Treatment for prostate cancer depends on various factors such as the stage and grade of cancer, overall health, and personal preferences of the individual. Here are the questions men must ask themselves as they choose a treatment option.
What is the STAGE of my prostate cancer? Is it localized to the prostate or advanced beyond? Is my cancer locally advanced or widely metastatic? If my cancer is localized to the prostate is it high volume or low volume?
The STAGE is determined by the PSA, prostate exam, MRI and prostate ultrasound results as well as possibly and PET scan, bone scan or CT scans.
What is the GRADE of my prostate cancer? Is it growing quickly or slowly?
The grade of the prostate cancer is determined when the pathologist reviews the biopsies under the microscope. The grade of prostate cancer is given either as a Gleason Score or as a Grade Group. Further testing such as Decipher testing can help predict the future growth of the cancer, ie. is it likely to turn to a faster growing variant in the future?
What other health concerns do I have that will determine my choice of treatment? What is my expected longevity?
Men with longer life expectancy and better health should be biased towards treatment of the prostate cancer at initial diagnosis. Men with shorter life expectancy and multiple health concerns are better candidates for surveillance protocols or watchful waiting of their prostate cancer.
What are my goals for my care? What is important to me?
Some men will be biased towards more aggressive treatments by their personal choice or tolerance of surveillance. Some men will be more comfortable with surgery; other men will choose radiation. There is no one right answer in each case. Because there are alternative, a man’s personal preferences becomes a major factor in choosing a treatment option
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Active surveillance is monitoring the cancer over time. Active surveillance is employed for men with slower growing cancer, less cancer volume, and men with shorter life expectancy.
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A robotic radical prostatectomy is removal of the entire prostate. This is the most common treatment for localized prostate cancer that is expected to grow in the future.
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Radiation damages the cancer cells through a concentrated treatment of radiation to the prostate and the cancer cells. This is a good treatment option for men with localized prostate cancer or for men with local recurrence of prostate cancer after prostatectomy.
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Focal therapy is used in limited circumstances, the cancer would need to be confined to a portion of the prostate that can specifically be identified on imaging such as MRI. There are several options that can deliver ablativ treatment to a portion of the prostate.
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Hormone therapy is the standard for slowing down prostate cancer cells. Prostate cancer is sensitive to the male hormone testosterone. By reducing testosterone the cancer cells will slow their growth and may even top growing entirely and recede. Hormonal treatment are typically used for men with advanced prostate cancer but is also used in conjunction with radiation therpy.
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Advanced Prostate cancer is cancer that has spread beyond the prostate to other area of the body . Unfortunately there is no cure for this type of cancer and we must focus on slowing its growth. The good news is that there are a number of treatment options that exist.
In the picture above I outlined the algorithm of treatment choices available for men with prostate cancer. An algorithm takes a man down to treatment choices based on the parameters of his individual cancer.
Active Surveillance
Active surveillance of prostate cancer is the process of monitoring the cancer over time. Many prostate cancers do not need treatment because they are slow growing, and the rate of growth and spread will not impact a man’s quality or quantity of life. For elderly men or men with shorter life expectancy a surveillance process is often the best choice to avoid the complications that can occur with treatment. Some younger and healthier men may also choose surveillance as an option for their cancer if the disease is small and slow growing; the goal of monitoring in men with longer life expectancy is to “catch” the cancer and treat when the disease is showing signs of growth or increased rate of growth.
daVinci Robotic Radical Prostatectomy
Radical Prostatectomy is the most common choice for treatment for men with prostate cancers that are large enough in size and growing fast enough to require treatment. Radical Prostatectomy refers to the removal of the entire prostate and the attached seminal vesicles and, in most cases, a sampling of lymph nodes within the pelvis to check for cancer spread. Although radical prostatectomy is a great choice for many, men choosing prostatectomy should be aware of the potential for urinary incontinence and erection problems that can occur after prostatectomy.
Picture of the Male Pelvis. You can see the bladder and prostate in relation to the male genitalia and other external landmarks.
The prostate sits below the bladder. The urethra connects at the prostate and becomes the prostatic urethra.
The robotic instruments are long, thin instruments with six degrees of movement allowing for fine dissection of tissue.
The connective tissue around the prostate contains the nerve bundles that allow for erections and ejaculation.
The dissection begins around the prostate.
We mobilize carefully all of the tissue.
The urethra is divided at the level of the bladder and at the pelvic floor.
The neurovascular planes are spared if possible by dissection of the connective tissue around the prostate.
The prostate is removed from below the bladder.
There is a gap that requires an anastomosis between the bladder and the urethra.
A catheter is required to allow the anastomosis to heal.
The gap is usually easily bridged by bringing the bladder down to the level of the urethra.
The connection is made by suturing the anastomosis.
Once the anastomosis is complete the surgery is completed by removing the prostate from the body and closing the incisions.
Radiation Therapy
Radiation therapy is a general term used for the various types of methods to deliver radiation to the prostate to treat a man’s cancer. Radiation treatment are a good choice for many men as an alternative to surgical removal of the prostate. A radiation oncologist delivers the radiation treatment. Radiation therapy avoids some of the surgical risks of prostate removal, but complications can occur due to the radiation exposure to organs surrounding the prostate. The bladder and rectum are most at risk of radiation side effects. Changes to sexual function also are possible after radiation.
Focal and Alternative Therapies
As alternative to radiation and surgery, other options exist. While treatments other than radiation and surgery have not proven superior, many are options for whole gland treatment as well as the emerging role for “focal” therapy. Most men requiring treatment will need the entire prostate treated because of the amount of cancer present. Some men with cancer in just one portion of the prostate, however, may be candidates for treating just that portion of the prostate where the cancer exists.
Treatment for Advanced Prostate Cancer, Cancer Recurrence, or Metastatic Disease
Prostate cancers that have spread beyond the prostate are typically not candidates for treatment such as surgery, radiation, or alternative treatments. For those men the treatment is a combination of androgen deprivation therapy (aka ADT; lower the testosterone to very low levels), chemotherapy, immunotherapy, and other evolving treatments. Many cancers can be stopped simply by lowering the testosterone. For men with widespread cancer or when the ADT is no longer effective the additional treatments are employed.