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Treatment Options for Disease That Has Spread
If your cancer has grown beyond the prostate gland (Stage III), it cannot be stopped with local therapies-although radiation therapy can help to keep the tumor in check and hormonal therapy may slow its advance. If your prostate cancer is metastatic (Stage IV), it is usually treated with hormonal therapy, which can relieve painful or distressing symptoms and slow the progress of disease. Another option for metastatic disease is to enter clinical trials and accept new treatments that are being studied.
Hormonal therapy combats prostate cancer by cutting off the supply of male hormones (androgens) such as testosterone that encourage prostate cancer growth. Hormonal control can be achieved by surgery to remove the testicles (the main source of testosterone) or by drugs.
Hormonal therapy targets cancer that has spread beyond the prostate gland and is thus beyond the reach of local treatments such as surgery or radiation therapy. Hormonal therapy is also helpful in alleviating the painful and distressing symptoms of advanced disease. Further, it is being investigated as a way to arrest cancer before it has a chance to metastasize (See Clinical Trials Web site http://cancertrials.nci.nih.gov). Although hormonal therapy cannot cure, it will usually shrink or halt the advance of disease, often for years.
Surgery to remove the testicles (orchiectomy or surgical castration) is usually an outpatient procedure. The testicles are removed through a small incision in the scrotum; the scrotum itself is left intact. To help offset the operation's psychological toll, some men opt for reconstructive surgery in which the surgeon replaces the testicles with prostheses shaped like testicles.
A variety of hormonal drugs can produce a medical castration by cutting off supplies of male hormones. Female hormones (estrogens) block the release and activity of testosterone. Antiandrogens block the activity of any androgens circulating in the blood. Still another type of hormone, taken as periodic injections, prevents the brain from signaling the testicles to produce androgens.
Either surgical castration (orchiectomy) or medical castration (hormonal drug therapy) can produce a striking response. Both approaches cause tumors and lymph nodes to shrink and PSA levels to fall. However, both castration methods can cause hot flashes, impotence, and a loss of interest in sex. Medical castration by treatment with hormonal drug therapy can cause breast enlargement and can increase a man's risk of cardiovascular problems, including heart attacks and strokes.
Hormonal therapy has been tried in many combinations. One approach, known as maximum androgen blockade or complete hormonal therapy, combines castration (either surgical or medical) with an antiandrogen pill, taken daily, for months or years. However, studies show that single hormone treatments have similar effectiveness compared to maximum androgen blockade. Combining surgery with hormonal therapy appears to relieve symptoms.
Medical castration by hormonal therapy can be costly, but, unlike surgical castration, its effects can be reversed by stopping the drug. Moreover, halting hormone treatments will sometimes, paradoxically, temporarily interrupt the progress of an advanced and advancing cancer.
Unfortunately, hormonal therapy for metastatic disease works only for a limited time. Remissions typically last 2 to 3 years. Eventually, cancer cells that don't need testosterone begin to flourish, and cancer growth resumes. When that happens, a variety of other, secondline hormonal-type drugs (for example, hydrocortisone or progesterone) may be tried.
Many techniques are being tried in investigational studies. They have not been used in enough patients or for a long enough time to prove themselves better than conventional treatments.
Cryosurgery uses liquid nitrogen to freeze and kill prostate cancer cells. Guided by TRUS, the doctor places needles in preselected locations in the prostate gland. The needle tracks are dilated for the thin metal cryo probes to be inserted through the skin of the perineum into the prostate. Liquid nitrogen in the cryo probes forms an ice ball that freezes the prostate cancer cells; as the cells thaw, they rupture. The procedure takes about 2 hours, requires anesthesia (either general or spinal), and requires 1 or 2 days in the hospital.
During cryosurgery; a warming catheter inserted through the penis protects the urethra, and incontinence is seldom a problem. However, the overlying nerve bundles usually freeze, so most men become impotent.
PSA and Outcomes
The first use of PSA tests was to gauge the success of treatment. After the prostate - the source of PSA - has been eliminated by surgery, PSA levels can be expected to fall. If PSA still can be detected, it suggests that some prostate cells still may be present somewhere in the body. If, sometime in the future, the PSA level begins to rise, it may be the first sign of recurrence. Sunch a biochemical relapse typically precedes clinical relapse - symptoms - by months or years. However, it is not known if treatment should start again or change based solely on a rise in PSA.
Now research suggests that pretreatment PSA levels may provide another important clue to prognosis, independent of stage and grade. in one study, nearly 90 percent of the men with low pretreatment PSA level (4 ng/ml or less) remained free of any signs of relapse (either symptoms or a rising PSA level) 5 years after surgery. But among men with a high preoperative PSA level (20 ng/ml or higher), just one-quarter remained relapse-free.
Early Hormonal Therapy
Early or neoadjuvant hormonal therapy is started as soon as prostate cancer is diagnosed, in hopes of slowing the growth of cancer that has spread into nearby tissues or of cancer that has invaded the lymph nodes. Given prior to surgery, neoadjuvant hormonal therapy often helps to shrink a tumor.
Chemotherapy, which kills fast-growing cells, has not proven partic-ularly effective against slow-growing prostate cancer cells. Several promis-ing new anticancer drugs are under study, being added to either surgery or radiation therapy for men with Stage III prostate cancer. Chemo-therapy is also being tried in con-junction with hormonal therapy for men whose advanced cancers are no longer responsive to hormonal therapy alone.
Conformal radiation therapy
A 3-dimensional conformal radiation therapy (3D-CRT) uses sophisticated computer software to conform or shape the distribution of radiation beams to the 3-dimen-sional shape of the diseased prostate, sparing damage to normal tissue in the vicinity of treatment.
In addition to medical treatment, some cancer patients want to try complementary therapies. Comple-mentary therapies include acupuncture, herbs, biofeedback, visualization, meditation, yoga, nutritional supplements, and vitamins. Some prostate cancer patients feel that they benefit from some of these therapies.
Before you try any of these therapies, you should discuss their possible value and side effects with your medical doctors. You should let them know if you are using any such therapies. Be aware that these therapies may be expensive, and some are not paid for by health insurance. As with any treatment, you should ask the therapist for evidence of how the therapy has helped others.
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