The stage, Gleason score, and PSA reading along with a man's anticipated life expectancy are all used to formulate a treatment strategy which will offer the greatest chance for cure.  A man may choose one form of therapy over another based on potential risk or morbidity.

To Treat or Not to Treat:
For men with a life expectancy of under 5 years, treatment may not be necessary until the development of symptoms.  For men with a life expectancy of less than 10 years, "watchful waiting," or simple monitoring may be appropriate.  This is because low stage and low grade prostate cancer is unlikely to become symptomatic during the remaining years of life.  When the Gleason score is high and the cancer is locally extensive or metastatic, treatment may be worthwhile in any man to delay the onset of unpleasant symptoms or complications.  For a man expected to live 10 or more years some form of cancer treatment is generally recommended.

Available Therapies:
Initial treatment options include radical prostatectomy (RP-surgical removal of the entire prostate), external-beam radiation (EBRT), brachytherapy or radioseed implant (BT), and hormonal therapy (HT).

Surgery

Radical prostatectomy means the surgical removal of the entire prostate with the attached seminal vesicles.  The whole prostate, and not just the portion with the cancer, is taken out because cancer is usually found in many parts of the prostate which may not have been detected on the biopsy. 

 Until recently a radical prostatectomy was major surgery, requiring a substantial incision from the naval to the pubic bone.  A hospital stay from 2 to 4 days was required.   A temporary urinary catheter is left in place after such surgery for about 2 weeks after and men were able to  resume normal activities in 6 to 8 weeks.  The risks included intra-operative blood loss (2 to 10%), urinary incontinence (1 to 8%), and erectile dysfunction (20 to 40%).

Fortunately, new techniques have dramatically reduced such risks.  Laparoscopic surgery avoids the larger incision of standard surgery and diminishes the risk of bleeding.  With smaller incisions, the degree of discomfort is reduced, hospital stay is shortened and many men can return to most activities by 2 to 3 weeks.

 The latest surgical option is Robotic-assisted laparoscopic radical prostatectomy.  A computerized robotic system operated by the urologic surgeon enhances the accuracy of laparoscopy.  The robot employs a 3-D video system and ergonomically advanced miniaturized "hands" that accurately respond to the surgeon's commands.  Superb anatomic views can be obtained using magnification and more precise surgery can be performed.  Blood loss during robotic surgery is often minimal, hospital stay may be as short as one day, and the urinary catheter can be removed by a week.  Sparing of the neurovascular bundles for erections may be achieved to a greater degree due to the magnification and ability to delicately manipulate the tissue using the robotic system.  Like laparoscopy, the incisions are small "keyholes" reducing post-operative discomfort and allowing more rapid return to normal activities.

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Radiology

External-beam radiation (EBRT) means the delivery of high-energy radiation from an external source to the prostate.  Since the radiation passes through the skin and organs near the prostate, it must be given in small doses each day over a period of 7 to 8 weeks.  Most men can continue normal activities throughout most of the treatment.  The risks include temporary anemia, nausea, diarrhea, and fatigue, and rarely, long term injury to the rectum.  Conformal radiation allows higher doses of radiation to be delivered without increased risk.  The most advanced method is IMRT, or Intensity Modulated Radiation Therapy, which uses a computerized imaging system to limit the amount of radiation to surrounding tissues allowing higher doses of energy to the prostate. The radiation field includes not only the prostate, but areas at risk for local spread around the prostate, such as pelvic lymph nodes.  Radiation is administered under the directed of a radiation oncologist, a medical physician with special training and expertise in the field.

Brachytherapy (BT) involves the implantation of tiny titanium pellets containing a radioactive isotope into the prostate.  The procedure, which involves passing a few needles into the prostate through the skin, is usually done on an outpatient basis with a recovery time of only a few days.  The radiation is released within the prostate over a  3 to 6 month period  The risks include discomfort during urination, urinary frequency, blood in the urine, or radiation injury to the rectum.  Most of these side effects are self-limiting.  Urinary incontinence is rare, but erectile dysfunction can occur 1 to 2 years after such treatment.   Higher doses of radiation can be delivered since the radiation does not have to pass through surrounding tissues as occurs with EBRT.  However, since the radiation field is limited to the prostate, only men with cancer confined to the prostate will benefit.

Some centers combine EBRT with BT.  The EBRT allows treatment of the pelvic lymph nodes and areas adjacent to the prostate while the BT permits high dose radiation with the prostate. Despite the higher overall amount of radiation, the risk of complications does not appear to be greater than with either modality alone.

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Hormonal Therapy

Hormonal therapy (HT) ablates the production of the male hormone testosterone, creating a "male menopause."  Such treatment works because most prostate cancers depend on testosterone for growth.  While hormonal therapy does not completely eradicate cancer cells, the significantly reduced amount of circulating testosterone often leads to clinical remission.  The PSA dramatically falls and most symptoms disappear.  The benefit of HT may last many years.  Side effects are due to the decline in testosterone, namely, loss of sex drive, weight gain, hot flashes, and osteoporosis.  HT may be used with EBRT or BT when the cancer is of high grade or locally advanced.  Hormonal therapy is most commonly given by an injection in the doctor's office every 1 to 4 months.  A hormone implant that lasts for a year is also available. 

Some cancers may become "hormone resistant," meaning that the prostate cancer cells can survive even in the absence of testosterone.  When this occurs additional oral medications may be added which may block certain functions of the prostate cancer cells themselves.  These drugs likewise may only have a temporary benefit and chemotherapy is usually the next line of treatment.

Men who undergo hormonal therapy are at risk for osteoporosis and in time, fractures.  Therefore, bone mineral density (BMD) assessment using dual energy x-ray absorptiometry (DEXA) may be recommended before starting as well as at various intervals during HT.  When osteoporosis is detected, biphosphonates are recommended.  Biphosphonates inhibit bone loss and encourage new bone formation.  Men are advised to take vitamin D and calcium supplements, as well.

When bone metastases are present, biphosphonates are added to prevent skeletal complications.  Weightbearing exercise, vitamin D and calcium supplements are also recommended.  Such therapy not only maintains bone strength but has been shown to reduce pain as well.  Biphosphonates are administered intravenously every few weeks.  The most common side effects are self-limiting flu-like symptoms.  Kidney function must be monitored during treatment.  Because biphosphonates are associated with osteonecrosis (bone destruction) of the jaw especially after dental procedures, a dental examination and any required invasive dental work should be completed before starting therapy.

Systemic chemotherapy until recently was considered somewhat experimental and only used when all prior therapy proved unsuccessful.  Furthermore, the perception has been that chemotherapy was not effective.  The treatments hopefully offered palliation and gave hope for better future therapies.  Such therapies are administered by oncologists.

 Now, however, certain forms of chemotherapy have been shown to improve survival in the setting of hormone resistant prostate cancer  (HRPC) and have been approved by the FDA.  Docetaxel has become one of the most commonly used chemotherapeutic agents in prostate cancer.  Because of its success, a number of clinical trials are now focusing on combining docetaxel with other agents to further improve survival for men with HRPC.  Agents used with docetaxel may include steroids, calcitriol  (targets the vitamin D receptor), monoclonal antibodies (immunologic target seeking proteins), or anti-angiogenesis agents (block tumor blood vessel growth).  A number of these treatments have been approved by the FDA; others are available through clinical trials, which are carefully designed studies which make incompletely tested drugs available to men in a controlled setting to determine their effectiveness.

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