The long-term picture

taken from Small Gland, Big Problem 4th Edition
by Professor Roger Kirby, Health Press 2011

Long-term studies provide information on the prospects of men who have undergone these procedures. While many men want this kind of information, it is important not to take the figures given here too much to heart without discussing your own individual circumstances with your urologist. Progress in medicine means that patients’ long-term prospects are improving all the time, and in due course the results of ongoing clinical studies will resolve many controversies.

Active surveillance

The likelihood that your cancer will spread depends, as has already been said, on the nature of your cancer (that is, how aggressive it is). For men whose cancer has a low Gleason score (i.e. well-differentiated tumours), the 10-year survival rate is 87%, which means that, after 10 years, 87 men in 100 will not have died from prostate cancer. With more aggressive cancers (those with higher Gleason scores), the survival rate drops considerably (the 10-year survival rate for men with poorly differentiated tumours has been put at 26%). Active surveillance is often a good option to start with as more active treatment can always be instituted if signs of cancer progression develop. However, careful follow-up and regular testing are essential.

Outcomes from radical prostatectomy

More than 80% of men who have this operation are alive 10 years afterwards, and 60% are still alive at 15 years. An important Scandinavian study compared the long-term outcomes of men who chose active surveillance with those treated by radical prostatectomy. The results suggest that radical prostatectomy is the treatment option most likely to offer a complete cure for younger men with higher-risk tumours, as it physically removes both the cancer and the entire prostate from the body, making recurrence and spread to the bones much less likely. Another study published recently also showed a definite survival advantage in patients treated with surgery after 8 years of follow-up.

Results from a study by Pound and colleagues confirm that 82% of men undergoing radical prostatectomy at Johns Hopkins Hospital in Baltimore (USA) were free of recurrence at 15 years (as determined by PSA measurement). The study also offers some comfort to those men whose PSA level rises years after the operation. As we have already said, after a radical prostatectomy, your PSA level drops to an undetectable level and, if it starts rising again, it can signal cancer recurrence. The data from the study in question indicate that, though this is the case, the cancer spreads in only around one-third of men with an elevated PSA. Furthermore, unless a man had a particularly aggressive cancer (in which case his PSA level would tend to rise relatively quickly after the operation), the spreading cancer would not become life-threatening for several years, and would likely be amenable to treatment with radiotherapy or LHRH analogues (see page 58).

Outcomes from radiotherapy

At best, the survival rates with radiotherapy are comparable with those associated with radical prostatectomy. Several published studies have put the 15-year survival rates at 40–60% (that is, in a group of 100 men, between 40 and 60 will still be alive after 15 years). Recent data suggest that the ongoing use of LHRH injections or anti-androgens to shrink the prostate ahead of radiotherapy can increase the likelihood that treatment will be successful (see page 60). The risk of serious side effects with radiotherapy is decreasing as improved technology means that the cancer-destroying rays can be targeted more accurately at the cancer, leaving adjacent structures, such as the rectum, undamaged. Proponents of brachytherapy also report improving results as techniques and patient selection are enhanced. However, problems with potency are still frequently encountered after radiotherapy and, in fact, are much more common when this treatment is combined with hormone therapy.

A sequential rise in PSA after either external-beam radiotherapy or brachytherapy does suggest that recurrence has occurred. Although salvage surgery is technically feasible in some cases, it is often difficult and associated with a high complication rate. Sometimes, cryosurgery or high-intensity focused ultrasound (HIFU) can be used to destroy the residual cancer (see the following section), but more commonly hormone therapy is used.

The pros and cons of radical prostatectomy versus radiotherapy
Radical prostatectomy Radiotherapy / brachytherapy

Pros

  • Offers a cure for tumours confined to the prostate
  • Can now be carried out by keyhole surgery with robotic assistance
  • Allows the doctor to stage your tumour accurately
  • Coexisting BPH is treated
  • Your PSA level should become undetectably low
  • You are likely to feel reassured about your condition after the operation
  • Monitoring for cancer reappearance is easy
  • Radiotherapy can be given afterwards if the cancer returns

Cons

  • Major surgery
  • Small risk of severe bleeding associated with operation
  • Success/side effects depend on the skill of the urologist
  • Possible side effects (see text)

Pros

  • Offers a potential cure
  • Avoids prolonged catheterization and surgery
  • Given on an outpatient or short-stay basis
  • Hormone therapy can increase the chance of success

Cons

  • Treatment is prolonged (6 weeks in external-beam radiotherapy)
  • It is relatively difficult to assess whether the treatment has been successful
  • Accurate staging is not possible
  • Coexisting BPH is untreated
  • You may feel more concerned about the possible chance of success afterwards
  • Your PSA level may not drop to very low levels
  • Repeat radiation treatment is not possible
  • Surgery after radiotherapy carries greater risks and is only suitable for a very few selected cases
  • Possible side effects (see text)
radical prostatectomy
Radical prostatectomy is most likely to offer a better long-term outcome in terms of survival compared with active surveillance

Experimental options

Newer treatments such as cryotherapy and HIFU may become useful but are currently only available as part of a clinical trial.

Cryotherapy

Cryotherapy uses freezing to destroy the prostatic tissue. An ultrasound probe in the rectum enables the position of the prostate to be seen on a computer screen. A number of ‘cryogenic’ probes are then inserted into the prostate, and liquid nitrogen is circulated to reduce the temperature to around –180ºC. At this temperature, the tissue surrounding the probes is destroyed. The urethra is protected by circulating warm water through a catheter. Some studies have reported survival rates similar to those achieved with radical prostatectomy, but others have described rectal and urethral damage, which can be difficult to repair. No long-term randomized controlled trials to compare cryotherapy with established treatments have yet been carried out. Currently, it is mainly used as a treatment for prostate cancer that has recurred after radiotherapy, since other treatment options in that situation are limited and the technique does offer potential cure. Some surgeons are, however, starting to use it as a primary treatment for patients with locally advanced cancers who wish to avoid radiotherapy. Cryotherapy is technically demanding so it is important that the team treating you has wide experience of this procedure.

liquid nitrogen
Liquid nitrogen is circulated through the cryogenic probes producing ‘ice balls’, which destroy the prostatic tissue

High-intensity focused ultrasound (HIFU)

HIFU is a technology that allows ultrasound waves to be focused on prostate cancer cells. It involves the insertion of an ultrasound probe into the rectum under anaesthesia and then the destruction of the cancer cells by ultrasound energy; the treatment can take up to 3 hours. It can be used to treat both newly diagnosed cancers and recurrences after radiotherapy. Currently it is possible to have this treatment only as part of a clinical trial; it is not yet accepted by the National Institute for Health and Clinical Excellence (NICE) for general use in the NHS. Initial results look encouraging, since the PSA levels seem to decline and side effects are not prominent, although a catheter is required for several days and sometimes longer after treatment because the prostate swells in response to therapy.

Damage to the bladder and rectum have been described as a result of HIFU, as well as incontinence, so you should ensure your surgical team has extensive experience with this technique if you are offered this as an option. Much longer-term follow-up and trials comparing it with surgery and radiotherapy will be required before HIFU can be regarded as a mainstream treatment, but early results are positive. ‘Focal’ treatment, when only half the prostate is treated by ultrasound, is possible – and may preserve potency – but again longer-term follow-up is necessary before this is accepted as a standard therapy.

hifu probe
hifu
The HIFU probe is inserted into the rectum so that ultrasound waves can be focused on the cancer cells in the prostate. The results of treatment look promising so far in terms of the length of time before the cancer recurs
Case study

Douglas, a 58-year-old banker, with an uncle and a father who had both suffered from prostate cancer, went to his GP complaining of the need to get out of bed several times at night to pass urine. A PSA test was requested which came back elevated at 7.8 ng/mL. He was referred to his local urology department and underwent a biopsy of the prostate, the results of which revealed Gleason grade 4 + 3 = 7 prostate cancer on the left side of the gland. An MRI scan showed no evidence of disease outside the prostate.

He researched his treatment options on the internet and discussed his case with various helplines. He was attracted to both high-intensity focused ultrasound (HIFU) and brachytherapy as he was nervous about surgery. Further investigations confirmed that his prostate was enlarged and that he was not emptying his bladder properly, and so he followed the advice of his urologist and underwent open radical prostatectomy.

He made a rapid recovery and, on removal of the catheter, was able to pass urine with an improved flow and was completely continent. Examination of the tissue removed confirmed a 2-cm tumour on the left that had been completely removed. Currently, his PSA is undetectable and he is able to function sexually with the help of sildenafil (Viagra).