Prostate Cancer Treatment
Prostate cancer occurs when some cells in the prostate gland grow abnormally. Cancer is a rapid growth of these abnormal cells that may invade and destroy nearby tissues and organs or spread to other parts of the body. Prostate cancer is most commonly found in the posterior or back portion of the prostate gland which is closest to the rectum, but may also arise in other locations or sites in the prostate gland. If prostate cancer can be detected early while it is confined to the prostate gland, proper treatment may result in a complete treatment. Early stage prostate cancers can be treated with brachytherapy alone. More advanced prostate cancers may require a type of external beam radiation such as IMRT. IMRT stand for intensity modulated radiation therapy, and is used to deliver a precise field. A newer treatment, IGRT, or Image Guided Radiation Therapy can reduce radiation exposure to adjacent normal tissue even more effectively.
Compared with most cancers, cancer of the prostate gland tends to grow slowly. Early prostate cancer often does not cause symptoms. However, some of these problems may be caused by prostate cancer:
- A frequent need to urinate, especially at night
- Inability to urinate
- Weak or interrupted flow of urine
- Difficulty in starting to urinate or holding back urine
- Pain or burning sensation during urination
- Blood in urine or semen
- Difficulty in having an erection
- Painful ejaculation
Any of these symptoms can be caused by cancer or by other, less serious health problems, such as an infection. If you are experiencing any of these symptoms, you should consult with as doctor.
Diagnosing Prostate Cancer
To diagnose prostate cancer, your physician will ask you questions about your personal and family health history, as well as performing a physical examination, a digital rectal exam, a urine test to check for blood or infection and a PSA blood test. Other things that could be ordered to assist your physician in making a determination of the cause of your symptoms are a transrectal ultrasound and a cystoscopy.
Stages of Prostate Cancer
Once your physician has diagnosed cancer in your prostate gland, the next step is to determine the stage or the extent of the disease. This process is called staging and the purpose is to find out if the cancer has spread, and if it has, to what extent as well as what areas of the body are affected.
Staging the disease is a complex process. Your physician may use a Roman number (I-IV) or a capital letter (A-D) in describing the stage of your prostate cancer.
- Stage I or A: Your physician does not feel your cancer when he is doing a rectal exam, and there is no evidence that the cancer has spread outside of the prostate.
- Stage II or B: Your physician is able to feel the tumor during the rectal exam and this stage means that the tumor involves more tissue than just the prostate gland. There is no evidence that the cancer has spread outside the prostate gland at this stage.
- Stage III or C: The cancer has spread to nearby tissues around the prostate gland.
- Stage IV or D: The cancer has spread to lymph nodes or other parts of the body.
Making your treatment choice after receiving a diagnosis of prostate cancer is overwhelming. In reaching a decision for treatment, we suggest that you involve your wife/partner in this process. Discuss each treatment option, including benefits and side effects. There are also prostate support groups that are available to you. Our office would be happy to assist you in contacting a local group in your area.
Treatment options for prostate cancer include watchful waiting, surgery, radiation therapy or hormonal therapy. Some patients receive a combination of therapies. Watchful waiting can be suggested if the cancer is found at an early stage and appears to be slow growing. This also applies to men who are older and have certain medical conditions that would outweigh the possible benefits of treatment.
Patients with a diagnosis of prostate cancer should be evaluated and counseled regarding the several treatment options available. A careful physical examination and review of the patient’s diagnostic tests and pathology slides is performed to insure a cancer diagnosis and to confirm that the prostate cancer is likely confined to the gland. Depending on the patient’s stage or medical condition, he may be a candidate for prostate brachytherapy (either alone or in combination with external beam irradiation therapy).
Surgery involves two techniques and the surgeon can remove part of the prostate or the entire gland and the lymph nodes. During this surgery, the surgeon will try to remove the prostate and lymph nodes while trying to spare the muscles and nerves that control urination and sexual function.
Radiation Therapy uses high-energy X-rays to kill cancer cells. Radiation may be directed at the body by a machine, called external radiation, or it may come from tiny radioactive seeds placed inside and near the tumor, which is called brachytherapy. The seeds deliver a higher dose of radiation than the external beam does. Some men with prostate cancer receive both types of radiation therapy. For external beam radiation, patients come to the clinic 5 days a week during the course of the treatment. Because external beam requires no surgery, it is an advantageous method for older men or men with medical conditions or health problems making surgery no longer an option.
Hormonal therapy works against the prostate cancer by cutting off the supply of male hormones or androgens, such as testosterone that assist the prostate cancer growth. Hormonal therapy targets the cancer that has spread beyond the prostate gland and thus is beyond the reach of local treatments such as radiation therapy or surgery. Although hormonal therapy cannot treat, it can assist in shrinking or halting the advancement of the disease, often for many years.
One of the most recent improvements in prostate cancer therapy was in the development of an interactive technique, fluoroscopic and biplanar ultrasound guidance during brachytherapy. Dr. Gordon Grado originally considered this an option for locally recurrent prostate cancer after previous surgery or radiation therapy. Because of his success with locally recurrent prostate cancers, the approach and technique was expanded to include early stage or locally advanced prostate cancer. The images obtained for the biplanar transrectal ultrasound probe combined with fluoroscopic imaging, allowed a more accurate placement of the needles and radioactive sources throughout the prostate gland. We are now able to treat patients with all sizes and shapes of prostate glands including those patients with enlarged prostates or patients who have previously undergone prostate surgeries such as a TURP.
In order to treat the cancer, radioactive Iodine-125 or Palladium-103 seeds are placed directly into the prostate gland through after loading needles with a specialized “gun” or with seeds preloaded into needles. Both of these isotopes give off low energy x-rays with the majority of the radioactivity released within a few months. Only a small volume of prostate tissue is irradiated by each seed and therefore many seeds have to be placed throughout the prostate tissue to cover the entire prostate and the cancer site within the gland. Because of the low x-ray radiation energy released, radiation exposure to adjacent normal organs is reduced. The entire prostate gland is treated because microscopic cancer cells may be present at multiple sites within the gland even though the biopsy may have been positive in only one location. The number of seeds implanted into the prostate for treatment depends on the size and shape of the prostate gland, as well as the activity of the seeds. On average, approximately one-hundred seeds may be implanted into the prostate through eighteen or so needles.
Before the procedure, the patient is carefully evaluated to make sure they are an appropriate candidate for prostate brachytherapy, which is defined by several staging tests.
Clinical History & Physical Exam
All patients will have a detailed clinical history obtained as it relates to their general health, prostate cancer diagnosis, previous surgery or radiation treatment to aid in the evaluation process. This will be followed by a complete physical exam and detailed digital rectal exam.
Prior to the implant procedure, blood work, an electrocardiogram (EKG) and a chest x-ray are done. These tests aid the anesthesiologist in determining the patient’s ability to receive anesthesia. Either a spinal or general anesthesia will be given.
Prostate Ultrasound Volume Study
This is a specialized ultrasound exam of the prostate. This will examine the prostate gland to make sure the capsule is intact and that the cancer is in an early stage within the prostate. From these “pictures” we can calculate the number and position of the needles and radioactive sources that are needed to be placed throughout the prostate gland. Ultrasound staging and evaluation of the neurovascular bundles will be performed. If the prostate gland is determined too large for the template (>6 cm wide), hormonal downsizing may be required.
CT Scan of the Pelvis
This is an x-ray that takes thin slices or pictures through the pelvis area. This test is utilized to look for any pelvic lymph node enlargement or evidence of cancer outside of the prostate region. The relationship of the prostate to other normal structures in the pelvis is identified as well as its association to bony anatomy. Contraindications for the prostate seed implant may be detected by this x-ray exam.
Preparing for the Prostate Seed Implant
Any aspirin product or non-steroid medication being taken should be discontinued seven days prior to the implant. It is important to review the medications being taken with the physician, as some drugs could adversely affect the procedure or cause an unnecessary delay in performing the procedure, such as “blood thinner” medication. The day before the implant a special diet and bowel prep will be started. This will remove fecal material from the lower bowel and rectum that could interfere with the ability to obtain a clear ultrasound image of the prostate at the time of surgery. The patient should not eat or drink anything after midnight the day before the procedure. Any prescription medications may be taken with a small sip of water. If you are a diabetic you will want to check with the doctor before taking medications to lower your blood sugar.
Prostate Seed Implant
The procedure is done in a sterile operating room as an outpatient. The patient will be asked to report 1-2 hours prior to the procedure for registration and preparation. The entire procedure lasts approximately one hour. After the patient is precisely positioned on the operating room table, an individual specializing in prostate ultrasound will place the biplanar ultrasound probe in the rectum to image the prostate. The ultrasound probe is carefully held in position by a stabilizing device that is attached to the O.R. table. Biplanar transrectal ultrasound along with fluoroscopy gives a multi-dimensional view of the prostate gland on several TV screens in the O.R. These images of the procedure are used to accurately place the needles and space the radioactive sources within the prostate gland. The implant procedure does not require a surgical incision. Needles are advanced through an area of skin, called the perineum (behind the scrotum and in front of the rectum) into the prostate with the aid of a template attached to the ultrasound probe and computer plan designed specifically for the patient’s prostate gland size. Radioactive seeds are then deposited through the needle into the prostate gland based on a precise plan or map that was developed before going to the O.R. and then rechecked and modified at the time of surgery. The dose needed is calculated by pre-implant dosimetry from the volume study. The seeds are permanently placed in the prostate gland and give off the radiation over the seed’s life span of 3 months to a year (depending on the radioactive seed that is selected). Both the probe and needles are removed when the procedure is completed and a foley catheter left in the bladder until the patient recovers. Cystoscopy at the completion of the procedure is rarely needed except to evaluate the urethra and the bladder if necessary. The patient will then be transferred to the post-anesthetic care unit for an hour or more of recovery where the patient will wake up and receive discharge instruction, once recovered, he will be discharged.
When the catheter is removed, the patient will be taught self-intermittent catheterization should he have any voiding difficulty. Most patients, however, do not have to catheterize themselves. The patient’s urine may contain a small amount of blood for a short period of time. This is nothing to be alarmed about and should subside in 24-48 hours.
A CT scan of the prostate and PSA will be done prior to discharge. The CT scan and postoperative films will be utilized for evaluation of seed placement and to calculate the total dose delivered. Later in the day or the following morning following the procedure, the patient will have a post-op visit.
Discharge instructions will be given after the procedure. Antibiotics will be given for five days following the procedure. If necessary, prescriptions for pain medications will be provided. Heavy lifting or strenuous activity should be avoided for 30 days after the procedure, but walking, swimming and golfing are fine. After that, the patient may return to a normal level of activity. A two to three month follow-up appointment will be scheduled which will consist of a PSA blood test, a physical exam including a digital rectal exam, and an x-ray of the seeds within the prostate gland, or ultrasound if necessary.
Iodine-125 and Pallaldium-103 are low energy radioactive materials. This means that the radiation passes only a short distance with the majority of radiation effects delivered within the prostate area, “shielded” by the surrounding body tissues. Exposure to family and friends is minimal and special precautions are not indicated unless otherwise advised by the doctor or nurse.
Short-Term Side Effects
Some patients experience some burning or discomfort with urination that may last from a few days to several weeks. Patients may also experience some increased frequency and urgency with urination. This is due to swelling in the prostate that results from the placement of needles during surgery. There are medications available to decrease these side effects. When the swelling subsides, so do the side effects. In our experience, most of the side effects are gone within a few months.
Long-Term Side Effects
After receiving radiation to the prostate gland, it is important to discuss any future anticipated surgery to this region of the body with the Radiation Oncologist involved in the procedure. Such procedures that require caution include colonoscopy, proctoscopy, sigmoidoscopy, and cystoscopy. The majority of delayed long-term side effects can be avoided by careful instructions from the physician regarding subsequent procedures to the area. While patients are concerned with impotency and incontinence, the observed impotency rate is small and the incontinence rate is negligible unless a previous surgical procedure to the prostate or transurethral resection of the prostate has been performed or hormonal deprivation utilized.
With the techniques and equipment we now have available, radioactive sources can be very carefully positioned throughout the prostate gland and the prescribed treatment delivered. We have developed specialized techniques for patients having undergone a TURP (transurethral resection of the prostate), previous radiation to the prostate area, or patients with enlarged prostate glands requiring special consideration with regards to prostate brachytherapy. Radioactive sources can be positioned to deliver cancercidal radiation doses taking into account previous radiation delivered for prostate cancer or other malignancies. Prostate gland size may present some problems but can be accommodated. Gland sizes treated with this technique have ranged from 8 to 210 cc (cubic centimeters). Equipment development and expertise has allowed us to specialize in these more difficult patient problems.