Prostate Cancer Information

Active surveillance, also known as “watchful waiting” or “observation” involves regular screening to monitor cancer progression without radical treatment.

During active surveillance at University Urology Associates, the progression of your cancer is monitored through a series of screening tests performed on a regular basis. These tests include:

• regular PSA tests
• a periodic digital rectal exam (DRE)
• possible continued biopsies
• urine analyses (to look for blood in the urine)
• PCA3 tests to assess the need for continued biopsy

These tests are performed in order to monitor the progression of the cancer and determine if more invasive treatment methods are required to control it.

Surgical removal of the prostate, known as radical prostatectomy, involves removal of the prostate, seminal vesicles, and a portion of the urethra. The goal is to surgically remove all cancerous tissue and prevent cancer recurrence. This option is intended for men who have cancer that has not yet spread beyond the prostate.

If there is concern that cancer has spread beyond the prostate, lymph nodes surrounding the prostate are removed and examined for cancer. If the cancer has spread to the lymph nodes, other treatment options such as chemotherapy or radiation may be recommended.

Prostatectomy is the most aggressive treatment option and therefore has the greatest risk of life-altering side effects. The younger and healthier you are, the more successful your recovery is likely to be. When thinking about surgery, you must consider the effect that this will have on your life and weigh the possible benefits against the possible risks.

Advantages

• Prostate removed reducing risk of recurrence
• Cancer potentially entirely removed
• Long history of use for prostate cancer treatment
• Results easy to monitor with post-operative PSA tests
• Failures can be followed with radiation if necessary
• Outcomes relatively predictable

Disadvantages

• Risks associated with surgical procedures:
  – Blood loss
  – Infection, leaks, fistulae etc.
  – Mortality
• Side effects of radical prostatectomy:
  – Risk of impotence
  – Urinary incontinence
  – Urinary stricture
• Requires general anesthesia
• 1 – 3 month recovery period

Preserving Potency

A common side effect of prostatectomy is erectile dysfunction. This is because there are two bundles of nerves that lie next to the prostate which may be damaged during surgery. Improved surgical techniques allow surgeons to spare one or both of these nerve bundles in order to preserve potency. This is known as “nerve-sparing” surgery. Whether or not the nerves are spared depends on how close the cancer is to the nerves.

Conformal Radiation and Brachytherapy are the two main ways of delivering radiation in cancer treatments.

Radiation is the treatment of prostate cancer with high-energy beams, from x-rays or other sources, directed at a target inside the body. Radiation targets both cancer cells and normal cells, interfering with their ability to divide and grow. However, scheduled breaks between radiation sessions allow normal cells a chance to repair while not giving cancer cells enough time to recover.

Radiation therapy can be used to treat prostate cancers that are confined to the prostate gland or the surrounding area. For many men with localized disease, radiation offers very effective results without the risk and recovery time associated with surgery. For early-stage prostate cancer, clinical outcomes obtained with surgery or radiation are very similar. In certain cases, radiotherapy can be combined with brachytherapy. For larger or more aggressive tumors, radiotherapy may be used in combination with hormone therapy. After surgery, radiation may also have a very important role to treat tumors that have a higher risk of recurrence, those that are not completely removed, or those that recur after surgery.

Advantages

• Suitable treatment for anyone (no selection criteria)
• No hospitalization is required
• It is a painless procedure
• Less invasive than surgery, and no general anesthetic
• Treatment does not significantly disrupt daily activities
• Outcomes relatively predictable

Disadvantages

• Treatment program is prolonged (approx. 39 sessions) and daily transportation may be a problem
• Some risk of long-term side effects including:
  – Impotence
  – Urinary frequency & urgency
  – Rectal bleeding after treatment
• The prostate is not removed
• Failures usually cannot be treated with surgery

Chemotherapy is one of the main methods of treating cancer. It uses specific cancer-targeting drugs to kill cancer cells.

Chemotherapy is usually used in cases of prostate cancer that are in the refractory period or fairly advanced stages. It may also be recommended for individuals who have distant metastasis as a result of their prostate cancer.

Chemotherapy drugs are delivered intravenously – they are given through an IV in your arm. Typically the treatment is very well tolerated by prostate cancer patients. While you have your chemo, any hormonal treatment you are on (LHRH agonist/antagonist) will be maintained.

Some chemotherapy treatments require taking drugs prior, during and after the infusion of the treatment in order to prevent side effects.

Prostate cancer needs testosterone to grow. Hormone therapy fights cancer by reducing the amount of testosterone available to cancer cells.

Male sex hormones (androgens) are naturally produced in the adrenal glands, testis, and fatty tissue in the body. When prostate cancer cells develop, their continued growth is dependent upon a type of androgen called testosterone. It has been found that cancer cells may produce their own androgens, contributing to their continued growth.
 
The goal of hormone therapy is to slow the growth of prostate cancer by reducing the availability of testosterone. This can be done surgically, by removing the source of testosterone, or by using medications that block the production of testosterone.

Side Effects

The degree to which men experience side effects from hormone therapy varies greatly depending on the drugs being used, the treatment regimen, and a man’s general health. The drastic reduction of male hormones in the body can cause:

• sweating
• hot flashes
• decreased sexual desire and function
• breast swelling and tenderness
• anemia
• lack of energy
• mood swings or depression
• a decrease in muscle and bone strength
• risk of fractures in the long bones of the body

Hormone therapy is often used in combination with other therapies which will have their own treatment side effects, so it can be difficult to determine which side effects an individual is likely to experience.

Advantages

• Excellent means of dealing with complications and pain of metastatic cancer
• May decrease complications in patients with extensive prostate cancer
• Modest side effects
• May prolong survival of patients with extensive prostate cancer
• Easily administered (surgery/drugs)
• Not curative

Disadvantages

• Can produce these side effects, such as:
  – Loss of libido, potency
  – Loss of muscle and bone strength
  – Flushing, breast swelling, and anemia
• Only works for a limited time that is variable

Focal therapy is a minimally-invasive treatment (read about HIFU treatment at UUA).

With the introduction of the prostate specific antigen (PSA) test, a blood test that can indicate prostate cancer, more men are being diagnosed with prostate cancer while it is still curable. The contemporary treatment options are either radical therapies which entail surgical removal or irradiation of the prostate, or active surveillance which leaves the cancer untreated until there is clinical evidence of progression.

HIFU is an acoustic ablation technique that uses precision-focused ultrasound waves to heat and destroy the targeted cancerous tissue in two to three seconds. The waves only target the clinically-significant tumour while leaving the rest of the prostate and surrounding structures intact.

How Does HIFU Work?

The tumour is first located using biopsies and medical imaging such as MRI or ultrasound. A doctor will then create a treatment plan and identify which area of the prostate to target. The HIFU probe is most often inserted into the rectum, but is sometimes inserted through the urethra. The doctors monitor the treatment as it progresses to ensure that the tumour reaches the temperatures at which cancer cells are destroyed.

An advantage of focal HIFU is that most of the prostate remains intact and healthy tissues surrounding the prostate are spared. As such, the common side effects of radical therapy are less likely to occur. Nearly all men who are continent and potent prior to treatment will regain continence and potency within a few months after treatment.

A pill called tadalafil (trade name Cialis) may be taken orally. It works in reponse to sexual stimulation.  Cialis may be prescribed as a 5mg daily dosage which should be taken at about the same time each day, or as a 20mg as-needed dosage, which should be taken 30-60 minutes before sexual activity.

Side Effects

May cause headaches, indigestion, back pain, muscle aches, stuffy nose or flushing. Should not be used in combination with nitrates or any other antihypertensive drug.

Pros

This medication is painless and discreet (no additional equipment is needed).

Cons

• Unlike local medications that act directly on the penis, this pill circulates throughout the entire body.
• This medication can trigger a sudden drop in blood pressure and should not be used in combination with nitrates or any other antihypertensive medication.
• This medication should not be used by men with a history of coronary problems.

A pill called vardenafil (trade name Levitra or Staxyn) may be taken orally. It works in response to sexual stimulation. Vardenafil comes in 2 forms:  Levitra (20mg or 10 mg) which is swallowed, or Staxyn (10mg) which may be placed on the tongue to dissolve.

Levitra may be taken on an as needed basis 25-60 minutes prior to sexual activity.  Staxyn may be taken on an as needed basis 45-90 minutes prior to sexual activity.

Side effects

May cause headaches, flushing, stuffy nose, indigestion, dizziness and back pain. Should not be used in combination with nitrates or any other antihypertensive drug.

Pros

This medication is painless and discreet (no additional equipment is needed).

Cons

Unlike local medications that act directly on the penis, this pill circulates throughout the entire body. This medication can trigger a sudden drop in blood pressure and should not be used in combination with nitrates or any other antihypertensive medication. This medication should not be used by men with a history of coronary problems.

A pill called sildenafil (trade name Viagra) may be taken 1-2 hours before sex. It works in response to stimulation.

Side effects

• May cause headaches, and/or a drop in blood pressure
• Should not be used in combination with nitroglycerin or any other antihypertensive drug
• Some users experience temporary vision problems

Pros

This medication is painless and discreet (no additional equipment is needed).

Cons

Unlike local medications that act directly on the penis, this pill circulates throughout the entire body. This medication can trigger a sudden drop in blood pressure and should not be used in combination with nitroglycerin or any other antihypertensive medication. This medication should not be used by men with a history of coronary problems.

Using transurethral therapy, you insert a small applicator into the end of your penis. A suppository (a tiny medicated pellet) is released into your urethra. The medication (Alprostadil, trade name MUSE) relaxes the smooth muscle cells and allows blood to enter the penis, thus causing an erection.

Side effects

• Some men experience discomfort from the applicator
• Occasionally an erection may last longer than wanted (priapism)

Pros

The transurethral applicator may be applied 5 to 10 minutes before sex and may be used twice daily.

Cons

• Some men may find the application uncomfortable
• The erection may not disappear at orgasm
• This method should not be used with a pregnant partner

With self-injection therapy, you inject a small 1/2″ needle into the base of your penis about 10 – 20 minutes before sex. The medication, Alprostadil, (trade name Caverject) relaxes the smooth muscle cells and allows more blood to enter the penis, thus causing an erection.

Side effects

• Some men experience discomfort from the injection
• Occasionally an erection may last longer than wanted (priapism)

Pros

The injection method is reported as the most successful amongst users. Erections lasting 30 – 60 minutes may be achieved on demand.

Cons

• The injection method cannot be used every day
• Some men find the injection uncomfortable
• The erection may not disappear at orgasm

The external vacuum device consists of a clear plastic cylinder, a vacuum pump and a tension ring. The cylinder is placed over the penis and the vacuum pump draws blood into the penis. A tension ring placed around the base of the penis, traps blood inside the penis and maintains the erection.

Side effects

At first some men may develop reddish pinpoint dots (petechiae) or bruising (ecchymosis) on the penis from the negative pressure of the vacuum pump.

Pros

• It is a non invasive technique (is used on the body not in the body)
• An erection may be obtained within a few minutes

Cons

• Some men find the vacuum device awkward to use
• The penis is cooler to the touch because fresh blood is not circulating through the penis
• The tension ring must be removed within 30 minutes (after several minutes the process may be repeated)
• Ejaculation may be difficult

There are currently 3 main types of penile implants available (mechanical, inflatable, or hydraulic). Two synthethic cylinders are surgically placed inside the corpora cavernosa of the penis. After 4 – 6 weeks you would be ready to engage in sex.

Side effects

• There is a risk of infection (from surgery) and of malfunction of the device
• This treatment is irreversible and should be considered a last resort

Pros

• This device can be hidden and fitted to your body
• Many of these rods may be inserted on an outpatient basis with a local anaesthetic

Cons

• The surgery is not reversible and all erections require the implant, so it must be worn for life
• Erection is achieved through the implant parts, not the flow of blood into the penis