Treatment Options for Prostate Cancer
Prostate cancer is the most common cancer in American men today, and the second-leading cause of cancer-related death. The most appropriate treatment choice for prostate cancer depends on many factors, including tumor volume and stage or extent of cancer, the pathologic Gleason score, prostate specific antigen (PSA) level, and patient’s age and general health. Each treatment option offers comparable results with varying degrees of side effects. Patients are encouraged to consider both the predicted cancer control rates and side effects after each therapy when deciding a treatment choice. Certain patients may not be candidates for one or more of these treatment options. When diagnosed with prostate cancer, men should discuss all treatment options thoroughly with their physician.
At CPMC we offer a Multidisciplinary GU/Prostate Cancer Clinic providing comprehensive, individualized medical and surgical management of genitourinary (GU) and prostate cancers. Our multidisciplinary approach brings together specialists in all areas of GU and prostate cancer who collaborate on each case.
*Gleason score: Using a scale of 6 to 10. The Gleason score is a powerful tool for predicting how aggressive a tumor will be. The higher the Gleason score, the more likely the tumor is to grow rapidly and spread (metastasize) to other parts of the body.
Radiation Oncology Options
Prostate Brachytherapy involves ultrasoundguided
placement of approximately 80 to 120 radioactive seeds (iodine-125) directly into the prostate gland. Transrectal ultrasound (TRUS) guidance allows customization of the implant based on a 3D reconstruction of the patient’s exact prostate size and shape. This sophisticated prostate radiation therapy technique allows a high concentration of radiation to the prostate gland, but avoids high doses of radiation to the healthy surrounding tissues.
Brachytherapy is performed on an outpatient basis, patients are able to leave the hospital within a few hours postimplant and, in many cases, resume their normal activities within a few days. Patients typically experience a lower-than-average rate of impotence.
High-Dose-Rate (HDR) Brachytherapy usually given as a treatment prior to external beam radiotherapy, has become an accepted cancer treatment. HDR involves surgically inserted hollow plastic catheters in the cancerous organ to deliver radiation treatment at any point inside the catheter with millimeter accuracy, allowing the most accurate delivery of radiation to an organ. The HDR unit has a single radiation source of Iridium-192 welded to a long wire controlled by computer-driven motor. Patients typically receive one to 10 HDR treatments, lasting approximately 45 minutes, spaced at least six hours apart. Once the final HDR treatment is delivered, the catheters are removed and the patient is discharged home when appropriate.
External Beam Radiation Therapy uses some of the newest technologies available, 3D conformal therapy and intensity modulated radiation therapy (IMRT), to direct and shape the radiation beams, maximizing radiation dosage to the prostate, while minimizing radiation exposure to the surrounding healthy tissues.
IMRT is an advanced type of high-precision conformal radiation using computer-controlled x-ray accelerators to deliver 3D radiation beams conformed closely to the shape of the tumor. This precise targeting enables physicians to control the intensity of the radiation beam dose distribution within a given area. Multileaf collimators or beam shaping devices can be turned on or off during treatment, varying the radiation beam intensity across the targeted field.
Radiation therapy is carefully planned using 3D computed tomography (CT) with computerized dose calculations to determine the dose intensity pattern that best conforms to the tumor shape. IMRT combined with 3D CT, called inverse treatment planning, creates the custom-tailored radiation dose consisting of several hundred small beams of varying intensities that pass through normal tissue without doing significant damage, but converge to give precise doses of radiation at the tumor site.
Cone Beam CT (CBCT) improves tumor targeting using high-resolution, low-dose digital imaging in the treatment room. This allows our radiation therapists to confidently manage treatment and target tumor movement, before and during treatments. The use of kV image technology can result in lower patient radiation dose and better image quality than megavoltage imaging.
Image-Guided Radiation Therapy (IGRT) coordinates the radiation treatment plan with 3D images to enhance radiation beam accuracy on targeted tumors. The high-resolution images produced by the IGRT On-Board Imager™ enables clinicians more precise treatment delivery and planning, improving radiation beam accuracy by pinpointing tumor location with unprecedented speed. Increased precision ensures targeted accuracy, avoiding surrounding critical structures. A tighter tissue margin spares surrounding healthy tissues and allows a bigger radiation therapy dose delivery rate directly to the targeted tumor. A larger radiation dose destroys cancer cells more quickly without increasing treatment side effects.
Tumors move during radiotherapy due to biological reasons such as breathing, swallowing, and bladder filling. By combining scanning and radiation equipment to produce real-time images of the patient’s organs in treatment position at treatment time optimizes accuracy and radiotherapy precision. Using the IGRT On-Board Imager, we verify tumor location prior to each treatment and make any needed adjustments.
Surgical removal of the prostate gland has been the most common prostate cancer treatment for many decades. For men with cancer confined to the prostate gland, this procedure offers excellent cancer control rates and is well tolerated. Performed under general or spinal anesthesia, the prostate and frequently the surrounding lymph nodes, are removed using a midline incision below the belly button. A pathologist examines the prostate gland and lymph nodes to ensure all the cancer has been removed. In many cases, surgeons perform nerve-sparing prostatectomies, to preserve erectile function and continence. Modern surgical techniques reduce the length of hospitalization and recovery time compared to older techniques, but patients usually spend two-three nights.
Da Vinci Robotic Radical Prostatectomy is the latest in minimally invasive approaches to remove the prostate. Using the da Vinci robot, small "Band-Aid" incisions are made in the low abdomen through which surgical telescopes and the surgeon-controlled robotic instruments are used to perform the surgery. Many surgeons feel that the enhanced visibility and fine control of the da Vinci robot allows for a more delicate and precise operation. This is especially important when sparing nerves to maintain erectile function and minimize blood loss. The cancer cure rate is comparable to open surgery. Most patients return to their normal activity within one-three weeks.
Androgen deprivation therapy (ADP) lowers male hormone levels and can often help shrink prostate cancers or slow their growth. This treatment is a stop-gap measure when patients are not candidates for surgery or radiation therapy or can be used in conjunction with radiation treatments to try to shrink a tumor prior to treatment.
Close observation without treatment may be an appropriate therapeutic option for select patients with less aggressive, slow growing tumors, low PSA level, or men who are unsuitable for aggressive treatment.
Bryan Hemming Cancer Care Center
California Pacific Medical Center
Comprehensive Cancer Services at California Pacific Medical Center’s Bryan Hemming Cancer Care Center in San Francisco. CPMC features some of the top-rated cancer physicians and best cancer surgeons in the San Francisco Bay Area, Marin county and Northern California. We provide personalized patient care using some of the most successful cancer treatment options available.
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