There are many treatment options for localised or locally advanced prostate cancer making it very difficult for patients to choose. Newly diagnosed patients must consider a myriad of factors including the risk of potential side effects, recommendations from physicians, family and friends, economic circumstances, prior medical care experiences, emotional feelings about a cancer diagnosis as well as many other influencing factors.
For all men, deciding a course of treatment is no easy task. But there is one thing for sure – each patient must be comfortable in his decision.
There are seven tumour factors, which dictate the best type of treatment for an individual cancer. The clinical stage, the prostate specific antigen (PSA) level, the Gleason score, the position of the cancer, the extent of the cancer and the likelihood of disease penetrating the capsule are all factors which influence the choice of therapy. For example nerve sparing prostatectomy should only be considered in those patients where the cancer is almost certainly contained within the prostate or at worse minimally outside of the prostate.
Alternatively, brachytherapy seed implant should only be considered when the PSA is less than 10, the Gleason is less than 8 and the clinical stage is less than T2.
High dose rate brachytherapy in combination with external beam radiotherapy should be considered where surgery is highly unlikely to cure the cancer. This includes patients suffering very extensive cancers with a high clinical stage and a PSA above 20.
Hormone therapy should be considered where there is extensive local cancer particularly when there is a T4 tumour or where the PSA is greater than 100.
High intensity focused ultrasound (HIFU) which is relatively experimental is best with lower stage, lower grade tumours in older patients where the consequences of inadequate tumour eradication are less significant.
Active surveillance should be considered in less aggressive microscopic tumours particularly in older patients where the Gleason score is 3+3 or at worst 3+4.
The size and shape of the prostate as well as urinary symptoms may influence decisions. Urinary symptoms include obstruction, irritative symptoms and prostatitis. For example a very large prostate may not be suitable for seed therapy or high dose rate brachytherapy and a patient with severe urinary obstruction may not be suitable for any radiotherapy treatment until the obstruction is alleviated.
If a patient has severe bladder frequency it may be wise to avoid radical prostatectomy because these patients have an increased risk of incontinence after surgery. Prostatitis may suggest that the patient should not have seed therapy as heavy calcification makes the therapy more difficult.
Local factors that may influence therapy include previous surgery or radiotherapy and the pelvic anatomy such as its shape, the presence of a previous fracture or patient obesity.
When a patient is extremely obese he may be better and safer to have either a non surgical option or a minimally invasive surgical option and if a patient has had a previous severe fractured pelvis it may be wise to totally avoid surgery as this could lead to incontinence.
In patients who have ulcerative colitis of the rectum, HIFU and radiotherapy should be avoided and if the patient is taking Warfarin on a long term basis then radiotherapy should be avoided, if possible, as it can lead to severe bleeding.
The patient's current sexual status and personal situation, for example his relationship and the importance he places on sexual potency, are important factors in making a decision. His preparedness to use sexual aids is also an important factor. For example a man who has recently married a younger partner and wishes to choose the treatment with the lowest chance of sexual side effects would either select low dose rate brachytherapy or an extremely carefully performed nerve sparing technique performed by an expert nerve sparing surgeon.
The patient's current status with regard to urinary and irritative symptoms as well as his fear of incontinence may have a bearing on treatment. For example if a patient has a particular fear of incontinence he should not consider surgery and seek other options.
The patient's current bowel status with regard to previous treatment, the presence of underlying bowel problems such as ulcerative colitis, Crohns disease or irritable bowel symptoms may have a major bearing. If he is particularly fearful of long term bowel side effects such as faecal incontinence for example he should not consider radiotherapy options.
The age of the patient and his life expectancy, the presence of longevity in the family as well as other health problems, the various medications he takes such as Warfarin and the presence of obesity will have a profound effect on the therapy chosen.
For example if the patient has a life expectancy of less than 10 years and has a relatively slow growing tumour he will be better to consider active surveillance. If he has an unstable cardiovascular disease he may be better to consider less invasive treatment options. He should also try to avoid hormone therapy if his cardiovascular disease is unstable as there is an increased risk of death.
I have produced videos to assist patients to review the complex factors, which may influence their treatment choice and give them the optimal outcome. See the Resources page for the complete video gallery.