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Treatment Options for Localized Disease
If your prostate cancer is confined to the gland, or localized (Stage I or II/low Gleason score), you are a good candidate for treatments that can result in long-term survival. There are three main approaches to managing localized cancer: watchful waiting, surgery, and radiation therapy.
Watchful waiting is based on the premise that cases of localized prostate cancers may advance so slowly that they are unlikely to cause men - especially older men-any prob-lems during their lifetimes. Some men who opt for watchful waiting, also known as "observation" or "surveillance," have no active treatment unless symptoms appear. They are often asked to schedule regular medical checkups and to report any new symptoms to the doctor immediately.
Watchful waiting has the obvious advantage of sparing a man with clinically localized cancer-who typically has no symptoms-the pain and possible side effects of surgery or radiation. On the minus side, watchful waiting risks decreasing the chance to control disease before it spreads, or postponing treatment to an age when it may be more difficult to tolerate. Of course, treatments may also improve over time if watchful waiting is chosen. Another potential disadvantage is anxiety; some men don't want the worry of living with an untreated cancer.
The most obvious candidates for watchful waiting are older men whose tumors are small and slow-growing, as judged by low grade / Gleason score and low stage.
Many men who choose watchful waiting live for years with no signs of disease. A number of studies have found that, for at least 10 or even 15 years, the life expectancy of men treated with watchful waiting (primarily older men with less lethal forms of prostate cancer) is not substantially different from the life expectancy of men treated with surgery or radiation - or, for that matter, of the population at large.
In the early 1990s, roughly 30 percent of prostate cancer patients in the United States were treated by surgery, 30 percent by radiation, and 20 percent by watchful waiting. (Most of the rest were treated with L combination of therapies.) In Europe, by contrast, watchful waiting constitutes the standard treatment for asymptomatic prostate cancer.
The popularity of surgery in his country has grown tremendousy in recent years. A study of Medicare patients' records found hat the number of men nationwide receiving radical prostatectomy by 1990 was six times greater than the Lumber recorded for 1984, and the increase was seen in all age groups, from the youngest (that is, age 65) o men in their eighties. Recent statistics, however, indicate that since 1993, the rate of prostatectomies has been dropping.
"Conservative management (watchful waiting) of localized prostatic cancer is difficult for the physician to advise and the patient to accept, in part because both public and physician education (in the United States) have been focused on early diagnosis and cure and because of the powerful emotional impact provided by cancer mortality."
Willet Whitmore, M.D., Emeritus
Memorial Sloan-Kettering Cancer Center, New York
An operation called radical prostatectomy completely removes the prostate and nearby tissues. A radical prostatectomy is further described in terms of the incisions used by the surgeon to reach the gland. In a retropubic prostatectomy, the prostate is reached through an incision in the lower abdomen; in a perineal prostatectomy, the approach is through the perineum, the space between the scrotum and the anus. In radical prostatectomy, the surgeon excises the entire prostate gland, along with both seminal vesicles, both ampullae (the enlarged lower sections of the vas deferens), and other surrounding tissues. The section of urethra that runs through the prostate is cut away, as is the bladder neck (and with it some of the sphincter muscle that controls the flow of urine).
Pelvic lymph node dissection is done routinely as part of a retropubic prostatectomy; with a perineal prostatectomy, lymph node dissection requires a separate incision.
Radical prostatectomy is a complicated and demanding procedure that typically requires general anesthesia and takes 2 to 4 hours. Patients stay in the hospital for about 3 days, and need to wear a tube to drain urine (catheter) for 10 days to 3 weeks. About 5 to 10 percent of patients experience surgery-related complications such as bleeding, infection, or cardiopulmonary problems. There is a small risk of death from surgery; it is less for men who are young and healthy than men who are older and frail.
Prostatectomy also carries the risk of serious long-term problems, notably urinary incontinence, stool incontinence, and sexual impotence. (The procedure also makes it very unlikely for a man to father children, since little ejaculate is produced without the prostate.)
Most men experience urinary incontinence following surgery. Many continue to have intermittent problems with dribbling caused by coughing or exertion. A few men permanently lose all urinary control. Some men can be helped with an artificial urinary sphincter, surgically implanted, or with injections of col-lagen to narrow the bladder opening.
Infrequently men may develop stool or fecal incontinence after radical prostatectomy. Fecal incontinence is the loss of normal muscle control of the bowels. Muscle damage can occur during rectal surgery. Stool incontinence may also be caused by a reduction in the elasticity of the rectum, which shortens the time between the sensation of the stool and the urgent need to have a bowel movement. Surgery or radiation injury can scar and stiffen the rectum.
At one time, prostatectomy almost invariably resulted in sexual impotence. Today, the risk of impotence may be reduced by nerve-sparing surgery. This technique carefully avoids cutting or snatching two bundles of nerves and blood vessels that run closely along the surface of the prostate gland and that are needed for an erection.
However, nerve-sparing surgery is not possible for everyone. Sometimes the cancer is too large or is located too close to the nerves. Even with nerve-sparing surgery, many men-especially older men - become impotent.
Most men will lose a degree of sexual function. (If a man has trouble with erections prior to treatment, nerve-sparing surgery is probably not indicated.) Depending on age, extent of disease, and type of surgery, the chances of impotence vary widely - somewhere between 20 and 90 percent.
A Survey of Prostate Cancer Patients
Half were between ages 65 and 70 years old at the time of prostatectomy, half were age 70 and older.
Two-thirds reported problems with urinary incontinence.
Nearly one-third used something like absobent pads cope with wetness.
About 60 percent were unable to have an erection firm enough for intercourse - even though almost all of them said that they had been able to have erections to at least some extent before surery.
About one-fifth needed treatment to relieve urinary complications caused by scar tissue in the urethra. In the hands of the most experienced surgeons - and for younger men - some of these complications may be less common.
Radiation therapy uses high-energy x-rays, either beamed front a machine or emitted by radioactive seeds implanted in the prostate to kill cancer cells. When prostate cancer is localized, radiation therapy serves as an alternative to surgery. External beam radiation therapy is also commonly used to treat men with regional disease, whose cancers have spread too widely in the pelvis to be removed surgically, but who have no evidence of spread to the lymph nodes. In men with advanced disease, radiation therapy can help to shrink tumors and relieve pain.
External beam radiation therapy
External beam radiation therapy generally involves treatments 5 days a week for 6 or 7 weeks. The treatments cause no pain, and each session lasts just a few minutes. In many cases, if the tumor is large, hormonal therapy may be started at the time of radiation therapy and continued for several years. (See Hormonal Therapy)
The primary target is the prostate gland itself. In addition, the seminal vesicles may be irradiated (since they are a relatively common site of cancer spread). Radiating the lymph nodes in the pelvis, once common practice, has not proven to produce any long-term benefits for most patients, but it may be necessary in certain circumstances.
Because the radiation beam passes through normal tissues-the rectum, the bladder, the intestines-on its way to the prostate, it kills some healthy cells. Radiation to the rectum often causes diarrhea, but the diarrhea-as well as radiation-induced fatigue-usually clears up when treatment is over.
Radiation can also cause a variety of long-term problems. These include proctitis, inflammation of the rectum, with bleeding and bowel problems such as diarrhea, and cystitis, inflammation of the bladder, leading to problems with urination. In addition, some 40 to 50 percent of men treated with radiation therapy become impotent.
With newer techniques, available at state-of-the-art radiation therapy centers, side effects may be fewer. Higher-energy radiation beams can be more precisely focused, while computer technology allows a radiation oncologist to tailor treatment to the anatomy of the individual patient.
Internal radiation therapy
Radiation can also be delivered to the prostate from dozens of tiny radioactive seeds implanted directly into the prostate gland. This approach, known as interstitial implantation or brachytherapy, has the advantage of delivering a high dose of radiation to tissues in the immediate area, while minimizing damage to healthy tissues such as the rectum and bladder.
As practiced today, internal radiation therapy relies on ultrasound or CT to guide the placement of thin-walled needles through the skin of the perineum. Seeds made of radioactive palladium or iodine are delivered through the needles into the prostate, according to a pattern customized-using sophisticated computer programsto conform to the shape and size of each man's prostate.
The implantation procedure can be completed in an hour or two under local anesthesia; the patient typically goes home the same day.
The seeds emit radiation for several weeks, then remain permanently and harmlessly in place. Alternatively, some doctors use much more powerful radioactive seeds over a period of several days. Such temporary implants, which require hospitalization, may be combined with low doses of external beam radiation.
Because the experience with modern internal radiation therapy techniques is relatively recent and limited to carefully selected patients, long-term results are not yet known. At 5 years, more than 90 percent of patients remain free of disease.
Internal radiation therapy is not well suited for large or advanced tumors, or for men previously treated with transurethral resection of the prostate (TURF) for benign prostatic hyperplasia (BPH), who run an increased risk for urinary complications. For men with small, well-differentiated tumors, it may provide an option that is less invasive, has fewer side effects, takes less time to do, requires less time in the hospital, and is less costly than either external radiation or surgery.
Post-implant discomfort can usually be controlled by oral painkillers. The man can expect a few weeks of incontinence, but long-term complications such as prostatitis or urinary incontinence are uncommon and generally not severe. Sexual impotence occurs in about 15 percent of men under age 70 and 30 to 35 percent of men over age 70.
The men most likely to do well after external beam radiation therapy are the same as those most likely to do well after radical prostatectomy or watchful waiting: They have well-differentiated Stage I or Stage II tumors.
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