The decision on the choice of treatment depends on the prostate cancer profile. This profile depends on several factors, including :
- Age and expected actuarial survival
- Medical condition and risk factors
- Presence of significant illnesses, such as myocardial infarction, stroke, diabetes, etc.
- PSA level
- Gleason Score (derived from the pathologist’s assessment of the prostate biopsy)
- Presence of metastasis (extensive spread of disease)
- Status of DRE (digital rectal examination)
There are different types of treatment for people diagnosed with prostate cancer.
Selected persons may be closely monitored by blood tests and repeat biopsies and treatment is initiated when there is evidence of cancer progression. This is usually used in older men or men with early-stage small volume cancer who are willing to comply with the follow-up protocol.
Those in good health are usually offered surgery as treatment for prostate cancer. Known as radical prostatectomy, this is a surgical procedure to remove the prostate, surrounding tissue, and seminal vesicles. Depending on their cancer profile, the pelvic lymph nodes around the prostate gland may also be removed in selected cases.
This procedure allows the removal of the entire prostate gland, enabling a complete examination by pathologists. This histological assessment will tell us how advanced the cancer is, the risk of cancer recurrence and if additional treatment will be needed. As the prostate gland is removed, the PSA level will drop to undetectable levels. This helps doctors to monitor for recurrence. Radiation can be given after surgery, if necessary.
The surgery is performed in two ways :
a. Open radical retropubic prostatectomy.
The prostate gland with the attached seminal vesicles and vas deferens are removed via a 15 cm incision below the navel in the midline of the abdomen.
b. Da Vinci robot-assisted laparoscopic radical prostatectomy.
The same operation is performed via special laparoscopic instruments through fi ve to six keyhole-sized incisions in the abdomen. These instruments are manipulated by the robotic arms of the Da Vinci surgical robotics system that are controlled by surgeons. This technique allows a magnifi ed, threedimensional view of the operating fi eld and allows the exact surgery to be performed with smaller incisions with less bleeding, allowing for faster recovery and less post-operative pain.
Complications of prostatectomy
Some men may experience mild to moderate amounts of urinary leakage especially immediately after surgery. Most patients show signifi cant improvement within three months after surgery. Some may experience diffi culties with erection and require alternative treatment for impotence.
Radiation therapy is a cancer treatment that uses high-energy x-rays to kill cancer cells or keep them from growing. There are two types of radiation therapy :
a. External beam radiation therapy
uses a machine outside the body to send radiation towards the cancer in the prostate. Patients may require pre-treatment gold seed implant in the prostate to improve the consistency of radiation therapy. The treatment usually lasts about seven weeks, and may require additional hormonal therapy in addition to the radiation.
b. Brachytherapy or internal radiation therapy
involves small radioactive seeds implanted directly into the prostate. It is performed under anaesthesia and involves the mapping and evaluation of the prostate to estimate the number of radioactive seeds needed for a given brachytherapy procedure. Radioactive iodine and palladium are used to deliver the energy into the prostate.
Complications of radiation therapy
Radiation cystitis (inflammation of the bladder) and radiation proctitis (inflammation of the rectum) can occur after treatment as the radiation often has to travel through the bladder and the rectum. Most symptoms improve after the radiation treatment is completed.
The radiation oncologist will sometimes suspend radiation if the side effects are signifi cant and will resume once the symptoms have subsided. There is an increased risk of bladder cancer and/or rectal cancer in men treated with radiation therapy. Impotence and urinary problems may occur in men treated with radiation therapy.
In prostate cancer, male sex hormones can cause prostate cancer to grow. Hormonal therapy works by removing the source of male hormones or opposing its action on the tumour cells with drugs or surgery. Drug treatment may be in the form of subcutaneous or intramuscular injections (luteinising hormone releasing hormone agonists or antagonists) or oral medications (antiandrogens, ketoconazole or oestrogens). Surgery involves removal of both testes (orchiectomy), which is the main source of male hormones. Hot flashes, impaired sexual function, and loss of desire for sex may occur in men treated with hormone therapy.
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or stopping them from dividing. Chemotherapy is usually given to patients in an advanced stage of prostate cancer when they are no longer responsive to hormonal treatment. Patients may experience nausea, hair loss (alopecia), inflammation of the cheeks, gums, tongue, lips, and roof or floor of the mouth (stomatitis) and abnormal blood profile that increases the risk of infection.