Treatment Options for Localised Cancer 2

External beam radiotherapy is an effective treatment option for localised prostate cancer. It typically involves daily treatment for approximately 8 weeks however shorter protocols can also be used. In some cases extra radiation can be delivered to the prostate by inserting small tubes into the prostate through the skin behind the scrotum. These are used for a short time to deliver iridium which is a radioactive substance to the prostate to provide extra radiation in an attempt to control more aggressive cancers. This is called high dose rate (HDR) brachytherapy. HDR cannot be performed if your prostate is too large and / or you have severe urinary symptoms already.

The advantage of radiotherapy is that it avoids major surgery. However the major disadvantage is that there are limited options available if the cancer is not totally cleared. This is because radiation damages the tissues and inhibits healing processes. Surgery, ultrasound treatment (HIFU) and freezing of the prostate (cryotherapy) are options in cases of radiation failure but the complication rates of these salvage treatments can be significant. It is for these reasons that radiotherapy is generally not recommended in the very young man.

• Avoids major surgery.
• Can treat areas beyond the confines of the prostate if there is a high risk that the cancer has spread outside of the prostate gland into the adjacent tissues or lymph nodes.

• 8 weeks of treatment.
• Salvage treatments are limited in cases of cancer recurrence and are associated with high complication rates.
• Impotence - Erectile function deteriorates over time at around 10% per year producing impotence rates of approximately 50% at 5 years and then deteriorates by approximately a further 5% per year thereafter.
• Severe urinary and rectal toxicity - approximately 5% of patients experience long-term problems with urinary urgency, frequency, bleeding and rectal urgency frequency and bleeding.
• Urethral scarring (stricture) - this produces a blockage of the urethra (water pipe that passes from the bladder through the penis) and is especially a risk in HDR where the rate is about 8%. The strictures can be dense and very difficult to treat.
• Fistula (abnormal connection between the urinary tract and the rectum).

Low does rate brachytherapy is a treatment option for localised prostate cancer which involves the use of radioactive seeds being placed into the prostate. Typically 80 or more seeds of radioactive iodine-125 are placed into the prostate gland under a general anaesthetic. The procedure usually takes approximately 2 hours. Low levels of radiation are emitted by the seeds directly to the prostate. Very little radiation penetrates outside of the prostate gland. This allows the prostate to be specifically treated while minimising the effects to adjacent tissue. The procedure takes approximately 2 hours. A catheter will be placed in your bladder and an ultrasound probe will be placed in your rectum to visualise the prostate gland. Approximately 80 seeds are then inserted into the prostate under ultrasound guidance using a number of needles which are placed between the scrotum and the anus. The needles are removed and the seeds are left within the prostate gland. You will then be admitted to the ward and your catheter will be removed the following morning. A postoperative CT scan will be obtained either the next day or at 1-3 months after the procedure.

• Avoids major surgery
• Shorter duration of treatment than external beam radiotherapy.
• Minimally invasive.

• Not all patients are suitable for brachytherapy.
• Salvage treatments are limited in cases of cancer recurrence and are associated with high complication rates.
• Impotence- The risk of impotence is approximately 22% at 1 year after the implant and is approximately 50% at 5 years. Impotence then worsens by approximately 5% per year thereafter.
• Stricture (5%) - There is a small chance that scar tissue may form in the urethra. The urethra is the tube that carries urine from the bladder through the prostate and penis. It is the tube that you pass urine through in order to urinate. In these instances the scar tissue may need to be opened with further surgery.
• Dysuria (pain with urination) and urinary urgency and frequency is experienced by most (over 70%) men at 3 months. This typically resolves over time. The risk of some ongoing urinary symptoms at 1 year may be up to 20%. At 2 years it is approximately 2.5%, at 3 years 1.25%, and 1% at 5 years.
• Retention (2-3%) - There is a risk that you may not be able to pass urine after the procedure. This is due to swelling of the prostate gland. If this occurs, you may need to learn to pass catheters (small plastic tubes) intermittently into the bladder each time you need to pass urine. You may have to do this for some months. It is also possibly that at a much later date you may require a rebore of the prostate (TURP) to help you pass urine. There is a higher risk of incontinence associated with TURP following brachytherapy.
•   Approximately 1% of patients will experience a syndrome of urinary frequency, pain and reduced bladder volume in the long term.
•   Rectal toxicity - Up to 5% of patients may notice increased frequency of bowel movements and blood in the bowel motion.
•   Incontinence. There is a risk that you will leak urine after the procedure. This risk is approximately 2% at about 5 years.
• Fistula (1%). There is a risk that you may form an abnormal connection between the bladder and the bowel which can result in ongoing urine infections and may require further complex surgery.
• You should not father children for at least 1-2 years after the implant until all the radiation is gone.

HIFU is a newer treatment option for localised prostate cancer. It is touted as a minimally invasive option with minimal side-effects that allow retreatment of the prostate but side effects including impotence and incontinence are not insignificant. Long-term data is limited and HIFU does not appear to be as effective as the more established treatment options of surgery radiotherapy or brachytherapy. It is generally not recommended as first-line prostate cancer treatment.

Cryotherapy involves freezing the prostate gland by inserting needles into the prostate gland and freezing it with argon gas. Similar to HIFU long-term data does not match that of the established treatment options and generally it is not recommended as primary treatment.

Prostate cancer grows in response to testosterone. Testosterone can be blocked by injections which can be administered every 1, 3 or 6 months, by tablets or by removing the testicles. This can cause the prostate cancer to shrink back. It does not cure the cancer but holds it at bay.

Primary hormonal therapy is not indicated for the treatment of localised prostate cancer.
It may however be used in conjunction with radiotherapy or brachytherapy.

The most common cause of death within 10 years following a diagnosis of prostate cancer is heart disease. Therefore diets that are healthy for your heart are also healthy for your prostate. There are no specific dietary supplements that have been universally proven to inhibit prostate cancer. The following points can be used as a guide to increase your general well-being and your chances of a longer life expectancy.

• Normal cholesterol and blood lipid levels
• Normal blood sugar levels
• Normal blood pressure
• Low stress /anxiety
• 1-2 serves of fibre each day
• Exercise 30 minutes per day including resistance training
• 1-2 standard drinks of alcohol per day
• Normal waist circumference