Prostate Cancer Treatments/Surgery

Prostate cancer is the second most common cancer in Western world. Though still less common in India, its incidence is gradually increasing with improving socio-economic status and Westernizing diet, i.e. low fiber, high fat and high sugar diet. It is rare before the age of 40 years; 65% of cases occur after 65 years of age. Similar disease in 1st degree relatives (father, brother) is a strong risk factor.

What are the symptoms of prostate cancer?

A prostate cancer in its initial stage is entirely asymptomatic. It is usually picked up incidentally. But advanced stage may present with symptoms like: -

• Decreased urinary stream
• Urinary frequency
• Blood in urine
• Bone pain
• Lower limb numbness or weakness
• Bladder/bowel incontinence

How is prostate cancer diagnosed?

When a person goes to urologist for evaluation of his voiding difficulties, a simple physical examination (digital rectal examination) and a blood test – serum prostate specific antigen (s. PSA) are done. On the basis of these, prostate biopsy is done to confirm or refute the findings. Further specialized tests like CT scan, MRI scan and Bone scan are ordered to stage the disease if cancer is diagnosed.
In some patients, prostate cancer is diagnosed after assessment of TURP – biopsy specimen.

What is s. PSA?

Serum PSA is an organ specific product, which is found in miniscule amounts in blood of men. It is NOT disease specific. PSA is increased due to BPH, prostatitis, prostate massage, prostate biopsy, cystoscopy, TURP apart from cancer. It is decreased due to 5α reductase inhibitors (finasteride, dutasteride), hypogonadism, obesity and statins. There is also a time bound variation in s. PSA levels. Free PSA levels are also altered with hemodialysis/peritoneal dialysis. Thus, a single elevation in s. PSA level should not trigger for a prostate biopsy. The levels should be repeated 48 hours post ejaculation and three to six weeks post prostate biopsy/cystoscopy/TURP. As in India, infection of prostate is very common, a short course of antibiotics is usually administered and s. PSA repeated after around 3 weeks. If persistently elevated, biopsy is advisable. The s. PSA is NOT a specific marker of prostate cancer. And there is no specific cut off level that can differentiate cancerous from non-cancerous lesion. Rather, it reflects a continuum of risk-probability of harboring prostate cancer. In up to 25% of patients, s. PSA can be in a very low range (normal).

How is prostate biopsy done?

It is done under local anesthesia and USG guidance. As prostate gland lies just in front of rectum (end part of alimentary tract, just before anal opening), it is easily and painlessly accessible. The patient is asked to come after getting fresh in morning (bowels should be empty) and having light breakfast and a single dose of antibiotic. A spring-loaded needle is inserted under USG guidance and 10 – 12 pieces are removed and sent for biopsy.

Post procedure, patient can expect some amount of blood in stools/urine or ejaculate. It usually subsides spontaneously. In rare circumstances, the patient can suffer from fever and UTI and needs higher antibiotics. The patient is usually sent home on short course of antibiotics the same day, once he has passed urine.

Who are candidates for prostate cancer screening?

Any man above 40 – 50 years with no co-morbidities and a life expectancy of more than 10 years can go for prostate cancer screening after having a detailed discussion with his urologist regarding risks and benefits of such screening.

Is prostate cancer aggressive disease?

In majority of patients, prostate cancer is a slow growing, indolent disease. Most patients die with prostate cancer rather than due to the disease. Only in some cases, the disease is fast growing and need aggressive treatment. Unfortunately, till date, there is no such definite marker, which can separate the two types of patients. Your urologist is the best person to guide you after he has evaluated you and studied all of your reports.

What are the treatment options available for prostate cancer?

1. Watchful waiting

The patient is kept on follow up with periodic blood test till he develops disease spread, which requires palliative management. Only patients with a low-grade disease, patients with multiple co-morbidities and with a life expectancy of less than 10 years are kept on watchful waiting.

2. Active surveillance

In an endeavor to avoid over-treatment in vast majority of patients who harbor a slow growing, indolent disease, active surveillance protocol has been devised. The patient is followed up with serial s.PSA and prostate biopsies to detect progression of disease. Definitive treatment is then taken up.

3. Surgery

Surgical intervention is undertaken with intention of removing whole of prostate to ensure complete eradication of prostate.

a. Open radical prostatectomy

The traditional surgery in which whole of prostate is removed

b. Laparoscopic radical prostatectomy

The same surgery is done using keyhole technique. A few small holes are made on tummy and the surgery is done using specialized instruments under camera. The results are equivalent to open surgery while benefiting the patient with lesser blood loss, less pain and early discharge and return to normal life. The surgeon must be an experienced laparoscopist for doing this technically demanding surgery.

c. Robot assisted radical prostatectomy

It is a technological advancement over laparoscopic surgery, in which, the surgeon sits on console and operates robot to do the surgery. This technology increases surgical finesse and accuracy, at the same time, providing all the advantages of keyhole surgery.

4. Radiotherapy

a. Curative Radiotherapy

Radiotherapy is another option instead of surgery for localized prostate cancer. With advancement in technologies, the side effects of radiation therapy (due to radiation to adjacent normal organs like urinary bladder and bowels) have been minimized. However, with radiotherapy, one cannot be 100% sure of complete extirpation of cancerous cells. Also, as no tissue is taken out for biopsy, grading and staging of disease is less accurate as compared to radical surgery.

b. Adjuvant Radiotherapy

If after surgery, biopsy reveals tumor having extended out of prostate, radiotherapy to the prostatic bed kills the residual tissue and improves chance of recurrence-free survival.

c. Palliative Radiotherapy

In case of locally advanced or metastatic disease, the aims for palliation of symptoms of patient, without curing the disease

5. Hormonal therapy

The prostate cancer is a hormonally sensitive tumor, in that hormone testosterone (the male hormone) secreted from testis aids in growth of tumor. The basic premise of this therapy is to cut off supply of hormone (castration of patient) to decrease disease load and to slow progress of disease. It is NOT a curative therapy, but is for alleviation of symptoms and increase quality and quantity of life.
This therapy is reserved for men with widespread disease, in whom curative therapy is not an option left and we want to improve their quality of life and add some years to it.

a. Surgical Castration: Under local anesthesia, a small procedure is performed in day care with long lasting effects. Patient becomes to improve symptomatically within a day.
b. Medical Castration: In men who have got reservations against surgical procedure and negative body image post procedure, the same effect can be brought with the help of injections, which need to be administered every one/three/six months depending upon the preparation.
Hormonal therapy is monitored with serial s. PSA levels, done every 3 monthly. In case of medical castration, serum testosterone levels are also monitored to ensure adequacy of dosage. A rising s. PSA level in spite of adequate hormonal suppression is a sign of alarm and requires next stage of treatment for continued benefits.

6. Chemotherapy

Chemotherapy is the treatment of cancer with specialized drugs. Tremendous advancements have been made in understanding the onset and biology of prostate cancer and therapies devised to improve patient outcomes. Chemotherapy is given in case of progression of disease to improve patient survival.
In prostate cancer, chemotherapy comes into the scene when patient starts progressing after hormonal therapy. There are various types of chemotherapy, which can be administered step wise with the goal of improving quality of life and adding it.