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Prostate Cancer

Know your options before choosing a prostate cancer treatment

Nearly 181,000—or one in seven—U.S. men will be diagnosed with prostate cancer this year, according to the American Cancer Society. After taking the time to absorb the diagnosis, the first step will be to get information about what your cancer journey will look like. It's a time to ask questions, and many of the topics may be ones you're not used to talking about—like sexual dysfunction, incontinence, problems urinating, reproductive challenges and other often-taboo issues that men usually don't discuss openly.

When the disease is caught and treated early, it has high survival rates. That means that, for many men with prostate cancer, selecting a treatment is less about choosing a lifesaving option and more about protecting their quality of life after treatment. That may be part of the learning curve—anticipating short-term changes to their body and their lifestyles that they may not be expecting. "Most men are not planning for their quality of life tomorrow," says Dr. Sean Cavanaugh, Chief of Radiation Oncology at our hospital near Atlanta. "They're planning on maintaining today's quality of life for the rest of their lives."

Let's talk about sex

Many prostate cancer survivors may undergo treatments that cause adverse side effects, including sexual and intimacy issues, frequent urination, incontinence, pelvic pain and psychological distress. "The main problem that many men worry about is erectile dysfunction," says Dr. Cavanaugh. "Even though prostate cancer doesn't always mean the end to your sex life, it may mean a change."

Treatments vary according to the type of prostate cancer, its stage and the risk level for the cancer spreading. Options range widely, from active surveillance to hormone therapy to surgery, radiation therapy, chemotherapy, immunotherapy or a combination of therapies. Understanding the benefits and risks of each treatment will help arm patients with the information they need to make educated decisions about their care. "I think a man who's educated and informed about what's going on in his body is more likely to make a healthy decision for him and his family," says Dr. Cavanaugh.

Active surveillance

For some low-risk men, the recommended approach is keeping a watchful eye on the disease and its progression. Oncologists typically monitor for changes during regular checkups and with the help of PSA tests, which measure prostate-specific antigen (PSA) levels in the blood. This is known as active surveillance, and it is generally recommended for men who are at low risk that the cancer will grow or spread and for those with a life expectancy of more than 20 more years. It is also recommended for some men with elevated PSA levels who are at risk of developing cancer but have not yet been diagnosed with the disease.

"I recommend active surveillance for 10-15 percent of my patients," says Dr. Evan Pisick, Medical Oncologist at our hospital near Chicago. "Some of them may never need therapy due to low risk of their disease ever progressing, while others may be too sick for therapy."

Here's a list of the advantages and disadvantages associated with active surveillance:

Active surveillance

  • Advantages
  • No surgery involved
  • No hospital stay required
  • No surgery-or-radiation therapy side effects like urinary incontinence and erectile dysfunction
  • Imaging technology offers more accurate monitoring capabilities
  • Disadvantages
  • Less proactive
  • Frequent follow-ups with doctors for blood, rectal and other tests
  • Potential for repeat biopsies
  • Potential for cancer to spread
  • Potential for further treatment if cancer begins to grow
  • Potential for anxiety, worry or other psychological stress

Starving the cancer with hormone therapy

In order to grow, prostate cancer needs the male hormone testosterone, so doctors may prescribe hormone therapy to reduce testosterone levels and starve the cancer. Hormone therapy may also shrink the cancer or lower the risk of an early prostate cancer coming back after treatment. "Men with metastatic disease, stage IV disease or those with high-risk disease who are undergoing radiotherapy as a primary treatment are typically good candidates for hormone therapy," says Dr. Pisick.

Hormone therapy was Jeff Austin's first treatment after his initial diagnosis in May 2011. "I understand that it was effective in dropping my testosterone, which was fueling my prostate cancer," the Atlanta, GA resident says. "But the side effects were almost immediate. I became more emotional and experienced hot flashes, a loss of libido and erectile dysfunction." Now 59 years old, Austin also has experienced some long-term side effects, including fatigue and decreases in body hair and muscle mass.

A biopsy revealed his cancer had spread to his lymph nodes. A few months after his diagnosis, Austin had surgery to remove the cancerous lymph nodes, but surgeons opted not to remove his prostate. Two months later, he began external beam radiation treatments.

Here's a list of the potential side effects associated with hormone therapy:

Hormone therapy

  • Potential short-term side effects
  • Hot flashes
  • Decreased muscle mass
  • Decreased mental capacity
  • Fatigue
  • Depression
  • Impaired sexual function
  • Loss of desire for sex (libido)
  • Nausea
  •  
  • Diarrhea
  • Itching
  • Weight gain
  • Mood swings
  • Breast tissue growth
  • Bone fractures
  • Insulin resistance
  • Potential long-term side effects
  • Some patients may not return to pre-treatment testosterone levels

Radiating cancer inside and out

External beam radiation therapy (EBRT) is delivered from a machine outside the body, sending high-energy rays to tumors. Treatment typically involves several weekly visits. The long-term effects of Austin's external beam radiation included rectal bleeding and acute proctisis, or inflammation of the rectum and anus. "This went off and on for the better part of 18 months," he says. Dr. Cavanaugh says rectal bleeding is a rare side effect of radiation: "Frequent urination and mild to moderate burning during urination are essentially guaranteed with any form of radiation therapy, including brachytherapy. In general, the urinary frequency will be increased a mild amount to a moderate amount."

Brachytherapy, also known as seed implantation, is delivered in high and low doses. "Brachytherapy, in general, is radiation implanted inside the tumor," says Dr. Cavanaugh. "It's a way of focusing the radiation very specifically. There is no shorter path to get to the prostate than radiating it from the inside out. That gives us very good control of where the radiation goes."

Following his radiation treatments, John Beavers of New Franklin, Ohio experienced different side effects than Austin. "I had hot flashes," says the 49-year-old firefighter. "My internal thermometer stopped regulating my temperature. I had to turn on the air conditioner or put ice on myself." As time went on, he also began to feel fatigued. "I had no energy," he explains. While Beavers was used to dealing with tough situations in his professional life, he struggled through his recovery from radiation. "After my treatments, my doctor reminded me that my body was recovering from cancer treatment, not the flu."

Here's a list of the potential side effects associated with external beam radiation and brachytherapy:

External beam radiation

  • Potential short-term side effects
  • Fatigue
  • Frequent urination
  • Painful urination
  • Urinary leakage
  • Diarrhea
  • Abdominal cramping
  • Potential long-term side effects
  • Some risk of erectile dysfunction
  • Changes in bowel habits including fecal incontinence
  • Secondary cancers in treated areas
  • Rectal bleeding

Brachytherapy (seed implantation)

  • Potential short-term side effects
  • Pain
  • Burning during urination
  • Urinary retention
  • Blood in urine
  • Frequent urination
  • Return to pre-operative urinary function for many
  • Potential long-term side effects
  • Some risk of erectile dysfunction
  • Narrowing of the urethra (urethral stenosis)
  • Rectal bleeding (rare)

Cut the cancer out

Small business owner Mark Pattullo of Lewiston, Michigan, decided early on that radiation treatments would not be part of his plan. "When I was told I needed eight to 10 weeks of radiation treatment, I passed out during my first appointment," he says. The 54-year-old became aware of his elevated PSA levels during a checkup a couple of years ago. But after watching his wife undergo radiation treatments for breast cancer, he wanted something different. He opted for a targeted surgical approach, robotic prostatectomy, in October 2015 at our hospital outside Chicago.

The post-surgical side effects were immediate and included impotence and incontinence. 'It took me by surprise how much it put me down," says Pattullo. "From constipation to the urination problems, the overall recovery process was more difficult than I expected. I was told it was going to take time, but I assumed I would just bounce back, but I didn't."

The sexual side effects did not take Pattullo by surprise. "My therapists were completely open about something everyone knows about, but no one wants to talk about," he says. "Most of the men I talk to avoid this topic, too. Women share everything. But men don't want to talk about impotence problems. It's not the end of the world."

Here's a list of the potential side effects associated with surgery:

Surgery

  • Potential short-term side effects
  • Leakage of urine from bladder, or stool from bladder (incontinence)
  • Shortening of penis
  • Potential long-term side effects
  • Chronic leakage of urine from bladder
  • Erectile dysfunction

Immunotherapy brings optimism

In 2012, less than a year after his EBRT treatments, Austin had a CT scan that revealed newly active metastatic resistant prostate cancer. His PSA levels were rising. "The first treatment we tried was an immunotherapy drug for prostate cancer," he says. "I experienced no side effects, and I understood that the benefits are long term, but difficult to measure."

Immunotherapy is a treatment designed to stimulate the body's own immune system to kill cancer cells. "I'm excited by the new immunotherapies with PD-L1 inhibitors," says Dr. Pisick. "These new treatments are showing promise."

Here's a list of the potential side effects associated with immunotherapy:

Immunotherapy

  • Potential short-term side effects
  • Fever
  • Chills
  • Shortness of breath
  • Nausea
  • Vomiting
  • Fatigue
  • Hypertension
  •  
  • Increased heart rate
  • Anemia
  • Back pain
  • Dizziness
  • Muscle pain
  • Weakness
  • Flu-like symptoms

(Most side effects are mild to moderate and last one to two days.)

Austin had another surgery, but the cancer was still active. In 2013, he started chemotherapy.

Treating cancer with chemotherapy

Chemotherapy involves one or combination of cancer-fighting drugs that are either injected into a vein or given by mouth. Chemotherapy may be recommended for patients with metastatic disease, like Austin, and those who were first diagnosed with hormone-sensitive cancers. "It's also an option for men with metastatic disease who have failed multiple other therapies, and men with metastatic disease with a lot of symptoms secondary to their metastatic disease," says Dr. Pisick.

Initially, Austin experienced few side effects, but on the third day, he felt weak and tired after each treatment. His hair also thinned out a bit. "I cut it very short so you couldn't tell," he says. He experienced other issues as well. "My vision changed so much, I had to buy glasses and wear them all the time. I had heard about 'chemo fog' before, and learned what it's all about. I could forget who I was talking to on the phone or what they were talking about."

In March 2016, Austin started chemotherapy treatments at our hospital near Atlanta. The side effects—including constipation, indigestion, fatigue and thinning hair—continue, but the severity varies. "The issues were worse during the first 10 days of the cycle." says Austin.

Here's a list of the potential side effects associated with chemotherapy:

Chemotherapy

  • Potential short-term side effects
  • Hair loss
  • Mouth sores
  • Loss of appetite
  • Nausea
  • Vomiting
  • Diarrhea
  • Increased chance of infections (from having too few white blood cells)
  • Easy bruising or bleeding (from having too few blood platelets)
  • Fatigue (from having too few red blood cells)
  • Potential long-term side effects

    Certain side effects are seen more often with specific chemotherapy drugs, including:
  • Severe allergic reactions
  • Nerve damage
  • Numbness
  • Tingling

Knowing your options

For most men with prostate cancer, there is no one right treatment, but there may be one or a combination of therapies that may be right for them. That's why knowing your treatment options and the potential side effects are important. "Treatments need to match the patients," says Dr. Cavanaugh. "Patients deserve numbers, they deserve to know what risk they're facing and what their quality of life may be like afterwards."

No case is typical. You should not expect to experience these results.

Learn more your prostate cancer risk and the PSA test.

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