Issues to Consider

This section summarizes key points to consider when you’ve been diagnosed with early-stage prostate cancer. The list is by no means exhaustive, and there might be other points that you want to think about as well. The goal is to help you focus on what you need to know about each stage of disease so you can hold meaningful, regular dialogues with all members of your health care team as you find the treatment path that’s right for you.

1. The Gleason grading scale runs from 1 to 5, where 1 represents cells that are very nearly normal, and 5 represents cells that don’t look or act much like normal prostate cells at all. The Gleason score, or sum of the two most common Gleason grades (and therefore on a scale from 2 to 10), tends to predict the aggressiveness of the disease and how it will behave in your body. Tumors with higher Gleason scores, typically above 7, tend to be more aggressive.
2. The PSA level that you had before you were diagnosed with prostate cancer, known as your pre-diagnostic PSA, is often used as an indicator of how advanced your cancer was before it was detected. Usually, the higher the PSA, the more aggressive the disease. Also, the more rapidly the PSA has risen in the year prior to diagnosis and treatment, the more aggressive the disease.
3. Nomograms are simplified charts that have been specially constructed to weigh different contributing factors and to provide a single assessment of the likelihood of remaining disease-free after treatment. They can play an important role in helping to decide whether to undergo additional treatments or whether to enroll in clinical trials assessing new therapeutic regimens or agents. One useful (there are many) nomogram webpage is found through Memorial Sloan Kettering Cancer Center: http://www.mskcc.org/mskcc/html/10088.cfm.
4. Active surveillance might be appropriate for men who, for one reason or another, have decided not to undergo immediate surgery or radiation therapy based on his age, risk with surgery, and prostate cancer risk group. For example, immediate treatment might not make sense for men who have very slow growing or very early cancers, or in men who have a limited life expectancy (<10 years), while men who have other serious medical conditions might not be healthy enough to undergo surgery or radiation therapy.
5. During prostatectomy, the prostate and nearby seminal vesicles are removed. If performed laparoscopically or robotically, a few small incisions are made and blood loss is typically minimized. However, the procedure is technically difficult and the learning curve is steep. Surgical skill and practice with this approach is key. Ask your doctor about their surgical volume and years of experience. Currently there is little data to claim that robotic procedures offer advantages over the more traditional open radical prostatectomy, and in either case, it depends on experience.
6. If you decide on surgery, the decision on whether to attempt a nerve-sparing procedure should be yours—only you can know how important it is to maintain your erectile function. But ultimately the decision on whether to perform the nerve-sparing procedure is up to the surgeon based on his or her years of experience and expert clinical judgment. If the surgeon does not feel that he or she can cure your cancer and leave the nerves intact, the nerves will not be spared.
7. The goal of radiation therapy is to kill the prostate cancer cells where they live. To accomplish this, very high doses of x-rays are delivered to the prostate, concentrated on the small clusters of tumor cells that comprise the cancer within the prostate gland. Ask your radiation doctor about the dose of radiation, how many fractions will be given, and whether testosterone lowering therapy is needed to make the radiation work better. There are different forms of external radiation, including intensity modulated radiation therapy (IMRT) and proton beam therapy. Currently there is little data to suggest that proton beam therapy offers a real advantage over more traditional radiation. Technology is improving constantly, with the addition of special markers to track the prostate in real time during the radiation therapy, 3-dimensional CT scan planning to guide the radiation dose, and hormonal therapies which can increase the chances for some men that radiation will cure them. The decision to use hormonal therapy with radiation is based on your overall health and prostate cancer risk. Some men will get 6 months of testosterone lowering therapy, and some men will get several years of this additional therapy. Typically hormonal therapies are started before radiation, continued during radiation, and completed after radiation.
8. The most common type of radiation therapy is external beam radiotherapy. Radiation oncologists and technicians use CT scans and MRIs to map out the location of the tumor cells, and x-rays are targeted to those areas. With brachytherapy, tiny metal pellets containing radioactive iodine or palladium are inserted into the prostate. Over the course of several months, the seeds give off radiation to the immediate surrounding area, killing the prostate cancer cells.
9. A number of studies have shown that the use of neoadjuvant (before and during radiation) hormone therapy can shrink larger tumors, thereby making it easier for oncologists to localize the radiation needed to kill the tumor cells, and significantly improving outcomes. This approach is now used in many institutions for men with high-grade or bulky cancers and you should ask your doctor if this is indicated for you (see above).
10. The three most significant clinical factors used to determine which initial therapy might be best are the extent of your tumor, your overall health, and your age. Psychological factors can also play an important role: only you can know how you want to deal with your disease and whether the potential side effects of one treatment outweigh those of another.
11. Technique plays an important role in determining whether urinary control and function will be maintained after surgery, and sparing the urinary sphincter is key. But pre-surgical urinary function can play an important role as well. If you’ve already experienced some hesitation and/or lack of bladder control, it will be harder for you to regain full control and function.
12. During prostatectomy, damage to the rectum is rare, and the bowel changes seen in the first few weeks following surgery are more likely the result of the body adjusting to the increased abdominal space with the loss of the prostate. Radiation therapy, however, can cause significant damage to the rectum, resulting in diarrhea or frequent stools; fecal incontinence or the inability to control bowel movements; and/or rectal bleeding. Much depends on practitioner skill, so be sure to select a doctor who possesses the experience and skill to spare the rectal tissue as much as possible.
13. Regardless of whether the nerves were spared during surgery or whether the most precise dose planning was used during radiation therapy, nearly all men will experience some erectile dysfunction for the first few months after treatment. However, within one to two years after treatment, nearly all men with intact nerves will see a substantial improvement. However, some men never quite recover the sexual function that they had prior to surgery or radiation, and require assistance with pills, shots, or implants for successful sexual intercourse.
14. Despite the best efforts of surgeons and radiation oncologists, it is nearly impossible for a man to retain his ability to father children through sexual intercourse after undergoing localized treatment for prostate cancer. For men who wish to father children after surgery or radiation therapy, the best chance for fertility is sperm banking; after thawing the frozen semen, up to 50% of sperm will regenerate and can be used for artificial insemination.
15. Dietary and lifestyle changes should be an important part of every man’s battle with prostate cancer, complementing any drug therapy, surgery, and/or radiation treatment that you might undergo. Eating healthier foods, avoiding smoking, prevention of obesity, and exercising more will help keep your body strong to help fight off your disease.