Treatment Options for Localised Prostate Cancer 1

The following is a list of treatment options for clinically localised prostate cancer. It is important to note that no treatment is effective 100% of the time. Please note that this is a general summary and treatment options will vary depending on your individual situation.

• Active Surveillance
• Surgery - Radical Prostatectomy
• External Beam Radiotherapy +/- HDR (High Dose Rate Radiotherapy)
• LDR Brachytherapy seeds
• High-Intensity Focussed Ultrasound (HIFU)
• Cryotherapy

Not all prostate cancers that are detected are considered to be clinically significant. Active surveillance aims to prevent the overtreatment of clinically insignificant cancers that may never cause you a problem. If the prostate cancer appears to be potentially insignificant then it is monitored periodically with PSA tests and repeat biopsies. If it appears that the cancer is progressing then active primary therapy can be performed at that stage. The criteria for active surveillance are yet to be fully defined but generally include low volume low grade disease. Active surveillance protocols continue to be defined and are yet to be fully validated. The timing of when to intervene is ill-defined and studies are currently underway to determine what constitutes disease progression and when to intervene.

• Aims not to over-treat a potentially clinically insignificant cancer.
• Avoids the complications of treatment.
• Quality of life is maintained.
• Decreased initial costs.

• Prostate examination, prostate biopsy and PSA tests may not accurately determine whether the cancer is indeed insignificant from the outset.
• Chance of missed opportunity for cure.
• The cancer may progress or spread while on surveillance so that it may require more extensive treatment or become incurable.
• Treatment of a larger, more intense cancer may be more intense with greater side effects.
• Nerve-sparing at subsequent prostatectomy may be more difficult which may reduce the chance of potency preservation after surgery.
• The anxiety associated with living with untreated cancer.
• The need for intense follow-up

Surgery involves complete removal of the prostate gland. It is highly effective treatment with good long term results in the appropriately selected patient; the major long-term side-effects of surgery include impotence and incontinence.

Impotence - The risk of impotence varies depending on your age and health and whether the nerves to the penis are removed or whether one or both of them are spared. If you have excellent erections before the operation, your chance of regaining your erections at 1 year either spontaneously or with tablets is approximately 70% if both nerves are spared and 20-30% if only one is spared. Erections tend to improve over time for 1-2 years after the surgery but it is possible that they may never return and you would need to consider using a vacuum pump, injections or possibly require prosthesis to achieve intercourse. Should your erections recover sufficient for intercourse, it is important to note that they are not likely to be as strong as prior to the operation. It is highly likely that you will need to use tablets (Viagra, Cilais, Levitra), injections or vacuum devices for some time (months / years) after the operation.

Incontinence - You should expect that you are likely to leak urine after your operation and will need to wear continence pads for the first few weeks or months. It is vital that you perform pelvic floor exercises. In general 25% of patients are pad free within 1 week, 70% within 3 months and 90% at 1 year. Therefore there is a 10% chance that at 1 year after the operation you will need to wear incontinence pads. Usually this is a security pad to catch small amounts of urine however approximately 2% of patients have severe incontinence which may require further surgery by way of injectable agents, a male urethral sling or an artificial sphincter. There is a chance that the incontinence will be permanent.

• The prostate gland is completely removed.
• Additional radiotherapy can still be applied if the cancer is at a high risk of recurring.

• Major surgery even if it is performed using key-hole techniques
• Impotence
• Incontinence
• Other risks including rectal injury (which may require a colostomy bag), ureteric injury, anaesthetic problems, heart attack, stroke, major bleeding, blood transfusion, unexpected return to the operating room, a small risk of death from the procedure, fistula (abnormal connection between the bladder and the rectum), blood clots in the legs and lungs, recurrence of cancer, anastomotic stricture (scarring at the join between the bladder and the urethra), inability to pass urine, and urine leak requiring prolonged drain placement and prolonged catheterisation.
• Risk of a positive margin which may imply that the cancer has not been completely cleared.
• Possible need for radiotherapy after the operation or hormonal therapy after the operation.