Men with Prostate Cancer May Not Know All Of Their Treatment Options and Risks

by Brian Miles, MD 

Urology

Houston Methodist Urology Associates

Professor of Urology, Institute for Academic Medicine
Houston Methodist – Weill Cornell Medical College

According to a September 2017 study by BJU International, men who have been diagnosed with localized prostate cancer and have consulted with a urologist often have a poor understanding of their treatment options and the consequences of each one. As a result, they tend to make decisions based on instinct – which does not necessarily result in getting the best treatment.

Typically, men diagnosed with localized prostate cancer — defined as cancer that is not beyond the capsule of the prostate gland and has not reached other parts of the body — are given three options: active surveillance, which can be stressful, radical (whole removal) prostatectomy or radiation therapy which all typically come with the side effects of incontinence and erectile dysfunction.

Often, patients on active surveillance believe they will need radiations in the future, however, only half of the patients watching and waiting require that. While men who are diagnosed don’t need to become experts in prostate cancer to be their own best advocates they should know their treatment options and the associated risks of each:

High Intensity Focused Ultrasound (HIFU)

 HIFU, which stands for High Intensity Focused Ultrasound, is a minimally invasive option for prostate tissue ablation through heating with a low occurrence of side effects. Using real-time image guidance — and sometimes paired with additional magnetic resonance imaging (MRI) and/or location of the biopsies in 3D  — the doctor directs a focused beam of ultrasound energy at the target area within the prostate through an ultrasound probe inserted into the rectum. No incisions are required to reach the targeted zone and ablate the prostate tissue at the focal point.

HIFU’s precise targeting minimizes damage to the surrounding healthy tissue, and has a low risk of post-procedure impotence and incontinence. Unlike radiation therapy or surgery, it is possible to repeat a HIFU procedure because it does not remove the prostate altogether.

Risks and side effects:

  • Rectal wall injury from probe
  • Catheter required following treatment
  • Potential ejaculation problems
  • Low rate of urinary incontinence

Recovery after a HIFU procedure is much faster compared to prostatectomy and radiation therapy. Patients can return to work and most activities of normal life by the next day.

Prostatectomy

Prostatectomy is a surgical approach to treating prostate cancer involving the removal of the entire prostate, seminal vesicles and usually associated pelvic lymph glands. It requires one-to-two night stay in a hospital.

Risks and side effects include:

  • Urinary incontinence (inability to control the flow of urine from the bladder)
  • Erectile dysfunction

Recovery after a prostatectomy usually occurs slowly over time. Each patient’s situation is different, so the doctor’s success rates and his/her personal evaluation is the best way to predict recovery outcomes.  

Radiation Therapy

Radiation therapy uses high-energy rays or particles to kill cancer cells. Radiatio, along with surgery, is one of the two most common initial treatments for cancer that is still in the prostate gland. Cure rates for men with these types of cancers are about the same as those for men treated with prostatectomy.

Risks and side effects:

Side effects include:

  • Bowel problems

–    Radiation can irritate the rectum and cause a condition called radiation proctitis (leading to diarrhea, sometimes with blood in the stool and rectal leakage)

  • Urinary problems

–    Radiation can irritate the bladder and lead to a condition called radiation cystitis (urinating more often, burning sensation while urinating and/or blood in urine)

  • Urinary incontinence (no control of urine)
  • Erection problems, including impotence

–       Problems with erections usually do not occur right after radiation, but slowly develop over time

–       After a few years, the impotence rate after radiation is about the same as that after surgery

  • Lymphedema

–       If the lymph nodes around the prostate are damaged by radiation, fluid may collect in the legs or genital region over time, causing swelling and pain

Most of these problems go away over time, but in rare cases normal functions do not return.

Cryotherapy

Cryotherapy is the use of very cold temperatures to freeze and kill prostate cancer cells. This treatment is sometimes used for early-stage prostate cancer, and is often an option if the cancer comes back after radiation therapy.

The doctor uses transrectal ultrasound (TRUS) that goes into the anus to guide hallow probes (needles) through the skin. Very cold gases are passed through the needles to freeze and destroy the prostate. A catheter is left in place for several weeks afterward to empty the bladder while recovering.

Risks and side effects

For men who have already had radiation therapy, side effects from cryotherapy tend to be worse, as opposed to men who have it as the first form of treatment.

  • Blood in urine
  • Soreness in the area where the needles were placed
  • Swelling of the penis or scrotum is common
  • Freezing may affect the bladder and rectum, leading to pain, burning sensations and frequent bowel movements
  • Erectile dysfunction

–       Freezing often damages the nerves near the prostate

–       More common after radiation than after a prostatectomy

  • Urinary incontinence (having problems controlling urine)

 

Doctors have less of an understanding of cryotherapy’s long-term effectiveness. Compared to surgery or radiation therapy, cryotherapy is not as effective for advanced prostate tumors.

The Bottom Line

Not enough men are getting a clear overview of the risks and side effects of each treatment, and this needs to change.

Nonetheless, patients should take the time to research and evaluate treatment options for localized prostate cancer and the potential side effects on their own. They should come to urology appointments prepared to ask questions and get the kind of answers they need to make informed decisions, evaluate all treatment options with their doctor (rather than default to the more common options) and get the best treatment that allows them to maintain their quality of life.

 

Brian J. Miles, MD

Dr. Miles is a board-certified urologist and Professor of Urology at Weill Cornell Medical College of Cornell University and Baylor College of Medicine.  He specializes in urologic oncology, especially cancer of the prostate.  He has authored over 175 peer-reviewed scientific papers and book chapters, and is  a guest writer for Malecare.