5.2 Active Surveillance

What is Active Surveillance 5?

Some prostate tumors grow very slowly and never cause health problems. Active surveillance involves regular testing and monitoring. Additional or definitive treatment can be started if cancer shows signs of progression.

Advantages of Active Surveillance:

• Avoid or delay treatment side effects including erectile dysfunction (chronic inability to achieve or maintain an erection satisfactory for sexual intercourse) and urinary incontinence (partial or complete loss of bladder control)

• Less impact on quality of life/normal activities

• Less risk of unnecessary treatment of small, slow-growing cancers

Active Surveillance Protocol

Disadvantages of Active Surveillance:

• Low chance of missed opportunity for cure

• Periodic follow-up MRI and/or prostate biopsies may be necessary

An example of an Active Surveillance protocol may include the following:

• PSA (blood test) every 3-6 months, or as directed by your urologist

• DRE (digital rectal exam) no more often than every 12 months, or as directed by your urologist

• Repeat prostate biopsy no more often than every 6-12 months, or as directed by your urologist

• MRI Imaging of the prostate may be paired with a biopsy

5.3 Definitive Forms of Treament 5

Men with more aggressive tumors should probably undergo treatment. The type and intensity of the treatment is usually tailored to the potential risk of the disease. The most common forms of treatment include surgical removal of the prostate, radiation therapy and hormonal therapy. When a single therapy is chosen, additional therapies may be considered later if the cancer should return.

Men with very aggressive cancer may be offered multiple forms of therapy at the beginning of their disease. National cancer guidelines offer suggestions as to which treatments may be the most appropriate based on the patient’s risk and potential outcomes of the treatment.

However, appropriate risk classification is very important in this decision and this actual risk assessment can be very difficult to make.

The final decision on whether to use a single or multiple forms of therapy is a shared decision between the patient and the physician. Factors for making this decision are: perceived aggressiveness of the disease, the outcomes of the treatment, potential side effects of treatment or treatments and, of course, how the patient and his family want to proceed.

Surgery - Radical Prostatectomy

Surgical treatment is an option for some patients with prostate cancer. Before deciding on this treatment, a doctor will evaluate if the patient is healthy enough for an operation. The goal of surgery is to remove all cancerous tissue. During this process, normal prostate tissue will also be removed.

Most surgeries can be divided into three types:

1. Radical Prostatectomy without pelvic lymph node dissection

2. Radical Prostatectomy with limited pelvic lymph node dissection

3. Radical Prostatectomy with extended lymph node dissection

What is Radical Prostatectomy?

Radical Prostatectomy (RP) is an operation in which the entire prostate, and sometimes other tissue is removed. This procedure is used when the tumor appears to be contained within the prostate. There are several types of RP including open, laparoscopic, and robotic assisted.

Open approach to prostatectomy

This option is the more traditional approach to doing a prostatectomy. Surgeons operate through a single cut to remove the prostate and nearby tissues. There are typically two methods used for open radical prostatectomy.

1. Radical retropubic prostatectomy

During this operation, the surgeon will make a single incision from below the belly button down to the pubic bone. The patient will be placed under general anesthesia or be given spinal or epidural anesthesia along with sedation during the surgery.

2. Radical perineal prostatectomy

During this operation, the surgeon will make an incision in the skin between the anus and scrotum (the perineum). This approach is used less often because the nerves that control erections cannot easily be spared and lymph nodes cannot be removed. However, it is often a shorter operation and might be an option if the patient does not prefer the nerve-sparing procedure, has had multiple previous abdominal or pelvic surgeries, or does not require lymph node removal.

Laparoscopic radical prostatectomy

For a laparoscopic radical prostatectomy (LRP), the surgeon makes several small incisions through which special instruments are inserted into the pelvis to remove the prostate. One of the instruments has a small video camera on the end, which allows the surgeon to see inside the abdomen.

Robotic-assisted radical prostatectomy

A laparoscopic prostatectomy can be completed with the assistance of a “robot.” During the operation, the surgeon sits at a control panel near the operating table and uses this to control robotic arms to operate through several small incisions in the abdomen. Many physicians believe the robot allows for making more precise cuts compared to the surgeon’s hands. Surgeons who perform robotic-assisted surgery go through intensive, specialized training.

What is Pelvic Lymph Node Dissection?

Additional procedures may be performed on men with advanced disease. One of these procedures are removal of lymph nodes. Pelvic Lymph Node Dissection (PLND) is an operation that removes lymph nodes from the pelvis. PLND is advised when there is a 2% or higher risk of cancer within the lymph nodes. Nearly half of men will have a PLND with their radical prostatectomy.

What are the potential side effects of surgical treatment?

The potential side effects of surgical treatment can include but are not limited to:

During

the operation:

• Bleeding requiring a blood transfusion

• Heart attack

• Blood clot formation

After the operation:

• Pain and swelling

• Urinary incontinence

• Erectile dysfunction

• Dry orgasms

• Infertility

Radiation

Radiation is a procedure used in cancer treatment that uses high-energy rays to kill cancer cells. Radiation treatment damages the cancer cells’ DNA, leaving them unable to survive, grow, and spread. Specialized doctors, called radiation oncologists, specialize in the treatment of prostate cancer, and currently use two common forms of radiation treatment, External Beam Radiation Therapy (EBRT) and Brachytherapy. Please consult your urologist or radiation oncologist when seeking more information on radiation treatments.

What is External Beam Radiation?

External Beam Radiation Therapy (EBRT) delivers radiation from outside the body using a large machine. The radiation passes through the skin and other tissue and targeted on the tumor. The treatment requires several sessions per week for many weeks.

What is Brachytherapy?

Brachytherapy delivers radiation therapy by placing radioactive seeds inside the prostate. The seeds are about the size of an uncooked grain of rice. They remain in the prostate to give a low dose of radiation to a specific area for weeks or months. After about 90 days, the radiation is completely gone.

What are the potential side effects of radiation treatment?

Potential side effects of radiation therapy can include, but are not limited to:

• Erectile dysfunction – over time

• Urinary problems

• Rectal problems

• Fatigue

Hormone Therapy

Prostate cancer cells need hormones called androgens to grow. Hormone therapy can slow tumor growth or shrink the tumor for a period of time. Hormone therapy is often given together with radiation therapy. Certain types of genomic tests like Prolaris ® can help you understand if you would benefit from hormone therapy or if you can avoid it.

Multiple types of hormone therapy exist. Speak to your doctor for a full list.

Bilateral orchiectomy:

Removal of the testicles can reduce the level of testosterone in the blood by 90 to 95 percent. This type of treatment, called surgical castration, is permanent and irreversible.

Antiandrogens:

These drugs block receptors on cancer cells from receiving testosterone. These drugs are often used in combination with orchiectomy or other forms of ADT. This combination can also be called combined androgen blockade, complete androgen blockade, or total androgen blockade.

LHRH (Luteinizing horomonereleasing horomone) agonists or antagonists:

Drugs that are used to stop the testicles from making testosterone. It can either be injected into a muscle, injected under the skin or implanted under the skin every 1,3,4,6, or 12 months.

Estrogens:

This form of treatment can stop the adrenal glands and other tissues from making testosterone.

What are the potential side effects of hormone therapy?

Side effects vary by type and include but are not limited to:

• Erectile dysfunction

• Reduced desire for sex

• Weakened bones

• Weight gain

• Loss of muscle mass

• Diabetes

• Heart disease

• Hot flashes

• Mood changes

• Fatigue

All prostate cancer diagnoses are different, and a certain form of treatment is not appropriate for all men. It’s crucial that you are aware of all treatment options available to make the best decision to fight your specific cancer. 5