CancerCare Manitoba
 
 
 
Treatment Options

 

There is no "one size fits all" treatment for prostate cancer, so each man must learn as much as he can about various treatment options and, in conjunction with the health care team, make a decision about what is best for him.

For most men, the decision will rest on a combination of clinical and emotional factors. Men diagnosed with localized prostate cancer today will likely live for many years, so any decision that is made now will likely have an influence on him and his family for a long time.

Careful weighing of the various options (listed below) is an important first step in deciding on the best treatment course.
  • Active Surveillance
    The concept of active surveillance is a viable option for men who, for one reason or another, have decided not to undergo immediate surgery or radiation therapy.

    During active surveillance, the cancer is carefully monitored for signs of progression. A PSA blood test and DRE are usually administered every three to six months along with repeated biopsies of the prostate. If tests indicate that the cancer is growing, treatment is usually initiated.

    Active surveillance might be a good choice for men who have very slow growing or very early cancers, or for men who have other serious medical conditions that are likely to shorten their lifespan.

    Also, many of the treatment options for prostate cancer have significant side effects, and better outcomes are seen in men who are otherwise healthy. If a man has been diagnosed with other disorders or diseases, such as heart disease, long-standing high blood pressure, or poorly controlled diabetes, his doctors might feel that it is in his best interest to hold off on surgery and avoid its potential complications.

  • Radical Prostatectomy (Surgery)
    A surgical approach toward the treatment of prostate cancer can be used to remove the prostate gland and seminal vesicles. Typically, men with early-stage disease or cancer that is confined to the prostate will undergo radical prostatectomy.

    In this surgery an incision is made in the abdomen and the prostate is cut out. This is called an open prostatectomy. Wherever possible, the surgeon attempts to avoid cutting the erectile nerves that run alongside the prostate.

    After removing the prostate, the surgeon stitches the urethra directly to the bladder. To allow internal healing to take place, the surgeon inserts a catheter into the bladder. With this in place, urine flows into a bag. The catheter is usually kept in place for about 10 to 14 days.

    Some surgeons are able to do this surgery using sophisticated instruments called laparoscopes. In laparoscopic surgery, very small incisions are made in the abdomen, into which the surgeon inserts narrow instruments fitted with cameras and/or surgical tools, allowing the surgeon to visualize and operate on the internal structures without making a larger incision in the abdomen.

    Side effects of surgery
    The side effects of this surgery include incontinence (leakage of urine) as well as erectile dysfunction.
    • Incontinence
      In the immediate period after the catheter is removed, most men will be unable to control the flow of urine. This is very distressing and many men feel hopeless when this occurs. There tends to be fairly rapid improvement of this immediate incontinence and most men manage with one or two pads a day for the first few months. As time passes, they gain more control and this is assisted if they do pelvic floor exercises on a regular basis. The nursing staff will give you instructions on how to do these exercises. There are also continence experts who can provide you with additional training and treatment using biofeedback. If you are interested in seeing a continence expert, ask the nurse for a referral.
    • Erectile dysfunction
      Immediately after surgery for prostate cancer almost all men will be unable to have an erection. Erections may return over the following weeks, months or even years. Return of erections depends on what your erections were like before surgery, your age, your general health and lifestyle factors, and the amount of damage to the nerves.

      Many men will have erectile problems after surgery. You may not have any erections at all, they may not be hard enough for penetration, and they may not last long enough to satisfy either you or your partner. Many men also notice that the penis is both shorter and smaller in girth than before. This results from both the surgery and shrinkage of tissue in the period following surgery when there is reduced blood flow to the penis due to lack of erections.

      There are a number of oral medications that can be taken that may help you have an erection. These medications prevent blood from leaving the penis once it has entered the tissues following physical stimulation of the penis. This is the least invasive method of treating erectile difficulties and is usually the first treatment that your doctor will suggest. More invasive treatments include the vacuum pump, the intra-urethral pellet (MUSE™) and penile self-injection therapy.

      There is some suggestion that taking oral medication to help get erections can increase the likelihood that spontaneous erections will return earlier after surgery. The Manitoba Prostate Centre offers a program for penile rehabilitation; you can ask your urologist about this.

      The Clinical Nurse Specialist at the Manitoba Prostate Centre can help you with sexual problems. She can be reached at 787-4495 and a physician referral is not necessary.


  • Radiation Therapy
    Radiation involves the killing of cancer cells in the prostate gland with directed radiation. There are two types of radiation therapy used to treat prostate cancer.

    • External Beam Radiation Therapy
      The most common type of radiation therapy is external beam radiotherapy. CT scans are used to map out the location of the prostate gland, and the radiation is targeted directly at this area. Using 3D conformal radiotherapy, a computerized program maps out the exact location of the prostate gland so that the highest dose of radiation can reach the cancer cells within the gland.

      Treatment is given five days a week for about seven or eight weeks in the Radiation Therapy Department of CancerCare Manitoba.

    • Brachytherapy ("seeds")
      With brachytherapy, tiny metal pellets (they look like small pieces of pencil lead) containing radioactive iodine are inserted into the prostate via needles that enter through the skin of the perineum (behind the scrotum). Careful and precise maps are used to ensure that the seeds are placed in the proper locations. This is a day procedure which is performed under general anaesthetic and men go home a few hours after.

      Over the course of several months, the seeds give off radiation to the immediate surrounding area, killing the prostate cancer cells. By the end of the year, the radioactive material degrades, and the seeds are inactive.


    Side effects of radiation therapy
    Men who have been treated with radiation tend to experience irritation of adjacent tissue from the radiation and this may affect bladder and bowel functioning.
    • Men may need to urinate more frequently and may experience some burning pain when they pass urine.
    • They may also have some diarrhea.

    These side effects tend to improve in the days and weeks following the end of treatment.

    Radiation therapy also poses a risk to erections although this tends to occur one to two years after treatment is completed and is much more gradual than the changes noticed after surgery. The same treatments used for erectile dysfunction after surgery can be tried by men after radiation therapy.

  • Androgen Deprivation Therapy (Hormone Therapy)
    Prostate cancer cells need testosterone to grow and survive. To starve the cancer of this hormone, androgen-deprivation therapy or ADT, is designed to stop testosterone from being released or to prevent the hormone from acting on the prostate cells. ADT is most often used for men with more advanced prostate cancer or in addition to radiation therapy. It may also be used if the cancer recurs after treatment.

    The majority of cells in prostate cancer respond to the removal of testosterone. But some cells grow independent of testosterone, and therefore remain unaffected by androgen deprivation therapy. As these hormone-independent cells continue to grow unchecked, over time, androgen deprivation therapies have less and less of an effect on the growth of the cancer.

    While androgen deprivation therapy does not cure the disease, it remains an important step in the process of managing advancing disease.

    The most common types of androgen deprivation therapies are described below. Although each of these therapeutic options is effective at controlling prostate cancer growth, the loss of testosterone causes significant side effects in nearly all men.

    • Orchiectomy
      Because about 90% of testosterone is produced by the testicles, surgical removal of the testicles, or orchiectomy, is an effective solution to blocking testosterone release. This approach has been used successfully since the 1940s, but is not commonly performed since the development of medical treatments.

      For men who choose this option, the procedure is typically done on an outpatient basis in the urologist's office. Recovery is rapid and no other treatment is needed.

    • luteinizing-hormone releasing hormone (LHRH) Agonists
      Luteinizing-hormone releasing hormone, is one of the key hormones released by the body which prompts the testicles to produce testosterone. (Note that LHRH is sometimes called GnRH, or gonadotropin-releasing hormone.) Blocking the release of LHRH through the use of LHRH agonists or LHRH analogues is one of the most common hormone therapies used in men with prostate cancer. This shuts down the body's release of testosterone.

      Drugs in this class, including leuprolide (Eligard, Lupron), goserelin (Zoladex) are given in the form of regular injections.

    • Anti-androgens
      LHRH agonists cause what is known as a "flare" reaction because of an initial transient rise in testosterone in response to the altered signals to produce testosterone. This can result in a variety of symptoms ranging from bone pain to urinary frequency or difficulty.

      Anti-androgens are medications which help to block the action of testosterone in prostate cancer cells. They are therefore often added to the LHRH agonist for the first 4 weeks of therapy when the flare reaction typically occurs. In this setting, anti-androgens can be helpful in preventing the flare reaction.


    Side effects of these treatments include the following:
    • hot flashes
    • fatigue
    • loss of energy
    • loss of libido (sexual desire)
    • erectile dysfunction


    Some men experience weight gain, hair loss and difficulties with memory and concentration. Long term use can also increase the risk of osteoporosis and men are encouraged to increase their calcium intake and exercise regularly. If osteoporosis does occur, there are treatments to prevent bone fractures which your physician will discuss with you.

  • Other Treatment Options
    Surgery and radiation therapy remain the standard treatment for localized prostate cancer, but other, less popular treatment options might be beneficial as well. As time goes on and the benefits of these treatment options are further explored, it's possible that they will move more into the mainstream. For now, though, none are seen as standard treatments for localized prostate cancer.
    • Cryotherapy
      Cryotherapy, also known as cryosurgery or cryoablation, uses freezing to destroy the prostate cancer. With this approach, probes are inserted into the prostate through the perineum (the space between the scrotum and the anus), and argon gas or liquid nitrogen is delivered to the prostate, literally freezing to death the prostate cells and any prostate cancer.

      The freezing may affect both urinary and erectile functioning and side effects tend to be quite common.
    • High-Intensity Focused Ultrasound (HIFU)
      High-intensity focused ultrasound works in the opposite way to cryotherapy: with HIFU, the prostate cells are heated until they die. A probe is inserted into the rectum, from which very high-intensity ultrasound waves are delivered to the target area. Although this technique remains experimental in the Canada, it's been used in Europe for a number of years with a fair amount of success.

      HIFU is not available at the Manitoba Prostate Centre.