Treatment of Prostate Cancer

Treatment options for prostate cancer are dependent on many different factors. You and your doctor need to consider the type of prostate cancer, the stage at diagnosis and the aggressiveness of the disease. A variety of options are available including surgery, radiotherapy, chemotherapy, and targeted therapy. Each patient’s disease is unique and therefore, medical management should be personalized for each patient. Below is an explanation of some of the treatment options that your doctor may recommend.

Treatment of prostate cancer by stage:

Stage I prostate cancer is often small and has not grown outside the prostate. The cancer usually grows very slowly and sometimes never cause any symptoms or pose other health problems. Elderly men may particularly benefit from active surveillance.

Stage II prostate cancer has not yet grown outside the prostate but is large, has higher Gleason scores (a way of measuring how aggressive the cancer is), and/or has a higher PSA level (blood test for a protein the prostate releases) than stage I cancers. Treatment options for men who are younger and otherwise healthy could include radical prostatectomy, external beam radiation, brachytherapy or a combination of brachytherapy and external beam radiation.

Stage III prostate cancer has grown outside of the prostate but has not extended to the bladder or rectum. Treatment options at this stage include a combination of external beam radiation and hormone therapy, external beam radiation and brachytherapy, or radical prostatectomy followed by radiation therapy.

Stage IV prostate cancer has spread to nearby areas such as the bladder or rectum, nearby lymph nodes, or distant organs such as the bones. Treatment options at this stage include hormone therapy, external beam radiation, radical prostatectomy, surgery, treatment aimed at bone metastases, and active surveillance.

(cancer.org)

Surgical Therapy

Surgery is a common choice to try to cure prostate cancer if it is not thought to have spread outside the gland.

The main type of surgery for prostate cancer is a radical prostatectomy. This operation involves the removal of the entire prostate gland plus some of the tissue around it as well as the lymph nodes, including the seminal vesicles. A radical prostatectomy can be performed in different ways.

Types of Radical Prostectomy Surgery

Radical retropubic prostatectomy– incision in the lower abdomen which also allows the removal of the prostate and lymph nodes if there is a reasonable chance the cancer has spread to them

Radical perineal prostatectomy– incision between the anus and scrotum to remove the prostate

Laparoscopic radical prostatectomy– a special instrument called a laparascope (thin, lighted tube) is inserted through several small incisions to remove the prostate

Robotic-assisted laparoscopic radical prostatectomy– laparoscopic surgery is done using a robotic interface controlled by a surgeon to remove the prostate.

(Cancer.org)

Pharmacological therapy – administered by Medical Oncologist

Chemotherapy

Chemotherapy treatment is the use of cytotoxic drugs to destroy cancer cells.  Chemotherapy is sometimes used if prostate cancer has spread outside the prostate gland and hormone therapy isn’t working. Chemo is not a standard treatment for early prostate cancer, but some studies are looking to see if it could be helpful if given for a short time after surgery.

Doctors give chemotherapy in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Each cycle typically lasts for a few weeks.

For prostate cancer, chemo drugs are typically used one at a time.

Common chemotherapy drugs:

  • Docetaxel (Taxotere®)
  • Cabazitaxel (Jevtana®)
  • Mitoxantrone (Novantrone®)
  • Estramustine (Emcyt®)
  • Doxorubicin (Adriamycin®)
  • Etoposide (VP-16)
  • Vinblastine (Velban®)
  • Paclitaxel (Taxol®)
  • Carboplatin (Paraplatin®)
  • Vinorelbine (Navelbine®)

In most cases, the first chemo drug given is docetaxel, combined with the steroid drug prednisone. If this drug does not work (or stops working), a newer drug called cabazitaxel is often the next chemo drug tried (although there may be other treatment options as well).

Common side effects:

  • Hair loss
  • Mouth sores
  • Loss of appetite
  • Nausea and vomiting
  • Diarrhea
  • Low blood cell counts
  • Lowered resistance to infection (due to low white blood cell counts)
  • Easy bruising or bleeding (due to low blood platelets)
  • Fatigue (due to low red blood cells)

Radiation Therapy – delivered by a Radiation Oncologist

Radiation therapy (RT), or radiotherapy, is the use of ionizing radiation to eliminate tumors by damaging the DNA of the cancer cells. External beam radiation and brachytherapy are the most common forms of radiotherapy for prostate cancer. High-energy x-ray machines are used to focus radiation specifically to the tumor.  Radiation may be used in many different ways when treating prostate cancer:

  • First treatment for cancer that is still in the prostate gland and is low grade
  • First treatment for cancers that have grown out side of the prostate gland and into surrounding tissue
  • If the cancer is not removed completely or returns in the area after surgery
  • If the cancer is advanced

Common side effects of Radiation Therapy

  • Diarrhea
  • Urinary incontinence
  • Sexual problems
  • Feeling tired
  • Lymphedema

Hormonal Therapy

Hormonal therapy aims to reduce levels of male hormones or to stop them from affecting prostate cancer cells. Lowering the hormone levels or stopping them from getting into prostate cancer cells often causes prostate cancers to shrink or grow more slowly. Hormone therapy is used:

  • If the cancer has spread too far to be cured by surgery or radiation or you cannot have these treatments for any reason
  • If the cancer remains or returns after surgery or radiation therapy
  • Along with radiation therapy as initial treatment if you are at a higher risk of the cancer returning
  • Before radiation to attempt to shrink the cancer to make treatment more effective for metastatic disease

Common side effects of Hormonal Therapy

  • Reduced or absent sexual desire
  • Erectile dysfunction
  • Shrinkage of testicles and penis
  • Hot flashes
  • Breast tenderness and growth of breast tissue
  • Osteoporosis (thinning of the bones causing an increased risk of bone fractures)
  • Anemia
  • Decreased mental sharpness
  • Loss of muscle mass
  • Weight gain
  • Fatigue
  • Increased cholesterol levels
  • Depression

Targeted Therapy

Targeted therapy uses a class of drugs that destroy cancer cells while minimizing damage to normal, heathy tissue. This is achieved by designing drugs that affect critical functions required for tumor cells to survive. Many of these drugs target the same mutations that cause a cell to become cancerous. Mutational analysis is often required to determine if a targeted therapy is appropriate. Notably, fewer side effects are associated with targeted therapies compared to chemotherapy.

Common targeted therapy drugs:

  • Abiraterone (Zytiga®)
  • Enzalutamide (Xtandi®)
  • sipuleucel-T (Provenge®)
  • Cabazitaxel (Jevtana®)
  • Treatment of Bone Complications
    • Zoledronic acid (Zometa®)
    • Denosumab (Xgeva®)
    • Radium Ra 223 dichloride (Xofigo®)

(Sources: texasoncology.com)

Who Qualifies

For some cancers the majority of patients will have an appropriate target for a specific targeted therapy. For other cancers, patients must receive a tumor tissue test to determine eligibility for a targeted therapy. If a patient’s tumor tissue displays specific gene mutations that are targets for targeted therapy they would be a candidate of targeted therapy. (cancer.org) At times a blood sample may be used to determine if a patient qualifies for a targeted therapy.

Side effects

Although targeted therapy doesn’t affect the body the same way that standard chemotherapy does, patients still may experience side effects. There is a large variety of targeted therapy drugs and the side effect of each varies depending on what each drug targets. Some drugs target substances that are found more prevalently on cancer cells, but are also found on healthy cells. Side effects occur when targeted therapy drugs affect healthy cells.

Some targeted therapy drugs cause more side effects than others. When drugs attack more than one target there is a greater chance of experiencing side effects. Not every person will get every side effect. Some patients get few side effects if any. Talk with your doctor about which side effects you are at risk for with your specific treatment regimen.

Common Side effects:

  • Skin problems
  • High blood pressure
  • Problems with bleeding or blood clotting
  • Problems with wound healing
  • Heart damage
  • Autoimmune reactions

Other side effects may include:

  • Nausea and vomiting
  • Diarrhea or constipation
  • Mouth sores
  • Shortness of breath or trouble breathing
  • Cough
  • Feeling tired all the time
  • Headache
  • Swelling in the hands and feet
  • Damage to organs such as the thyroid gland, liver, or kidneys
  • Allergic reactions
  • Increased risks of certain infections

(cancer.org)

Cancer Caregiver:

A caregiver is anyone who provides physical, emotional, spiritual, financial, or logistical support to anyone suffering from a disabling or life threatening illness. Caring for a loved one with cancer is the role of caregivers but it is also important that caregivers take care of themselves. Finding a balance between helping your loved one and helping yourself is imperative for all caregivers.

Every caregiver is at a different point in their journey. Understanding the important role caregivers hold helps them be effective at embracing their new life. Caregivers may face many obstacles while adapting to their new role, but there are resources to help them along the way. Some online resources include the American Cancer Society (cancer.org), the National Cancer Institute (cancer.gov), Cancer Support Community (cancersupportcommunity.org), OncoLink (oncolink.com), and Breastcancer.org.

Some tips that may help include:

Find support from others in similar positions: Communicating with other caregivers may help you relieve stress and become a better caregiver.

Educate yourself on their specific situation: Learning about what your loved one is going through will enable you to help them in many different ways.

Embrace new life changes: It is normal to feel like things are different and that they may never be how they once were. It is important to embrace your new situation and learn to adapt to the changes in life. Learning to balance what you have control of and what is out of your control may help remove some of the stress from your life.

Take time outs: It is ok to take time for yourself. Rejuvenating yourself is imperative to becoming the best caregiver you can be.

Remain connected with community, friends, and family: Becoming a caregiver should not involve you abandoning your old life. Being around people that love and care about you can recharge you and uplift your spirit. The level of involvement you have with friends and family may vary, but keeping them close can help give you strength and a positive attitude.

Allow help from others: Accepting help from others will take strain off of you and allow others to feel a part of caring for someone in need. People around you may want to help but don’t know how. If they ask to help, learn to say yes.

Maintain yourself physically, mentally, and emotionally: Taking care of yourself allows you to be a better resource to those in need. It is easy to overlook your personal wellbeing while taking on the role of a caregiver, but allowing time to keep yourself healthy will make you a more effective helper.

Find ways to relieve stress: It is important to plan stress relieving activities into busy schedules. Learning different ways that allow your body to relax can enhance the way your mind and body function.

Understand your limits: You can’t do everything, and that is ok. It is easy to get caught up feeling like you need to take care of every single responsibility. Ask for help when you need it, take a break when it’s hard, and try not to overwork yourself.

(Cancer.org)

(10 tips for caregivers: www.cancersupportcommunity.org)

Sources: Cancer.org, radiologyinfo.org, NCCN guidelines, FDA.gov, cancer.gov, cancerresearchuk.org, oncolink.com, cancersupportcommunity.org

Taxotere, Jevtana, Novantrone, Emcyt, Adriamycin, Velban, Taxol, Paraplatin, Navelbine, Zytiga, Xtandi, Provenge, Jevtana, Zometa, Xgeva, and Xofigo are either trademarks or registered trademarks of their respective owners.