It's unlikely most men spend as much time thinking about prostates as I do (occupational hazard), but with September being prostate cancer awareness month it is a good opportunity for all of us who have a gland ourselves, or a loved one with a gland, to pause and think for a moment about the number one cause of cancer (non-skin) in men. In fact, over 200,000 American men are diagnosed with the disease each year. Happily, prostate cancer is usually quite treatable with over 98% of men alive at five years after diagnosis. Nevertheless, certain cases of the disease may present in younger men, or with aggressive biology and consequently may threaten a patient's life, and every diagnosis of prostate cancer has huge implications on a patient's quality of life.
Screening for prostate cancer is important because early detection allows the disease to be treated with fewer side effects. When the disease is caught early, cure rates after treatment are also more favorable. Screening techniques for prostate cancer include the prostate-specific antigen blood test (PSA), as well as digital rectal examination performed by either a urologist or an internal medicine physician. It is important to understand that neither screening test is perfect, and a decision to move forward with further diagnostic studies including MRI of the gland, or prostate biopsy should be made after discussing the benefits and potential side effects in consultation with a board-certified urologist.
A diagnosis of prostate cancer can be exceptionally challenging for a man to navigate because the available treatment options are multiple and varied. They may include active surveillance, surgery, radiation, or hormone therapy. The best treatment option for any given patient will depend on the stage, extent, and biological aggressiveness of the disease at diagnosis, considered in the context of the patient's age, general health, as well as wishes and values. There is no one-size-fits-all option, and a treatment choice that may be best for one patient may be quite inappropriate for another.
While surgery and radiotherapy have been demonstrated to be equivalent in terms of cure probability in a head-to-head randomized trial, the side effects of the treatments are very different. Surgery is associated with pain, may not be appropriate for men with underlying medical conditions, and typically leaves a man impotent, while radiotherapy is gentler and has a better chance of preserving erectile function, but is more likely than surgery to worsen urinary obstructive symptoms such as urgency or frequency, or cause loose stool or diarrhea. Interestingly, when men are surveyed about their satisfaction with their choice in treatment, both men choosing surgery and men choosing radiotherapy are generally quite pleased with their quality of life after treatment.
Encouragingly, active surveillance, surgery, radiation therapy, and hormone therapy have all have been improved over the last several decades through clinical trial investigation. Genetic testing of tumor tissue allows us to best select for those men who are safe to be watched, advanced surgical techniques including laparoscopic and robotic approaches have resulted in less surgical morbidity and shorter hospital stays, improvements in linear accelerator design and computerized treatment planning have greatly diminished the side effects of radiotherapy, and new exciting hormonal treatments are available for patients who have failed first-line therapy.
One example of an exciting improvement in the treatment of prostate cancer-specific to radiation therapy is the development of the prostate hydrogel spacer. The hydrogel spacer is a small gelatinous pad that is injected into the space between the prostate and the wall of the rectum separating them by approximately 1 centimeter. The gel is applied prior to the delivery of radiotherapy and displaces the rectum away from the path of the radiation beam, thus mitigating the usual gastrointestinal side effects of treatment such as diarrhea or blood in the stool.
Another recent improvement in the field of radiation therapy is the development of high dose rate (HDR) brachytherapy, supplanting the older technique of permanent seed, or low dose rate (LDR) implant therapy. HDR therapy allows for the application of the entire radiotherapy course in just two to three treatment sessions instead of the traditional 5 to 8 weeks of once-daily treatments used for external beam and has been demonstrated to have superior urinary side effects to the older seed implant technique. Even conventional radiation treatments of prostate cancer using external beam radiotherapy have been improved allowing for shorter, more intense treatment courses that have been shown to have equivalent cure rates and favorable side effect profiles compared to longer traditional courses.
If you or a loved one is 45 or older and has not had a PSA drawn, consider it seriously. If you have already been diagnosed with prostate cancer, make sure that you carefully study all of the available treatment options and discuss them at length with both a urologist and radiation oncologist before deciding on the best treatment course for you and your family. Willful ignorance about prostate cancer is not an effective management strategy. It is common, it is treatable, and acting early generally saves a lot of headache and heartache later. The best weapon any patient can have when facing cancer is information.
Andrew Orton, MD
Andrew Orton, MD is the Medical Director of Radiation Oncology at Arizona Blood and Cancer Specialists. Their radiation clinics will be located in both Green Valley and Tucson. Dr. Orton is experienced in treating all types of cancer using different radiation treatment modalities and has special expertise using HDR brachytherapy to treat prostate cancer. He is certified to administer SpaceOAR™ Hydrogel, used to minimize injury to the rectum in men receiving radiation treatments for prostate cancer.