Staging of prostate cancer
The recommended treatment for your prostate cancer will be largely based on both your Gleason score, and what stage the cancer has progressed to. The stages of prostate cancer are explained below.
- T1 - there is a small tumour within the prostate gland. The tumour is too small to be detected with a rectal examination, but it may be detected during a biopsy. Generally the tumour will cause no symptoms.
- T2 - the tumour is still within the prostate gland but it is large enough to be detected with ultrasound or a rectal examination.
- T3 & T4 - the cancer has spread to the surrounding tissue.
- N1 - the cancer has spread to nearby lymph nodes (lymph nodes are glands that are found throughout our body.)
- M1a - the cancer has spread to other lymph nodes not near the prostate gland.
- M1b - the cancer has spread to the bones.
T1 and T2 tumours are known as localised prostate cancer.
T3 and T4 are known as locally-advanced prostate cancer.
Once the cancer has reached the N1 stage it is known as metastatic prostate cancer. It is unlikely that it will be able to be cured at this stage though the progression of the cancer can be slowed with treatment.
Deciding on a treatment plan
Once the cancer has been detected you will need to discuss possible treatment plans. It is likely that the discussion will take place with several doctors and other health professionals who each specialise in different aspects of treating cancer. They make up what is known as a multi-disciplinary team (MDT).
MDT often include:
- a clinical oncologist (a specialist in the non-surgical treatment of cancer using techniques such as radiotherapy and chemotherapy),
- a pathologist (a specialist in diseased tissue),
- a urologist (a specialist in the surgical treatment of prostate cancer),
- a social worker,
- a psychologist,
- a specialist cancer nurse, and
- a counsellor.
There are several factors that you will need to take into account when deciding on your treatment. They include:
- your age,
- the likely progression of your cancer,
- the stage of your cancer, and
- the possible side-effects of treatment.
No-one will try to hurry you into making a decision, and you should feel free to talk to as many people as you want, including friends, family and your partner.
Many people find that writing a list of questions at home to ask the MDT is helpful.
Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision will be yours.
Treatment options for prostate cancer are outlined below.
Watchful waiting
If the cancer is in its early stages, and is causing no symptoms, you may decide to delay any treatment and then wait to see if any symptoms of progressive cancer develop. This is often recommended for older men when it is unlikely that the cancer will impact on their natural life span.
Active surveillance
This is also a treatment option for the early stages of prostate cancer. It is normally recommended for younger men where there is a chance that the cancer will impact on their natural life span.
Active surveillance involves you having regular PSA tests and biopsies to closely monitor the progression of the cancer. If these tests reveal that the cancer is likely to spread beyond the prostate you can then make a decision about further treatment.
Radical prostatectomy
A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer.
Like any operation, this surgery carries some risks and there may be some side effects. These are outlined below.
- Some men have problems with urinary incontinence. This can range from leaking small drips of urine, to leaking larger amounts. However, for most men, this often clears up within 3-6 months of the operation. Less than 5% of men have long-term problems.
- Some men have problems getting an erection (erectile dysfunction). For most men, this improves with time, but some men will experience long-term problems.
- In extremely rare cases, problems arising after surgery can be fatal. For example, 0.1% of men who are under 65 years of age, and 0.5% of men who are over 65 years of age, will die following a radical prostatectomy.
For many men, having a radical prostatectomy will get rid of the cancer cells. However, for around two in five men, the cancer cells may not be fully removed, and for around one in three men, the cancer cells may come back some time after the operation.
Radiotherapy
Radiotherapy involves using radiation to kill cancerous cells. The levels of radiation are safe but they can cause side effects (see below).
Radiotherapy can be used to cure prostate cancer in its early stages, and also to slow the progression of advanced prostate cancer and relieve symptoms.
Radiotherapy is normally given in short sessions over the space of seven weeks. There are both short term and long term side effects associated with radiotherapy.
Short term effects of radiotherapy can include:
- discomfort around the rectum and anus (the opening through which stools pass out of your body),
- diarrhoea,
- loss of pubic hair,
- tiredness, and
- cystitis - which is an inflammation of the bladder lining which can cause you to urinate frequently and urination may be painful.
Possible long term side effects can include:
- an inability to obtain an erection - this effects between 30 to 50% of men, and
- urinary incontinence.
As with radical prostatectomy there is a one in three chance the cancer will return.
Brachytherapy
Brachytherapy is a form of radiotherapy where a number of tiny radioactive seeds are surgically implanted into the tumor.
The risks of sexual dysfunction are the same as with radiotherapy, but the risks of urinary incontinence are a lot lower.
Hormone therapy
Hormone therapy is often used in combination with other therapies. For example, you may receive hormone therapy before undergoing radiotherapy or a radical prostatectomy, in order to increase the chances of these therapies being successful. Or hormone therapy may be recommended after other treatments, to reduce the chances of cancerous cells returning.
Hormone therapy can also be used to slow the progression of advanced prostate cancer and relieve symptoms.
Hormones control the growth of cells in the prostate. In particular, prostate cancer needs the hormone testosterone to grow. So the purpose of hormone therapy is to block the effects of testosterone, either by stopping its production or by stopping your body being able to use testosterone.
Most hormone therapies will cause loss of sexual desire and the ability to obtain an erection. These side effects should pass once the therapy is completed.
Other possible side effects include:
- hot flushes,
- sweating
- tiredness,
- weight gain, and
- swelling of the breasts.
A surgical alternative to hormone therapy is to surgically remove the testicles. This has proved effective in treating the symptoms of prostate cancer of 90% of cases. Though many men are reluctant to undergo the treatment because of its considerable psychological impact.
Trans-urethral resection of the prostate (TURP)
This is a surgical procedure similar to a TURP biopsy, except a larger piece of your prostate gland is removed. This is done to relieve pressure from the urethra in order to treat any problematic symptoms you may have with urination.
Treating advanced prostate cancer
Once the cancer has reached an advanced stage it is no longer possible to cure it. But it is possible to slow its progression, prolong life, and relieve symptoms.
Treatment options include:
- radiotherapy,
- hormone treatment,
- chemotherapy,
- and the use of painkillers (analgesics)
Information on chemotherapy and pain relief is provided below.
Chemotherapy
Chemotherapy uses special medicines that kill cancerous cells.
Possible side effects of chemotherapy include:
- nausea,
- vomiting,
- tiredness,
- loss of appetite,
- hair loss, and
- mouth ulcers.
You will also be more prone to infection when receiving chemotherapy. You should see your GP if you suddenly feel ill, or your temperature rises above 38ºC (100.5ºF).
Pain relief
There are many different medicines that can be used to relive pain (analgesics).
The analgesics used will depend on the severity of your symptoms. If you are experiencing mild pain then paracetamol can be used.
If you have more severe symptoms, an opiate-based analgesic, such as codeine or morphine may be required.
Constipation is a common side effect of these types of analgesic, so you may also be given a laxative
It is important to contact your MDT if you feel that the painkillers you have been given are not effective in controlling pain.
Deciding against treatment
As many of the treatments above have unpleasant side effects that can affect your quality of life you may decide against treatment. Especially if you are at an age when you feel treating the cancer is unlikely to significantly extend your life expectancy.
This is entirely your decision and your MDT will respect it. Of course, pain relief and nursing care will be made available as and when you need it.
