Early Detection

If you have been diagnosed with prostate cancer, your doctor will discuss your treatment options with you. These will depend on several factors, including to what extent your cancer has developed, your PSA levels, your age and your general health status.

Treatment options by stage

Watchful waiting

Watchful waiting or deferred treatment, means taking no immediate action to treat the cancer.

Your doctor may suggest that the most appropriate option is careful observation of your condition. Treatment is only started when either symptoms appear or worsen, or there is a change in your condition.

Watchful waiting is particularly suited for older men who have small, localised tumours, which have been detected early and which have little chance of spreading outside the prostate. In addition, it may be suitable for those men who suffer with other diseases, which may complicate treatment.

The main advantage of this approach is that any possible side-effects related to treatment e.g. flushes or impotence are avoided. It therefore balances the potential impact of treatment on a patients quality of life against the symptoms caused by the disease itself.

However, it may decrease the chance of controlling the cancer before it spreads or postpone treatment to an age when it may be tolerated less well.

Alternatively, active surveillance involves close monitoring of the patient using a range of diagnostic methods e.g. DRE, PSA, biopsies, to identify those patients who are likely to benefit from early treatment. This may include surgery, radiation, or hormonal therapy. For details of these and other treatment options, please refer to the following sections.

Prostate cancer surgery

Surgery may be a treatment option and will depend on the type, size and spread of your cancer. The following types of surgery are used:

• Radical prostactectomy: surgical removal of the entire prostate and some nearby tissue. It is most often used during the early stages (I + II) of prostate cancer, when the cancer is located only within the prostate. It may also be used in combination with hormonal therapy (see Hormonal Therapy), when the disease has spread locally beyond the prostate (Stage III).
  
  
  
  Figure 1: Surgery
  
  There are two common types of procedure, retropubic where the surgeon removes the prostate through an incision in the lower abdomen or perineal, where the incision is made between the scrotum and the anus. The entire prostate gland, attached seminal vesicles, and some nearby tissue are removed during such surgery.
  
  
• Transurethral resection of the prostate: a surgical procedure in which an instrument is inserted through the urethra (the tube that carries urine from the bladder and out through the penis) and the cancerous tissue that is blocking the urethra is removed. It is not intended to completely remove the cancer.

Most men experience some temporary urinary incontinence following prostate surgery. However, permanent loss of urinary control is uncommon. Impotence may occur in men who undergo prostate surgery. Where possible, nerve-sparing surgery may be used in an attempt to spare the nerves that control erection.

• Orchidectomy (or surgical castration) is the removal of the testes, which are the organs that produce the male hormones e.g. testosterone. Such surgery is generally reserved for advanced prostate cancer (Stage IV). Whilst it is included here as a surgical technique, it can also be described as hormonal therapy, since it prevents the production of testosterone. It has now largely been replaced by the use of medical castration.

Radiotherapy

Radiotherapy uses radiation (eg high energy x-rays) either beamed from a machine (external-beam radiotherapy) or emitted by small radioactive ‘seeds’ implanted in the prostate (internal radiotherapy or brachytherapy), to kill cancer cells and shrink tumours.

If your prostate cancer is localised, your doctor may recommend radiotherapy as an alternative to surgery. External-beam radiotherapy is commonly used to treat prostate cancer that has spread too widely in the pelvis to be removed surgically but has not spread to the lymph nodes (lymph nodes are found throughout the body and produce white blood cells that fight infection). It may be used in combination with hormonal therapy (see Hormonal Therapy), when cancer cells have spread beyond the prostate and into the pelvic area (Stage III).  In advanced prostate cancer, radiotherapy can help to shrink tumours and relieve pain.

Figure 1: External-beam-radiotherapy

Brachytherapy targets cancer cells without harming the surrounding tissues and is not often recommended when the cancer has spread beyond the prostate gland. Brachytherapy may be used alone or can be combined with hormonal therapy or external-beam radiation therapy.

Figure 2: Brachytherapy

Diarrhoea and fatigue are common problems caused by radiotherapy however, these problems usually go away when treatment is complete. Some men may experience continuing problems such as urinary incontinence and impotence following external-beam radiotherapy. However, treatments are available that can help alleviate these problems.

Long-term complications are uncommon with brachytherapy. Most men will experience some post-implant discomfort and temporary urinary incontinence and some may experience temporary problems with impotence.

Hormonal therapy

What is hormonal therapy?

Hormonal therapy treats prostate cancer by decreasing the supply or blocking the action of male hormones (androgens) such as testosterone that encourage prostate cancer growth. Hormonal therapy can slow the growth of the cancer and reduce the size of the tumour(s).

The following are the main types of hormonal therapy which may be used in prostate cancer:

1. Orchidectomy or surgical castration, is the surgical removal of the testes, which are the organs that produce 95% of the body’s testosterone. Since the testes are the major source of testosterone in the body, this procedure is classified as hormonal therapy rather than surgical treatment. The aim is to deprive the prostate cancer cells of testosterone, thereby causing the cancer to shrink and/or to prevent further growth of the tumour. The testicles are removed through a small incision in the scrotum.
   
   
   
   Figure 1: Orchidectomy
   
   Most men who undergo surgical castration will experience a loss of sexual desire and impotence. In addition, hot flushes frequently occur. Surgery is permanent and the effects cannot be reversed.
   
   
2. Medical castration, is achieved by using luteinizing hormone-releasing hormone agonists (LHRHa’s). They work by ‘switching off’ the production of male hormones from the testicles by reducing the levels of a hormone called luteinizing hormone. This hormone, is produced by the pituitary gland (a pea-sized gland located at the base of the brain which regulates and controls the release of hormones which directly or indirectly affect most basic bodily functions).
   
   

   

   Figure 2: Medical-castration
   
   LHRHa’s work just as well as orchidectomy in advanced disease but do not involve surgery. They are also used in combination with radiotherapy as adjuvant therapy for earlier disease.
   
   They are given by injection either under the skin (subcutaneous) or into the muscle (intra-muscular). The injections are generally given every month or every 3 months.
   
   Most men who undergo medical castration will experience a loss of sexual desire and impotence. In addition, hot flushes frequently occur. However, medical castration is potentially reversible. If treatment is stopped, testosterone is produced once again.
   
   
3. Non-steroidal anti-androgens , which block the action and therefore prevent testosterone from working. They do this by attaching themselves to proteins (receptors) in the cancer cells. They are taken orally, as tablets.
   
   They are used in combination therapy (with an LHRHa) in advanced disease. Such therapy is known as Complete Androgen Blockade (CAB),Total Androgen Blockade (TAB), or Maximal Androgen Blockade (MAB).
   
   Monotherapy is also used in locally advanced disease where it has been shown to be as effective as medical or surgical castration. It is also used in combination with prostatectomy or radiotherapy as adjuvant therapy for locally advanced disease.
   
   Compared to castration, non-steroidal anti-androgens are less likely to reduce sexual desire or to cause impotence and hot flushes. However, some men will notice tenderness and/or enlargement of their breasts.Treatment is usually reversible and the effect of testosterone returns when treatment is stopped.

Other hormonal agents which may be used to treat prostate cancer include female sex hormones (oestrogens) and steroidal anti-androgens.


How is hormonal treatment used?

1. Monotherapy – only one hormonal agent is given e.g. monotherapy with an LHRHa or anti-androgen.
   
   In advanced disease, where the cancer has spread outside the prostate and the pelvic area and therefore affects the bones, monotherapy with an LHRHa . Although it will not cure advanced disease it will usually shrink the tumour and slow it’s progress. Such treatment is useful in relieving the pain and other symptoms associated with advanced disease.
   
   In locally advanced disease where the cancer has spread outside the prostate but is still contained within the pelvic area (it has not spread to  the bones), either monotherapy with an LHRHa or a non-steroidal anti-androgen.
   
   Monotherapy may also be considered for patients with earlier stage disease when the patient is unsuitable for, or unwilling to undergo, radiotherapy or surgery.
   
   Monotherapy with an LHRHa or a non-steroidal anti-androgen may also be used in addition to surgery (radical prostatectomy) or radiotherapy as:
   
   Neo-adjuvant Therapy – given before surgery or radiotherapy to reduce the size of the tumour prior to these procedures.
   
   Adjuvant Therapy – given after surgery or radiotherapy to kill any tumour cells, which may remain after these procedures. Goserelin has been shown to be very effective in this situation.
   
   
2. Combination therapy – Two different types of hormonal agents e.g. an LHRHa plus a non-steroidal anti-androgen, are used together to increase the effect on the tumour.
   
   Combination therapy not only prevents the action of testosterone produced by the testes but also the small, but important amount which is produced by other glands i.e. the adrenal glands. Such therapy is sometimes called Complete or Maximal Androgen Blockade (CAB or MAB).
   
   In advanced disease a combination of an LHRHa plus and non-steroidal anti-androgen can be used.
   Clinical trials identify that men treated with such combination therapy may live longer than those treated with an LHRHa alone.
   
   Combination therapy may sometimes be used prior to surgery or radiotherapy (neo-adjuvant) to reduce the size of the tumour.
   
   Combination therapy may also be used for a short time (7-10 days) to minimise the effects of tumour flare. This can occur in a small number of patients with advanced disease, when an LHRHa is given.
   Tumour flare is a brief worsening of symptoms such as pain caused by a temporary increase in testosterone levels when an LHRHa is first started.

If you require hormonal treatment, your doctor will discuss the various treatment options with you.

Chemotherapy

Chemotherapy is the use of powerful medicines which attack and kill the cancer cells. The medicines circulate throughout the body and kill any rapidly growing cells, including healthy ones. Chemotherapy medicines are carefully controlled, both in dose and how often they are given, so that the cancer cells are destroyed while minimising the risk to healthy cells.

There are many different types of chemotherapy medicines, each with their own strengths and weaknesses. They are often used in combination. Chemotherapy is generally only used in advanced prostate cancer, when other treatments are no longer effective. Chemotherapy may be given in hospital or on an outpatient basis and patients require special monitoring. Side-effects of chemotherapy may include hair loss, nausea, diarrhoea and lowered blood counts.

Cryotherapy

Cryotherapy is a surgical procedure which uses liquid nitrogen to freeze and kill prostate cancer cells. It is carried out under anaesthesia (general or spinal) and requires a short stay in hospital.It is generally used to treat early stages of prostate cancer, in which the tumour has not spread outside the gland (Stage I + II). Unfortunately, most men who have cryosurgery become impotent.

Palliative therapy

Palliative therapy is given to relieve the symptoms caused by advanced prostate cancer. It does not alter the course of prostate cancer but can improve your quality of life. For example, transurethral resection of the prostate may be used as palliative therapy in advanced prostate cancer, to relieve symptoms caused by the cancer.

Palliative therapy may also include the use of various drugs e.g. LHRHa’s and pain killers, to relieve symptoms.

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