Available Options

If prostate cancer has been diagnosed, graded and staged, there is much to consider before reaching a treatment decision. Patients often feel that they must make a decision quickly. However, it is essential that a patient allows adequate time to educate himself, and reaches a well-informed decision regarding his options. A patient should ask questions of his cancer care team. Ideally, seeking a second opinion is worthwhile. Prostate cancer is a complex disease, and physicians may differ in their opinions.

Seed Brachytherapy

Treatment of cancer using seed brachytherapy was pioneered in the 1980s as an effective alternative to surgery. The word brachytherapy is derived from the Greek prefix brachy, meaning "short" or "close", because the seeds containing radioactive material are implanted directly into the cancerous prostate gland. Over the past several decades technological advances as well as clinical experience, much developed at SPI, have greatly improved on the brachytherapy technique and outcomes.

Seed Brachytherapy is a one-time, minimally invasive procedure usually performed in an outpatient setting under spinal or general anesthesia. The procedure itself involves the placement of tiny radioactive seeds inside the prostate using ultrasound equipment.

The seeds emit radiation and kill the malignant cells inside the prostate. The time it takes for the radiation to deliver its total dose depends on the seed (isotope) used. There are currently 2 isotopes commonly used in prostate brachytherapy: Iodine125, and Palladium103 (Cesium131 is also rarely used). Brachytherapy seeds themselves are compatible with human tissue. After the procedure, patients are taken to recovery and are typically discharged a few hours later. Most patients resume normal activities within 24-48 hours. The most common side effect of brachytherapy is temporary urinary irritation including frequency and urgency. Typically, these symptoms will last from a few weeks to a few months. Long term sexual function is a known side effect, but most published series show a lower incidence and better response to medications as compared to surgery (Please see About Seed Implantation).

Surgery

There are several different types of surgical procedures for prostate cancer, each with different benefits and risks. Risks associated with the surgical removal of the prostate are much like those of any major surgery, including risk of infection, anesthesia, or organ damage. In addition, most men undergoing prostate surgery will be hospitalized, require a catheter for 2 weeks and experience a lengthy recovery time. Potential side effects of radical prostatectomy or robotic prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). These side effects are also possible with other forms of therapy, although with varying degrees of frequency and severity. At least one study concluded that the rate of complications is higher for less experienced surgeons (as compared to highly experienced surgeons) (Catalona, WJ, et al., "Potency, continence, and complication rates in 1870 consecutive radical retropubic prostatectomies". J. Urol., 1999.)

External Beam

External Beam radiation is similar to a standard X-Ray, but is of higher energy and produced by a large machine called a linear accelerator. One technique often used at SPI to optimize external beam is called IMRT (intensity modulated radiation therapy). This allows further shaping of the beams to avoid radiation to critical organs. Men go to a hospital or clinic for the treatment. On average, treatments are given 5 days per week for 8 1/2 weeks, requiring ongoing trips to the clinic. Rectal side effects such as frequent bowel movements and rectal pain can occur with external radiation. As with other forms of prostate cancer treatment, urinary and sexual side effects are common and vary depending on the health of the patient, skill of the treating physician, dose of radiation received and the cancer itself. Recent technological developments, presently in use at the Seattle Prostate Institute include Calypso Beacon GPS Transponders, which can improve the accuracy of external beam radiation and therefore improve outcomes.

Cyberknife Radiotherapy

The Cyberknife is a highly specialized advanced external beam radiation machine that is designed to give very focal conformal radiation to a high dose over a small volume with real-time tracking of the prostate via gold markers. Because it is very conformal (and complex), Cyberknife treatment is delivered over 5 fractions. The SPI is the lead investigation site of a national protocol investigating this treatment. Although not yet considered a standard of care option, we are excited by this new technology as a potential treatment option for prostate cancer ad are offering treatment on the national protocol. Presently only some insurance companies will reimburse this treatment because it is so new. We expect with longer follow-up, insurance reimbursement will not be an issue. Preliminary results from our institution have been very favorable showing excellent cure rates and low toxcity.

Proton Beam Therapy

Proton beam therapy is a form of external beam radiation therapy. In many ways proton therapy is much like X-ray treatment. Using powerful magnets and other machines, protons, which are small particles, are accelerated to near the speed of light and aimed at cancerous tissues. The nature of the proton particles, as compared to standard photons, allows the radiation beam to dissipate rapidly after reaching the cancerous prostate gland. Like IMRT, proton beam therapy also requires approximately 8 weeks of daily treatments.

Results evaluating the efficacy of proton beam therapy have only recently been reported. Only several thousand prostate cancer patients have been treated with this therapy. Results have been satisfactory; however, they have not shown to be superior to IMRT or brachytherapy for the treatment of prostate cancer. Furthermore, there are no urethral sparing techniques yet developed for proton beam therapy, which can potentially mean more urinary side effects. Finally, when compared to proton beam therapy, brachytherapy has a lower incidence of injury to the bladder and rectum, while still being capable of delivering the highest doses of radiation. No randomized study has shown protons to be more efficacious or less toxic than IMRT based external beam radiation. Proton therapy is enormously expensive and is limited to only a few centers in the country. Generally it is reserved for pediatric cancer patients, where unlike in prostate cancer, there is data showing lower long term toxicity when treating the brain or spinal cord or a few rare solid tumors.

HIFU

High intensity focused ultrasound (HIFU) is another form of treatment for prostate cancer. It is delivered through the rectum, using focused sound waves in a targeted area, which increases the temperature in the prostate to cause tissue destruction. HIFU is a 2-3 hour, one-time procedure performed under spinal or epidural anesthesia. It can be repeated if necessary.

Currently, there is no long-term data on the efficacy of this procedure. There are also some limitations; for example, the prostate gland must be of a certain size to perform the treatment effectively. Furthermore, side effects can include incontinence and impotence. Finally, this procedure is currently not FDA-approved for use in the United States.

High Dose Rate Brachytherapy

HDR brachytherapy involves the temporary placement of tiny plastic catheters into the prostate gland through a template that is sutured to the perineal skin below the scrotum. Once in place, a tiny radioactive seed is inserted on a temporary basis into the catheters in a sequential pattern. A computer controls the length of time the seed delivers its radiation through the catheter. After the radiation has been given, the catheters are removed, leaving no radioactive material in the gland. This type of treatment requires an overnight stay in the hospital and is usually combined with several weeks of external beam radiation. One advantage of this technique is that very fine tuning of the shape of the radiation field is allowed by varying the time each seed is placed in different ‘dwell positions’ within the catheter. Our physicians can discuss whether this technique may be indicated and advantageous for your particular case.

Cryosurgery

Cryosurgery, or freezing the prostate, is another treatment option for prostate cancer. Using ultrasound guidance, a urologist inserts a probe filled with liquid nitrogen through the skin into the prostate, which freezes the prostate tissue. Cryosurgery may require a hospital stay. After the procedure, a supra-pubic tube or catheter is often used to rest the bladder for up to two weeks. Damage to the nerves and blood vessels around the prostate can cause complications. There is a possible risk of incontinence and impotence is very common. Cryosurgery is more often used as a backup-option rather than as primary treatment. At SPI we work closely with urologists who are national experts in cryotherapy for the rare patient who suffers a local recurrence of their prostate cancer.

Hormonal Therapy

By itself, hormone therapy is non-curative but is often used with radiation therapy in the curative setting. The end result is a decrease in testosterone level. This stops the cancer from progressing for a temporary time. Hormone therapy is often used in combination with IMRT or seed brachytherapy in high risk patients. It can also be used to reduce the size of the prostate gland prior to seed implant in a low risk patient. This type of therapy can be administered orally or via injection. Short-term side effects can include hot flashes, mood swings, fatigue and loss of sex drive. Long-term side effects can include weight gain, diabetes, osteoporosis, high cholesterol, breast tenderness and/or enlargement and possible cardiac complications. However, despite those side effects, solid randomized data has shown a survival advantage to adding hormone therapy to radiation in high risk, and some intermediate risk, prostate cancer therapy.

Expectant Management (Watchful Waiting)

Depending on the characteristics of the cancer, some doctors may recommend an approach known as expectant management, or "watchful waiting." This approach involves closely monitoring the cancer without active treatment such as surgery or radiation therapy. This option may be recommended if your cancer is not causing any symptoms, is expected to grow very slowly, or is small and contained within one area of the prostate. This option, however, is not advisable for men of a life expectancy greater than 10 years. Watchful waiting can often be the best option for a particular as long as the patient has the correct mindset and level of comfort with this treatment plan.

Source: "What you need to know about Prostate Cancer". National Institute of Health, 2005.  "Understanding Prostate Changes". National Institute of Health, 2004.

[ to top ]