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Prostate cancer guide: The treatment dilemma

Choosing the best course of treatment for prostate cancer is a difficult decision and depends entirely on a patient’s individual situation. Benefits of a particular option must be carefully weighed against the risks and side effects. Factors such as a man’s age and overall health, stage of cancer, and chances for a cure should all be taken into consideration.

Choosing the best course of treatment for prostate cancer is a difficult decision and depends entirely on a patient’s individual situation. Benefits of a particular option must be carefully weighed against the risks and side effects. Factors such as a man’s age and overall health, stage of cancer, and chances for a cure should all be taken into consideration. Here are the most common treatments for prostate cancer; other options are currently being tested:

Risks and side effects
As with any major surgery, a radical prostatectomy can result in complications such as problems with anesthesia, blood clots, infection and bleeding, as well as a small increase in the risk for heart attack and stroke. Patients who have lymph nodes around the prostate removed also face a slight risk of lymphedema, which can cause swelling and pain in the legs and genital area.

The most common side effects of surgery for prostate cancer include incontinence and impotence, both of which can have serious physical and emotional consequences.

There are varying degrees of incontinence, ranging from total loss of bladder control to milder problems with leaking. For many men, bladder control returns to normal within several weeks or months of surgery, but in others it can become a long-term problem. In one study, five years after surgery about 14 percent of men had no bladder control, 16 percent leaked a few times each day and 29 percent wore pads to keep dry. In general, the more experienced a surgeon is, the lower the risk that the patience will experience incontinence.

Impotence, or the inability to maintain an erection, results when nerves involved in arousal and orgasm are damaged during surgery. Twenty years ago, impotence was a foregone conclusion, but today's state-of-the-art bilateral nerve-sparing surgery attempts to preserve potency. Still, most men have problems with impotence for up to three to 12 months after surgery, and for some, the problem can linger or become permanent. The younger a man is, the more likely he is to regain the ability to get an erection. However, semen will no longer be produced with orgasm and patients will be sterile. If men are concerned about being able to father a child, they should talk with their doctor about sperm banking before surgery.

Treatments with external beam radiation last only a few minutes each and can be performed on an outpatient basis. Most men receive up to five treatments each week for a duration of eight or nine weeks.

Internal radiation, or brachytherapy, uses small radioactive pellets or “seeds” to kill cancer cells directly in the prostate. About the size of a grain of rice, the pellets are inserted into the gland where they give off small amounts of radiation for several weeks. Most men can’t feel them and they are often left in the body after the radioactive material is used up.

Risks and side effects
Patients undergoing external beam radiation may experience exhaustion, diarrhea, bloody stools, leaking from the rectum, frequent or painful urination, and intestinal irritation that can last even after treatment stops. The long-term rate of impotence is similar to that of men who have had surgery although the problem usually does not begin immediately after treatment, as it does with surgery, but develops over one or more years.

Internal radiation therapy also causes impotence, as well as bowel and bladder problems, but at a lower rate than external beam radiation. However, there is a small risk that some of the radioactive seeds can leave the prostate and move to other parts of the body.

Hormone therapy surgery, known as an orchiectomy, involves removing the testicles, which are the main source of male hormones in the body. It is less expensive than some other procedures, but most men avoid this very permanent treatment approach. Instead, many opt for drugs called LHRH analogs or the newer LHRH antagonists, which temporarily lower levels of androgens as effectively as removing the testicles. The drugs are given as shots at regular intervals over several months. Because prostate cancer can become resistant to hormone therapy, the drugs are often stopped and started again over time.

Other drugs such as antiandrogens, which block the body’s ability to use male hormones, and female hormones, such as estrogen, are also occasionally used.

Risks and side effects
Hormone therapy can cause a variety of unpleasant symptoms during treatment. The most common side effect is impotence and loss of sexual desire, a problem experienced by almost 90 percent of men who undergo hormone therapy. Many also experience hot flashes, breast tenderness, growth of breast tissue, weight gain, anemia, depression, exhaustion and decreased mental sharpness. Most of these side effects disappear when treatment ends if hormone therapy involves drugs and not removal of the testicles. However, either form of treatment can result in a higher long-term risk for osteoporosis.

Risks and side effects
Since the cancer is not being actively treated, there is always the risk that it will suddenly become aggressive and more difficult to treat than if it had been addressed earlier. “Watchful waiting” is not usually considered an option for younger men or patients with fast-growing tumors.

Cryosurgery uses cold metal probes to freeze and kill cancer cells in the prostate. Incisions are made between the scrotum and anus and the probes are inserted directly into the gland. Cold gases are blown through the probes, creating tiny balls of ice that destroy the prostate and the diseased cells inside. After the procedure, the gland swells, preventing urine from leaving the bladder, so a catheter is often required for a couple of weeks until swelling subsides. Cryosurgery is only performed on men whose cancer has not spread outside the prostate.

Risks and side effects
Cryosurgery can result in temporary bruising and swelling of the penis and scrotum, as well as blood in the urine. Freezing can damage nerves and lead to impotence, incontinence and intestinal problems. Although the procedure itself is less invasive than surgery, the rate of side effects is higher and the long-term cure rate is not as well understood.

Risks and side effects
In addition to killing cancer cells, chemotherapy also destroys some of the body’s normal cells. This can result in a shortage of red blood cells, causing tiredness and exhaustion. It can also cause a decrease in white blood cells, which raises the risk of infection, as well as a shortage of blood platelets that can lead to problems with bruising and bleeding.

The drugs themselves can cause a range of side effects, including nausea and vomiting, hair loss, and mouth sores. The extent of these symptoms depends on the type of drugs used, the dosage and length of treatment. Most side effects disappear when chemotherapy ends.

Source: American Cancer Society; Cancer Research Institute