LOCALISED PROSTATE CANCER

What are the treatment options for localised cancer?

If the cancer is localised in the prostate gland, the three forms of treatment available are:

• surgery (radical prostatectomy);
• radiation therapy;
• observation only (watchful waiting).

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What does surgery (radical prostatectomy) involve?

Surgery for prostate cancer involves the removal of the whole of the prostate gland through a cut in the abdomen, called radical or open prostatectomy. The prostate and the part of the urethra within the prostate gland are removed, and the resulting gap is closed by joining the bladder to the urethra.

A hospital stay of between 3-7 days and a recovery period of up to 6 weeks is usually needed after a radical prostatectomy procedure. Immediately after the surgery, a thin tube or catheter will be present in the urethra running from the bladder through the tip of the penis to help empty the bladder during recovery. At what stage this catheter is removed will depend upon the advice from the doctor. Some degree of incontinence happens in many men when the catheter is removed because bladder muscles will have been disturbed during surgery.

Approximately 90% of men with localised cancer live for at least ten years after treatment and for 75% of men, the cancer does not return during this time . Based on these results, this surgery is recognised as being able to cure prostate cancer.

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What are the risks of radical prostatectomy?

There are risks associated with this operation. As with any open surgical procedure, there is the risk of bleeding during the operation, infection of the open wound and deep venous thrombosis where blood clots may form in the calves. These can lead to lung complications.

Complications with this type of surgery are common because surgery involves disturbance of the bladder neck, the external sphincter muscles (or on/off flow control) and the nerves surrounding the prostate gland which are responsible for erectile function.

• Less than 5% of men will have ongoing urinary incontinence after prostatectomy surgery. Many men will experience incontinence when the catheter is first removed but often this is mild and will rapidly improve. However, in up to 30% of men, moderate incontinence remains that will need pads for exertion.
• Approximately 75–85% of men will have erectile dysfunction (impotence). The nerves that are important for transmitting signals to the erectile tissue in the penis run close to the prostate gland and can be damaged during prostate surgery. The patients age and preoperative erectile function also affect the chance of recovery. A number of treatments are available for men to help restore erectile function following prostate surgery.
  
  More information: Erectile dysfunction

Radical prostatectomy can now be performed using laparoscopy or telescopic “keyhole” surgery. This can be done with or without the use of robotic technology.

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What is radiation therapy?

Radiation therapy is another treatment that involves a particular dosage of radiation being applied to the prostate gland at certain time intervals to destroy cancer cells. This type of treatment may also be used in combination with surgery, particularly when there is evidence that the cancer has spread into the urethra and bladder. Radiation therapy may also be used in combination with hormone therapy.

More information: Hormone therapy

The source of the radiation can be either:

• External Beam Radiation Therapy
  External beam radiation therapy involves small doses of radiation being given over a period of up to seven weeks. This type of radiotherapy is not as stressful as surgery and may be used by older people particularly if other illnesses prevent the use of surgery. It is estimated that about 60-65% of men will remain cancer free after ten years following treatment.
• Brachytherapy
  Brachytherapy is available at a limited number of centres in Australia.  Ten year outcomes are similar to surgery for well selected cases. By placing radioactive ‘seeds’ directly into the prostate gland, a high dose of radiation can be delivered straight to the cancer cells. This procedure aims to reduce some of the side-effects experienced with conventional external beam radiation therapy, particularly to the rectum and bladder, but erectile difficulties can also be a problem with this treatment.

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What are the risks of radiation therapy?

Risks associated with radiation therapy include:

• Erectile dysfunction (impotence) which may happen in 25-80% of cases depending on the age of the patient and the patient's potency before treatment.
• Radiation damage to other tissues that are close to the prostate, such as the rectum and the bladder. The radiation damage to the bladder and rectum can result in diarrhoea and inflammation to the bladder but usually settle down quickly.

A small number of patients require future intervention for these complications.  Attempting to prevent these risks may result in under-dosing of the desired area with radiation. 

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What is 'watchful waiting'?

Some men decide to have no treatment because of the side-effects of other forms of treatment for prostate cancer. These patients prefer to take a ‘watchful waiting’ approach and wait to see if any complications from their prostate cancer start to become evident, or they may wait until the PSA rises further and then proceed with treatment.

This approach is often used for men who are 75 years or older or who may have other health related problems. This approach is based on the relatively slow growth of prostate cancer, particularly those of low grade. Unfortunately, some low grade tumours can change and start to grow and progress more rapidly, making it important to continually monitor the cancer growth. It is not known why and which low grade cancers may change and progress more rapidly.

In men deciding to take a ‘watchful waiting’ approach, the PSA test can be used to measure the progression of the disease.

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