Andrew Siegel MD 6/29/19
The following is a brief overview of traditional prostate cancer treatment options based upon risk stratification (as reviewed last week). The entries that follow in future weeks will discuss each treatment option in detail.
It is important to understand that there is no one-size-fits-all treatment approach to prostate cancer as there are “competing” options, each with benefits that must be weighed against side effects. Many patients are fearful and confused about side effects that may occur after surgery or radiation—specifically, what they are, how frequently they occur, how severe they are, and how they are managed. Nowadays, side effects occur less frequently and are less severe than many imagine because of technical progress and advances in both the treatment of prostate cancer and in the management of side effects.
Stages of Prostate Cancer: Goal is to identify prostate cancer early in its course and treat potentially aggressive cases
Treatment for cure is pursued in men with potentially aggressive prostate cancer when the cancer is localized to the prostate, with the goal of eliminating all prostate cancer cells from the body. Localized cancer options are robotic-assisted laparoscopic prostatectomy and prostate radiation therapy. In general, if one is young and in good health, the option of choice is often surgical removal of the prostate as this is a highly effective means of long-term cure. Radiation therapy can be an excellent alternative to surgery with similar cure rates and less adverse effects and is often the option of choice in the older and less healthy population, as well as in men reluctant to undergo surgery.
Androgen deprivation therapy uses medication to suppress levels of the male hormone testosterone to “castrate” levels, the same levels that would be achieved if the testes were surgically removed.
Active surveillance is a means of vigilant tracking used in men with non-aggressive prostate cancer with no treatment per se aside from careful monitoring with plans for a change in strategy to active intervention if indicators worsen.
Observation is a means of monitoring with the expectation of palliative therapy (relieving pain and alleviating other problems that may arise) if symptoms develop or a change in exam or PSA suggests that symptoms are imminent.
Cryosurgery (freeze destruction of the prostate) and high intensity focused ultrasound, a.k.a. HIFU (heat destruction of the prostate) are alternative approaches and are not listed in the overview treatment option outline that follows.
TREATMENT OPTIONS BASED UPON RISK STRATIFICATION
Abbreviations:
RALP (robotic-assisted laparoscopic prostatectomy)
RT (radiation therapy)
ADT (androgen deprivation therapy)
AS (active surveillance)
Observation
Very Low Risk
< 10-year life expectancy: observation
10-20-year life expectancy: AS
> 20-year life expectancy: AS or RALP or RT
Low Risk
< 10-year life expectancy: observation
> 10-year life expectancy: AS or RALP or RT
Certain factors increase the likelihood of progression on active surveillance and their presence may influence a low risk patient to pursue active treatment. These include the presence of peri-neural invasion on biopsy (cancer involving the space surrounding a nerve), African American race, family history of prostate cancer or a genetic predisposition to metastatic prostate cancer. Low risk men most likely will have localized disease and have a 90-95% recurrence-free survival rate 5 years after RALP or RT. Surgery and radiation in the low risk population generally do not improve survival before 10 years of follow-up as compared to active surveillance but reduce prostate cancer progression and the occurrence of metastases thereafter.
Intermediate Risk
< 10-year life expectancy: observation or RT + ADT 4-6 months
> 10-year life expectancy: RALP or RT + ADT 4-6 months
AS may be a possibility in selected patients with favorable intermediate risk prostate cancer, but this will incur a greater chance of developing metastases as compared with definitive treatment. Intermediate risk men have a 65-75% recurrence-free survival rate 5 years after RALP or RT. Patients with intermediate risk prostate cancer have improved survival when short-term ADT is combined with RT.
High Risk
RALP or RT + ADT 2-3 years
High risk prostate cancer is aggressive and incurs a likelihood of metastases and death. There is no place for AS, although observation is preferred in a man with a life expectancy of fewer than 5 years. Under the circumstances of symptomatic disease and limited life expectancy, ADT alone is a reasonable option. High risk men have 50% recurrence-free survival rate 5 years after RALP or RT. Combined modality therapy is likely to be needed, such as RT plus long-term ADT, or RALP plus adjuvant RT (radiotherapy given as soon as the healing process after RALP is completed).
Very High Risk
T3b-T4: RT + ADT 2-3 years or RALP (in select patients) or ADT alone
Lymph node spread: ADT or RT + ADT 2-3 years
Metastatic disease: ADT
Treatment for palliation of cancer is used when prostate cancer advances well beyond the confines of the prostate gland, often to the bony skeleton. In palliative therapy the goal is reduction in the severity of the symptoms resulting from the cancer, but not cure. ADT is most often used in this setting.
PSA FOLLOWING TREATMENT
No matter what the treatment, careful follow-up is imperative. Paramount is PSA—an excellent marker for the status of the prostate cancer. After successful RALP, the PSA should be undetectable; after successful radiation, the PSA should drop to a very low level and remain so.
After definitive treatment, a rising PSA may be the sole indication of the recurrence of prostate cancer, a condition known as “biochemical recurrence.” The important question that needs to be answered is whether the PSA elevation is due to local recurrence, systemic disease, or both, and how to distinguish the low risk from high risk patient.
A single abnormal PSA does not necessarily indicate that a biochemical failure has occurred. After RALP, biochemical failure becomes a consideration after the PSA is in the 0.2-0.4 range. In general, a low pre-treatment PSA, a lower grade, a lower stage, a longer time from definitive treatment to PSA relapse, and a longer PSA doubling time prognosticate a low likelihood for development of systemic metastases and a greater likelihood of local recurrence.
Salvage radiation therapy (RT following RALP, after a biochemical recurrence is noted) is an appropriate consideration for localized recurrence after RALP. Cryosurgery, HIFU, or ADT are considerations for biochemical failure due to localized recurrence after RT.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Our Greatest Wealth Is Health 