Treatment types
Surgery
Transurethral Prostatectomy (TURP)
This is the removal of the central core of the prostate gland through the urethra and is done to improve urine flow when the prostate gland is enlarged and pressing on the urethra. It is not a treatment for prostate cancer. The chippings of the prostate are sent to the pathology lab and sometimes prostate cancer is detected in these.
Illustration: Cross section of the male pelvis viewed from the side, showing the location of the prostate gland and bladder. Image courtesy of Wellcome.
Radical Prostatectomy
This is major surgery, which involves removing the prostate gland from the pelvis and rejoining the bladder to the urethra at the end. It can be done open or laparoscopically - so called ‘keyhole’ surgery. This type of surgery can be curative if the cancer is completely removed. The recovery time is at least 6 weeks. Common long term side effects include urinary incontinence which is severe in 5% and impotence in 50-60% which may be permanent. It is common to have difficulty controlling urine flow for up to a year after this type of surgery. Other adjuvant treatments are not normally necessary after surgery.
Therapies
Radical Radiotherapy
Radical radiotherapy has a similar effect to radical prostatectomy; the prostate is not removed with surgery but is destroyed with radiotherapy. The main problem during treatment is diarrhoea which may become a long term problem in up to 5% because of the effect of radiotherapy on the rectum. Treatment lasts for 4-8 weeks and recovery, from tiredness and other symptoms takes 12 weeks. Fatigue may be severe and prolonged. Long term urinary incontinence is unusual, impotence occurs in around 35%. Men given radiotherapy may also be given hormone therapy at the same time.
Brachytherapy (internal radiotherapy)
This may also be used for prostate cancer. Iodine seed brachytherapy is the common form chosen as an alternative to surgery in good risk patients. This may be associated with urinary frequency, urgency and dysuria for the first 3 to 6 months. Long term urinary symptoms and bowel symptoms are rare. Impotence rates are lower than after treatment with external beam radiotherapy or surgery only affecting 15 to 20% of patients.
Cryotherapy
This is a new treatment. Ultrasound guided probes are inserted into the prostate, which freeze the prostate. Freezing cells destroys them because the expansion of water and formation of ice crystals within cells disrupts membranes. The urethra, which runs through the prostate gland, is protected from freezing and damage by keeping a catheter containing warm fluid in it. The main use of this treatment is for recurrent cancer confined to the prostate after radiotherapy treatment. It has a similar rate of urinary incontinence to radiotherapy and high rates of impotence. A rare complication is recto-urethral fistula.
High Intensity focussed ultrasound (HIFU)
High Intensity focussed ultrasound treatment (HIFU) is another new treatment for prostate cancer. It is given through a probe inserted in the rectum as a one off day case treatment. The treated area may be painful for a few days afterwards but other side effects are rare.
Hormone therapy
Hormone treatment reduces the response of the growing prostate cancer cells to the male hormone testosterone. It is used in both curative and palliative treatment. It is used in curative treatment:-
- As adjuvant treatment after radical prostatectomy (surgery) when there is a high chance of recurrent disease because the Gleason score is high or there is extra-capsular extension.
- Before during and after radical radiotherapy.
For the majority of men having hormonal therapy it is being used to control disease when cure is not possible i.e. as a palliative treatment:-
- In advanced disease when the cancer has spread outside the prostate and cannot be treated with either radiotherapy or surgery to the prostate gland alone.
Hormone therapy in prostate cancer mainly works by removing the source of testosterone in the body. This can be done surgically by removing both testicles (bilateral orchidectomy) or by blocking the action of testosterone made by the testicles, using drugs. There are two types of drugs that can block testosterone :
- LHRH analogue or agonist.
- Anti-androgen.
Luteinising Hormone Releasing Hormone (LHRH) is made by the pituitary gland in the brain and travels through the blood to the testicles and ‘tells’ them to produce testosterone. These drugs (LHRH analogues) fool the pituitary gland into thinking there is plenty of testosterone around already and stop the production of LHRH and therefore the production of testosterone.
Once hormone therapy has stopped working, it is usually stopped and other treatment started if available. If hormone therapy has stopped working, the cancer cells will start to grow again. Symptoms of this might be the return of bone pain if there are bony metastases. Blood test monitoring may show PSA measurements rising again.
Other treatments
Once prostate cancer has stopped responding to hormonal treatment, any further treatment is unlikely to improve survival although it may improve symptom control. Survival from this point is in the range 4-18 months. Taxotere chemotherapy is the only other treatment which has been shown to be effective, resulting in an average of two months extension of survival.
There are some trials underway of chemotherapy treatment with or without various other drugs which may be used to reduce symptoms. Other treatments under evaluation include various hormones such as, diethylstilboestrol with or without corticosteroids, growth factor inhibitors and non-hormonal treatments such as bisphosphonates and chemotherapy.
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Amended April 2008
