Following a prostate cancer diagnosis, the appropriate prostate cancer treatment decision will depend largely on whether your cancer is localized, locally advanced, or advanced. Before making a treatment decision, it is important to think about your answers to the following questions.
- What quality of life do you want to have after your treatment?
Most patients want as little change to their lifestyle as possible. This viewpoint may lead certain individuals to hold off on treatment altogether, or to do extensive research to find out what minimally invasive options are available that offer the lowest risk of side effects.
- How important is a “back-up plan” for your treatment?
For some men, especially those who are diagnosed and treated earlier in life, knowing that their treatment decision will not limit future salvage treatment options (if there is a recurrence) is very important. Some procedures are not repeatable and can limit the opportunity for alternative options as well.
The number and type of prostate treatments for localized prostate cancer has expanded greatly over the past two decades.
• Watchful Waiting / Active Surveillance – Watchful waiting and active surveillance are approaches to monitoring slow-growing tumors localized to the prostate. Watchful waiting may be used when the tumor is small and causing no symptoms. It requires less intensive monitoring. Active surveillance involves closer monitoring including regular doctor checkups as often every six months. Either approach can be a prelude for a more definitive treatment in the future.
Concerns – Anxiety around not pursuing treatment can leave you worrying that the cancer might begin growing faster than anticipated, even if there is no change in clinical condition, leading to an exploration of definitive treatment options.
• Surgery – A radical prostatectomy removes the entire prostate and presumably the cancer cells within the gland. This is the standard approach when the tumor is localized to the prostate and the patient is otherwise generally healthy. It also may be considered for locally advanced cancer that has spread to nearby lymph nodes just outside the prostate. The three main types of surgery are open, laparoscopic, and robotic-assisted surgery.
Concerns – While laparoscopic and robotic-assisted surgery tend to have less blood loss and shorter hospital stays than open surgery, all three approaches have similar rates of side effects, including urinary incontinence (defined as the use of any pads) in up to 60% of patients and erectile dysfunction of up to 70%. Surgery requires a somewhat prolonged recovery period during which activities of daily living, exercise, and ability to work may be limited.
• Radiation Therapy – External beam radiation, conformal radiation therapy, intensity modulated radiation therapy, stereotactic radiation therapy, proton therapy, and seed implants (or brachytherapy) all use radiation to kill the cancer tumor. They are used to treat localized prostate cancer in healthy men and in men who may not be candidates for surgery. All except brachytherapy are noninvasive procedures delivered over multiple sessions using external beams of radiation. Brachytherapy involves the temporary or permanent implantation of radioisotopes into the prostate to destroy the tissue from the inside out.
If cancer returns after treatment, radiation in general is not repeatable. Radiation therapy also may limit a patient’s ability to undergo a subsequent prostatectomy due to the weakened tissue.
Concerns – Side effects common to all three types of radiation include fatigue, urinary incontinence in up to 25% of patients, bowel problems, rectal bleeding, and erectile dysfunction in up to 60% of patients. External beam radiation therapy may require weeks of treatment although each individual session is usually of short duration.
• High-Intensity Focused Ultrasound (HIFU) – HIFU uses heat generated by high-frequency ultrasound beams to ablate (destroy) tissue within the prostate gland. This minimally invasive procedure is done as an outpatient with patients returning home the same day as the procedure and needing 1-2 days to recover before returning to routine activities. HIFU does not limit the patient’s options for a salvage treatment which can include repeat HIFU, surgery, or radiation therapy. While HIFU was authorized for use in the United States only a few years ago, it has been used and studied for use in prostate cancer around the world for over 15 years.
Focal HIFU – HIFU used to target specific areas of diseased tissue within the prostate gland. This technique was developed to preserve as much healthy prostate tissue as possible, resulting in lower risks of incontinence and erectile dysfunction. Focal HIFU can be delivered multiple times to address recurrent disease or disease that develops in a different portion of the gland. The treatment is visually guided using ultrasound to ensure that the proper tissue is receiving treatment. A recent study reported five-year disease control rates for focal HIFU therapy equivalent to those achieved with whole gland surgery or radiation therapy.2
Concerns – Focal HIFU may result in urinary incontinence (less than 2%) and erectile disfunction (15% of men, rates that are much lower than with other forms of intervention.1 It also may leave behind low risk residual disease in untreated portions of the gland that will need to be monitored over time.
• Cryotherapy – Uses cold to freeze cancer cells. Sometimes called cryosurgery, it involves inserting needles through the rectal wall and into the prostate tumor. Gas is pumped into the tumor to freeze the tissue. Cryotherapy can either freeze the whole prostate or be delivered only to a portion of the gland. Cryotherapy offers a minimally invasive option compared to surgery, with little or no blood loss and short recovery times.
Concerns – Is a minimally invasive, rather than a noninvasive procedure with the same constellation of side effects as other treatments whose incidence is somewhat greater than focal HIFU, and is not delivered under the continuous ultrasound guidance that is the hallmark of HIFU ablation.
This information provided by SonaCare Medical, a world leader in high intensity focused ultrasound (HIFU) and is committed to developing focused ultrasound related technologies that support precise and innovative procedures for the treatment of a range of medical conditions. Click here to find a doctor near you who can thoroughly discuss with you minimally invasive HIFU for prostate tissue ablation.
Dr. Michael Lazar offers a HIFU Program in partnership with HIFU Prostate Services, LLC (HPS). HIFU Prostate Services, LLC (HPS) is a leading provider of minimally-invasive prostate cancer treatments using High Intensity Focused Ultrasound (HIFU). HIFU prostate treatments are performed at San Francisco Surgery Center (SFSC). SFSC offers patients a state-of-the-art facility that is convenient to hotels and the airport.
Call Dr. Lazar at (707) 546-5553 for more information and to learn if you qualify , or simply fill out and submit the online form here.
1 Mehrdad Alemozaffar, MD, Meredith M. Regan, ScD, et al. Prediction of Erectile Function Following Treatment for Prostate Cancer. JAMA. 2011 Sep 21; 306(11): 10.1001/jama.2011.1333.
2 Guillaumier S, et al. A Multicentre Study of 5-year Outcomes Following Focal Therapy in Treating Clinically Signiﬁcant Nonmetastatic Prostate Cancer. Eur Urol (2018), https://doi.org/10.1016/j.eururo.2018.06.006