Prostate Cancer
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.
Your urologist should guide you in an unbiased fashion in making that decision and it is most helpful if you understand the disease, its stages and treatment options.
In this discussion, we will focus mainly on localized prostate cancer – cancer that has not spread beyond the prostate, because it is in this group of patients that treatment decisions can be challenging.
Prostate Cancer may be classified as Low, Intermediate or High Risk
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.
Low Risk
- PSA < 10
- Gleason Score < 6
- Stage T1-T2a
Intermediate Risk
- PSA 10 – 20
- Gleason Score 7
- Stage T2b-c
High Risk
- PSA > 20
- Gleason Score 8 -10
- Stage T3 -T4
What are the options for treating localized Prostate Cancer in South Africa?
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.
The Following Treatment Options for Localized Prostate Cancer are Available in South Africa:
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
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’).
Active Surveillance
Active Surveillance is undertaken when low risk prostate cancer is diagnosed in relatively healthy men in whom it is considered safe to monitor the cancer regularly over time. Active surveillance involves repeating the PSA blood test every 3 months and repeating either prostate biopsies or MRI scans every 12 – 18 months, and thereby ‘deferring treatment’ and its associated side effects. Treatment is recommended if there is evidence of disease progression, as determined by either a rising PSA, increasing Gleason score on repeat biopsies or change in appearance on MRI imaging. This is an effective treatment strategy in the well selected patient with excellent patient survival rates over a long period (> 15 years) as documented in the international literature.
In South Africa and in fact in most countries, it is widely agreed by urologists and oncologists that when localized prostate cancer is sufficiently aggressive to require definitive treatment, the prostate needs to be ablated. This is generally achieved by either surgical removal (Radical Prostatectomy) or Radiation (External Beam and/or Brachytherapy). Other ablative treatments such as HIFU, Cryotherapy, Cyberknife etc. are not available in South Africa and although being evaluated in many centers all over the world, they are at this current time still considered to be experimental and not standard of care.
The key issue in performing an ablation of the prostate with its contained cancer is to achieve good control/hopefully cure of the cancer with the least amount of damage to surrounding structures (the rectum, the sphincter muscles that provide urinary control/continence, the nerves that provide erectile function and the anatomical/physiological structures that maintain normal urination).
Radiation Therapy
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.
The patient visits the hospital radiation therapy department briefly every day Monday to Friday for between six to eight weeks. At each visit a specially designed machine delivers a focused beam of radiation to the prostate.
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
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.
The procedure is minimally invasive and usually well tolerated. Patients are usually discharged home either the same or next day.
In the properly selected patient brachytherapy provides very good cancer control with an acceptably low complication rate. It is however radiation therapy and has the potential to cause all the complications mentioned above under external beam radiation. For this reason and the fact that cancer control is not as good as with radical prostatectomy the international urological guidelines only recommend brachytherapy in older patients with low risk disease whose prostates are relatively small and non-obstructed.
It is widely accepted by urologists worldwide, and the international guidelines clearly state that for younger patients (e.g. < 60 years) requiring prostate ablation to treat their cancer, radical prostatectomy is recommended over brachytherapy.
Radical Prostatectomy
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.
Robotic Assisted Laparoscopic Radical Prostatectomy (RALP)
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.
How do I make a decision?
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.
