Treatment options for Prostate Cancer

What is Prostate? 

The prostate is a small gland present in the male body and plays an important role in reproduction. This walnut-sized gland is located between the bladder and the penis, and in front of the rectum. Urine generated by the kidneys is drained out of the body through a thin tube called the urethra. From the bladder, the urethra passes through the center of the prostate gland, before it reaches the penis.

The prostate secretes a fluid that provides nourishment to the sperm. During ejaculation, the prostate expels this fluid into the urethra. The vasa deferentia is a pair of tubes that bring sperm from the testes to a pair of glands called seminal vesicles. The seminal vesicles also contribute fluid, and drain the same through ejaculatory ducts that connect to the urethra. During ejaculation, both fluids come out of the penis as semen that contains sperm.

Like every other part of the body, the prostate too is vulnerable to cancer. According to various cancer registries, nearly 10 people for every 1 lakh males in India develop prostate cancer. That is why, it’s important to know about the condition and treatment for the same.

There are a wide range of treatment options available today.  Once prostate cancer is confirmed, a urologist or endocrinologist at a reputed hospital will consider the best course of treatment, in consultation with the patient. Parameters that will be considered are – the patient’s age, how advanced is the cancer (stage 1/2/3/4), how aggressive is the cancer, and benefits vs side-effects of each type of treatment. The last point is important as every treatment has its own side-effects.

Treatment for Prostate Cancer

There are multiple options classified under 5 headings:

1. First line of treatment
2. Surgery
3. Radiation
4. Focal therapies
5. Systemic treatments

First line of treatment

Active surveillance: Prostate cancer treatment has side effects that affect the person’s sex life. That is why, its preferable to defer the treatment especially when the cancer is low-risk and can be easily treated with surgery or radiation. In such cases, the cancer’s progress is actively surveilled by doctors from time to time and only when the condition starts deteriorating, will treatment be provided.

Watchful waiting: This is adopted for older adults with major health issues other than the prostate cancer. Instead of subjecting the elder to repeated tests and biopsies, active surveillance is done, both for the prostate cancer and the other health issues. Depending on how the 2 are progressing, at some point of time, the doctors may decide to treat the prostate cancer. Or even leave it as it is.

Surgery options

Radical (open) prostatectomy: In this, the prostate, the seminal vesicles and sometimes the lymph nodes in the pelvic area are surgically removed. The side-effects are reduced sexual function and urinary incontinence. Drugs, penile implants and injections can help overcome the sexual dysfunction while another surgery can help overcome the urinary incontinence.

Robotic or laparoscopic prostatectomy: Compared to the above procedure, this is a minimally invasive one. An endoscope fitted with surgical instruments and camera at the end are threaded through the body in position, to remove the prostate and seminal vesicles. There is less trauma and bleeding compared to open surgery, however the side effects are similar.

Bilateral orchiectomy: In this procedure, both the testicles are surgically removed.

Transurethral resection of the prostate (TURP): Another endoscopic procedure. Here the endoscope and surgical attachments help cut out cancerous tissues of the prostate while leaving the healthy tissue in place.

Radiation options

External-beam radiation therapy: Some people with low-risk or early-stage prostate cancer may need or prefer treatment instead of active surveillance. So also, some patients may not want the lymph nodes to be affected in order to maintain a healthy sexual function. Such people can go in for this option. Here, an external X-ray machine radiates X-rays to the prostate area, either in low-intensity bursts over several sessions or high-intensity bursts over a few sessions.

Brachytherapy: Compared to the previous option, here, the X-ray source is inside the body. Small beads of radioactive material, called seeds are inserted into the body in close proximity to the cancerous part of the prostate. These may be of low intensity which is left inside the body for a year nearly, or of high-intensity in which case its inserted into the body for 30-minute durations over several sessions. Generally, this treatment option is used along with another option.

Intensity-modulated radiation therapy (IMRT): Similar to the external beam radiation treatment but this achieves better precision by using a CT scan to create a series of accurate pictures of the cancer. Once the size and exact location of the cancer is understood, radiation can be focused to the precise spot in the precise intensity. This ensures the surrounding tissues are not damaged.

Proton therapy: Again, similar to the external beam radiation treatment but here instead of X-ray, high-energy proton beams are irradiated on the spot of the cancer.

Focal therapies

Cryosurgery / Cryotherapy / Cryo-ablation: A relatively newer option, so its efficacy and side-effects are not well-known. Here the cancerous cells in the prostate are frozen to render them inactive and prevent them from spreading. This is achieved by inserting a metal rod in the space between the rectum and scrotum to access the cancerous part and quickly cooling the area.

High-intensity focused ultrasound (HIFU): Similar to the above option but here ultrasound waves are used to heat up and destroy the cancerous tissue. There are many dependencies to this option so it’s not widely preferred.

Systemic Treatments

Hormonal therapy: The growth of prostate cancer tissues is fueled by the presence of male hormones or androgens in the body, especially testosterone. So lowering testosterone levels will delay the growth of the cancer. This is achieved by surgically removing the testicles (surgical castration), turning off the function of testicles through drugs (medical castration), inhibiting the production of testosterone by the body or inhibiting the functioning of testosterone (androgen axis inhibitors). There are various techniques and drugs available in this option.

Targeted therapy: In addition to androgens, other factors that fuel the growth of prostate cancer are specific genes, specific proteins and the tissue environment that promotes cancerous growth. So these parameters are targeted bio-chemically in order to slow down the cancer growth. This is achieved through drugs such as olaparib and rucaparib.

Chemotherapy: One of the common treatment options for cancers. As the name implies, here, chemicals are used to prevent the cancer cells from multiplying, dividing, growing and spreading.

Immunotherapy: Here, various drugs and vaccines are given to boost the body’s immune system so that it can successfully fight the cancer cells and destroy them eventually.

Radiation therapy by infusion: When the prostate cancer has spread to the nearby bones, quick action must be taken to destroy the cancer in the bone. This is achieved by intravenously injecting a radioactive substance like Radium-223 directly into the cancerous part of the bone. This destroys the cancerous tissue while leaving healthy tissue such as bone marrow unharmed.

Bone-modifying drugs: Hormonal therapy given to delay the growth of prostate cancer can affect bone-health causing conditions such as osteopenia and osteoporosis. To reverse or slow down this development or to reduce the damage, bone-modifying drugs are given.

 

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