How to choose the right treatment for your prostate cancer?

If you (or your loved one) has just been diagnosed with prostate cancer, there are a confusing array of treatments available so choosing the ‘right’ one depends on your unique situation. There is NO single treatment that is ideal for all men.

First let’s run through the factors I consider, in order to find the best option. Then we will run through the list of available treatment options, then in which situations each one is ideal (and on the other hand, when each treatment is ‘unsuitable’.

Factors to consider:

1) Whether the cancer is contained to the prostate (i.e. hasn’t spread elsewhere):

If the cancer has spread into the bladder or rectum, it is usually incurable so surgery should be avoided except in exceptional circumstances. If it has spread to surrounding lymph nodes then it is rarely curable so surgery should only be done in combination with other treatments and as part of trials (eg we have the PROTEUS, DETECT and Trombone trials open presently). If it has spread to lymph nodes or bones but only a small number of spots (eg less than 5) on bone scan, a combination of radiotherapy and hormone therapy is best.

2) Grade of the cancer

Prostate cancer is graded 1 to 5 (using the International ISUP grade system, rather than the outdated Gleason system).

Grade 1 can (and should) almost always be managed with active surveillance, ie close observation without any invasive treatment. Only in rare circumstances should treatment be given, because grade 1 tumour doesn’t spread (like a benign polyp in the bowel) so it is best observed closely and treatment only given if and when it becomes a higher grade tumour.

Grade 2 can undergo any treatment including surveillance (if very small), surgery, brachytherapy (radioactive seeds), any form of external beam radiotherapy or focal therapy.

Grade 3-5 can undergo surgery or radiotherapy, but surveillance, focal therapy and brachytherapy are best avoided due to the higher ‘risk’ of the cancer recurring or spreading in these higher grade tumours.

3) Location & size of the cancer in the prostate

A large tumour involving more than half (50%) of a biopsy ‘core’ or more than half (50%) of all biopsy needl samples may be more likely cured with surgery than radiotherapy/ brachytherapy/ focal therapy.

Tumours very close to the apex (bottom of the prostate, near the urethra and sphincter) or base (top of the prostate, near the bladder) may be more reliably cured with surgery than radiotherapy/ brachytherapy/ focal therapy and with less damage to those nearby structures.

4) Age and life expectancy

Younger men with a life expectancy of 15-20 years or more (eg aged <60yo) should always be managed with surgery unless there are exceptional circumstances, due to the late risks of radiotherapy and focal therapies:

cancer relapsing within the prostate
cancer caused by radiotherapy in the bladder or rectum
blockages of the prostate or urethra due to scar tissue
bleeding due to late radiation effects.

5) Fitness and other medical history

Some men are fit and healthy, making them ‘safe and suitable’ for surgery if they choose this option. Other men have complex medical conditions which render them at a higher-risk of complications with surgery compared to other treatments. Examples of common conditions that may represent a ‘contra-indication’ for surgery include:

A recent heart attack, stroke or ‘stent’ in the arteries within the last 3-12 months
Heart, liver or kidney failure
Emphysema (lung damage from smoking)
An unprovoked blood clot in the leg veins (DVT) or lungs (PE) or a blood condition strongly predisposing to blood clots
A medical condition for which it is dangerous to stop blood thinning medication, even for a short time (e.g. a metallic heart valve or blood clots when medications were stopped for short periods previously)
An inherited bleeding disorder (e.g. haemophilia or low platelets)
Severe obesity, i.e. a BMI or Body Mass Index above 35
Extensive previous surgery within the abdomen and/ or pelvis
Age over 80 years (the risks of incontinence and complications rise with age, especially above 70-75 years and become prohibitive by 80 years of age.

On the other hand, there are certain other conditions that are contra-indications for radiotherapy/ brachytherapy, such as:

Age below 60 years if otherwise healthy
Previous radiotherapy to the abdomen or pelvis
Bilateral hip replacements
Inflammatory bowel disease (Crohn’s disease, Ulcerative Colitis)
Severe obesity (especially for brachytherapy)
Severe urinary symptoms (e.g. due to enlarged prostate or Parkinson’s disease)
Past urethral stricture (scar tissue blocking the urine tube)

6) Urinary function

Men with bothersome urinary symptoms are best suited to surgery, whilst those with no (or mild) symptoms may be suitable for other treatments. Treatments such as radio/ brachytherapy can worsen urinary symptoms thus these treatments should generally be avoided in men with existing bothersome symptoms.

Examples of urinary symptoms to consider include:

slow flow
weak stream
straining to urinate
difficulty starting
a start-and-stop stream
frequency of urination (more often than every 3 hours)
urgency of urination (difficulty delaying when feeling the ‘urge’)
waking at night to urinate.Urinary functionMen with bothersome urinary symptoms are best suited to surgery, whilst those with no (or mild) symptoms may be suitable for other treatments. Treatments such as radio/ brachytherapy can worsen urinary symptoms thus these treatments should generally be avoided in men with existing bothersome symptoms.

To comprehensively assess this, a urologist such as Dr Thompson would generally perform a number of assessments including:

An IPSS questionnaire: this is a set of 7 questions scored 0-5 assessing severity of urinary symptoms (1-7=mild; 8-17=moderate; 18-35= severe symptoms)
A urine flow rate test: this involves urinating into a machine which measures the maximal and average ‘speed’ of urine flow and the amount left inside the bladder
A cystoscopy: this is where the urologist inserts a camera via the urethra (water-pipe/ urine tube in the penis) to inspect the inside of the bladder and prostate in order to see if there is any sign of blockage at the prostate or urethra
Imaging (ultrasound and/ or MRI): these scans measure the size of the prostate; a normal size (20-30 cm3) or mild-moderately enlarged prostate (40-70 cm3) is suitable for radiotherapy or brachytherapy. A large prostate (80 cm3 or larger is difficult to reliably treat with brachytherapy or radiotherapy and more likely to cause a urinary blockage, thus better suited to surgery.
A uro-dynamics test: in complex or difficult cases, this more complex and invasive test allows a series of pressure measurements from within the bladder during bladder filling and during urination to guide treatment decisions.

A urologist specialising in prostate cancer, such as Dr Thompson, will combine all this information to determine which treatment options are suitable and which will give the best result in terms of urinary function.

7. Sexual function:

Men in whom sexual function (the ability to get and maintain an erection and reach orgasm with ejaculation) is both normal and a major priority represent a challenge in prostate cancer treatment, because all treatments have side-effects on sexual function.

If the cancer appears contained within the prostate (i.e. hasnt breached the capsule into surrounding nerves), a man may be eligible for ‘nerve-sparing’ surgery where the nerves responsible for erections (which run along the surface of the prostate within less than 1mm of the capsule) can be saved. IF nerve-sparing is performed, then good recovery of erections is achieved in most men who have good erections before surgery, certainly adequate to have intercourse and achieve orgasm. This may require a ‘pill’ to help, such as Viagra or Cialis, and can take up to 1-2 years to fully recover. It usually does not recover 100% to ever being as good as it was before the surgery, but is usually ‘good enough’ for a satisfying sex-life in men who have normal erections before surgery and who can have nerve-sparing on both sides.

For men who are sexually active, for whom this is important to maintain, and who are thus unwilling to accept ‘weaker’ erections after surgery, they may be better suited to brachytherapy or radiotherapy if the cancer is small, lower grade and urinary symptoms are minimal.

It is important to understand that brachytherapy, radiotherapy and focal therapy all have some side-effects on sexual function, but the effect is slow in onset, progressively reducing ejaculation and erections over many years which is less distressing to most men, i.e. more akin to the gradual effects of ageing. Surgery, on the other hand, tends to cause a sudden decrease in sexual function, which then recovers over the following 1-2 years.

Although both affect sexual function, in the long-term (looking 5-10 years ahead) surgery tends to have a larger impact/ decline in sexual function compared to radiotherapy/ brachytherapy. Focal therapy has even less effect on sexual function. Active surveillance (close observation of small, low-grade tumours) obviously has the least side-effects on sexual function of all, but may or may not be a safe option depending on the size and grade of tumour.

How to choose? Bringing it all together

Your urologist should explore all the above factors with you to consider which treatment is best suited to your cancer, your medical background, your urinary and sexual function and your life priorities. Your urologist should always refer you to a radiation oncologist for their opinion and should be willing to offer a second opinion from another urologist, especially one who has expertise in sub-specialised prostate cancer treatments such as robotic surgery, brachytherapy and focal therapy.

If you are not completely satisfied with ,and confident in, with your current urologist, then contact Dr Thompson for an objective second opinion on which treatment is best suited to your situation. You can see Dr Thompson in person in various locations around Sydney (CBD, East and South Sydney) or can request a telehealth consultation if you are outside of Sydney.