“Prostate cancer is the most common cancer in men, and the second leading cause of cancer death among men in the U.S. About one in six men will be diagnosed with prostate cancer during his lifetime, but only one in 35 will die of it”.
“Prostate cancer is a malignant tumor that usually begins in the outer part of the prostate. In most men, the cancer grows very slowly. Many men with the disease will never know they had the condition. Early prostate cancer is confined to the prostate gland itself, and the majority of patients with this type of cancer can live for years with no problems”.
“Prostate cancer is characterized by both “grade” and “stage.” The size and extent of the tumor determine its stage. Early stage prostate cancer, Stages T1 and T2, are limited to the prostate gland. Stage T3 prostate cancer has advanced to tissue immediately outside the gland. Stage T4 prostate cancer has spread to other parts of the body.
To predict the aggressiveness of the prostate cancer, the physician will look at PSA (a protein excreted by the prostate gland) levels before a biopsy and will calculate the patient’s “Gleason Score.” The Gleason Score ranges from two to 10, with two representing the least aggressive form (confined to the gland) and 10 representing the most aggressive form of cancer (highest risk of spreading outside the gland). From the PSA levels and the Gleason Score, a treatment plan is devised”.
“PSA tests measure a protein in your blood called prostate specific antigen, or PSA. Prostate cancer makes PSA levels go higher, but high PSAs aren’t always a sign of prostate cancer. Sometimes, readings may be elevated because of something benign, such as ejaculating within 24 hours of the test. Your “normal” PSA depends on your age, but even if your PSA level is elevated between 4 and 10, you have only about a 25 percent chance of prostate cancer.
Common causes of inflammation in the gland, called prostatitis, can cause high PSA levels.” Prostatitis caused by bacteria can be treated with antibiotics. Another more common type of prostatitis, called nonbacterial prostatitis, can be harder to treat and last a long time. Prostatitis is the most common prostate problem for men younger than 50.
What to expect during transrectal prostate biopsy
In most cases, the urologist performs a transrectal prostate biopsy. For this procedure, your doctor will start by having you lie on your side, with your knees pulled up to your chest. In some cases, you may be asked to lie on your stomach.After cleaning the area and applying gel, your doctor will gently insert a thin ultrasound probe into your rectum. Transrectal ultrasonography is used to create images of your prostate using sound waves. Your doctor will use the images to identify the area that needs to be numbed with an anesthetic injection, if one is used. The ultrasound images are also used to guide the prostate biopsy needle into place.In most cases, an injection of a numbing medication is used to reduce the discomfort associated with the prostate biopsy. A needle is used to inject the anesthetic at various points near the base of the prostate.Once the biopsy device is situated, your doctor will retrieve thin, cylindrical sections of tissue with a hollow, spring-propelled needle. The procedure typically causes a very brief, uncomfortable sensation each time the spring-loaded needle takes a sample. Your doctor may target a suspicious area to biopsy or may take samples from several places in your prostate. In most cases, doctors will take 10 to 12 tissue samples. The entire procedure usually takes about five to 10 minutes.
If your biopsy finds cancer, the first piece of information you’ll want to note is the Gleason score. This numerical value grades prostate tumor cells according to how they look compared with normal cells and how mutated they appear under a microscope, a quality known as differentiation. (Normal cells are well differentiated and cancer cells are not.) Because tumors often consist of multiple cell types, the pathologist assigns two values between 1 and 5: the first to the predominant cell type, and the second to the next-most-prevalent cell type (see Figure 1). The sum, ranging from 2 to 10, is the Gleason score; the higher the number, the more aggressive the cancer. An ideal report also specifies how many samples, or cores, were removed during the biopsy.
The standard number of cores used to be six: three from the right side of the prostate and three from the left. However, this limited sampling meant that cancerous portions of the prostate, if there were any, might be missed. As a result, as many as one in four patients eventually diagnosed with prostate cancer was told, on the basis of the initial biopsy, that he did not have cancer — meaning that the test provided a false-negative finding. Today, most doctors agree that an initial biopsy should include at least 10 to 12 core samples. In certain situations, some doctors recommend doing a saturation biopsy, which typically removes 12 to 14 cores — and sometimes as many as 20 or more — but less agreement exists about this practice.
Depending on the situation, the treatment options for men with prostate cancer might include: Expectant management (watchful waiting) or active surveillanceSurgeryRadiation therapyCryosurgery (cryotherapy)Hormone therapyChemotherapyVaccine treatmentBone-directed treatment These treatments are generally used one at a time, although in some cases they may be combined.The treatment you choose for prostate cancer should take into account:
- Your age and expected life span
- Any other serious health conditions you have
- The stage and grade of your cancer
- Your feelings (and your doctor’s opinion) about the need to treat the cancer right away
- The likelihood that each type of treatment will cure your cancer (or help in some other way)
- Your feelings about the possible side effects from each treatment.
Many men find it helpful to get a second opinion about the best treatment options based on their situation, especially if they have several choices. Prostate cancer is a complex disease, and doctors can differ in their opinions regarding the best treatment options. Speaking with doctors who specialize in different kinds of treatment may help you sort through your options.
The main types of doctors who treat prostate cancer include:Urologists: surgeons who treat diseases of the urinary system and male reproductive system (including the prostate)Radiation oncologists: doctors who treat cancer with radiation therapyMedical oncologists: doctors who treat cancer with medicines such as chemotherapy or hormone therapyYour primary care doctor can also be a helpful source of information as you sort through your treatment options. It’s important to discuss all of your treatment options, including goals and possible side effects, with your doctors to help make the decision that best fits your needs.
Thinking about survival rates for prostate cancer takes a little mental stretching. Keep in mind that most men are around 70 when diagnosed with prostate cancer. Over, say, five years, many of these men will die from other medical problems unrelated to prostate cancer. To determine the prostate cancer survival rate, these men are subtracted out of the calculations. Counting only the men who are left provides what’s called the relative survival rate for prostate cancer. Taking that into consideration, the relative survival rates for most kinds of prostate cancer are actually pretty good. Remember, we’re not counting men with prostate cancer who die of other causes: 99% of men with the most common types of prostate cancer overall will survive more than five years after diagnosis. For the more than 90% of men whose prostate cancer is localized to the prostate or just nearby, the prognosis is even better. Almost 100% of these men will live at least five years.
Robotic-assisted laparoscopic radical prostatectomy
A newer approach is to do the laparoscopic surgery using a robotic interface (called the da Vinci system), which is known as robotic-assisted laparoscopic radical prostatectomy (RALRP). The surgeon sits at a panel near the operating table and controls robotic arms to do the operation through several small incisions in the patient’s abdomen. Like direct LRP, RALRP has advantages over the open approach in terms of pain, blood loss, and recovery time. So far though, there seems to be little difference between robotic and direct LRP for the patient. In terms of the side effects men are most concerned about, such as urinary or erection problems (described below), there does not seem to be a difference between robotic-assisted LRP and other approaches to prostatectomy. For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. Still, the most important factor in the success of either type of LRP is the surgeon’s experience and skill. If you are thinking about treatment with either type of LRP, it’s important to understand what is known and what is not yet known about this approach. Again, the most important factors are likely to be the skill and experience of your surgeon. If you decide that either type of LRP is the treatment for you, be sure to find a surgeon with a lot of experience.
The major possible side effects of radical prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). … Urinary incontinence: You may develop urinary incontinence, which means you can’t control your urine or have leakage or dribbling. There are different levels of incontinence. Being incontinent can affect you not only physically but emotionally and socially as well.
There are 3 major types of incontinence: Stress incontinence is the most common type after prostate surgery. Men with stress incontinence might leak urine when they cough, laugh, sneeze, or exercise. It is usually caused by problems with the muscular valve that keeps urine in the bladder (the bladder sphincter). Prostate cancer treatments can damage the muscles that form this valve or the nerves that keep the muscles working.Men with overflow incontinence have trouble emptying their bladder. They take a long time to urinate and have a dribbling stream with little force. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by scar tissue.Men with urge incontinence have a sudden need to pass urine. This problem occurs when the bladder becomes too sensitive to stretching as it fills with urine.Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence. After surgery for prostate cancer, normal bladder control usually returns within several weeks or months. This recovery usually occurs gradually, in stages. Doctors can’t predict for sure how any man will be affected after surgery. In general, older men tend to have more incontinence problems than younger men. Most large cancer centers, where prostate surgery is done more often and surgeons have more experience, report fewer problems with incontinence. Incontinence can be treated. Even if your incontinence can’t be corrected completely, it can still be helped. You can learn how to manage and live with incontinence. See our document Managing Incontinence for Men With Cancer to learn more about this side effect and what can be done about it. Impotence (erectile dysfunction): This means you can’t get an erection sufficient for sexual penetration.
Erections are controlled by 2 tiny bundles of nerves that run on either side of the prostate. If you are able to have erections before surgery, the surgeon will try not to injure these nerves during the prostatectomy (known as a nerve-sparing approach). But if the cancer is growing into or very close to the nerves, the surgeon will need to remove them. If both nerves are removed, you won’t be able to have spontaneous erections, but you might still be able to have erections using some of the aids described below. If the nerves on only one side are removed, you might still have erections, but the chance is lower than if neither were removed. If neither nerve bundle is removed you might have normal erections again at some point. Other treatments (besides surgery) can also damage these nerves or the blood vessels that supply blood to the penis to cause an erection. Your ability to have an erection after surgery depends on your age, your ability to get an erection before the operation, and whether the nerves were cut. All men can expect some decrease in the ability to have an erection, but the younger you are, the more likely it is that you will keep this ability. A wide range of impotency rates have been reported in the medical literature, from as low as about 1 in 4 men under age 60 to as high as about 3 in 4 men over age 70. Surgeons who do many nerve-sparing radical prostatectomies tend to report lower impotence rates than doctors who do the surgery less often. Each man’s situation is different, so the best way to get an idea of your chances for recovering erections is to ask your doctor about his or her success rates and what the outcome is likely to be in your case. If your ability to have erections does return after surgery, it often occurs slowly. In fact, it can take from a few months up to 2 years. During the first few months, you will probably not be able to have a spontaneous erection, so you may need to use medicines or other treatments. If potency comes back after surgery, the sensation of orgasm should still be pleasurable, but there is no ejaculation of semen – the orgasm is “dry.” This is because during the prostatectomy, the glands that made most of the fluid for semen (the seminal vesicles and prostate) were removed, and the pathways used by sperm (the vas deferens) were cut. Most doctors feel that regaining potency is helped along by trying to get an erection as soon as possible once the body has had a chance to heal (usually several weeks after the operation). Some doctors call this penile rehabilitation. Medicines (see below) may be helpful at this time. Be sure to talk to your doctor about your situation.
Advances in the precision of radiation therapy have lessened the risk of complications. Still, radiation can cause short- and long-term side effects, including incontinence (the involuntary loss of urine), erectile dysfunction, bowel problems, fatigue, and symptoms in other parts of the body (if you receive radiation therapy for disease that has spread outside the prostate).
With low-dose-rate (LDR) brachytherapy, we insert tiny titanium seeds containing radiation in or near the tumor while you’re under anesthesia. We use ultrasound imaging to guide the placement of the seeds. In 95 percent of cases, this technique is successful in eliminating the cancer. At MSK, we perform LDR brachytherapy on an outpatient basis. It usually takes a little over an hour. Although the seeds are permanent, they cause little or no discomfort, and their radioactivity lessens after several weeks or a few months. To ensure that the tumor receives high doses of radiation while the surrounding tissue is protected, we developed and use real-time image guidance when the radioactive seeds are implanted into your body. During the procedure, while you’re under anesthesia, a mobile CT scanner (called an O-arm) provides up-to-the-second images of your prostate. A sophisticated computer software system fuses ultrasound images obtained before the procedure with these real-time CT scans. Using this data, the computer analyzes millions of possible seed locations and, in a matter of seconds, selects the ones that will deliver a precise dose of radiation to the tumor while avoiding injury to healthy tissue. Before you leave the operating room, we take a final CT scan to ensure the seeds were placed at the ideal locations. Sloan Kettering
The two forms of brachytherapy performed today for the treatment of prostate cancer are low dose rate in the form of permanent seeds and High Dose Rate (HDR) temporary implants or HDR brachytherapy. Our physicians did hundreds of permanent seed implants before switching to HDR in 1991. We feel that HDR temporary implants are superior to permanent seed implants in most circumstances. To date, our center has done over 4,000 HDR brachytherapy implants for prostate cancer.
Low-dose-rate brachytherapy has the great advantage of being practically a one-time procedure, and enjoys a long-term follow-up database supporting its excellent outcomes and low morbidity. Low-dose-rate brachytherapy has been a gold standard for prostate brachytherapy in low risk patients since many years. On the other hand, HDR is a fairly invasive procedure requiring several sessions associated with a brief hospital stay. Although lacking in significant long-term data, it possesses the technical advantage of control over its postimplant dosimetry (by modulating the source dwell time and position), which is absent in LDR brachytherapy. This important difference in dosimetric control allows HDR doses to be escalated safely, a flexibility that does not exist for LDR brachytherapy.
High-dose (HDR) brachytherapy is most commonly used to treat prostate, cervical and head and neck cancer. During the procedure, the radioactive material, such as iridium, is temporarily placed in the tumor and then removed. The radioactive material travels through small plastic catheters to the targeted area. The precise location is determined with the aid of a specialized computer system. Since the position of the radioactive material can be precisely adjusted, customized dose distributions can be created to meet each patient’s needs. Recent technological advances at UCSF have led to breakthroughs in the delivery of HDR brachytherapy. Computerized tomography (CT) and magnetic resonance (MR) image guidance and clinical expertise create the optimal dose distribution.
HDR Brachytherapy can be used as the only treatment for prostate cancer or it can be used in combination with external beam radiation therapy (EBRT). When used as single treatment it is known as “HDR Monotherapy” and when used it is given with external beam it is known as “combined HDR and EBRT”. Basically, HDR Monotherapy is used for early or localized prostate cancer or in some cases where cancer has recurred after prior radiation therapy.
In terms of outcomes (ie PSA control) the data seem to suggest improved PSA control with brachytherapy compared with IGTheirRT to about 80 Gy.
Here is an abstract below from the recently updated RTOG 0126 trial that compared about 70 Gy to about 80 Gy IGRT and you would have been eligible for this trial. You can see that at 10 years the PSA control in the higher dose arm was 70% (30% of men had a PSA failure).
If we look at the outcomes with HDR monotherapy from one of the largest studies to date (abstract below) you will see that the PSA control at 96 months is 90% for the entire group (this includes higher risk patients than you).
In terms of toxicity I think the short term urinary side effects are a more intense than those of just IGRT but these usually subside within about 1-3 months after treatment otherwise I think the risk of long-term ED is about the same between the two (some people think they are less with brachytherapy but I think this is debatable). The risk of rectal complications is very low with both modalities.
Hope this helps.