Watchful Waiting / Active Surveillance

Points in Favour

Points Against

  No risk of side effects

  Cancer may spread

  No loss of time off works

  Cancer may cause local symptoms

  Life continues much as before

  Other treatments may cure

  Treatment may become needed later

Explanation

Prostate Cancer can be very slow to develop so this can be a useful option for treatment. This is better suited to older men with low grade cancer. This is because in these patients it is not common for cancer to be the cause of death.

The Procedure

Regular examinations are given to check if the cancer has progressed. The PSA and DRE tests will be given to achieve this. The frequency of the tests will depend on the results of the tests and your age. The biopsy may also be repeated. You may also be given other options like altering your diet.

What to Expect

The doctor will monitor your results every few months to see if your PSA levels have risen. You may be advised of other treatment options if you results show that the PSA levels are rising.

Possible Side Effects

There are no side effects with this treatment. Some men may feel depressed or anxious. There is also a possibility that after a time the passing of urine will be more difficult. Your doctor and your local support group are good sources of advise and encouragement.

External Beam Radiotherapy

Points in Favour

Points Against

  No loss of blood

  Possible damage to bladder/rectum  5%

  Simple and non-invasive

  Diarrhoea and cystitis short term 70%

  No anaesthetic required

  Risk of impotence approximately 30%

  Survival benefit comparable to surgery

  6 weeks of daily treatments

Explanation

This treatment aims to destroy the cancer cells by delivering therapeutic radiation. The aim is a complete cure from the cancer. The treatment is suitable for patients where the cancer is confined to the prostate or the outer lining of the prostate. Hormone treatment may also be given in addition to the radiotherapy.

The Procedure

The procedure is done as an outpatient and goes on daily (Monday to Friday) for about 4-8 weeks. Every day beams of high energy x-rays are focused on the prostate from different angles to achieve an overall intensity of therapeutic radiation while protecting surrounding tissues.

What to Expect

The daily treatments take 15-20 minutes. Initially you will undergo “Simulation”, a CT scan which will enable the doctor to see the size and shape of your prostate. Sometimes non-radioactive gold seeds will be placed in your prostate, these will be used to guide the radiation beams during the treatment. You will be placed on your back or stomach for the scan and you will be placed in the same position while having the radiation treatment. You will also having specific instructions on hydration and bowel habits while having the treatment.

Possible Side Effects

Early side effects can include discomfort, pressure or urgency with both urination or bowel movements. You may also suffer burning or soreness around the anus which can be treated with moisturising cream. These first symptoms start after about 2-3 weeks of treatment. People with other conditions like bladder problems, hemorrhoids or diabetes may have worse side effects. Longer term effects can include reduction in erectile function and occasional rectal bleeding or urgency.

Brachytherapy

Points in Favour

Points Against

  Simple one day procedure

  New Technique / success data for 15 yrs

  Rapid return to normal life

  Only available in a few UK hospitals

  As effective as Surgery / Radiotherapy

Possible burning sensation while urinating

  Low level of side effects

  Risk of impotency less than with surgery

Explanation

Brachytherapy is only suitable if the cancer is confined to the prostate, is of a low grade and your PSA level is low. Radioactive seeds are placed directly into the prostate with the aim of using the radiation to kill the cancer cells and cure you of cancer.

The Procedure

The procedure is a minor surgical treatment performed as an outpatient and is done under general anaesthetic. About 80 to 120 small metal seeds, each the size of a grain of rice, are inserted into the prostate. The seeds contain a radioactive material (iodine or palladium) and deliver a high dose of radiation to a small area over several months. These seeds are left in place permanently. A long needle is inserted between the scrotum and the anus to place the seeds in the prostate. The doctor uses an ultra sound probe placed in the rectum to see and guide the seeds to the precise position within the prostate.

What to Expect

You will initially undergo an ultrasound scan of the prostate. This will be used to work out the size and shape of your prostate. An initial estimate of the number, strength and positioning of the seeds is then made. The exact placement of the seeds may then be varied and refined during the implant procedure. The whole operation takes 1-2 hours and you can usually go home after about 2 hours. A catheter is left in the bladder overnight.

Possible Side Effects

Side effects can include blood in the urine, burning sensation while passing urine, slowing of urine flow and changes to urinary frequency. These symptoms are worse after 2 to 4 weeks of treatment and gradually get better over the following 4-6 months, occasionally longer. A few men will not be able to pass urine and will require to use a catheter. Rectal symptoms are rare. It is possible for impotence to occur and the incidence increases as time goes on.

Cryoablation / Cryosurgery

Points in Favour

Points Against

  Relatively painless procedure

  Catheter use for two weeks after

  Minor surgical procedure

  Urinary incontinence rare < 10%

  Kills cancer cells by freezing

 Short term loss of impotence

Explanation

This treatment can be used if the cancer is limited to the prostate or the outer lining of the prostate. The cancer cells are killed with the use of freezing temperatures.

The Procedure

Needles are placed into the prostate between the scrotum and the anus. The procedure is done under spinal anaesthetic. The tips of the needles freezes the temperature of the area down to -170°C creating an ice ball that surrounds the whole prostate. The doctor uses an ultrasound probe placed in the rectum to monitor the positioning of the needles.

What to Expect

The ultrasound probe allows the doctor to see the freezing of the prostate. The urethra or water passage is protected and kept warm during the procedure. This is a relatively pain free procedure and an overnight stay in hospital is normal.

A supra pubic catheter is placed in the bladder to drain urine.

Possible Side Effects

It will be two weeks until you are able to pass urine through the penis after the procedure. This is because it takes this time for the swelling in the prostate to return to normal. Occasionally, in less than 10% of cases, urinary incontinence or leakage may occur. All men will experience loss of erections about 47% recover over a one year period.

Radical Prostatectomy (Open or Keyhole Surgery)

Points in Favour

Points Against

  Cancer may be completely cured

  Risk of Impotence 70%

  PSA test for long term follow up

  Risk of incontinence 5%

  A week in hospital / 6 weeks off work

  Risk of death under anaesthetic

Explanation

The entire prostate is removed in this operation. This is suitable for where the cancer is confined to the prostate and are fit enough for surgery. This can mean a complete cure form the cancer.

The Procedure

This surgery can either be done by incision or by keyhole surgery. The operation takes 2-5 hours and is done under general anaesthetic. During surgery it can be checked if the cancer has spread beyond the prostate.

What to Expect

This is a fairly straightforward operation and it is not a painful operation. You will have to use a catheter to drain urine for 1-2 weeks. It usually takes about 6 weeks to fully recover from the operation. Your PSA levels should then be undetectable.

Possible Side Effects

The side effects seem to vary with age, extent of the cancer and the type of surgery used. You can expect some urinary incontinence after the catheter is removed. This is usually short lived but can last months. Long term about 15-25% of men suffer stress incontinence. You may also have difficulty getting or maintaining an erection.

Hormone Therapy

Points in Favour

Points Against

  No surgery involved

  Hot Flushes

  Can be stopped if side effects too great

  Loss of sex drive / fatigue

  Weight gain about half a stone

  Tenderness in breast area

Explanation

Hormone therapy aims to stop or reduce the production of testosterone. The reason for this is that testosterone acts like a fertilizer for prostate cancer cells. This treatment is used to treat more advanced prostate cancer but has also been used along with radiation

therapy in the early stages.

The Procedure

The regular way of reducing testosterone is using injections (LHRH agonists) or tablets (anti-androgens). If the treatment is combined with radiation the injections start months before the radiation treatments.

There is also a surgical option for this treatment called an orchidectomy or removal of the testicles.

What to Expect

The hormone therapy injections are given every 1-4 months for as long as the doctor

deems the treatment necessary. Tablets are given over a similar period.

Possible Side Effects

There are various side effects which can include hot flushes, decline in sexual desire, difficulty in obtaining an erection, tiredness and more rarely swelling in the breast area. Longer term therapy can cause loss of body hair, softening of the skin and loss of bone or body mass.

Orchidectomy (Removal of Testicles)

Points in Favour

Points Against

  Fairly simple operation

  Psychological impact

  80% with advanced cancer benefit

  May need additional hormone therapy

  Implants maintain testicle appearance

  Side effects not reversible

  No tablets or injections needed

Explanation
 

This procedure is done in cases of advanced cancer where the cancer has spread. Alternatively it is used to create the same results as for hormone therapy. Please see the notes on Hormone Therapy for more information.

HIFU (High Intensity Focussed Ultrasound

Points in Favour

Points against

 Only minimally invasive

 HIFU is relatively new

 Short hospital stay

 Swollen genitalia initially

 General anaesthetic or epidural injection

 Possible infertility

 Possible incontinence

Explanation

The treatment requires only a short hospital stay and has a low complication rate. The prostate will be destroyed by the thermal effect of HIFU (temperature rising to 85 degrees C) and requires no radiation treatment. HIFU treatment can also be repeated.

HIFU treatment is suitable for those patients who require treatment for contained prostate cancer for the first time but are unable or do not wish to undergo more routine treatments such as surgery or those who have had radiotherapy in the past and the cancer has now returned.

The Procedure

HIFU takes up to three hours, depending on the size of the prostate and how much of the prostate is being treated.The surgeon will pass a lubricated probe into the rectum. The probe will give out a beam of ultrasound, which the surgeon will focus so that it heats and destroys the prostate tissue with the cancer. The probe will have a cooling balloon around it to protect nearby areas from the high temperature. Images of your prostate will be displayed on a monitor. This will allow the surgeon to check how much tissue is destroyed during the procedure.

What to Expect

A rest until the effects of the anaesthetic have passed is required. Pain relief to help with any discomfort as the anaesthetic wears off may also be necessary. A catheter will be fitted. This is a fine tube that is passed through your penis or abdomen (tummy) to drain urine from your bladder into a bag. This is usually left in place for four to 14 days. Patients will usually be able to go home when they feel ready.

Possible Side Effects

Side-effects are the unwanted but mostly temporary effects that you can arise after having the procedure. Common side-effects include: swelling in your scrotum and penis - this can affect your ability to pass urine and you will need a catheter, blood in the urine - this can last for up to eight weeks, a burning sensation on passing urine, or feeling the need to pass urine more frequently and urgently.

Be aware that doctors do not know everything about the side-effects of HIFU treatment yet.