Early Prostate Cancer

Although prostate cancer is common in older men, many of whom will die without the cancer becoming apparent, it is also our 3rd commonest cause of cancer-related death, these men suffering from and dying prematurely of prostate cancer. It may be difficult to determine whether an individual is destined to develop significant, rather than silent, prostate cancer, at a stage when curative treatment is possible. PSA testing now identifies many younger men with prostate cancer, much earlier in their disease course. Fortunately, prostate cancer generally progresses slowly, allowing opportunity to consider the treatment options and to plan for treatment. Aspects of the treatments have changed and continue to change, but there remain a number of management options, each with its relative merits and disadvantages. Men over 70 years, with other significant health problems and slower growing tumours should consider carefully the risks of curative treatment and are probably better choosing conservative management. Fit, younger men with faster growing tumours are likely to benefit significantly from curative treatment for prostate cancer, but must decide between surgery and radiotherapy, and the relative side effects. Men appropriate for radical treatment but with “super-early” cancers (small volume on biopsy, intermediate grade prostate cancer and PSA below 6) may consider active surveillance, delaying radical treatment until prompted by PSA rise, change of rectal examination findings and change of grade and volume on follow up prostate biopsies.

Wakefield Hospital
Florence Street
Newtown
Wellington
New Zealand

Postal Address:
Wakefield Urology & Urodynamics
Private Bag 7909
Wellington South 6021
New Zealand

There are currently 4 primary management options for early prostate cancer:

1. Radical prostatectomy = surgery to remove the prostate and the prostate cancer
2. Radical radiotherapy = radiotherapy to destroy the prostate cancer
1. External beam is radiation delivered from the outside, focussed onto the prostate
2. Brachytherapy is radioactive seeds and rods implanted into the prostate
3. Active surveillance = delaying radical surgery / radiotherapy until the cancer is showing signs of progression.
4. Watchful waiting / delayed hormone manipulation = no treatment until the cancer has advanced and is causing symptoms or PSA is rising rapidly. Medical or surgical castration is then performed to cause the cancer to regress.

The decision in favour of a particular therapy is on the basis of:

1. current life expectancy
2. likelihood of death or symptomatic disease from prostate cancer, considering biopsy grade, cancer volume and PSA
3. likelihood of cure from radical treatment
4. side-effects of treatment

1) Life expectancy and prostate cancer progression:

Life expectancy can be estimated from age, other medical problems and longevity in the family. Most early prostate cancers do not become apparent before 8-10 years after biopsy diagnosis. It appears that PSA-testing identifies predominantly faster growing cancers, rather than the silent cancers, and recent studies suggest an overdiagnosis rate (people identified to have prostate cancer who do not develop symptomatic disease in their lifetimes) of 30%. Patients likely to fall into this 30% or those who can successfully be managed with hormone treatment alone should avoid more radical treatments. Patients with small volume, intermediate grade cancer and low PSA should consider active surveillance, delaying radical treatment, watching for cancer progression.

2) Benefits of treatments:

Radical therapies aim to cure. Currently, radical treatment is either surgery or radiotherapy, rarely both. Chemotherapy is still an experimental treatment in prostate cancer.

There is good evidence that radical surgery significantly reduces the chances of dying from prostate cancer at 10 years after diagnosis and provides a cancer-specific survival advantage of some years over hormonal manipulation/watchful waiting. Moreover, radical surgery significantly reduces the risks of bone metastases and local tumour progression compared with watchful waiting. Unfortunately, as with all cancers, not everyone can be cured. The statistics are percentages for populations, but for the individual, cure is 100% (and ‘no cure’ similarly). The likelihood of cure is guided by examination findings, PSA and biopsy results. PSA change prior to diagnosis is an important predictor of curability.

Several studies indicate a greater survival advantage in patients following radical surgery, compared with radiotherapy, particularly in patients with aggressive cancers. Almost all prostate cancers grow under the influence of testosterone. Hormonal manipulation removes this stimulus, resulting in prostate cancer regression for a variable length of time, before the cancer recurs. Hormonal manipulation, early or late, temporarily controls (but cannot cure) prostate cancer.

3) Side-effects of treatment:

Adverse effects of watchful waiting relate to the psychological stress of having cancer and latterly to the effects of cancer progression around the bladder. Hormonal manipulation may be surgical castration, monthly / 3 monthly injections or daily tablets.

These are roughly equivalent in terms of efficacy, surgical castration being the most effective and reliable. All reduce vigour, cause impotence and reduced sexual interest, breast tenderness and swelling, hot flushes and loss of body hair. Some of these side-effects are more associated with a particular treatment. Specific potential side-effects of tablets include nausea and diarrhoea, liver disturbance and cardiac effects; of injections: neurological effects. Tablets or injections are significantly more expensive than surgical castration and may interact with other medications, but can be readily discontinued if side-effects occur.

Radical prostatectomy is the surgical removal of the prostate, rejoining the bladder to the urethra. Whilst it is a major procedure, it is well tolerated, hospital stay is 4 days and recovery is rapid. The operation is performed through a lower abdominal incision. A laparoscopic and robotic approach has been used, but has not demonstrated significant advantages over the open procedure. The rate of significant early complications is 5%, blood transfusion 10%, and death 0.5%. Long-term side-effects, which are more common in older men, may include troublesome incontinence 10% and impotence. Effective medical and surgical treatments are available for both incontinence and impotence.

Radical radiotherapy is the destruction of the prostate and cancer with high intensity radiation. It is often combined with a period of hormonal manipulation. Radiotherapy may be delivered by external beam daily over 6 weeks, at a single sitting by implantation of radioactive seeds into the prostate (brachytherapy), or a combination of the two. Brachytherapy is the newest of these options, and appears suitable in older patients with small volume, better grade prostate cancer. Whilst the initial treatments are generally well tolerated, adverse effects of radiotherapy accumulate over time. These result from radiation damage to neighbouring tissues. Significant radiation effects on the bladder occur in 20% of patients, causing incontinence, bloody urine, irritative bladder symptoms, and when severe, a small capacity rigid bladder. Significant radiation effects on the rectum and intestines occur in 20%, causing bloody mucous diarrhoea, altered bowel habit and soiling. Impotence occurs in 40%. In the long-term, there is a risk of non-prostate cancers secondary to the radiation.

With overall cure rates being reasonably similar between radiotherapy and surgery groups, quality of life is an important outcome. The majority of patients, having decided on a treatment, remain happy with that decision and would choose the same treatment again.

Comparisons between specific aspects of radiation and surgery show:

• urinary dysfunction is more frequent in surgical patients, but overall is a more severe problem in the radiotherapy group
• radiotherapy patients report worse bowel function and bother
• sexual dysfunction is more frequent in surgical patients, but improves over time, whereas this deteriorates over time in radiotherapy patients, with potency rates equal in surgery and radiotherapy groups at 3 years post-treatment.

And comparing surgery with watchful waiting patients:

• erectile dysfunction and incontinence each occur twice as often in the surgery group (but occur nonetheless to some extent in the watchful waiting group)
• obstructive urinary symptoms occur twice as often in the watchful waiting as in the surgery group
• overall quality of life is similar between the two groups indicating (not surprisingly) that untreated prostate cancer progression impacts on quality of life
• there is a psychological burden too and patients on watchful waiting/hormone therapy worry more about their cancers than do patients post radical therapies

This fact sheet complements the discussion during your consultation, which will apply your individual circumstances to the above facts