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Treatment of prostate cancer

Treating prostate cancer is in close correlation with the stage of the disease and extent. It is very important to differentiate between prostate cancer that is treated to cure the disease or in a palliative situation. Unfortunately, the boundaries between these groups are not clear. Many circumstances are taken into consideration when choosing treatment such as the age of the patient, comorbidity, and side effects of different treatment types. It is very important to explain the treatment alternatives. The patient's partner should be included in the discussion of treatment alternatives, and it may also be beneficial to have both the oncologist and surgeon present information together. 

The treatment forms chosen may vary between country, hospital, and specialist, which is not a favorable situation for the patient.

Curative treatment

Due to PSA screening, many patients today have organ localized disease at the time of diagnosis (T ≤ 2), and it is therefore possible to offer more patients treatment intended to cure the disease. 

Possible treatments may be:

  • radical prostatectomy
  • external conform radiation therapy
  • brachytherapy
  • combined brachytherapy and external radiation therapy
  • combined hormone treatment and radiation therapy

The frequency of recurrence and survival is considered equal for surgery and radiation therapy. The side effect profile for these treatment methods differes, but quality of life studies show equal quality of life for patients having undergone different treatment types. For T3 disease (capsule rupture), both surgery and radiation is considered in some cases.

Focal therapy

With focal therapy the tumor is removed without removing the entire prostate.

  • Cryoablation therapy
  • High-Intensity Focused Ultrasound - HIFU ( heat therapy)
  • Photodynamic therapy (PTD)

None of these treatments are available in Norway today.

Observation/waiting

Curative treatment (surgery or radiation) may have severe side effects and reduce the patient's quality of life. In many cases, prostate cancer has a low growth potential and metastasize late. If the patient is high in age, the disease may not cause serious problems within their lifetime. If the disease is not very agressive, it is usually best for the patient to forgo treatment.

"Active monitoring" means the disease is monitored (3–6–12 months) to obtain an impression of the malignancy potential of the tumor and possibly initiate curative treatment at a later time if the disease shows signs of progression. It is then possible to postpone treatment and bothersome side effects for multiple years, or possibly avoid treatment completely.  

Palliative treatment

Some patients who already have signs of the disease either have locally advanced disease or metastasis. There are many treatment options for these patients, even if they are not intended to cure the disease. 

Patients who cannot be given curative treatment because of advanced disease at diagnosis or other causes, can be offered different palliative alternatives. The purpose of palliative treatment is to help the patient live as long and good life as possible with the disease.

Treatment alternatives often combined are:

  • Hormone manipulation
  • Surgery
  • Radiation treatment
  • Chemotherapy

Hormone manipulation

The prostate cells are dependent on testosterone stimulation to grow and develop. This applies also to most malignant prostate cells. If the production of testosterone is stopped, most of the malignant cells will die (apoptosis) and both the local tumor and metastases will go into remission. This remission can last many years, but the disease is not cured. The tumors can start to grow again, despite lack of stimulation by testosterone. The disease is then testosterone independent (hormone refractory).

Hormone manipulation can dramatically alter the clinical course of the disease, even if it is unknown whether the treatment prolongs the patient’s life.  It is unclear whether such hormone treatment should be started early or wait until the patient has clinical symptoms or metastases. In recent years, there have been reports that hormonal manipulation provides a somewhat longer survival. To start treatment at an early point in time requires assessment of the side effects from treatment versus the relatively marginal improvement in survival. In recent years, new hormon drugs have become available. Treatment with enzalutamide or abiraterone have shown prolonged survival.

Surgery

For local symptoms (obstruction/bleeding), transurethral resection of the prostate/tumor (TUR-P) is good palliation. This can also be combined with radiation therapy. For bone metastases in weight bearing bones, and for neurological symptoms from the spinal cord, orthopedic surgery should be assessed, in combination with postoperative radiation therapy. 

For infiltration of the base of the bladder with obstruction of the urethra, the urinary tract from the kidney must be secured. The alternatives are re-implantation of the urethra if bladder outflow is good, or stenting of the ureteres if the prognosis is not good. Urinary diversion (Bricker diversion, cutaneous ureterostomy, pyelostomy) may be appropriate depending on the prognosis and general medical condition. 

Radiation therapy

  • To prevent metastases
  • Pain treatment
  • Spinal column for threatening neurological symptoms
  • Palliative radiation of the prostate tumor

Palliative radiation therapy is given as external radiation therapy. The goal is to reduce pain or to reduce the tumor size and thereby remove or reduce locoregional problems. Adjuvant radiation therapy is also given after metastasis surgery (vertebral column, bones). Targeted radiation therapy (radium 223) may be used as pain treatment and may in some cases cause prolonged survival.

Chemotherapy

For locally advanced cancer or metastases from hormone refractory cancer, there is sufficient documentation to consider the use of chemotherapy with docetaxel (Taxotere®).

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