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Early stage prostate cancer treatments

Early stage prostate cancer is cancer that is still localised to the prostate and hasn’t spread. The management of localised prostate cancer includes options of watchful waiting or active surveillance, radical prostatectomy, external beam radiotherapy and brachytherapy.

Active surveillance / Watchful waiting

Active surveillance or watchful waiting is the name given when prostate cancer has been diagnosed and a decision has been made to not treat the cancer. It is used in two types of circumstances. The first is when a man around his 70’s with significant other medical problems is diagnosed with prostate cancer and a decision is made not to treat him with curative intent. For men to benefit from prostate cancer treatment with curative intent they need to have a life expectancy of greater than 7 years. A man in this situation is likely to die of other causes before the prostate cancer causes him problems. So in this situation, he is monitored with regular PSA tests and is usually treated with hormone therapy should his prostate cancer progress.

The second situation where active surveillance or watchful waiting is used is when a younger man is diagnosed with prostate cancer and he is definitely suitable for treatment with curative intent. Men with a low Gleason Score of 6 and a low PSA have approximately a 20% chance of their prostate cancer progressing. In this situation not all men will die from their prostate cancer but some will die with it and die from other causes. These men are suitable for an active surveillance program. The premise of an active surveillance program is that there is a low risk of the prostate cancer progressing so aconservative approach of close monitoring of the prostate cancer is undertaken and if there is evidence that the prostate cancer is progressing then active treatment is undertaken at that point.

An active surveillance program consists of the following:

  • A repeat saturation prostate biopsy to ensure that the prostate cancer was not under graded (which can occur in 30% of cases)
  • 6 monthly PSA tests
  • 6 monthly digital rectal examinations
  • 18 -24 monthly prostate biopsies

Patients are then treated with curative intent if they have evidence of a change in their digital rectal examination findings, a rising PSA or more aggressive cancer found on the follow up prostate biopsies.

It has been found that in long-term follow-up of patients undergoing no active treatment, the outcomes have been comparable to the outcomes of active treatments, though this must be in low grade or slow growing cancers.

Radical prostatectomy

Radical prostatectomy is surgery to remove the prostate gland and the surrounding tissues and structures in men who have early localised prostate cancer. This may include open radical prostatectomy or a minimally invasive laparoscopic or keyhole technique known as robotic assisted prostatectomy. This is also a pure laparoscopic technique. Generally, the patient most likely to benefit from radical prostatectomy is one with life expectancy of more than 10 years, who has no significant surgical risk factors or serious health issues. Radical prostatectomy can have potential side effects.

Robotic prostatectomy

The latest innovation in the context of laparoscopic surgery is robotic prostatectomy or robotic assisted laparoscopic radical prostatectomy, utilising the da Vinci Robot. Dr Swindle uses the state of the art da Vinci system for suitable patients.

The benefits of robotic prostatectomy over pure laparoscopic radical prostatectomy are the improved vision resulting from the 3D camera and vastly superior instrumentation of the da Vinci robot.

Outcome parameters for robotic prostatectomy are generally considered equivalent to that of open radical prostatectomy in terms of cancer control, continence and potency, however some studies have reported improved outcomes for robotic prostatectomy. For additional information on minimally invasive surgery with the da Vinci Surgical System visit www.davincisurgery.com or watch the video below.

Open radical prostatectomy

Open radical prostatectomy is the traditional or oldest method of surgery for prostate cancer and there may be situations where open surgery is the preferred option. Open prostatectomy requires a small incision in the lower abdomen to remove the prostate.

External beam radiation therapy (EBRT)

Radiation therapy is an appropriate treatment for early stage prostate cancer and in certain situations late stage prostate cancers. Radiation therapy is generally recommended for patients with no significant risk factors for radiation toxicity and who have a preference for this treatment.

Men receiving radiotherapy are generally slightly older than patients undertaking prostatectomy. EBRT is a treatment for prostate cancer where high energy x-rays are transmitted through body tissues and directed to the prostate. It involves leaving the prostate in the body and relying on the x-ray beams to kill the cancerous cells within the prostate. It involves going to the radiotherapy suite each day Monday to Friday for approximately 1 hour to be treated. This treatment lasts for approximately 7 weeks. Radiotherapy is completely painless. Bowel movements and the frequency of urination can increase during the treatment. These short-term side effects usually settle down within 3-6 months. Impotence can occur and approximately 50% of men will become impotent in the long-term.

There are a variety of ways of delivering radiation therapy and these varying forms of radiotherapy are suitable for different risks groups. The different forms of radiotherapy include; 3D Conformal Radiotherapy, Intensity Modulated Radiotherapy (IMRT) and Image Guided Radiotherapy (IGRT).

3D Conformal radiotherapy

This involves minimising the amount of normal surrounding tissues that receive radiotherapy and maximising the amount of radiotherapy delivered directly to the prostate. This results in improving cancer control and minimisation of side effects.

Intensity modulated radiotherapy (IMRT)

Intensity Modulated Radiotherapy is a technique which uses a technology where the radiotherapy beams are modulated and adjusted to allow more accurate delivery of the radiotherapybeams to the prostate and minimises damage to surrounding organs. This technique is able to achieve tightly conformal dose distributions through the use of variable radiation beams. Each beam is divided into multiple segments to modulate the dose.

Image Guided Radiotherapy (IGRT)

Image Guided Radiotherapy is a technique where fiducial markers (gold seeds placed into the prostate prior to the radiotherapy commencing) allow the prostate to be better visualised at the time of the radiotherapy thus resulting in improved delivery of the radiotherapy beams to the prostate.

 

Brachytherapy

The term brachytherapy is derived from the Greek word ‘brachys’, meaning short or brief, and this cancer treatment involves electromagnetic radiation delivered via radioactive ‘seeds’ placed a short distance from, or within, the tumour. Implants can be temporary or permanent. Brachytherapy appears to offer cancer control comparable to these other prostate cancer surgical techniques.

Low dose rate brachytherapy (LDR)

Low Dose Rate Brachytherapy is a prostate cancer treatment using radioactive seeds, the size of a gram of rice, inserted permanently into the prostate gland. The seeds then emit the radioactivity, which kills the prostate cancer, from within the prostate. This differs from conventional external beam radiotherapy, which travels through body tissue before reaching the prostate gland. The seeds are 4-5 mm long, are coated in titanium and emit radioactivity from a source of Iodine 121.

LDR Brachytherapy provides a high dose of extremely localised radiation, minimising the effects on the surrounding tissues such as the rectum and bladder. This option is for men with low to intermediate risk prostate cancer who have a small prostate, minimal urinary symptoms, a good urinary flow rate and at least 10 years of life expectancy.

This approach has the advantage of a short hospital stay and the avoidance of any incisions, however a worsening of urinary function for 12-18 months will result, and while potency may initially be preserved, it can deteriorate over time. With surgery however, potency is lost at the time though subsequently recovers following the operation.

High dose rate brachytherapy (HDR)

High Dose Rate Brachytherapy is where hollow rods are inserted through the perineum (the area behind the scrotum) directly into the prostate. These rods stay in place for 36 hours during which time radioactive wires are inserted down the rods into the prostate on three separate occasions. This results in a high dose of radiotherapy delivered directly into the prostate.

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