Treatment of prostate cancer

The treatment of prostate cancer depends very much on the stage of cancer at the time of diagnosis and whether the cancer is low, intermediate, high risk or metastatic. Listed below are options of treatment for each category.

Treatment of Low risk Prostate Cancer

Low risk prostate cancer is one where the risk of spread of cancer to other parts of the body is low and the cancer is less aggressive when compared to other groups. The various options of treatment are:

Active surveillance: This is an option in some patients where the risk of cancer increasing or spreading is very low. Here treatment of any form is not given and the patient is actively monitored until a time comes when the disease shows signs of increasing. A large number of studies have shown that there will be a group of patients with prostate cancer that will not increase over a number of years and they can continue to be on active surveillance over that time. A number of patients in this group may not see any progression of cancer in their lifetime. Curative treatment can be offered at a time when there is a sign that the cancer is increasing. This is a treatment option that can be discussed with your oncologist as not all people will be suitable for it.

Radical Prostatectomy: This is a surgical option for treatment of prostate cancer. Here the prostate along with lymph nodes in the pelvis are removed to treat the cancer. This operation can be done by an open method or laparoscopic method or robotic method. The laparoscopic or robotic methods are less invasive and patients recover more quickly. In open prostatectomy, the surgeon makes an incision in the lower part of the abdomen. This is called retropubic prostatectomy. The other option (perineal) that some surgeons use is to make an incision between the testes and the anus. The prostate gland is removed along with the lymph nodes of the pelvis, as well as the seminal vesicles which are present behind the prostate.

In the laparoscopic operation, the surgeon uses a tube with a light source which is connected to a camera which helps the surgeon to look inside the tummy. A small cut is made in the abdomen to insert this tube. More cuts are made in other parts of the abdomen to insert surgical instruments. The prostate and other tissues are removed as in the above procedure. This method is known to reduce bleeding as well as reduce hospital stay and has similar outcomes as compared to standard surgery.

The robotic method involves the use of the da Vinci system. This is another form of laparoscopic surgery where the surgeon uses the help of a robot. This is a machine which has 4 arms. One arm holds the camera and the other 3 arms hold the surgical instruments. The surgeon sits at a separate console from where he performs the operation. This method has been shown to be at least as effective as the laparoscopic operation, if not better.

Like all treatments, radical prostatectomy has certain side effects. These can be impotence or leakage of urine (incontinence). In early prostate cancer, a nerve sparing prostatectomy can be done, which reduces the risk of impotence after surgery.

Radiotherapy: Radiotherapy is another curative treatment option in this group of patients. In radiotherapy, there are two main ways of giving the radiotherapy.

External beam radiotherapy is an option where radiotherapy is given with a machine that is outside (like an X-ray machine) and delivers high energy X-rays to the prostate. The other option is brachytherapy, where radioactive sources are inserted into the prostate, where these sources deliver the radiation. Not all patients are suitable for undergoing brachytherapy as a mode of treatment. Patients who would not be suitable for this approach include those with a large prostate and those with a lot of urinary symptoms, among other things. Sometimes, a combination of external beam radiotherapy and brachytherapy is used.

In external beam radiotherapy, various techniques of delivering the radiotherapy exist. The usual duration of treatment is about 7.5 to 8 weeks, with treatment administered once daily, 5 days a week.

3D conformal radiotherapy is a method where a CT scan is used to plan the treatment and the treatment is shaped to fit the shape of the prostate. This is an older technique and is the minimum standard of care in treating this condition.

Intensity modulated radiotherapy or IMRT is a more specialised method than 3D conformal treatment in that the area that is being treated with radiation can be shaped even more accurately than the above method. This helps in reducing the side effects and also gives a higher dose of radiation to the target.

IGRT is image guided radiotherapy which uses images taken regularly (CT scan or X-ray) before each radiotherapy treatment to improve accuracy. IGRT can be used with any of the techniques described in this section.

Rapid Arc or VMAT is a specialised form of intensity modulated radiotherapy where the treatment is given in the form of an arc and can be more accurate with less toxicity, as compared to standard intensity modulated radiotherapy.

Cyberknife is also a form of intensity modulated radiotherapy, which is given with a type of machine called the CyberKnife. This machine delivers external beam radiotherapy similar to rapid Arc or VMAT but the differences lie with CyberKnife being a completely different type of radiotherapy machine using different methods of delivering radiotherapy, while being as accurate as the above treatments.

SBRT or stereotactic body radiotherapy is a form of external beam radiotherapy, where the number of radiotherapy treatments are less, usually ranging from 3-10 as compared to standard radiotherapy, and lasting up to 8 weeks. Here, a high dose of radiotherapy is given with each treatment and, therefore, the total number of treatments is less. A high degree of precision is needed to deliver this treatment.

SBRT may be a suitable option in some low and intermediate risk prostate cancers.

Proton Beam Therapy is a form of radiotherapy (particle radiotherapy) that is currently not available in India. This treatment involves the use of protons instead of high energy X-rays that are given with standard radiotherapy. Proton therapy is more beneficial than standard radiotherapy in certain cancers, but has not been shown to be significantly better than standard radiotherapy in prostate cancer.

The side effects of prostate radiotherapy include mild tiredness, urinary symptoms in the form of burning sensation, increased frequency of urination during the day and night, urgency of urination, diarrhoea, passing of mucus and frequency of opening bowels. These effects will be at their maximum after completion of the treatment, but will usually resolve a few weeks after the treatment. There can be long term effects of radiotherapy as well, which can be discussed with the oncologist prior to starting treatment.

Hormone Treatment or Orchidectomy: A small group of patients with low-risk prostate cancer, who are not suitable for either surgery or radiotherapy, may benefit from having hormone treatment with tablets or injections. There is also an option of having an orchidectomy (removal of testes) instead of using hormonal medications. Either of these options will help control prostate cancer.

Treatment of intermediate risk prostate cancer

Patients with intermediate risk prostate cancer are those with a PSA between 10-20, or Gleason score 7, stage IIa-IIb. The options for treatment of patients in this group include radical prostatectomy, radiotherapy and hormones. Active surveillance is usually not an option in this set of patients.

For patients with intermediate risk prostate cancer choosing to have radiotherapy, hormones in the form of LHRH analogues are given for 2-3 months prior to, and during radiotherapy. This helps in achieving better control on the prostate cancer. The option of having hormones is not recommended for patients going for prostatectomy as their benefit has not been proven. In patients who are not fit for either surgery or radiotherapy, hormones alone can be an option of treatment.

Treatment of high risk prostate cancer

Prostate cancer is said to be high risk when the PSA is greater than 20, or the Gleason score is 8 or more, or it is stage TIIc or more.

When the disease is said to be confined to the prostate gland, radical prostatectomy may still be an option of treatment. However, when the disease is found to be extending outside the prostate gland, radiotherapy will be the main option of treatment. In such situations surgery to remove the prostate gland is not done.

Hormonal treatment is used along with radiotherapy. It is given for 3 months prior to radiotherapy, during radiotherapy and for up to 2-3 years in total duration.

In patients not suitable for radiotherapy, hormonal treatment is given on its own. The other option is an orchidectomy (removal of testes) which does the same job.

Treatment of Metastatic Prostate Cancer

Metastatic prostate cancer occurs when there is spread of prostate cancer to distant sites in the body. The following are the treatment options available in metastatic prostate cancer. Once, metastatic prostate cancer is diagnosed, treatment options are mainly able to control the disease rather than cure it.

Hormonal treatment: This form of treatment is the mainstay in the management of metastatic prostate cancer. Hormones can be given as tablets or injections and are usually given from the time of diagnosis of the metastatic disease. Prostate cancer tends to grow by feeding on testosterone produced in the body. The hormonal agents that are used help by either reducing the production of testosterone or blocking the effects of testosterone.

Hormonal agents such as leuprorelin, goserelin, triptorelin and degarelix are used which are given in the form of injections, usually once every 1-3 months. Other agents such as bicalutamide, enzalutamide and abiraterone are given as tablets. Hormonal treatment works for a period of time after which the cancer can start to grow again. It is then called hormone refractory cancer. The usual time period for which the hormones work is measured in years.

Chemotherapy: Chemotherapy is frequently used for treatment of prostate cancer. Commonly used drugs in this setting are Docetaxel, Mitoxantrone and Cabazitaxel. These agents can be given at the same time as the hormonal treatment or after the hormonal treatment stops working. These drugs help to reduce the prostate cancer and give relief from the symptoms associated with cancer. They help in prolonging survival.

Radiotherapy: Radiotherapy in metastatic prostate cancer is mainly used to control the symptoms that are being produced by the cancer. These symptoms could be varied and include pain and bleeding. The duration of radiotherapy in this setting is usually short ranging from 1-15 treatments. Only very occasionally is radiotherapy given for longer than that in the setting.

Other treatments: Other treatments that are used in metastatic prostate cancer include steroids, oestrogens and progesterones. Radioactive sources such as Strontium-89 and Radium 223 are used for the treatment of bone metastases. Drugs called bisphosphonates are used also to reduce symptoms due to bone metastases.

Monitoring of disease in metastatic prostate cancer is usually done with the help of serial PSAs and scans. The scans used are CT scans and isotope bone scans. PET CT scans are usually not recommended for regular monitoring of the metastatic disease.

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