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Prostate Cancer (cont.)

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What are the treatment options for prostate cancer?

Treatment options for prostate cancer are many, and while this is an advantage in that prostate cancer is such a common disease in men, it can also be a cause of great confusion. The following overview presents some information about these options, but it is not a complete explanation of any of these. You can find more information on treatment options in the NCCN Clinical Practice Guideline for Patients on Prostate Cancer for 2016 and the Physician Data Query (PDQ) website of the National Cancer Institute.

Conventional medical treatment options for prostate cancer include the following:

  • Observation
  • Active surveillance
  • Surgery (radical prostatectomy: open, laparoscopic, robotic, perineal)
  • Radiation therapy (external beam therapy and brachytherapy
  • Focal therapy, including cryotherapy
  • Hormonal therapy
  • Chemotherapy
  • Immunotherapy/Vaccine and other targeted therapies
  • Bone-directed therapy (Bisphosphonates and denosumab)
  • Radiopharmaceuticals (radioactive substances used as drugs)
  • Research techniques including high-intensity focused ultrasound (HIFU) and others

Observation and active surveillance

These two options are not the same. Both observation and active surveillance therapies share in common the decision up front to hold on treatment of the cancer and to follow the cancer periodically to determine if there is progression. Observation involves monitoring the course of the prostate cancer with the goal of treating the cancer with palliative care for the development of symptoms or changes in physical examination or PSA that suggest that symptoms will develop soon. Observation treatment is not trying to cure the cancer, rather to treat symptoms of cancer progression. Thus, observation treatment is preferred for men with low risk prostate cancer and with a life expectancy of less than 10 years.

Active surveillance involves actively monitoring the course of the prostate cancer with the intent to intervene, with the intention to cure if the cancer appears to be progressing. Active surveillance is preferred for men with very low risk prostate cancer and a life expectancy of < 20 years. Cancer progression may have occurred if a repeat biopsy shows a high Gleason score (Gleason 4 or 5) or if cancer is found in a greater number of the biopsies of greater extent of the core compared to prior biopsy.

The NCCN guidelines for prostate cancer (as of March 2016) note the following for active surveillance for prostate cancer:

  1. The PSA test should be obtained no more than every six months unless clinical changes support more frequent testing.
  2. A DRE should be performed no more than every 12 months unless clinical changes support more frequent examination.
  3. A repeat prostate biopsy should be done within six months if the initial biopsy removed less than 10 cores or the examination findings were not consistent with the biopsy results.
  4. A repeat biopsy should be considered as frequently as every year to assess for progression of the cancer.
  5. If one's life expectancy is less than 10 years, then repeat biopsy is not needed.
  6. If the PSA is rising and biopsy is negative, consider multiparametric MRI.

Active surveillance has advantages and disadvantages: From an advantage standpoint, it avoids unnecessary treatment and avoidance of possible side effects of such treatments. Disadvantages of active surveillance include the risk of missed opportunity for cure, although the risk of this is very low if you are followed regularly, and the need for periodic prostate biopsies and the side effects of prostate biopsy.

Observation has advantages and disadvantages: From an advantage standpoint, observation avoids/delays the possible side effects of treatment. There is, however, the risk of troubles urinating (urinary retention) or bone fractures occurring before treatment is started.

Medically Reviewed by a Doctor on 11/9/2016

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