Treatment Choices

Are you being presented with all of the options to treat localized prostate cancer?

Studies have indicated that men often select a treatment therapy for their prostate cancer based upon the specialty of the physician they consulted.

There are six broad categories of therapy options for treating prostate cancer.

High intensity focused ultrasound (HIFU)

Cryoablation (freezing)

Radiation (various types)

Surgery (various procedures)

Active Surveillance (AS)

Androgen Deprivation Therapy (ADT)

The first four,HIFU,Cryo,radiation,and surgery are DEFINITIVE THERAPY options for localized prostate cancer and unfortunately many urologists and prostate cancer support groups have little or no experience with all four definitive therapy options so men are usually counseled on the one or possibly two therapies that their physician is familiar with. Therefore,it behooves a man and his spouse to do their homework regarding prostate cancer treatment and mine the web for information in order to empower themselves. In this manner the patient and his partner will be better informed in deciding which therapy option they feel comfortable with.

As part of his homework,a patient should always have his prostate biopsy slides forwarded to a reference laboratory for validation. This is because there is considerable subjectivity involved in reading the slides leading to a lack of concordance between many pathologists and therefore concern for the true status of your prostate and cancer.

If the VALIDATED pathology report concurs with the original,you should consider the following:

a) the usual 12 core office prostate biopsy has about 70% accuracy.

b) if your biopsy report indicates only a small amount of cancer,less than 1% (termed a microfocus) you should simply choose active surveillance as should those men whose reports show only high grade prostatic intraepithelial neoplasia (HGPIN) and or atypical small acinar proliferation (ASAP). Monitoring during active surveillance is done with digital rectal exams (DRE) of the prostate,PSA,%free PSA,PCa3 and prostate biopsies at a later date.

c) if your validated prostate biopsy report indicates more than a microfocus of prostate cancer,note the number of positive needle cores and the volume of prostate cancer within the cores as well as the Gleason score. If there is a high amount of tumor volume and or high Gleason grade at the base or apex of the prostate,consider having the margins of the prostate at the base and apex biopsied to ensure that the margins are free and that the cancer is localized to the prostate and suitable for a definitive treatment.

d) with the results of your imaging studies (CAT scan and Bone scan),PSA,Gleason score and number of positive needle cores you can categorize your pretreatment risk assessment into Low,Intermediate and High risk. Also, you should factor in your age and general health when considering a treatment option for your prostate cancer.

Definitive treatment options,HIFU,cryo,radiation and surgery are generally reserved for men in the Low ( PSA<10,Gleason < or equal to 6) to Intermediate ( PSA 10-20,Gleason 7) Risk groups as their prostate cancer is more likely to be localized to the prostate.

Men in the High Risk category (men with a PSA >20 and or Gleason 8-10) may be better off with a radiation option as these men are likely to have cancer cells outside the prostate and therefore a cancer not localized to the prostate.

All men with localized prostate cancer may be treated with any one of the four definitive treatment options of Hifu,cryo,radiation or surgery as in the appropriately selected patient,these four treatment options for localized prostate cancer have SIMILAR SURVIVAL BENEFITS.

If the survival benefits for localized prostate cancer with these four treatment options are similar,what other factors can we examine in order to separate these four definitive therapy options and make an informed choice for treatment of localized prostate cancer?

I recommend that the patient and his spouse examine the various complications associated with each of the four definitive treatment options for localized prostate cancer and determine how these different complications can impact their quality of life (QOL). The incidence of complications is profoundly different between the four treatment options.

Because prostate cancer is one of the few diseases where the treatment complications affect not only the man but directly impact the spouse and their partnership,both man and wife should spend considerable time and effort in reviewing quality of life issues associated with the treatment option they have chosen or that has been proposed for them.

Surgical options (including robotic removal) have the highest incidence of complications and the biggest negative impact on quality of life for both the man and his partner. Since the survival benefits between the four treatment options for localized prostate cancer are similar whether the prostate is surgically removed or not, and the three non surgical options have less complications and a better quality of life,we encourage men to consider the three non surgical options of HIFU,cryo or radiation. Of these three non surgical definitive treatment options,HIFU is most precise and appears to be uniquely positioned to afford cure and with a superior QOL as well as being non radiation and accomplished in an outpatient setting.