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Prostate Cancer is the most common visceral malignancy to affect men older than 50 years and although it is still a leading cause of cancer deaths in men, it is generally slow growing and most men diagnosed with prostate cancer will die of other causes.
Prostate Cancer may be classified as Low, Intermediate or High Risk disease, based on the PSA (Prostate Specific Antigen) blood test, the Pathology (Gleason Score), and the Stage of the cancer (using DRE – digital rectal examination and/or MRI imaging).
The Gleason score is determined by the pathologist examining the prostate biopsies and is used to evaluate how aggressive the cancer appears under low magnification. A primary and secondary score is given to obtain a score out of 10, with Gleason 3+3=6 representing the lowest possible score with the lowest risk and Gleason 5+5=10 representing the highest possible score with the highest risk. It’s important to remember that Gleason scores can be upgraded in almost a third of final prostatectomy histological evaluations, and can sometimes also be downgraded.
The Gleason score can seem confusing, and it’s important to not get lost in the detail regarding this. The final score is most important and is used to determine the risk of the disease – as outlined below.According to international guidelines, an MRI scan of the prostate and pelvis is obtained before treatment (or even before prostate biopsies in some places) to determine the clinical stage of the cancer. It can accurately determine how much of the prostate is involved with cancer, whether the cancer is confined to the prostate (‘localized’), or if there is evidence of spread beyond the prostate capsule (‘locally advanced’). MRI imaging also gives additional information, such as prostate size and appearance, possible involvement of the seminal vesicles or pelvic lymph nodes and helps greatly in planning treatment.
The following D’Amico risk classification is used to determine the likely aggressiveness of the disease and how likely the cancer is to spread beyond the prostate. Low and intermediate risk represents disease most likely to be confined to the prostate and potentially curable, whereas the high risk category patients may already have microscopic spread (metastases) and have significantly less chance of cure. Appropriate treatment can then be planned according to the risk category.
In high risk disease, a bone scan and/or other imaging modalities (e.g. CT or PET-CT scan) can be used to determine whether metastatic disease is present – where cancer spreads to places beyond the prostate such as in lymph nodes and/or the bony skeleton. If metastatic disease is confirmed then cure becomes much less likely, although there are several treatment options available which increase survival and improve quality of life. These include hormonal and chemotherapeutic agents (amongst others) and are administered by specialist oncologists.
In South Africa, there are different evidenced-based treatment options to suit every man at each stage of his cancer. Each option has advantages and disadvantages and while they do all share some fundamental risks (such as urinary incontinence, erectile dysfunction, damage to the rectum and the possibility of non-cure), the vast majority of patients should do very well when the appropriate procedure is selected. In order to decide which treatment is the most appropriate, the following major factors are considered:
Patient’s age, general health and life expectancy
Prostate Cancer risk category – Low, Intermediate or High
Various anatomical factors – body habitus, prostate size, presence of bladder outlet obstruction, previous abdominal or pelvic surgeries
Patient’s lifestyle and support system
Patient’s expectations
While some of the following statements may be challenged by other urologists and oncologists, Drs Eppel and Smit consider them to be evidence based and consistent with international guidelines. References are available on request.
1. Watchful Waiting
2. Active Surveillance
3. Radiation Therapy
a. External Beam
b. Brachytherapy
4. Radical Prostatectomy
a. Open
b. Robotic Assisted Laparoscopic
Watchful Waiting is generally reserved for significantly older men or men with other major medical problems who happen to have been diagnosed with low risk prostate cancer – a situation where prostate cancer is unlikely to affect their lives. Hormonal treatment is offered to control the cancer if there is evidence of significant disease progression (‘deferred palliation’).
External Beam Radiation is generally reserved for patients who for various reasons, are unsuitable for either surgery or brachytherapy. The patients may be older with other significant medical conditions, and may not be able to undergo general anaesthesia. They may have very aggressive disease, or disease that has extended outside the prostatic capsule, although there is increasing evidence to suggest that surgery upfront (if feasible) for locally advanced disease followed by adjuvant or salvage radiotherapy might be best as part of a multimodal approach.
Cure rates are not as good as with surgery and brachytherapy, partly because the cancer may be more aggressive. Side effects include radiation damage to the bladder and rectum with chronic urinary frequency, urgency, burning and difficulty with urination (voiding dysfunction) and chronic diarrhea, rectal urgency and pain. Secondary tumours may occur in the rectum and bladder. Salvage surgery is sometimes performed if radiation fails to control the cancer, but carries a much higher risk of complications than surgery performed without prior radiation.Notwithstanding the above, when external beam radiotherapy is performed by an experienced oncologist on the correctly selected patients, reasonably good cancer control can be expected with few side effects.
Brachytherapy involves the insertion under general anaesthesia of tiny radiation-emitting seeds (either iodine-125 or palladium-103) via the transperineal route into the prostate under transrectal ultrasound guidance.
This involves surgical removal of the prostate, the seminal vesicles (glands attached to the prostate) and a certain amount of surrounding tissue, including sometimes the pelvic lymph nodes (if clinically indicated). Traditionally the operation was performed via an open surgical incision through the abdomen or perineum, but is now increasingly being done by the robotic assisted laparoscopic technique (RALP).Surgery is appropriate when tests show that there is a high likelihood of the tumour being completely removed and a cure obtained.
Cancer cure rates are higher than with all forms of radiation treatment, and in good surgical hands, complications are few and often improve with time. Principal adverse events are urinary incontinence (< 2-3%), erectile dysfunction (about 50% - this should be less with RALP). A significant advantage of surgical removal is that histological examination of the specimen gives precise information whether all the cancer was removed and an immediate cure obtained or whether there is extraprostatic extension requiring additional treatment (radiation and/or hormonal therapy).As mentioned earlier, there is increasing evidence that locally advanced or high risk prostate cancer is best managed as part of a multimodal approach – this includes surgery upfront, followed by adjuvant or salvage radiotherapy later (if indicated by histological evaluation). The advantage of surgery upfront is that if it is unable to control the cancer, then it can be salvaged by external beam radiotherapy with acceptable side effects. Conversely, if radiotherapy fails to control the cancer, then it becomes very difficult to salvage with surgery with a much higher risk of complications.There is also anecdotal evidence to suggest that prostate cancer with low volume of metastases can be successfully treated with surgery upfront, followed by a combination of radiotherapy, hormonal therapy or chemotherapy as needed. There are currently large multicenter international randomized clinical trials underway to evaluate this.
This innovative treatment uses state-of-the-art robotic technology to provide a minimally invasive approach to performing prostatectomy – a complex and delicate surgery. The operation is performed through small incisions similar to traditional laparoscopy. The tiny instruments bend and rotate far better than the human wrist. The instruments are held by robotic arms and are controlled by a surgeon from an ergonomically designed console. The surgeon controls the da Vinci® Surgical System through a magnified 3D high-definition vision system contained within the console.RALP compared to open surgery, is much better tolerated by patients, is associated with significantly less blood loss, less pain, shorter hospital stays and rapid return to work. Recent studies comparing robotic surgery vs. open surgery have demonstrated fewer complications, with less incontinence and improved erectile function. It is anticipated that longer studies will show improved cancer control rates.A significant advantage of using robotic surgery to remove the prostate is the improved ability to do a nerve-sparing operation and therefore improving the possibility of preserving the nerves that are important for erectile function after surgery. An MRI scan obtained pre-operatively is used to determine how much of the prostate is involved with cancer and whether there is any risk of extracapsular extension on either side. This will determine whether unilateral, bilateral or no nerve-sparing procedure should be attempted.
It is essential to remember that you are not making this decision alone – your consulting urologist will guide you through the decision-making process. The treatment should be selected by carefully and objectively considering your specific factors (such as your age, anatomy, presence of other disease processes, expectations) and cancer factors (such as low/intermediate/high risk prostate cancer, size of prostate and the presence/absence of prostate obstructive symptoms).
Drs Eppel and Smit combine their extensive knowledge, expertise and experience using different treatment modalities, to provide an individual approach that is objective, in order to find the least invasive but most effective treatment for you.