When the cancer does need to be actively treated, you will most likely be offered surgery or radiotherapy.

Diag 3 - Excision [Radical Prostatectomy]

Radical prostatectomy (the dotted line shows organs that are removed)

Surgery

To treat the cancer, the prostate is removed through surgery. This is called a radical prostatectomy and can successfully stop the cancer in many cases if it has not yet spread beyond the prostate gland. It involves the removal of the entire prostate gland as well as some of the tissues surrounding it. Surgery is generally offered to healthy men whose cancer has not spread to other parts of the body.

A radical prostatectomy can be done in different ways:

  • Open radical prostatectomy: A cut is made below the navel to the pubic bone, to get to the prostate gland.
  • Laparoscopic radical prostatectomy: Also known as ‘keyhole surgery'. A number of small cuts are made to allow insertion of a camera and instruments. Early recovery after the operation is usually faster than for open surgery.
  • Robotic assisted radical prostatectomy: Similar to laparoscopic surgery, but performed with more advanced instruments controlled using a robotic console, which makes the keyhole surgery easier to carry out. This is currently offered only in a few hospitals, and mostly in private rather public hospitals.

N.B. Laparoscopic and robotic assisted surgery have similar recovery periods and the same side effects, so the choice of surgery is largely dependent on what your surgeon feels most comfortable with. Neither technique is proven to be better than the other.

PROS
  • All the cancer might be removed
  • Treatment is completed in one day
  • Rapid fall in PSA and easy follow-up of PSA
  • Lower rates of bowel problems compared with radiotherapy.

CONS
  • Risk of long-term impotence (problem having an erection)
  • No ejaculation at orgasm
  • Infertility
  • Possibility of incontinence of urine and/or faeces after surgery, which may (rarely) continue long-term.
POSSIBLE SIDE EFFECTS
  • Temporary or permanent incontinence
  • Temporary or permanent erectile difficulties
  • Change in penis size
  • Infertility.

 

Further questions to ask:

The following questions could be useful for you to ask your doctor about the form of radical prostatectomy that is recommended to you:

  • LWhy are you recommending this particular option instead of radiotherapy?
  • What are the advantages and disadvantages of this form of surgery for my situation?

 


Radiotherapy

This form of treatment for localised prostate cancer has a curative intent. There are two main types of radiotherapy – external beam radiotherapy (EBRT) and brachytherapy. External beam radiation (EBRT) uses high energy x-ray beams directed at the prostate from outside the body. Generally people have this treatment in a hospital outpatient department five days per week for 6-8 weeks. EBRT may cause side effects such as burning, fatigue, skin discomfort around the area where the rays penetrated the skin, and erectile problems and/or some urinary or bowel symptoms. Radiotherapy may lead to infertility, so discuss alternatives such as sperm banking if you might want to father children in the future.

POSSIBLE SIDE EFFECTS
  • Bowel and urinary problems
  • Fatigue
  • Skin changes
  • Sexual difficulties
  • Infertility.

 

Brachytherapy is when radioactive material is inserted directly into the prostate. It is given at either at a low dose rate (LDR) or high dose rate (HDR).

  • LDR: given by implanting permanent radioactive seeds directly into the prostate. The seeds give off concentrated amounts of radiation to the prostate with the aim of killing the cancer cells. LDR brachytherapy is used to treat localised prostate cancer with a curative intent. Placement requires an operating room procedure that may take a few hours but you will only have to stay in hospital overnight.
  • HDR: also given by inserting radioactive material directly into the prostate. Unlike LDR seeds, the placement of the material is temporary and for shorter periods. The procedure takes place in hospital and will require a longer stay than LDR.

Possible side effects after the brachytherapy procedure include soreness, frequent and difficult urination, and bowel discomfort. Because the seeds are radioactive you may be advised to take certain precautions like avoiding sexual intercourse for a while and taking care when babies or young children sit on your lap. Brachytherapy may not be available in your local public hospital.

In high risk cases, both surgery and radiotherapy may be used in combination to totally eradicate all the cancer cells.

POSSIBLE SIDE EFFECTS
  • Bowel and urinary problems
  • Fatigue
  • Sexual difficulties
  • Fertility issues.

PROS
  • Less chance of urinary incontinence than with surgery
  • Radiation can kill cancer cells that may have spread beyond the prostate (locally advanced prostate cancer).


CONS
  • You will have to make regular visits to hospital over several weeks (for EBRT)
  • Some side effects may get worse with time
  • Greater risk of bowel problems than with surgery
  • Risk of infertility.

Questions to ask:

The following questions could be useful for you to ask your doctor about the form of radiotherapy that is recommended to you:

  • Why are you recommending this form of radiotherapy and not surgery?
  • What are the advantages and disadvantages of this form of radiotherapy for my situation?

Radiotherapy can be also given after surgery if:

  • there is a risk that your cancer might have spread after surgery – this is called adjuvant radiotherapy
  • your PSA level started to rise – this is called ‘salvage’ radiotherapy.

 


Hormone therapy or androgen deprivation therapy

Prostate cancer is driven by hormones. By reducing hormones, particularly testosterone, it is possible to slow the growth of the cancer. Research shows that using hormone therapy (also known as androgen deprivation therapy or ADT) before and during radiotherapy can reduce the chance of the cancer spreading. For men with higher risk cancer, hormone therapy is also given after radiotherapy to improve treatment outcome and overall survival. Hormone therapy is given in pill form or injections, sometimes both at the same time.

POSSIBLE SIDE EFFECTS
  • Loss of libido and erectile difficulties
  • Hot flushes
  • Tiredness (fatigue)
  • Weight gain
  • Thinning of the bones (osteoporosis).
  • Risk of heart disease
  • Diabetes
  • Depression or mood swings
  • Poor memory, concentration and physical unsteadiness
  • Breast enlargement and breast tenderness.