The modern management of localised prostate cancer

This article presents an overview of the latest treatment options for localised prostate cancer. We believe that this article will be of interest to anyone who has been diagnosed with prostate cancer in the early stages and would like to know what their various treatments could involve.

Contents

Introduction

Prostate cancer can be cured or managed in a number of ways. These are: 

All of these are different modalities, however the management an individual receives will depend on whether the patient has:

  • A low, intermediate or high risk for disease progression (dependent on the PSA at presentation, the clinical stage and the Gleason grade of the tumour)
  • The presence or absence of significant lower urinary tract symptoms
  • The presence of significant co-morbidity, their age and their life expectancy
  • Whether they have good erectile function or not
  • Access to the resources to deliver the various treatment modalities

Comprehensive treatment programme

A Comprehensive Integrated Localised Prostate Cancer Treatment Programme is essential to ensure that the treatment an individual patient receives is most appropriate for that person and his disease. A dedicated Prostate Service supported by Urology Nurse Specialists, Clinical Oncologists and Urological Surgeons with the back up of Specialist Pathology and Radiological services are the essential components. Unless a centre can offer all the available treatment modalities it cannot consider its service to be comprehensive. Over the last 7 years, with the support of the Guy’s & St Thomas’ Charitable Foundation, we have developed such a programme at Guy’s Hospital. We are prospectively evaluating our experience with Open Radical Prostatectomy and Laparoscopic Radical Prostatectomy, Conformal External Beam Radiotherapy and Dynamic Intra Operative Brachytherapy. In 2005, we purchased the Da Vinci Intuitive Robotic System and have the largest experience in the UK of robotic surgery.

Dealing with the diagnosis of prostate cancer

The diagnosis of prostate cancer can be terribly emotive and have a major impact upon relationships and family. An element of depression and stress is a common feature of the normal response to the diagnosis and it is absolutely crucial that you take time to reflect upon your treatment options as explained to you. Decisions should not be taken too quickly and a focused, reasoned, and calm attitude will be an asset in dealing with the pressures you will face.

Remember- if a particular treatment doesn't feel right for you, then it probably isn't suitable. If a treatment feels right, then it probably is. Keep asking questions until you are satisfied. After studying all of your options, and speaking to the appropriate specialists, make use of the knowledge gained and trust your instincts.

Be realistic. If a man is not generally in good health, surgery may not be the best option. Surgery of any kind is hard, and recovery is easiest when a person is in good shape. If a man has bowel or bladder problems already, radiation of any kind may make them worse. Fortunately, for many patients, there are a number of other options, including various forms of radiation therapy and hormone therapy, or a combination of treatments, which may still result in a successful outcome.

The ideal treatment for early prostate cancer would both provide an excellent chance of cure (over 90% of the time) and minimal side effects with regard to urinary continence (leakage) and potency (erectile function). Unfortunately the ideal treatment does not exist (if it did then there would be no question about the benefit of prostate cancer screening), they all have significant side effects and an individual’s options are very dependant upon a number of interrelated factors:

Radical Prostatectomy

The open radical prostatectomy is a well-described and reproducible technique with very few major complications reported. The indications for an open radical are predominantly for patients with extensive but localised disease, where the need to feel the extent of the disease is required to best assure a complete excision. This procedure is often combined with an intra operative frozen section of the excision margins to achieve a complete removal of the tumour. The need for blood transfusion, post-operative pain relief and the risk of wound infection remain significant issues. Nonetheless it remains the Gold Standard against which all other treatment modalities must be compared

Urinary continence rates overall are excellent (95% complete control, no pad), 50% of patients may expect to have immediate urinary control with 30% of patients having incontinence for between 6 to 12 weeks. The remaining 15% regain urinary control over a longer period. The degree of incontinence varies with the extent of surgery. Those with high risk disease requiring a wide excision may have urinary leakage for longer but in the long term continence rates are the same. Artificial Urinary Sphincters can be used to achieve continence but this is rarely required.

Erectile Function after radical prostatectomy will always be compromised and although important, it is not the priority, cancer control and continence are paramount. Increasing experience of the nerve sparing approach and oral treatments has improved long term outcomes. Patients will often have significant improvement up to 3 years following surgery. Outcomes with regard to return of erectile function are best when surgery is combined with an intensive penile rehabilitation programme involving the use of regular oral medication such as cialis, the use of a vacuum pump daily to promote penile blood flow and prevent shortening and injection therapy if necessary. With this regime up to 70% of patents can regain function at 1 year.

Laparoscopic Radical Prostatectomy

Laparoscopic Radical Prostatectomy has a long learning curve and the need for specialist training in the technical aspects of the surgery before embarking on a programme is essential. 

Although preservation of erectile function seems better because of improvements in visualisation and nerve sparing techniques, surprisingly the immediate and early continence rates are no better than in open surgery. In the long term however urinary continence rates are comparable. The major advantage is the more rapid recovery from surgery and reduced length of stay. There is less blood loss , a reduced  need for blood transfusion, post operative analgesia, and risk of wound infection are considerably reduced when compared to open surgery; however there is a greater risk of significant complications such as a urinary leak or rectal injury during the early part of a surgeon’s learning curve which can result in greater morbidity. This experience seems to be a reflection of the learning curve during the first 120 cases and is common to all surgeons irrespective of the approach.

Robotic Assisted Radical Prostatectomy (DaVinci)

Robotic Assisted Radical Prostatectomy has been popularised by the Vattikuti Institute in Detroit and offers the advantages of the laparoscopic approach (better vision, reduced bleeding, better nerve preservation, less analgesia and reduced length of stay) with the enhanced dexterity of the endowrist offering 360 degree intuitive movement. This allows surgeons trained in predominantly open surgery to translate their pelvic surgical skills to a laparoscopic environment. For this reason this procedure is gaining increasing popularity in the USA and now in Europe & the UK. 

The department’s experience in open and laparoscopic radical prostatectomy and laparoscopic urology, combined with the mentoring programme supported from Detroit and the Cleveland Clinic, fulfilled the clinical governance requirements for the introduction of new surgical procedures into the UK. This surgery has now become routine in our department and we now carry out over 150 of these procedures each year at Guy’s Hospital, with the majority of patients discharged within 48 hours of the surgery. There is no doubt that Robotics is the surgery of the future and our experience confirms this.

Dynamic Intra Operative Prostate Brachytherapy (Potters’ Technique)

Brachytherapy for early and low risk prostate cancer is a very attractive alternative to radical surgery and radiotherapy for many patients, with comparable relapse free survival rates as radical surgery at 10 years. Simplistically, this is the targeted insertion of titanium seeds impregnated with radioactive Iodine (I125) directly in to the prostate to achieve a high dose to the cancer. We have been the first group in the UK to introduce a Single Stage dynamic approach with seed implantation carried out under real time ultrasound with intra-operative dosimetry. This provides immediate feedback on the quality of the implant and allows us to maximise the dose to the prostate whilst minimising the dose to the urethra, bladder and rectum. Louis Potters, the American, who developed the technique at the Memorial Sloane Kettering Cancer Center  has mentored our own programme. We have treated over 400 patients between December 2003 and October 2009

Day case brachytherapy treatments

The procedure is conducted as a single visit day case or overnight stay, no catheter is required and patients can return to work in a day or two. Urinary control is excellent although most patients will experience some frequency and urgency this is rarely a significant problem and is minimised by careful patient selection. Erectile function is very well preserved when compared to the alternative options such as nerve sparing radical surgery or hormone radiation. 

It makes use of the principle of Inverse Planning and uses modern hardware and software developments to deliver a Dynamic Real Time Implant with Intra- operative Dosimetry. Thus allowing dose optimisation to maximise treatment of the prostate cancer whilst minimising the dose to the urethra, rectum and bladder.

The procedure has been extremely well tolerated and 96% of patients have been discharged within 16 hours of the implant. The urinary side effects can take up to 3 – 6 weeks to develop and so many patients experience no immediate morbidity and can work or travel as they please. 

Brachytherapy for large prostates and previous TUR surgery

The other major advantage of Potters’ intra-operative dynamic approach is the ease with which it can be adapted and applied to patients with large prostates. Many centres would have difficulty treating these cases and would have to give many months of hormones to shrink the prostate beforehand, with a consequent worsening of the side effect profile. We have also successfully implanted, with out any difficulty or early complications over 50 patients who have previously had trans-urethral prostate surgery (TURP).

High Intensity Focused Ultrasound (HIFU) and Cryotherapy

These are minimally invasive approaches to treating prostate cancer which uses ultrasound guidance to deliver a high intensity of focused ultrasound to the prostate in segments (HIFU) or the placement of cryoprobes to freeze the prostate or part of it (Cryotherapy). They can be used as both a primary treatment and as salvage treatment after radiotherapy. Patients will generally require a limited resection of the prostate (TURP) at the time of the procedure to prevent urinary retention with HIFU. The catheter is removed the next day. The long term data with these treatments are limited to 5 years but the best available suggest that about 70% of patients with “low risk” disease will be free of disease at 5 years, compared to over 90% of patients treated with radical surgery or brachytherapy. Nonetheless it is an option to be considered in selected patients who would be unfit or unsuitable for these other treatments. 

Conclusions

Treatment advances in prostate cancer are dependant upon a multidisciplinary approach and the resource to invest in new technology. Our department has been more fortunate in this regard than others and we have a comprehensive and integrated treatment programme. In some respects, this makes it harder to advise patients when the choice is so broad but I would rather that my patients were well informed on their options. Most often, it is not which treatment would be best for an individual but why one particular choice would be a bad idea.  

For further information on the author of this article, Consultant Urological Surgeon, Mr Rick Popert, please click here.
The organ that stores urine. Full medical glossary
A fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. Full medical glossary
A common name for the large and/or small intestines. Full medical glossary
A type of radiotherapy where radioactive pellets or wires are inserted into the tumour. Full medical glossary
Abnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. Full medical glossary
A tube used either to drain fluid from the body or to introduce fluid into the body. Full medical glossary
The basic unit of all living organisms. Full medical glossary
A condition that is linked to, or is a consequence of, another disease or procedure. Full medical glossary
Feelings of sadness, hopelessness and a loss of interest in life, combined with a sense of reduced emotional well-being Full medical glossary
The process of determining which condition a patient may have. Full medical glossary
The measurement and calculation of the correct dose of ionising radiation. Full medical glossary
The removal of a piece of tissue or an organ from the body. Full medical glossary
The basic unit of genetic material carried on chromosomes. Full medical glossary
A system used to assess the extent of abnormality of prostate cancer cells. Full medical glossary
An abbreviation for high intensity focused ultrasound, a relatively new method for treating cancer using focused ultrasound waves. Full medical glossary
A substance produced by a gland in one part of the body and carried by the blood to the organs or tissues where it has an effect. Full medical glossary
The involuntary passage of urine or faeces. Full medical glossary
Invasion by organisms that may be harmful, for example bacteria or parasites. Full medical glossary
An element present in haemoglobin in the red cells. Full medical glossary
A keyhole surgical procedure. Full medical glossary
A large abdominal organ that has many important roles including the production of bile and clotting factors, detoxification, and the metabolism of proteins, carbohydrates and fats. Full medical glossary
Relating to a group of healthcare professionals with different areas of specialisation. Full medical glossary
Bundle of fibres that carries information in the form of electrical impulses. Full medical glossary
Relating to the pelvis. Full medical glossary
A gland that surrounds the urethra near the bladder. It produces a fluid that forms part of the semen. Full medical glossary
Surgical removal of the prostate, a gland that surrounds the urethra near the bladder. Full medical glossary
An abbreviation for prostate-specific antigen, an enzyme that is produced by the prostate. High levels are present in the blood when the prostate gland is enlarged or inflamed. Full medical glossary
Energy in the form of waves or particles, including radio waves, X-rays and gamma rays. Full medical glossary
The surgical removal of the entire prostate gland. Full medical glossary
The treatment of disease using radiation. Full medical glossary
Relating to the rectum, the lowest part of the bowel leading to the anus. Full medical glossary
The last part of the large intestine, where faeces are stored before being passed. Full medical glossary
The treatment of a person with an illness or disability to improve their function and health. Full medical glossary
A return or worsening of the symptoms of a disease after a period of remission. Full medical glossary
The surgical removal of part of the body. Full medical glossary
septic arthritis Full medical glossary
A way to identify people who may have a certain condition, among a group of people who may or may not seem to Full medical glossary
Relating to injury or concern. Full medical glossary
An abnormal swelling. Full medical glossary
An abbreviation for transurethral resection of the prostate, a procedure to shave away some of an enlarged prostate. This eases the pressure from the prostate on the urethra, the tube that carries urine from the bladder. Full medical glossary
transurethral resection of prostate Full medical glossary
A diagnostic method in which very high frequency sound waves are passed into the body and the reflective echoes analysed to build a picture of the internal organs – or of the foetus in the uterus. Full medical glossary
The tube that carries urine from the bladder, and in men also carries semen during ejaculation. Full medical glossary
Relating to the urethra, the tube that connects the bladder to the genitals. Full medical glossary
The channels that carry urine from the kidneys to the outside of the body. Full medical glossary
Relating to the sense of sight (vision). Full medical glossary