Most men who learn they have prostate cancer will be told they have a relatively early stage of the disease. This article is for them. Not because later-stage disease is untreatable, but because men with early prostate cancer must choose among a wide range of different treatment options.
Having options is a good thing, but having to choose is hard. Each choice has its advantages -- and its disadvantages. And once most of these choices are made, there's no going back. Even if other options still remain, they will be affected by the original decision.
"Of the men today diagnosed with prostate cancer, 90% have localized cancer," says Peter Scardino, MD, chair of the urology department at New York's Memorial Sloan Kettering Cancer Center. "The dilemma they face is, 'What shall I do about this? Should I treat it at all, or is the word cancer scaring me into taking potentially dangerous treatments? It is an agonizing decision."
"You have to be aware of the risks -- and you have to make decisions," says Thomas Keane, MD, associate professor of urology at Emory University School of Medicine, in Atlanta. "The only way you can do that is to get the knowledge in the first place. If you are the kind of patient that doesn't do well with that, you need to sit down and spend a lot of time with your doctor."
To choose among treatment options, a man must know how aggressive the cancer seems to be and if the tumor is localized or if it has spread to the lymph nodes or other parts of the body.
A man with localized prostate cancer has four main treatment options:
Prostate cancer usually takes a long time to go from localized cancer to painful, metastatic disease. For a man in his late 70s or 80s with a non-aggressive tumor, it might be a good idea to do nothing at all except keep track of how the disease is progressing, and to deal with symptoms when and if they arise. This is called "watchful waiting." The idea is to wait until the cancer is serious enough to justify the risks of treatment.
Treating prostate cancer lowers the likelihood of dying from the disease. However, many men who do not receive treatment will not die of prostate cancer, "Roughly two of three men treated with surgery will survive without a detectable PSA [prostate specific antigen], and you see similar results in men who receive other forms of treatment. We just don't know the relative benefit of being treated or not being treated." Scardino says.
What's good about watchful waiting is that it avoids the side effects treatment for early stage cancer. It can also give a patient time to more carefully consider his treatment options.
The downside of watchful waiting it that it can be anxiety-provoking to live with untreated cancer. And there is no way to be sure the cancer won't become incurable.
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.
Prostate cancers like to have testosterone around to help them grow. Taking away this supply of testosterone greatly slows tumor growth. There are two ways of doing this: by surgical removal of the testicles (orchiectomy), or by the use of potent drugs that block the production or effects of male hormones (chemical castration).
What's good about hormonal therapy is that it can greatly improve the outcomes of other treatments, particularly in the later stages of disease. When used alone, it can keep a cancer in check for many years, although it does not cure it.
The downside is that sexual function and sexual desire can be lost. While orchiectomy has the disadvantage of being permanent, chemical castration has the disadvantage of cost. In both cases, there may be hot flashes and a variety of other side effects.
Cryotherapy kills prostate tumors by freezing them. It can also freeze the urethra, the tube that carries urine and semen. However, new techniques to warm the urethra have led to new interest in this technique. Despite these advances, most doctors still consider cryotherapy experimental.
The good thing about cryotherapy is that it is minimally invasive and requires only a one-day hospital stay. There is almost no bleeding, and the risk of urinary incontinence is very low. Patients treated with this technique can still choose other treatment options in the future.
The downside is that nobody knows the long-term effectiveness of this treatment. About two-thirds of men treated with this technique become impotent. Patients who choose this option should find a doctor who has a lot of experience using this technique.
So What Do I Do?
Treatment of prostate cancer has two goals, says Mark S. Litwin, MD, MPH, a urologist at UCLA Jonsson Cancer Center. These goals are survival, and preserving -- or even improving -- the quality of a person's life.
"Dying of prostate cancer takes a long time compared to other cancers -- so the effects of treatment remain with a man for a very, very long time. This is the human cost of prostate cancer," Litwin says. "Health is not merely absence of disease, but a state of complete physical, emotional, and social well-being. To me that means we have to go about task of [considering] these different components."
More than for any other disease, the choice of treatment for early-stage prostate cancer depends on the person making the choice. It's not a choice your doctor can make for you. So there are questions every patient must ask himself: Which treatment has the best chance of success? Which side effects of treatment would bother me the most? Which would bother me the least?
"Some patients want to be heavily involved in this decision, and others want their doctor to make the decisions for them," says Michael W. Kattan, PhD. "But I think with prostate cancer it's not going to work very well for the patient to try to stay uninvolved in that decision, because it just is not a black-and-white thing."
One way to start thinking about the problem is to visit the web site of the American Cancer Society, www.cancer.org. The site has a helpful step-by-step tool to help consider the various treatment options as well as the various possible side effects. It also offers links to support groups.
Another resource is a version of a tool called a nomogram developed by Kattan's team at Memorial Sloan-Kettering Cancer Center. This computer program allows your doctor to enter a great deal of information -- not only about your tumor, but also about the things you want and don't want in a treatment. Once this detailed information is entered, the program offers an estimate -- based on real patient data -- of how likely it is that a certain treatment will have certain side effects. The program is free to physicians and can be found at www.nomograms.org.
"I think that with the nomogram, a patient is getting is our best prediction of his outcome with various treatment options," Kattan says. "He's got a better handle on how a treatment is going to work in his particular case, and it makes it easier to weigh the pros and cons of a treatment if you have better estimates of the likelihood of the outcomes."
"We advise patients to get a second opinion from someone in a different discipline," Scardino says. "If you have talked to a urologist, talk to a radiologist or an oncologist. Patients do feel caught in a dilemma about it. But just as there is not one right decision for you somewhere if you could only find it, no decision is always wrong. A surgeon, for example, may overestimate benefits of surgery and underestimate benefits of radiotherapy -- but both of those treatments can work."
What One Doctor Tells His Patients
The prostate biopsy has been taken, and today your doctor is going to tell you the results. He might tell you there's nothing to worry about. Or he might tell you that you have prostate cancer.
Here's how one doctor -- UCLA's Mark Litwin -- handles this life-changing interview, as told to WebMD.
"The first thing I do is, when I do a prostate biopsy I always schedule another appointment a week later. I always tell them to come with their spouse or with a family member. If the tumor is benign, well, they've only wasted a trip. If not, I give them the news that the biopsy was positive for prostate cancer. It ends up being a one-hour consultation. I tell the patient and his family what we do and don't know about his prostate cancer.
"The first thing we talk about is what we know: the tumor grade, his PSA level, how aggressive the tumor is, and whether it appears to be confined within the prostate capsule. If he has a high PSA -- greater than 10 -- or a Gleason score greater than 6, I send him to get a bone scan to see whether the cancer has spread.
"During that one-hour consult, I tell him that I want to cover all the treatment options -- even though some might not be appropriate for him. We talk about radiation therapy, surgery, and watchful waiting.
"Then I go on to see if waiting is appropriate for him. If he is a younger man, I mention it because I want him to know it is available, but I do not think this is the appropriate choice for a young man with a higher-grade tumor. If he is an older man with a low-grade tumor, we talk more about waiting. Then we talk about prostatectomy, and then about whether to attempt nerve-sparing surgery or not. We talk about the risk of blood loss, about the risk of impotence, incontinence, and the chances of a cure. Then we talk about radiation in its different forms and about what we do and don't know about this treatment.
"When all is said and done, I tell him he has to spend some time thinking about it. I give him web sites to visit, and books to read.
"Of course, some people just want to be told what to do. I work really hard to get this kind of patient involved in the process. Very often patients will ask me, 'What would you do?' I try not to answer directly, because I think it is important for a person to evaluate his own situation and his own response to risk and come to his own decision. I say, 'Well, I am 41 years old, my take on the risks and benefits may be completely different from yours. If they push me, I will tell them what I would do, but I try hard to make them come to their own decision. It is really critical -- any of the treatments will yield benefits and downsides. To the degree that the risks end up being long-lasting problems, it is my experience that patients tend to be more satisfied with their decisions -- even if they have side effects -- if they have been active in choosing a treatment rather than being told what to do."
"I ask them to tape record this session if they are so inclined, and try to gauge their interest in different treatment options. Some are very clear about wanting surgery or radiation therapy right out of the gate. But if they are less than sure, I tell them about how to get a consultation with a radiation oncologist who can counsel them about brachytherapy or external beam radiation. I tell them to make an appointment to see me after they have had this consultation and we will make a final decision.
"I think that the right decision is very much an issue of a person's constitution than a medical question. In my medical opinion, some men would be better off with radiation therapy, but they can't stand the idea of having a prostate with cancer inside them and they insist on surgery. Others just hate the idea of going to sleep and going under the knife. These are the men who are willing to tolerate more risk over the long term.
"In a small study I ran last year, one of the side projects was to run focus groups with men who had surgery and with men who had radiation. We made the observation that those who chose surgery tended to be more trusting of the doctor, whereas those who chose radiation therapy were more deliberative in their process. These are small groups, but it is reflective of some of the decision problems men have.
"There is, of course, the 10-year rule. If, in your assessment, the patient is going to live for at least 10 more years, he should really think about surgery because after 10 years a radiation-therapy failure could do him in. But radiation therapy is best for the older patient with a moderate-grade tumor. It is also best for the person who is really inclined toward radiation therapy because this person is really not going to be happy with surgery. If any tiny thing goes wrong, he will not be happy and will regret it.
"In the end, nobody would be reading this interview if the answer about what to do were clear. Patients have to go to a lot of trouble sorting through the literature and making the best decision."