PROSTATE CANCER
( By JASCAP )

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Treatment for locally-advanced prostate cancer

Overview of Treatments

The treatment options for locally-advanced prostate cancer include radiotherapy, hormonal therapy, watchful waiting (observation) and surgery.

Sometimes a combination of treatments will be given.

Choosing treatment

Deciding on the best treatment is not always straightforward and a number of factors have to be taken into account. The most important of these are:

  • your general health
  • the grade of the prostate cancer
  • the size of the cancer
  • your PSA level
  • the likely side effects of treatment
  • your views about the possible side effects of treatment and how much you are willing to risk side effects for the possible benefits in controlling the cancer
  • whether you have had treatment before
  • your age.

The possible treatments for your situation are likely to be discussed by a group of doctors working together. This is known as a multidisciplinary team and includes a surgeon (urologist) and doctors who are specialists in radiotherapy, hormonal therapy and chemotherapy treatments (clinical oncologists).

The team may also include specialist nurses, social workers, and physiotherapists. It is common to see a surgeon, an oncologist and a specialist nurse to help you to make the decision.

Treatment choices

Many men with locally-advanced prostate cancer are offered radiotherapy to the prostate. Hormonal therapy is often given with radiotherapy and can be started before the radiotherapy begins and continued after it is finished.

Some men are offered hormonal therapy as a treatment on its own. It is also used to treat men who aren't able to have radiotherapy, or those who can't have surgery because they aren't able to have a general anaesthetic, or because of other medical problems they may have.

In elderly men who have no symptoms from the cancer, or who have other medical problems, it may be best to give no treatment (but continue regular monitoring with PSA tests) and control any symptoms that occur. This is known as watchful waiting and is a common way of dealing with locally-advanced prostate cancer. It is used because the growth of the cancer may be so slow that it is not worth risking the side effects that may be caused by treatment.

Surgery to remove the prostate gland (a prostatectomy) may be possible for a small number of men. Hormonal therapy may be given before or after surgery. Sometimes radiotherapy is given after surgery. Surgery to relieve problems with passing urine, known as a TURP, may be suitable for some men.

You may be offered a choice of treatment. Each of the treatments has different benefits and side effects.

Second opinion

Some people find it helpful to have another medical opinion to help them to decide about their treatment. Doctors can refer you to another specialist for a second opinion if you feel that this would be helpful

Treatment or not?

You may be advised to be monitored instead of having treatment immediately. This is known as watchful waiting. Many locally-advanced prostate cancers grow extremely slowly and may cause very few problems within a man's lifetime. However, it's not possible to tell from blood tests and biopsies how quickly the cancer is going to grow.

The treatments for prostate cancer can cause side effects such as erection problems or incontinence, which for some men may be worse than the effects of the cancer. Your doctors may advise waiting to see whether the cancer is likely to cause problems, rather than having treatment straight away.

Consent to treatment

Before you have any treatment, your doctor will explain its aims to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

  • the type and extent of the treatment you are advised to have
  • the advantages and disadvantages of the treatment
  • any other treatments that may be available
  • any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

You may feel that the hospital staff are too busy to answer your questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can't make a decision when it is first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you do not have it. It is essential to tell a doctor or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages of treatments for locally-advanced prostate cancer

Your doctor will explain the benefits and possible disadvantages and side effects of the treatments to you. You can then decide which is best for your particular situation. The benefits and disadvantages of the treatments for locally-advanced prostate cancer are outlined in the following pages. Before you have any treatment it is important that you are fully aware of them.

It is not possible for doctors to predict accurately who is going to be affected by the side effects of each treatment. For this reason you need to be given full information about the risks beforehand and have plenty of opportunity to discuss them. Remember, there are often choices to be made about which treatment you have, or even whether to have treatment. You can take as large or small a part in those choices as you wish.

External beam radiotherapy

This is the use of high-energy rays to destroy cancer cells.

Benefits: Radiotherapy can help to control locally-advanced prostate cancer for many years and may lead to a cure in some situations. The benefits in small, slow-growing cancers are uncertain. A complete course takes up to seven weeks. Giving hormonal therapy before and during the radiotherapy may improve the results.

Risks: For every 100 men who have external beam radiotherapy: up to 30 will develop occasional bleeding from the rectum (back passage); about 10 may have bleeding, a change in bowel habit and some discomfort; and up to 70 will develop erection problems (though this depends on age). Rarely, some men may have leakage or incontinence of urine.

Hormonal therapy

This lowers the levels of testosterone in the body, using tablets or injections, or by surgical removal of the testes. Hormonal therapy may be used on its own or given with radiotherapy or surgery.

Benefits: Can slow or stop the growth of cancer cells for many years. Does not involve surgery or radiation so there is little risk of bowel or bladder problems.

Risks: It will not get rid of all the cancer cells if it is the only treatment given. It can cause a range of side effects that include breast swelling and hot flushes, impotence and lowered sex drive.

Watchful waiting

Some locally-advanced prostate cancers are very slow-growing and may never cause any symptoms. For this reason, some men and their specialists decide to wait and see whether the cancer is getting bigger (progressing) before starting any treatment. The watchful waiting approach involves regular check-ups with PSA tests and digital rectal examinations.

Benefits: Many men who choose watchful waiting will avoid the side effects of treatments like radiotherapy or hormonal therapy.

Risks: Some men find it difficult just to wait and see if their cancer progresses before starting any therapy. Some men will need treatment with radiotherapy or hormonal therapy if their cancer shows signs of developing.

Surgery

Surgery can be used to remove the whole prostate gland (prostatectomy), or to relieve symptoms of urinary obstruction (Trans-urethral resection of the prostate TURP).

Benefits of a prostatectomy: Removing the whole prostate gland may stop the cancer from spreading and may result in a cure. Radical prostatectomy appears to prolong life for some men with a higher grade cancer (see page 00), but isn't suitable for many men with locally-advanced prostate cancer.

Risks of a prostatectomy: Over half of men who have a prostatectomy for locally-advanced prostate cancer will have a recurrence of their cancer and need further treatment, with either radiotherapy or hormonal therapy.

For every 100 men who have a radical prostatectomy: up to 20 will develop slight leaking of urine; around 5 will have incontinence of urine; and around 70 will have problems getting an erection. One in 200 men over 65, and one in 1000 men under 65, may die from problems caused by the surgery.

Benefits of a TURP: Can help to relieve symptoms with passing urine.

Risks of a TURP: It will not get rid of the cancer cells. There a risk of urinary incontinence. Some men have problems getting an erection after a TURP.

Radiotherapy for locally-advanced prostate cancer

Radiotherapy treats cancer by using high-energy x-rays to destroy the cancer cells, while doing as little harm as possible to normal cells in the surrounding area such as the bladder or back passage (rectum). Radiotherapy for locally-advanced prostate cancer usually uses a machine similar to a high-powered x-ray machine (external beam radiotherapy). Your doctor may suggest that you have hormonal therapy before or after your radiotherapy.

The treatment is given in the hospital radiotherapy department, usually as daily sessions from Monday to Friday, with a rest at the weekend. For locally-advanced prostate cancer, radiotherapy will be given for 4-7 weeks.

Planning radiotherapy

Planning is a very important part of radiotherapy and may take one or two visits. The treatment has to be carefully planned to make sure that it is as effective as possible. You will be asked to have a CT scan or lie under a machine called a simulator, which takes x-rays of the area to be treated. The treatment is planned by a cancer specialist (clinical oncologist).

Marks are usually drawn on your skin to help the radiographer (who gives you your treatment) to position you accurately and to show where the rays will be directed. These marks must stay in place throughout your treatment. Permanent marks (like tiny tattoos) may also be used. These are very small and will only be done with your permission. You may feel a little discomfort while they are being done.

Treatment sessions

At the beginning of each session of radiotherapy, the radiographer will position you carefully on the couch and make sure you are comfortable. During your treatment you will be left alone in the room, but you will be able to talk to the radiographer who will be watching you. Radiotherapy is not painful, but you have to lie still for a few minutes while the treatment is being given.

Conformal radiotherapy and intensity modulated radiotherapy

Conformal radiotherapy (CRT) or intensity modulated radiotherapy (IMRT) are increasingly being used, although these are not available at all hospitals.

In conformal radiotherapy (CRT), a special attachment to the radiotherapy machine carefully shapes the radiation beams to match the shape of the prostate gland. Shaping the radiotherapy beams reduces the radiation received by the healthy cells in nearby organs such as the bladder and rectum. This reduces the side effects of radiotherapy and may allow higher doses to be given, which could be more effective.

Intensity modulated radiotherapy (IMRT) is a newer, more complex type of conformal radiotherapy that allows the radiotherapist to vary the dose of radiation given to different parts of the tumour and surrounding tissue. It is not yet known whether IMRT is better than conformal radiotherapy.

Short-term side effects

Radiotherapy to the prostate can make it more difficult to have an erection. There are various treatments which can help (see dealing with side-effects).

Radiotherapy to the prostate area may irritate the rectum, and cause discomfort and diarrhoea. It may cause soreness around the anus. Your doctor can prescribe medicines to reduce this and you may be advised to change your diet.

The radiotherapy may also cause cystitis, which can make you want to pass urine more often or cause a burning feeling when you pass urine. Your doctor can prescribe medicines to reduce this. These effects usually disappear gradually a few weeks after the treatment has ended. Rarely, if you have difficulty in passing urine, it may be necessary to have a urinary catheter put in.

Radiotherapy can also cause general side effects such as tiredness, which are mild for some men and more troublesome for others. The radiographer will be able to advise you what to expect. Try to balance rest with regular, gentle exercise, especially if you have to travel a long way for treatment each day.

The radiotherapy may make some of your pubic hair fall out. When you have finished the course of treatment, the hair will grow back. However, the hair may be thinner or finer than it was before.

Most side effects of radiotherapy gradually disappear once the treatment has ended. However, others may continue for some months and some may even be permanent. If you have any problems during your treatment, talk to the radiotherapy staff as they will be able to help you.

Radiotherapy does not make you radioactive and it is perfectly safe for you to be with other people, including children, throughout your treatment.

Our general booklet on radiotherapy gives more details about this treatment and its side effects.

Possible long-term side effects

Radiotherapy to the prostate area can sometimes lead to long-term problems.

Radiotherapy for prostate cancer can cause an inability to have an erection (impotence) in about 3-5 in 10 (3050%) of the men who have this treatment; this may develop over a period of 25 years. Our page on dealing with side effects discuss ways of coping with erection problems. This side effect of treatment can be very difficult to deal with and can affect your sex life and your relationship with your partner. You may find it helpful to read our section on sexuality. Many organisations offer counselling for sexual or relationship problems.

In a number of men, the bowel or bladder may be permanently affected by the radiotherapy. The blood vessels in the bowel and bladder can become more fragile and this can make blood appear in the urine or when you pass bowel motions. This can take many months or years to occur. If you notice any bleeding, it is important to let your doctor know so that tests can be carried out and appropriate treatment given. Occasionally bowel movements may be more urgent after radiotherapy and, rarely, there may be some difficulty in controlling the bowels.

Often, radiotherapy can help to improve problems with passing urine, but for some men radiotherapy can lead to leakage of urine due to damage to the nerves that control the bladder muscles (urinary incontinence). This is unlikely unless you have had a TURP or prostactectomy as well. If this happens it is important to discuss it with your doctor, who can arrange for you to see a specialist continence nurse. You may also find it helpful to contact the Continence Foundation.

If radiotherapy has been given to the lymph glands in the pelvic area as well as to the prostate, it can cause some swelling of the legs, known as lymphoedema.

We have further information about the long-term side effects of pelvic radiotherapy.

Hormonal therapy for locally-advanced prostate cancer

Hormonal therapy may be given before radiotherapy , and sometimes before surgery - this is known as neo-adjuvant therapy . It is also sometimes given after either radiotherapy or surgery, which is known as adjuvant therapy . The aim is to reduce the chance of the cancer coming back.

Hormonal therapy can also be given as a treatment on its own, and has been shown to improve survival.

Hormones control the growth and activity of cells. In order to grow, prostate cancer depends on the hormone testosterone produced by the testicles. Hormonal therapies reduce the amount of testosterone in the body. They can be given as injections or tablets, and occasionally an operation ( subcapsular orchidectomy ) will be done to remove the part of the testicles that produces testosterone.

Injections

Some drugs 'switch off' the production of male hormones from the testicles by reducing the levels of a hormone produced by the pituitary gland. These drugs are called pituitary down- regulators or gonadotrophin releasing hormone analogues (GnRH analogues) . They include goserelin (Zoladex®), leuprorelin (Prostap®) and triptorelin (Decapeptyl®).

They are usually given as a pellet injected under the skin of the abdomen (goserelin), or as a liquid injected under the skin or into a muscle (leuprorelin or triptorelin). Injections are given either monthly or every three months.

Tablets

Other hormonal therapy drugs work by attaching themselves to proteins (receptors) on the surface of the cancer cells. This blocks the testosterone from going into the cancer cells. The drugs are called anti-androgens and are often given as tablets. Commonly used anti- androgens are flutamide (Chimax®, Drogenil®), bicalutamide (Casodex®) and cyproterone acetate (Cyprostat®).

Anti-androgen tablets are also usually given for two weeks before the first injection of a pituitary down-regulator. This prevents tumour flare, which is where symptoms get worse after the first dose of treatment.

Side effects

Unfortunately most hormonal therapies usually cause erection difficulties and loss of sexual desire for as long as the treatment is given. If the treatment is stopped, the problem may disappear. Some types of anti-androgens are less likely to cause impotence than others.

In about half the men who have hormonal therapies, the side effects that cause them the greatest problem are hot flushes and sweating. Flushes stop if the treatment is stopped. Some medicines can help while you are having treatment.

Hormonal treatment can also make you put on weight and feel constantly tired, both physically and mentally. Some drugs (most commonly flutamide and bicalutamide) may also cause breast swelling and tenderness. Some hormonal therapy, particularly GnRH therapy, may increase your risk of developing diabetes or heart disease.

However, the benefits of hormonal treatment generally outweigh the possible risks. You can discuss the possible side effects with your doctor before you start treatment. Being warned about possible side effects can make them easier to cope with.

We have factsheets about individual hormonal therapies , with more information about how the drugs work and tips on coping with possible side effects.

Subcapsular orchidectomy (removal of testicles)

Subcapsular orchidectomy is a simple operation. A small cut is made in the scrotum (the sac that holds the testicles), and the part of the testicles that produces testosterone is removed. The scrotum will be smaller than before. The operation can be done as a day patient under a local or general anaesthetic. Sometimes both testicles are completely removed.

Some men find the idea of this operation very distressing and feel that it makes them less of a man. However, others do not find this a problem. Orchidectomy can be effective in controlling the cancer and reducing symptoms in up to 90% of men (9 in 10).

After the immediate effects - some pain, and often swelling and bruising of the scrotum - the side effects of hot flushes and sexual impotence are similar to those of hormonal therapy drugs. Subcapsular orchidectomy avoids the use of drugs and some of the possible side effects such as breast enlargement and tenderness.

Subcapsular orchidectomy and other hormonal treatments are equally effective.

Watchful waiting for locally-advanced prostate cancer

Watchful waiting means that your doctors will keep a close eye on you to see if the cancer is growing significantly. You will usually have blood tests every 1-3 months to monitor your PSA levels, frequent digital rectal examinations, and will be asked if you have developed any new symptoms. You may also have prostate biopsies every one or two years.

If these regular tests show that the cancer is starting to grow, or if you develop more symptoms, your doctors will then discuss treatment options intended to control the cancer and improve the symptoms, such as hormone therapy. If your cancer is not growing or developing, it is safe to continue with watchful waiting.

Surgery for locally-advanced prostate cancer

Surgery may be a treatment option for you. Before any operation, make sure that you have discussed it fully with your doctor. It is important that you understand what it involves, the chances of success, the likely side effects, and whether there are other treatment options that may be more appropriate to your particular circumstances. Your doctor may suggest that you have hormonal therapy before or after your surgery.

There are three types of surgery used to treat locally-advanced prostate cancer:

Radical prostatectomy

A radical prostatectomy is carried out by specialist surgeons. The whole prostate gland is surgically removed either through a cut made in the tummy area (abdomen) or through a cut made between the scrotum and the back passage. This aims to get rid of all of the cancer cells. This operation is only suitable for a small number of men with locally-advanced prostate cancer. You can discuss with your specialist whether a prostatectomy would be suitable for you.

The operation often causes impotence - the inability to have and maintain an erection. In a few men it can also cause problems with control of passing urine (urinary incontinence). Sometimes it is possible to do a special type of operation, called a nerve-sparing prostatectomy, which can reduce the risk of erection problems.

As doctors cannot predict which men will be affected by these side effects it is important that you are fully aware of these risks beforehand. Your doctor will discuss the operation, its possible side effects and other possible treatment options with you.

Although prostatectomy can get rid of the cancer cells completely for some men, the cancer cells may come back in the area of the prostate a while after the operation. If this happens, external radiotherapy may be given to the prostate area. The treatment is given over a larger area, which can cause more side effects.

Laparoscopic prostatectomy

With a laparoscopic prostatectomy your surgeon doesn't need to make a large opening but can take out your prostate gland using only four or five small cuts (about 1cm each) in your tummy area (abdomen). The surgeon uses specially designed instruments that can be put through these small cuts. This type of surgery is also known as keyhole surgery.

After making the small cuts the surgeon uses carbon dioxide gas to fill (inflate) the abdomen. A tiny video camera gives a magnified view of the prostate gland onto a video screen. The prostate gland is then cut away from surrounding tissues and removed through one of the cuts in the abdomen.

Most studies have shown that laparoscopic surgery is as successful at treating prostate cancer as open surgery. Your surgeon can discuss with you the potential risks and benefits. This type of surgery is only carried out by surgeons with specialised training and experience in the technique.

After your operation

After prostatectomy you will have a drip (intravenous infusion) into a vein in your arm and a tube (catheter) to drain urine from the bladder. If the operation is done through the abdomen you will also have an abdominal wound. You may have a small tube in the wound to drain any excess fluid that is produced. After your operation you may have some pain or discomfort which may continue for a few weeks, particularly when you walk. Regular painkillers should help to ease this, so let the staff on the ward know if you are still in pain.

You will probably be ready to go home a week to ten days after your operation. Your catheter will probably stay in for one to three weeks to allow the urethra to heal. Arrangements can be made for a district nurse to visit you at home, and if you have any problems you should contact your doctor as soon as possible.

Side effects of radical prostatectomy

Surgery to the prostate can cause problems in getting an erection (sexual impotence) and in controlling the bladder (incontinence). Erection problems are caused by a reduction in the blood flow to the penis due to damage to the arteries or nerves. Often the need to remove all of the cancer cells makes it impossible to avoid nerve damage. In men aged under 60 who have had nerve-sparing prostatectomy, the risk of erection problems after total prostatectomy may be 1 in 2 (50%) or higher. The risk increases to about 4 in 5 (80%) or more in men over the age of 70 and may be higher if nerve-sparing techniques are not used.

Problems with controlling the bladder as a result of radical prostatectomy are less common. Most men have some incontinence when the catheter is first removed, but this usually improves with time. About one year after the operation up to one in five (20%) of men will leak an occasional drop of urine. Some men may need to wear an incontinence pad, but it is very rare to be completely incontinent and need to have a permanent catheter. Another less common effect of surgery is scarring of the bladder which can make it difficult to pass urine. This is fairly easily treated with minor surgery (known as a bladder neck dilation).

Some men may find that they have diarrhea or constipation for a few months after prostatectomy.

Trans-urethral resection of the prostate (TURP)

A TURP is carried out if it is necessary to remove the part of the tumour that is blocking the urethra (the tube that drains urine from the bladder). A tube which contains a miniature camera is passed through the urethra, into the prostate. A cutting instrument attached to the tube is then used to shave off the inner area of the prostate to remove the blockage.

This can be done under a general anaesthetic or an epidural. With an epidural, the lower body is numbed temporarily by injecting an anaesthetic into the spine so that you can't feel anything even though you are awake.

A TURP can't remove all of the cancer cells. It is used to relieve problems with passing urine.

After your TURP

After your operation you will probably be up and about the next morning. You will usually have a drip, giving fluid into your vein. This will be taken out as soon as you are drinking normally. A tube (catheter) will drain fluid from your bladder into a collecting bag. It is usual for the urine to contain blood.

To stop blood clots from blocking the catheter, bladder irrigation may be used. This means that fluid is passed into the bladder and drained out through the catheter. The blood will gradually clear from your urine and the catheter can be taken out. At first you may find it difficult to pass urine without the catheter, but this should improve. Some men find that they have some urinary incontinence following this procedure. It can also cause some long-term difficulty in passing urine.

Most men are able to go home after three or four days. Occasionally it is necessary to keep the catheter in for a while after you go home. Before you leave hospital the nurse will show you how to look after your catheter and arrangements can be made for a district nurse to visit you at home to help with any problems.

You may have pain and discomfort for a few days after your operation, for which you will be given painkillers. These are usually very effective, but if you continue to have pain it is important to let the doctor or nurse looking after you know as soon as possible so that a more effective painkiller can be found.

Following a TURP about 1 in 5 (20%) men may have retrograde ejaculation. This means that, during ejaculation, semen goes backward into the bladder instead of through the urethra, so your urine may look cloudy after sex. This is harmless.

Orchidectomy (removal of testicles)

Although this is an operation, the aim of removing the testicles is to reduce the levels of testosterone (male hormone) in the body, so it is discussed in the section about hormonal therapies. As there are many hormonal therapy drugs available now, orchidectomy is not used very often.

Care after an operation

If you think that you might have any difficulties coping at home after your surgery, let your nurse or social worker know when you are admitted to hospital so that help can be arranged.

As well as being able to offer practical advice, many social workers are also trained counsellors who can offer valuable support to you and your family, both in hospital and at home. If you would like to talk to a social worker, ask your nurse or doctor to arrange it for you.

Before you leave hospital you will be given an appointment to attend an outpatient clinic for your post-operative check-up. This is a good time to discuss any problems you may have.

Newer treatments for locally-advanced prostate cancer

The following are sometimes used for locally-advanced prostate cancer; however they are not widely available. If you think that one of the treatments may be suitable for you, it is best to discuss this with your cancer specialist. They can advise whether the treatment could be helpful in your particular case.

Brachytherapy

Brachytherapy is a type of radiotherapy that uses radioactive 'seeds' inserted into the prostate. It is available in some hospitals in the UK. It is sometimes called internal radiotherapy, implant therapy or seed implantation. It can be carried out under a general anaesthetic or a spinal anaesthetic (epidural).

Brachytherapy is only suitable for a small number of men with locally-advanced prostate cancer and is usually given in combination with external beam radiotherapy.

There are two ways of giving brachytherapy:

Standard brachytherapy uses small radioactive metal 'seeds' that are inserted into the tumour so that radiation is released slowly over a period of time. The seeds are not removed but the radiation gradually fades away over about six months. There is no risk of it affecting other people.

Temporary HDR (high dose rate) brachytherapy involves placing tiny plastic tubes (catheters) into the prostate gland. Radioactive seeds are inserted into the catheters for a set period of time, and then withdrawn. After the treatment, the catheters are easily removed and no radioactive material is left in the prostate gland.

Brachytherapy may cause some swelling of the prostate, which can lead to blockage of the urethra, so a further catheter is sometimes inserted into the bladder to drain urine. This may be removed after a couple of hours or left in place overnight.

Antibiotics are given after the implant, to prevent infection. Most men go home the day after the implant, but some leave hospital as soon as they have recovered from the anaesthetic and are able to pass urine normally. After the implant it is best to avoid heavy lifting or strenuous physical activity for two or three days.

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