'You've Got Prostate Cancer'
An American man has a 1 in 5 lifetime chance of hearing those 4 words. What he will do about them is a decision that will affect the rest of his life.
Radical prostatectomy: big, scary words that mean surgery.
The idea is to cure the cancer by removing the prostate gland and quickly getting rid of the tumor. The best candidates for surgery are patients with a good chance that their cancer has not spread beyond the walls of the prostate gland. This is not an exact science: Some 30% of these patients will not be cured because of greater-than-expected cancer spread.
What's good about surgery is that it offers the fastest and most complete chance for a cure. The downside is that the operation carries serious risks, including reactions to anesthesia, blood loss, infection, rectal injury, inability to hold one's urine, difficulty passing urine, and -- most disturbing to some patients -- impotence.
New techniques -- nerve-sparing surgery and nerve grafts -- often can prevent permanent loss of erections, urinary incontinence, and other side effects. But even when nerve-sparing surgery is a success, the incontinence and impotence usually last for months after the operation. Because prostate tumors have a nasty tendency to grow near the bundle of nerves that control erections and urination, it often is impossible to spare or repair these nerves.
External Beam Radiation
Improvements in radiation therapy -- using three-dimensional imaging for more accurate targeting of the cancer -- yield results generally considered as impressive as those achieved by surgery. However, the side effects can be just as devastating, if not as immediate. Radiation therapy requires short daily treatments for as long as seven weeks.
What's good about radiation therapy is that it avoids the risks of surgery. Some studies suggest that there is less risk of impotence and incontinence.
The downside is that radiotherapy can cause swelling of the bladder wall, leading to frequent and painful urination. It can also cause radiation proctitis, leading to increased pain, frequency, and urgency of bowel movements. Treatment also can cause extreme fatigue. And although many patients choose radiation therapy to avoid the risk of impotence after surgery, there is no guarantee that sexual function will be preserved. The same thing goes for urinary incontinence. And once a patient has elected radiotherapy, surgery is no longer an option.
Radioactive Seed Implants
Another way to undergo radiotherapy is to have tiny radioactive seeds implanted in and around the prostate tumor. This technique, known as brachytherapy, can be used in combination with external beam radiotherapy and hormonal therapy.
What's good about brachytherapy is that there is no surgery -- the seeds are placed using a needle guided by ultrasound or MRI. The seeds give off a high dose of radiation only in the tissues where they are placed; they are intended to spare healthy tissues in the bladder and rectum. After a short time, they become inactive. Brachytherapy is thought to carry a much lower risk of impotence than surgery, but more recent data suggest that rates of erectile dysfunction may be higher than previously thought.
The downside is that brachytherapy can cause impotence, pain or discomfort when urinating, frequent urination during the night, and urinary incontinence. It can also lead to difficulty in urination. The seeds also may become displaced and migrate into the urethra, where they can be passed to a sexual partner during intercourse. Implants can't be repeated, and the implants make surgery much more difficult if further treatment is needed.