What Prostate Cancer Treatment is Right for Me?

How do you decide which prostate cancer treatment is best for you?

1354136651There are many things to consider when trying to choose the prostate cancer treatment that is right for you. Most men diagnosed with prostate cancer haven’t had the disease spread beyond the gland and may be classified as low risk. Others may have more advanced stages of the disease and will be considered intermediate or high risk.

Doctors use the serum PSA test and the Gleason score to help decide which type of prostate cancer they are dealing with. Treatment options vary depending on these factors and more. Dr. Farshid Dayyani details what these factors are and how you can use them to find the correct prostate cancer treatment for you.

Video Transcripts

Farshid Dayyani, MD: The majority of men are diagnosed with what we call localized prostate cancer meaning that the cancer has not spread beyond the gland. While some of them might live forever and never die of their cancer even without treatments, others will have much more aggressive disease and will need more aggressive treatment upfront.

In order to stratify the patient in different risk categories to guide them through treatment, we have used clinical parameters such as the serum PSA, the Gleason score which is found on the biopsy results as well as the extent clinically through rectal exam and imaging to build a prognostication system that will guide our treatment. Based on these three factors, we have patients with low risk of disease progression, intermediate and high risk.

For patients with very low risk, active surveillance is actually a recommended modality, meaning close followup, serial PSA checks and repeat biopsies and treatment at the time of disease progression. The patients who have low risk disease can choose, in selected cases, between active surveillance or treatment with radiation or radical prostatectomy.

Patients with intermediate grade disease probably should not observe and decide on treatment with either radiation or surgery and if they choose to undergo radiation therapy, should be treated with six month of hormone deprivation therapy. High risk patients meaning those who are at the highest risk for progression and metastasis should either undergo prostatectomy or if they choose to have radiation therapy will combine this with two to three years of androgen deprivation.

How to choose between surgery or radiation will depend on the patient profile. If the patient is not a good surgical candidate because of other comorbid conditions he has such as heart disease, diabetes, or advanced age, then treatment is likely to be radiation with or without hormone deprivation. A younger fit patient, for example, in his 50s who has no other medical issues and a very aggressive disease might probably benefit more from upfront surgery.

The side effects associated with radiation and surgery are explained by the technique and I will explain to you in a second. With surgery, the main goal for quality of life is to try to preserve the nerve bundles that mediate sexual function, so for the surgeon who performs this procedure, the question is can I preserve the nerve bundle safely meaning without leaving any disease behind? This should be discussed with the patient prior to the procedure.

Based on the risk level, the surgery will also entail removal of lymph nodes in the pelvis which might cause some problems down the road such as edema. If the so called urinary sphincter muscle is affected during the surgery, the patient might suffer from incontinence after the surgery. Most of these side effects will improve over time and by about two years after surgery depending on what study we look at, 30 to 50% of patients will have some decrease of these functions, although they are not very severe.

It is important to know that for example, sexual dysfunction can be treated with implants and medication, so counselling the patient is very important to know that we are able to control most of the side effects. The patients who elect to undergo radiation will have more acute side effects such as irritable bowel that is in the radiation field and is manifested by frequent bowel movements, urgency and sometimes also rectal bleeding, but again these are acute side effects and most of them resolve over the first one or two years.

The urinary symptoms that patients with who undergo radiation experience are explained by what we call radiation cystitis, so it’s more the irritation of the bladder rather than interaction with the sphincter muscle, so again they will have urgency, meaning to have to go to the bathroom a lot, they’ll have some burning sensation, but this overtime will improve as well.

Sexual dysfunction, on the other hand. is a side effect that will develop over time and increase typically over the first one or two years in the patients who undergo radiation, but if you look at two years in most studies, there is not a major difference in terms of long term side effects of surgery versus radiation in the majority of men, so other medical problems as mentioned earlier will help guide the decision making.

Farshid Dayyani
Dr. Dayyani earned his medical degree in Munich, Germany at Ludwig-Maximilians Universitaet before completing his internal medicine internship and residency at Beth Israel Deaconess Medical Center in Boston, Mass.
Farshid Dayyani

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