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Oncological Urology

9 Prostate Cancer Treatments explained

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  1. WW (Watchful Waiting) 

it’s a treatment method mentioned in the guidelines and other medical publications and it is based on the fact, that early prostate cancer grows very slowly. During WW patient is not provided any active medical treatment, but is closely monitored and in case of any changes in the test results – action will be taken

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considerable for the patients with:

 

  • low volume of cancer, within the prostate gland

  • Gleason Score up to 6

  • PSA density (PSAD) less than 0,15

  • other factors to be discussed with doctor (age, other health conditions (CCI), family history, patient preference, race)

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disadvantages of WW 

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  • need of frequent medical monitoring

  • small risk of cancer developing faster than expected

  • psychological effect of increased fear level for some people

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advantages of WW 

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  • no intervention

  • doesn't change quality of life

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ROBOTIC

2. Surgery - Radical Prostatectomy

according to the current standards “The goal of the RP by any approach is eradication of the cancer, while whenever possible preserving continence and potency..”. During the procedure entire prostate gland and seminal vesicles will be removed and urethra anastomosed to the bladder neck. Much depending of the experience of the surgeon and surgical technic (Robotic, Laparoscopic or open) the possible complications might be reduced to the very low level, sexual and urinary functions fully preserved. For the patients with localized (not spread to the other organs) the survival rates for the very long periods of time (over 20 years) are on the very high level

​considerable for the patients with:

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  • sufficient health conditions for surgery

  • best outcomes for T1 & T2 cancer classification

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disadvantages of Radical Prostatectomy

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  • possible erectile and urinary side effects if performed by less skilled or experienced surgeon

  • risks connected to anesthesia

  • other surgical complications risks 

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advantages of Radical Prostatectomy

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  • significantly reduces risk of death from Prostate Cancer in a long period of time

  • minimally invasive – if performed with Robotic Assisted or Laparoscopic technic 

  • little blood loss

  • short recovery time

  • high probability prevention of sexual and urinary functions if performed by experienced surgeon

 

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3. Immunotherapy Sipuleucel-T (Provenge®)

the idea of the immunotherapy is to boost the immune system to identify and fight the disease. It is a vaccine, composed of own immune cells of the patient. They are set to attack PAP (prostatic acid phosphatase) protein

considerable for the patients with:

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  • patients with advanced, metastatic disease

  • patients resistant to hormonal treatment

  • minimal or no pain patients

  • slow growing tumor

  • no need for urgent shrinkage

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disadvantages of Immunotherapy

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  • possible side effects as headache, fatigue, nausea, joint pain, fever, chills, should diminish within 3 days after infusion

  • can not be used for all patients

  • does not lower PSA, treat symptoms, or delay disease progression

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advantages of Immunotherapy

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  • not invasive

  • relatively short – about 6 weeks

  • prolongs life

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4. Brachytherapy (type of radiation therapy)

is a type of therapy, when the source of radiation is implanted directly to the affected organ. The aim is to destroy the cancer cells. There is a choice of LDR (Low Dose Rate) and HDR (High Dose Rate) with the dose rate meaning the speed with which it is delivered. Placement of the “carriage” take place in the hospital under anesthesia. With HDR for shorter periods – day or two. With LDR “seeds” will be releasing small dose of radiation during the next year 

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considerable for the patients with:

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  • LDR - for patients with cancer not spread outside the prostate gland, no previous prostate surgery, minimum urinary symptoms

  • HDR - when disease is spread outside the prostate gland with higher Gleason Score and bigger volume. HDR is usually used in conjunction with the other treatments, such as (androgen deprivation) therapy and/or external beam radiation therapy (EBRT)

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disadvantages of Brachytherapy

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  • side effects like (stinging, burning, poor urine stream, urgency in passing urine, frequency of urination or needing to pass urine more at night, constipation) over a few months

  • lower libido, erectile disfunction

  • radiation protection needed for career (LDR)

  • for HDR swelling and bruising of scrotal area, resolving in the weeks

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advantages of Brachytherapy

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  • minimally invasive

  • doesn’t require repeated treatments

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5. External Beam Radiation Therapy EBRT

during the EBRT therapy the beam of the radiation is directed to the prostate gland from the outside of the body. Procedure is short and takes a few minutes. Fitted plastic mold created individually, ensures static and identical patient position during each session. The location of the prostate is mapped digitally and ensures high precision to prevent the exposure to the healthy tissue 

considerable for the patients with:

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  • low grade of cancer, not spread from the prostate gland

  • whose other health conditions exclude surgery

  • cancer spread to the specific area of the bone to relieve the bone pain

  • cancers that have grown outside the prostate gland as a first treatment along with hormone therapy

  • recurrent cancer in the area of the prostate after surgery

  • advanced cancer to help keep it under control and to relieve symptoms

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disadvantages of EBRT

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  • long treatment usually 5 days a week, during several weeks

  • possibility of diarrhea, blood in the stool, rectal leakage

  • need to urinate more often, burning sensation while urinate, and/or blood in urine 

  • fatigue 

  • limphedenema –  if lymph nodes around prostate are damaged by radiation, they may collect fluid, that cause swelling and pain

  • erection problems, impotence and urinary incontinence (lost of control over urine, leakage or dribbling). The risk is low right after treatment, but it goes up each year after it, for several years

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advantages of EBRT

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  • minimally invasive, short procedure

  • painless during the procedure

  • no incisions, no anaesthesia

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6. Stereotactic body radiation therapy (SBRT)

uses advanced image guided technics to deliver large doses of radiation to the precisely localized area of the body. This is still investigational therapy and due to the luck of the robust clinical studies is not considered a routine practice. The therapy takes name of the mashine like Gamma Knife®, X-Knife®, CyberKnife®, and Clinac® 

Image courtesy of Varian Medical Systems, Inc. All rights reserved.

considerable for the patients with:​

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  • men with smaller tumor, that occupy only about 5-10% of the prostate volume

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disadvantages of SBRT

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  • similar side effects as EBRT

  • no robust clinical study on oncological outcomes yet

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advantages of SBRT

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  • shorter time, therapy takes a few days

  • ​prostate cancer spread too far to be treated by surgery or radiation

  • recurrent disease after surgery or radiation therapy

  • before the radiation therapy to shrink the cancer

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7. Hormonal Therapy, Androgen Deprivation Therapy (ADT)

the goal of it is to reduce the levels of Androgens (male hormones) in the body to stop them from stimulating the prostate cancer to grow

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considerable for the patients with:​

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  • prostate cancer spread too far to be treated by surgery or radiation

  • recurrent disease after surgery or radiation therapy

  • before the radiation therapy to shrink the cancer

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disadvantages of ADT

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  • erectile disfunction

  • absence or reduction of libido, shrinkage of the male genitals

  • hot flashes

  • anemia

  • breast tissue growth and tenderness

  • osteoporosis 

  • loss of muscular mass

  • fatigue

  • increased cholesterol

  • depression

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advantages of ADT

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  • can help to stop of reduce the speed of cancer grow

  • may shrink an enlarged prostate

  • no incisions, no anaesthesia

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8. HIFU High Intensity Focused Ultrasound

high frequency Ultrasound waves are emitted from transducer to damage the malignant tissue mechanically and by temperature grown by mechanical friction 

​considerable for the patients with:​

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  • cancer not spread out of the prostate grand

  • low Gleason score

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disadvantages of HIFU

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  • erectile disfunction (23%)

  • urinary incontinence (10%)

  • recto-urethral fistula formation (5%)

  • urinary retention (10%) – disability to empty the bladder completely

  • no long term studies on oncological outcomes yet

  • difficulties to achieve the whole prostate gland ablation (destruction by coagulative (temperature) necrosis)

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advantages of HIFU 

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  • non invasive procedure

  • no incisions, no anaesthesia

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9. Cryotherapy

uses the freezing technique to destroy the cancer cells

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​​considerable for the patients with:​

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  • patients, who can not go through the surgery or radiotherapy

  • patients for whom other therapies do not work

  • small localized cancer

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disadvantages of Cryotherapy

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  • erectile disfunction (18%)

  • urinary incontinence (2-20%)

  • urethral sloughing (blocking of the urine by the dead tissue) (0-38%) 

  • recto-urethral fistula formation (0-6%)

  • urinary retention (10%) – disability to empty the bladder completely

  • no long term studies on oncological outcomes

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advantages of Cryotherapy

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  • minimally invasive

Images used on this site are courtesy of Pixabay.com

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