CHOOSING A TREATMENT

Which treatment is right for you

Choosing a treatment is the most difficult part of the prostate cancer journey for many patients. It is important to understand the process you must go through, to help you make the best decision. The guide below will help to lead you through this. You need to get educated about prostate cancer. We will help you go through this process. We have an experienced prostate cancer specialist nurse, Lisa Ferri, on site to guide you and answer your questions.

1. Understand your disease

  • Grade – how aggressive is the disease?
  • Stage – how advanced is the disease? Where is it? It is resectable?
  • Risk category – Is my cancer low, moderate or high risk?
  • What is the natural history my cancer? What will happen if I do nothing?

You should have a copy of your pathology report or an explanation of your disease grade and stage from your doctor.
Prostatic_adenoncarcinoma

2. Understand the treatments and their pros and cons

There are several options:

  • Active Surveillance
    No immediate treatment. Regular check ups with PSA, biopsy and possibly MRI.When it is unclear that a cancer will cause you harm, this can be a good option. The aim is for you to die of something else, never troubled by prostate cancer. We are trying to avoid the side effects of treatment, when treatment is not needed. This treatment course is best for smaller, slow growing cancers in older men. There is a risk of disease progression during observation, as our follow up tests are imperfect. In some cases progression may be beyond cure.
  • Radiotherapy
    uses ionising radiation to treat the whole prostate. The aim is to kill the majority of the cancer and neutralise remaining disease so that it cannot behave like a cancer. We have long term data that shows radiotherapy is a highly effective treatment. The best radiotherapy gives the highest dose to the cancer (effectiveness), and the least to the surrounding tissues (side effects). Modern radiation treatments give higher doses where they are needed and lower doses beyond than ever before. Radiation can be given beyond the prostate boundaries and can be given after surgery. The downside of radiotherapy is that it does not kill all the cancer, with recurrence of the disease common over the long term. This is more likely for aggressive cancer, As it is not possible to do surgery after radiotherapy, this limits its use in younger patients, especially if the cancer is high grade. Side effects of radiation relate to damage to tissue, with bladder and bowel urgency, bleeding, irritation and pain the most common long term side effects. Short term side effects are common, but usually mild to moderate in severity. Most radiotherapy courses run for 2 months and commence after 6 months of medication to block testosterone. Taking away testosterone causes the loss of libido, erection problems, altered sleep, poor concentration, loss of muscle, weight gain and many other minor side effects. The long term cancer results for radiotherapy are worse than for surgery. Seed brachytherapy is often done without hormone medication, and is as effective as surgery in the right patient.

    radiotheraphy

    Multiple radioactive seeds placed into the prostate gland

  • Surgery 
    has a simple logic. If the cancer is contained to the prostate, then removal of the prostate will cure the disease. It is now possible to cure with surgery even if the cancer extends beyond the prostate or to the lymph nodes. Surgery is usually done via a keyhole approach, with a 1-2 night hospital stay and a one week catheter time. The Robot is usually used with this procedure. Cure rates are the highest for any treatment and second line therapies are available if there is incomplete resection or spread to lymph nodes. Follow up is simple, as the PSA should become undetectable. Significant operative complications are very rare, however all patients can expect a period of incontinence and erectile dysfunction. Incontinence is usually short lived, however some patients take several months to achieve. Surgery is sometimes done to restore continence. Erection problems are also common. In men with good erections before surgery, who undergo nerve sparing, most men regain erections, although this can take more than 12 months. In men wth poor erections or more advanced disease, erectile recovery is uncommon. For more information visit the Robotic Surgery page.

    surgery

    Surgeon seated at console operating small instruments held by robotic arms

  • Focal Therapy
    focal therapy involves treating just the cancer and leaving the prostate in place. It can be done by heating (HIFU), freezing (Cryo) or electrical current (nanoknife). Focal therapy can have a low rate of side effects, although heat and cold damage to erections, continence, bladder and bowel function have been reported. Focal treatment is limited by the fact that most cancers are multifocal and incomplete treatment is common. Whether focal therapy can achieve cancer control with minimal side effects is unknown at this time. Most patients considered for focal therapy have low risk cancer that may be suitable for active surveillance. Focal therapy is considered experimental.

Treatment Summary

Treatment Period 1 Yr Later 10yrs Later
Active Surveillance Surgery Radiotherapy Focal Therapy
Indefinite period of observation. 1-2 days. Back to work in 1-3 weeks. 8 months combined medical and radiotherapy treatment. Daily radiotherapy for 2 months. Short, day surgery. Rapid recovery.
MRI, PSA and repeat biopsies Most patients recover previous sexual and urinary function. Others treated. Less than 40% of men recover testosterone. Sexual, urinary and bowel problems can worsen late. 20% incomplete treatment rate at 1 yr
No side effects from treatment, but increased risk of bone metastases and death. Highest chance of living beyond 10 yrs Increased risk of late failure. Lower survival rate than surgery. Small risk of a radiation induced cancer. No long term data exists