One of the problems facing prostate cancer patients is the uncertainty of many issues surrounding the management of the disease. It is not known, for instance, whether surgery is better than radiation therapy or whether treatment is better than no treatment in some cases. This means that making decisions about treatment is not easy.
This uncertainty is related to the fact that it is difficult for a physician to predict whether a prostate tumor will grow slowly and cause no health problems or will grow quickly and become life threatening. Until recently, there were no randomized trials that compared the relative benefits of treating early-stage patients with radiation therapy, radical prostatectomy (surgical removal of the entire prostate gland along with nearby tissues), or watchful waiting (following the patient closely and postponing aggressive therapy unless symptoms of the disease progress).
Added to this problem is that it is not at all clear that aggressive treatment is indicated in all cases. Although prostate cancer is the most frequently diagnosed cancer aside from skin cancer in men, the fact remains that as much as 80 percent of the time, not treating prostate cancers does not decrease survival rate or quality of life. Nevertheless, most cases of prostate cancer are treated because a few men clearly do benefit from early diagnosis and aggressive treatment of the cancer and, in fact, may die without it. Unfortunately, doctors cannot predict in general who will benefit and who will not. For this reason, treatment is usually recommended for most men who have prostrate cancer though many men experience negative side effects as a result of treatment and most of them would not be harmed if the cancer were not treated.
However, studies have found that on average, men treated for prostate cancer can expect the same general quality of life two years after diagnosis regardless of the treatment they choose. Men who are more bothered by urination or impotence are more likely to report worse quality of life. Individual patients must weigh the unique and significant risks of urinary, bowel, and sexual dysfunction association with the different prostate cancer treatments before making a decision about therapy choice.
The specific type of treatment chosen for prostate cancer varies a great deal, depending on the extent of cancer, its chance of spreading, and the man’s age, life expectancy, willingness to risk side effects, and underlying health conditions.
If the cancer is confined to the prostate gland and has not spread, there are at least three treatment options — watchful waiting, radiation treatment, and surgery to remove the prostate (prostatectomy).
Watchful waiting In watchful waiting, the patient receives no immediate medical or surgical treatment, but a doctor monitors regular PSA level testing and DRE results. This strategy generally is reserved for men who have a low-grade or intermediate tumor as evidenced by their Gleason score or for elderly men who are too weak to tolerate radiation therapy or surgery or who also have serious medical conditions that limit life expectancy to less than 10 years.
Radiation therapy External beam radiation therapy entails five to seven weeks of treatment given by machine aimed at the prostate. Alternatively, the radiation can be administered internally (brachytherapy) by implanting radioactive seeds or pellets directly inside the prostate with a sterile needle guided by either ultrasound or magnetic resonance imaging (MRI). Side effects of radiation therapy may include impotence (in up to 50 percent of patients), diarrhea, rectal bleeding, and incontinence.
In general, more men experience side effects from external beam radiation than from brachytherapy. Sexual dysfunction is the most common problem after external beam radiation therapy; problems continue to increase 12 to 24 months after radiation. Bowel function problems often increase at six months but improve after 24 months.
Earlier studies have reported adverse effects of radiation therapy on sexual, bowel, and urinary function, but most of these studies were small and conducted in referral centers or academic institutions. In comparison, the prostate cancer outcomes study (PC OS) examined long-term complications of external beam radiation therapy for prostate cancer in a large random sample of men who had clinically localized prostate cancer from six population-based cancer registries in the United States. The study population included 497 white, Hispanic, and African-American men who had localized prostate cancer diagnosed between October 1, 1994, and October 31, 1995, and were treated initially with external beam radiotherapy. The study authors found that sexual function was the most adversely affected aspect of quality of life. A total of 43 percent of men who were potent before diagnosis became impotent after 24 months, while the urinary function score was relatively unchanged. Bowel function problems increased at six months but were somewhat better by 24 months. Despite these side effects, the men were very satisfied with therapy: More than two-thirds said they would make the same decision again.
Surgery A radical prostatectomy entails the removal of the prostate gland, the seminal vesicles, and sometimes the nearby pelvic lymph nodes. Side effects of this procedure can include incontinence and impotence, both of which are more common after radical prostatectomy than after radiation therapy. Recently, a new nerve-sparing surgical technique has helped preserve sexual potency in many men who undergo radical prostatectomy.
Men with clinically localized prostate cancer who are treated with radical prostatectomy are more likely to experience urinary and sexual dysfunction than those treated with radiation, according to the PCOS study. Bowel dysfunction, on the other hand, is more common among men receiving external radiation therapy. In general, prostatectomy had very little effect on bowel function, whereas radiation therapy produced bowel function problems within the first four months of treatment, with recovery of some function over two years. No clear difference in emotional and mental health or overall physical health status was seen between the two groups.
Of the 1,591 men aged 55 to 74 who were treated for localized prostate cancer and followed for two years in the PC OS study, the 1,156 men who had a radical prostatectomy reported more urinary incontinence (9.6 percent versus 3.5 percent) and were more affected by this side effect (11.2 percent versus 2.3 percent) than the 435 men receiving radiation. More men treated with prostatectomy also reported being impotent (79.6 percent versus 62.5 percent), and among men ages 55 to 59 years, the prostatectomy patients were more affected by the loss of sexual function than were the radiation therapy patients (59.4 percent versus 25.3 percent).
In general, men in the radical prostatectomy group recovered some urinary and sexual function during the second year after treatment; men in the radiation group remained the same or became slightly worse. Two years after treatment, men who had radiation reported more diarrhea (37.2 percent versus 20.9 percent) and bowel urgency (35.7 percent versus 14.5 percent) than did men who had a radical prostatectomy.
On the other hand, radical prostatectomy causes significant sexual dysfunction and some decline in urinary function, according to the PC OS study. At 18 months or more after surgery, at least 8.4 percent of the patients were incontinent and at least 59.9 percent were unable to achieve an erection. At 24 months, 8.7 percent of men were bothered by the lack of urinary control; 41.9 percent reported that sexual function was a moderate to major problem. Nevertheless, most men were satisfied with their treatment choice.
Hormonal therapy and radiation therapy For men whose prostate cancer has grown beyond the prostate capsule but has not spread to other locations in the body, radiation therapy combined with hormonal therapy (androgen deprivation therapy) is usually the preferred treatment. Androgens are male sex hormones (such as testosterone); androgen deprivation therapy reduces levels of testosterone and other androgens that stimulate the prostate cancer to grow. Today, doctors most commonly use drugs either to block the effects of testosterone or to stop its production by the testicles. An alternative way of blocking the androgens is to remove the testicles surgically (orchibctomy).
Side effects of androgen deprivation therapy include impotence, weight gain, decreased sex drive, and osteoporosis. Some men experience hot flashes, which often can be controlled by medication.
However, men who are considering androgen deprivation therapy as an initial treatment should be aware that sexual function and some aspects of physical well-being are likely to be affected in the first year after treatment. In the ongoing PC OS study, 245 patients received androgen deprivation therapy (ADT) and the remaining 416 patients received no therapy. Among men who were sexually potent before diagnosis, 80 percent of those on ADT reported being impotent after one year, compared with 30 percent of those receiving no treatment. Patients who had ADT reported more physical discomfort one year after diagnosis than did men who had received no therapy. Men who had ADT also experienced a statistically significant decline in vitality, but not in physical function. However, patients who received ADT were more likely to be satisfied with their treatment decision than those who received no therapy.