Am Fam Physician. 1998;57(7):1545-1547
See related article on prostate cancer.
How does my doctor find out I have prostate cancer?
A physical exam of the rectum (the area where the prostate gland can best be felt) and a test of the level of prostate-specific antigen (also called PSA) in the blood are the usual ways to find prostate cancer. A PSA level higher than 4 ng per mL is considered suspicious. If your doctor suspects you have prostate cancer, a biopsy (a small bit of tissue) will be taken from your prostate gland. The tissue is checked by a special kind of doctor, called a pathologist, to see if you have prostate cancer.
What are the treatment choices for prostate cancer?
In general, tumors that have grown beyond the edge of the prostate can't be cured with either radiation or surgery. They can be treated with hormones that slow the cancer's growth. For tumors that are still inside the prostate, radiation therapy and a surgery called radical prostatectomy are the most common treatment options. “Watchful waiting” is also a treatment choice. In this approach, no treatment is given until the tumor gets bigger. Watchful waiting may be the best choice for an older man who has a higher risk of dying from something other than prostate cancer.
What is radical prostatectomy? What are its risks and benefits?
Radical prostatectomy is the surgical removal of the whole prostate gland and the nearby lymph nodes. After the prostate gland is taken out, a catheter (a narrow rubber tube) is put through the urethra into the bladder to carry urine out of the body until the area heals.
If you're in good health, the short-term risks of this surgery are low. The hospital stay is usually two to three days, with the catheter left in place for two weeks. You're usually able to go back to work in about one month. You shouldn't have severe pain with this surgery. Most men regain bladder control a few weeks to several months after the surgery. However, it might take as long as one year to regain bladder control. A few men never get it back completely. It can also take up to a year for sexual function to return to normal after surgery. Sometimes sexual function never gets back to normal.
The main advantage of surgery is that it offers the most certain treatment. That is, if all of the cancer is removed during surgery, you are probably cured. Also, the surgery provides accurate information about how advanced the cancer is, since the lymph nodes are taken out along with the tumor. Surgery does have risks and complications. You could lose a lot of blood during this surgery. Before the surgery, you might want to save about two units of your own blood in case you need a transfusion during the surgery. The main risks of surgery are incontinence (lack of bladder control) and impotence (loss of erections). Fortunately, less than 1 percent of men have severe incontinence after radical prostatectomy. About 20 percent of men have a little accidental leakage of urine during heavy lifting, coughing or laughing. The chance of impotence decreases if the surgeon is able to avoid cutting the nerves. This may not be possible if the tumor is large. Your age and degree of sexual function before the surgery are also important factors. If you're under 50 when you have this surgery, you're likely to regain sexual function. If you're older than 70, you're more likely to lose sexual function. Remember, even if the nerves are cut, penile feeling and orgasm remain normal. Only the ability to get a rigid penis for sexual intercourse is lost. There are medicines and devices that can help make the penis rigid.
What is radiation therapy? What are its risks and benefits?
There are two types of radiation therapy. In one type, radiation is given from a machine like an x-ray machine. In another type, radioactive pellets (called “seeds”) are injected into the prostate gland. Both types work about the same in curing prostate cancer.
The machine therapy is usually given over six weeks, which you might find time-consuming. However, you don't need any anesthesia. The side effects are milder than the side effects that can come with seed therapy. However, seed therapy can be done with just one hospital visit. You would have to have anesthesia for a few minutes, but you should be able to go home right after the treatment. In seed therapy, higher doses of radiation can be put right on the cancer. You may feel more discomfort after this treatment.
Radiation therapy has a cure rate about the same as the cure rate for surgery, but no surgical risks. There's no risk of bleeding. You don't have to stay in the hospital. You'll recover faster. Daily activities can usually go on during the treatment. Incontinence is extremely rare afterward. About one half of patients become impotent. Many men feel very tired at the end of the treatment period. About 30 percent have urinary burning, urinary bleeding, frequent urination, rectal bleeding, rectal discomfort or diarrhea during the treatment. Serious complications are rare. However, a degree of uncertainty goes along with radiation treatment. Since the prostate gland and the lymph nodes are not taken out, the doctors can't tell the exact size of the tumor. The cancer could come back many years after radiation treatment.
At 10 years after treatment, cure rates are about the same for radiation therapy and radical prostatectomy. However, surgery may give you a better chance of cure over the long term.
What is the purpose of hormone therapy?
The purpose of hormone therapy is to get the male hormone, testosterone, out of your body, because testosterone helps the prostate tumor grow. You either get monthly shots or have your testicles surgically removed. Once the testosterone is out of your body, the prostate cancer usually shrinks. Hormone treatments are most often used in patients with cancer that has already spread out of the prostate gland. While prostate cancer usually responds to one or two years of hormone therapy, after some time most tumors start to grow again. Once this happens, the treatment goal is to control symptoms. No treatment can cure prostate cancer after hormone treatment stops helping.
What are the risks and benefits of watchful waiting?
Many prostate cancers are small and grow slowly. Because many men with a slow-growing tumor have the same life expectancy as men who don't even have prostate cancer, it may not be necessary to treat very small, very slow-growing prostate tumors. In watchful waiting, you get no treatment, but you see your doctor often. If there's no sign the cancer is growing, you still get no treatment. Hormone therapy can be started if the cancer starts to grow.
It can be hard to tell if a small tumor is going to grow slowly or quickly. Your doctor will get clues from your PSA level, the biopsy tissue and the rectal exam about the way your tumor will grow, but the choice of watchful waiting is up to you.
Who can I contact for more information about prostate cancer?
Your family doctor, your cancer doctor, the radiotherapist and your urologist can give you information. Your local hospital or cancer center may refer you to a local prostate cancer support group, where you can meet other men who have had this cancer. The organizations listed below can also give you information before you make your decision about prostate cancer treatment:
Prostate Health Council/American Foundation for Urologic Disease
1128 N. Charles St.
Baltimore, MD 21201
American Cancer Society
Telephone: 1-800-227-2345, or check your local telephone directory
US TOO International, Inc. (independent network of support groups)
930 N. York Rd., Suite 50
Hinsdale, IL 60521
Telephone: 1-800-808-7866 or 1-630-323-1002