Metro Urology

Prostate cancer affects more than 200,000 men a year in the United States, with 30,000 men dying each year from advanced prostate cancer. In the last ten years, there has been a 25% decline in mortality, most likely due to early detection and aggressive treatment.

Unlike other disease processes, there are many different treatment options offered by various disciplines in medicine/surgery. The urologist is generally the first doctor a patient will encounter with prostate cancer. Treatment of prostate cancer is a complex process involving many factors. One must balance the stage and grade of the cancer with the patient’s age, health and personal situation.

There are six different options available for the treatment of prostate cancer:

1. Watchful Waiting is a good option for men in poor health, elderly or select patients with early prostate cancer. Untreated prostate cancer may take years to progress to metastatic disease. Careful monitoring of the PSA and patients condition are performed. Any changes usually lend to a more aggressive option.
2. Radiation Therapy is the use of high-energy rays to kill cancer cells. Radiation therapy is used for both local disease and to palliate advanced disease. There are two standard forms of radiation, external beam radiation and brachytherapy;
   1. External beam radiation therapy – focused X-rays to the prostate. The radiation oncologists determine the dose and number of treatments. Usually therapy is five days a week for eight weeks.
   2. Brachytherapy – involves placement of radioactive seeds, usually palladium or gold, into the prostate using needles placed through the perineum. Either low does rate (LDR) or high dose rate (HDR) technique are offered. LDR is the most common performed. The seeds are permanently placed in the prostate. Radiation is given off over a period of months. HDR brachytherapy places temporary radioactive probes into the prostate. The radiation is given off over minutes. Brachytherapy is a primary treatment for localized prostate cancer.
3. Cryoablation involves freezing and thawing of the prostate gland destroying cancerous cells. Under an anesthetic, the doctor inserts approximately six to ten cryoprobes through the perineum into the prostate. Thermal sensors track the temperature around the prostate to avoid damaging adjacent structures. Liquid argon gas is circulated through the probes freezing the prostate to 40 degrees centigrade. Once the target temperature is reached, helium gas replaces the argon gas to thaw the tissue. The freeze/thaw cycle is then repeated. This therapy is for localized prostate cancer.
4. Surgery involves removal of the entire prostate gland. The lymph nodes in the pelvis are sampled to assess for metastatic disease. There are two basic approaches used to perform a radical prostatectomy.
   1. Radical retropubic prostatectomy – an operation performed though an incision between the umbilicus and pelvic bone. A two to three day hospital stay is required. A Foley catheter is removed in ten to fourteen days. A patient may return to normal activity in five to six weeks. Nerves can be spared to facilitate sexual function.
   2. da Vinci Robot Assisted Laparoscopic Radical Prostatectomy This procedure is minimally invasive. The operation is performed through five one-centimeter incisions. A one-day hospital stay is required. Compared to open surgery, there is less blood loss, less pain, faster recovery and return to normal activity in the ten to fourteen days. A Foley catheter is removed in five to seven days. Potency and continence are at least equal to open surgery. The da Vinci prostatectomy is quickly becoming the procedure of choice for carefully selected patients.
5. Hormone Therapy Testosterone is a known hormone that drives prostate cancer. If testosterone production by the testis is decreased, or the action that testosterone has on the prostate cells blocked, then the cancer will usually go into remission. Hormonal therapy cannot cure prostate cancer. It is most commonly used to treat prostate cancer that has spread outside the prostate. There are two ways to decrease or block the action of testosterone.
   1. Orchiectomy – removing the testes, the site of hormone production.
   2. Drug Therapy – two classes of drugs;
   3. LHRH analogs (luteinizing hormone-releasing hormone) a drug that prevents testosterone production by the testis
   4. Nonsteroidal antiandrogens – a class of drug, which blocks the action of testosterone at the prostate
6. Chemotherapy Drugs given intravenously that destroy cancer cells. Often chemotherapy is used in advanced hormonal refractory prostate cancer. Traditionally, chemotherapy is the last line of defense against prostate cancer. Recently, several new drug trials are underway and show promise.

Prostate cancer is the most common malignancy in men other than skin cancer. This means that thousands of men each year are faced with an important life decision. The treatment approaches are many, therefore it is critical that multiple factors are considered prior to recommending treatment. A patient’s age, health status, and lifestyle wishes all need to be considered carefully, and the patient and his family need to be well informed of all of the treatment options. The art of medicine, taking all of these factors into account, can become as important as the science of medicine. Yet, through a careful and thoughtful approach, the patient can receive aggressive, effective yet appropriate treatment for their particular situation and disease state.