell destruction. Although it is considered a minimally invasive procedure, it is still a major operation and may require an overnight hospital stay. A catheter is inserted after the procedure and worn for one to three weeks. Over 90% of the patients treated with classic cryoablation are impotent and less than 10% are incontinent. Focal cryoablation can be performed on small cancers, significantly decreasing the chances of impotence and incontinence. 1 Five years experience of transrectal high-intensity focused ultrasound using the Sonablate device in the treatment of localized prostate cancer. Toyoaki Uchida, et al. Dept. of Urology University of Tokai Hachioji Hospital. International Journal of Urology 2006.

2Long JP, Bahn D, Lee S, Shinohara K, Chinn DO, and Macaluso JN. Five year retrospective, multiinstitutional pooled analysis of cancer-related outcomes after cryosurgical ablation of the prostate. Urology 2001, 57:518-523.

3Health-Related Quality-of-Life Effects of Radical Prostatectomy and Primary Radiotherapy for Screen-Detected or Clinically Diagnosed Localized Prostate Cancer. Joanna B. Madalinska, Marie-Louise Essink-Bot, Harry J. de Koning, Wim J. Kirkels, Paul J. van der Maas, Fritz H. Schröde

4Bahn DK, Lee F, Badalament R, Kumar A, Greski J, Chernick M. Target cryoablation of the prostate: 7-year outcomes in the primary treatment of prostate cancer. Urology 2002, 60 (Supp 2A): 3-11.

5Han M, Partin AW, Pound CR, Epstein JI, Walsh PC. Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy. The 15-year Johns Hopkins experience. Urol Clin North Am. 2001 Aug;28(3):555-65.

6Ljung G, Norberg M, Hansson H, et al. Transrectal ultrasonically-guided core biopsies in the assessment of local cure of prostatic cancer after radical external beam radiotherapy. Acta Oncologica 1995, 34:945-952.

7Dinges S, Deger S, Koswig S, et al. High-dose rate interstitial with external beam irradiation for localized prostate cancer-results of a prospective trial. Radiother Oncol1998, 48:197-202.

8Stock RG, Stone NN, DeWyngaert JK, et al. Prostate specific antigen findings and biopsy results following interactive ultrasound guided transperineal brachytherapy for early stage prostate carcinoma. Cancer 1996, 77:2386-2392.

9Potters, L, Permanent Prostate Brachytherapy in Patients with Clinically Localized Prostate Cancer. Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center. 2004. http://www.malecare.com/new_page_93.htm

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