Treatment of Prostate Cancer
Once it is determined that you have prostate cancer,
your doctor will explain the treatment options
available to you and recommend the most appropriate
option for you.
Watchful waiting (also called deferred therapy,
active surveillance, or
simply observation) puts off treatment for a
program of regularly monitoring. Under this approach,
your doctor will place you on a schedule of regular
prostate exams, PSA blood tests, urinalysis, and
consultations. Physicians who use this treatment
approach will do so only in cases involving men who
are not likely to live for several years even if their
prostate cancer is successfully treated. Typically,
these cases involve men who are in their mid 70s or
older, who have other significant health risks, and
who have prostate cancer that is believed to be a
low-grade, small-volume disease.
The problem with this approach, however,
is that the grade and volume of the prostate cancer
might be underestimated. Thus, the physician may
estimate that the prostate cancer is small, is slow
growing, and has not spread, while in actually the
cancer is large and aggressive. This is why many
urologists take the position that if prostate cancer
has been detected because of an abnormality on the
digital exam or because of elevated PSA levels, there
is most likely a significant cancer present.
Further, even if the cancer is not yet advanced or
15% or more of men who do not undergo treatment
eventually develop advanced prostate cancer and die
from it within ten years. After ten years, the chances
for rapid growth and spread of the cancer, and for
death from the cancer, rise dramatically.
Watchful waiting is thus an approach that can allow
the prostate cancer to grow, become aggressive, and
spread to other parts of the body. If this happens,
an otherwise treatable disease may become untreatable
and result in a decreased likelihood of survival or
eventual death from the cancer.
Radiation therapy uses radiation to kill or inactivate
the cancerous cells. The radiation is delivered by
one of two main techniques. The first technique, called
external-beam therapy (also known as
teleradiotherapy), focuses external beams of
high-energy radiation onto the prostate. This technique
requires treatment five days a week for a period of
approximately seven weeks. The second technique, called interstitial
radiotherapy, which is also known as radioactive
seed therapy or brachytherapy, inserts
radioactive pallets within the prostate. This technique
requires a treatment period of one to two days.
Because malignant (cancerous) cells are less efficient
in repairing radiation injury than normal cells,
radiation therapy kills or inactivates the cancer cells
while saving a sufficient number of normal cells to
allow them to repair themselves and continue their
normal function. Unfortunately,
radiation therapy is not effective for large,
aggressive, high grade cancers. It is also not
effective if the cancer has spread. Men with a PSA of
more than 10, a Gleason sum of 7 or more, or a large
prostate, are thus likely to fail this treatment.
For men with small volumes of low-grade cancer, a
PSA of less than 10, and a small prostate, the
survival results from radiation therapy are seven
to ten years. Radiation therapy is thus typically
used on such men if they (1) are older and have a life
expectancy of approximately seven to ten years, and
(2) cannot or will not have their prostate removed,
or face a significant risk from surgery.
One of the main problems with radiation therapy is
that your doctor will not be able to evaluate the
lymph nodes to be sure the treatment is the correct
one. Thus, you may need to undergo a laparoscopic
lymph-node dissection before starting radiation.
Further, even when radiation therapy is successful,
you must be continuously monitored with regular
prostate exams and PSA tests. Radiation therapy is
not a permanent cure. The cancer can return. The
likelihood that the cancer will return increases
greatly after seven to ten years.
Cryotherapy, also called cryosurgery and
cryosurgical ablation, is the controlled freezing
of the prostate gland in order to kill the cancer cells
in the prostate. In order to perform cryotheraphy,
your doctor inserts probes throughout the prostate.
Ultrasound is used to confirm the proper placement of
the probes. Liquid nitrogen is then circulated
through the probes, freezing the tissue of the prostate.
A rectal ultrasound probe monitors the freezing and
allows the surgeon to determine when enough prostate
tissue has been treated. A catheter placed in the
urethra circulates a warming solution to protect the
urethra from damage during the procedure.
Radical prostatectomy is a surgical operation in
which the entire prostate gland, attached seminal
vesicles, and some nearby tissue are removed.
It is one of the most common operations being
Generally, the goal of the surgery is to remove
the cancer from the body before it has had a chance
to spread. As such, it is most often performed
on men with prostate cancer in the early stages
(Stages T1 and T2), when the cancer is located
only within the prostate.
Even if the cancer has already spread beyond the
prostate, however, by removing the cancerous
prostate, radical prostatectomy may
make it easier for your body's immune system,
assisted by medication and other treatments, to
more effectively fight the cancer.
Failure to recommend a radical prostatectomy
to a patient whose cancer is in the early stages
may result in the spread of the cancer, which can
in turn lead to a reduced likelihood of survival.
Similarly, failure to recommend a radical
prostatectomy to a patient whose cancer has
spread beyond the prostate can leave the patient
with so much cancer in his body that his immune
system, even with medication and other treatments,
is unable to effectively fight the cancer. This
patient may also experience a reduced likelihood
Because prostate cancer is hormone-sensitive,
eliminating the male hormones removes a major stimulant
of the cancer's growth. After hormone treatment, the
cancer generally stops growing and may even enter a
dormant stage. There are a number of treatments
available to eliminate the male hormones from
the body, including taking female hormones, orchiectomy
(the surgical removal of the testicles), LHRH analog
injection therapy, total androgen blockade, and
Hormone therapy is typically used when there is
widespread metastatic disease. Indeed, if the cancer
has spread to the lymph nodes or to the bones, hormone
therapy is generally considered the correct treatment
option. Hormone therapy may be used before surgery and
before or during radiation to reduce prostate size
or keep the cancer in check.
Failure to recommend hormone therapy, especially for
a patient whose cancer shows signs of progression
after radiation and/or surgery, may result in
continued spreading of the cancer, which can
in turn lead to a reduced likelihood of survival.
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