Prostate Cancer Treatment
Prostate cancer is a problem that perhaps every man can face. To date, there are neither reliable methods of preventing this disease, nor reliable ways to find out in advance what is the risk of encountering a disaster in each case. However, doctors have already learned to recognize prostate cancer in the very early stages, as well as successfully treat tumors. Therefore, if the oncologist suggests the presence of prostate cancer - do not rush to fall into despair, because the chances of recovery are high.
Stages and features of the course of prostate cancer
The prostate gland is a small organ (the size of a ping-pong ball) located at the base of the bladder. Its main function is the synthesis of the secret, which is part of the sperm, and participation in the process of ejaculation.
Prostate cancer implies the appearance and increase in size of a tumor capable of rapid growth and metastasis (transfer of malignant cells to other organs and tissues). This disease can occur at any age, but in the vast majority of cases it is diagnosed in men over 60 years of age.
Prostate cancer is the third most common cancer among men in Russia after lung cancer and stomach cancer. It is found in one of fifteen men over 40 years old. Every year in the world, malignant prostate tumors are diagnosed in a million people, and about one in three of them die due to this pathology.
Why does prostate cancer develop? It is known that this is associated with changes in the hormonal background, genetic predisposition, malnutrition and the impact of some other factors, the role of which is still not fully established.
From the moment the first cancer cell appears to the development of symptoms that lead the man to a consultation with a doctor, usually several years pass. For this reason, often the patient is seen by an oncologist with a neglected, overgrown tumor that is difficult to cure.
In total, it is customary to distinguish four stages of prostate cancer:
- Stage 1 characterized by small tumor sizes, the absence of involvement of lymph nodes in the pathological process (cancer cells can get there with lymph flow) and the patient's well-being. As a rule, at this stage, prostate cancer is detected by chance - during the treatment of another disease of the gland. The prognosis for the life of the patient is favorable; therapy does not take much time.
- 2 stage Prostate cancer means that the neoplasm has increased in size. It can be probed - during a rectal examination (the prostate is adjacent to the front wall of the rectum, so the doctor can reach it with a finger). In this case, the symptoms of the disease are often still not manifested. Therefore, it is so important to regularly undergo a preventive examination by a urologist. About 80% of patients whose prostate cancer was diagnosed in stage 2 recover.
- 3 stage The disease is characterized by the growth of the tumor beyond the envelope of the prostate. Cancer cells are found in the lymph nodes of the pelvis and in some neighboring organs. At this point, the patient usually feels discomfort: urination is disturbed due to the deformation of the gland, pain in the perineum appears. Surgery is no longer enough to defeat a tumor, which is why oncologists often use combined tactics, combining different approaches to the destruction of cancer cells. The survival rate at this stage of prostate cancer is less than 40%.
- 4th stage implies that, in addition to the prostate, the cancer has affected distant organs or lymph nodes. Metastases can be found in bones, lungs, liver, etc. If the patient is an elderly person with severe chronic diseases, doctors will decide to abandon the operation in favor of gentle methods of therapy that will prolong the life and alleviate the suffering of the patient, although they will not help to defeat cancer .
The main factors that determine the choice of an appropriate treatment method:
- Your age and expected life expectancy,
- do you have other serious illnesses
- stage and extent of your cancer,
- Your opinion (and your doctor’s opinion) about the need for cancer treatment,
- Will the use of a topical treatment method cure cancer (or assess the benefits of this method),
- Your attitude to the side effects that are inherent in each treatment method.
It may seem to you that you should make a decision as soon as possible, but take your time, summarize and carefully study all the information. Discuss everything with your doctor. Consult a prostate cancer specialist who has studied all treatment methods well. You must weigh all the pros and cons of each treatment method, you must also think about their shortcomings, side effects and weigh all the possible risks. Only after that you should make a decision.
Signs of prostate cancer and factors provoking it
Since the disease usually begins with the peripheral parts of the prostate gland, the tumor develops painlessly and does not manifest itself for a very long time. The only way to detect it in the early stages is to get tested for the level of prostate-specific antigen. This is an enzyme that synthesizes prostate cells, and its level can increase not only with carcinoma, but also with benign prostatic hyperplasia (BPH) and chronic inflammation (prostatitis). Nevertheless, it is this screening method that the American Cancer Society recommends, stipulating that a low level of prostate-specific antigen does not guarantee the absence of malignant changes.
In Russia, digital rectal examination is used for screening, but this method (regardless of the “love” of patients for it) reveals asymptomatic prostate cancer in only 1–4% of cases.
Symptoms of the disease can be divided into 3 large groups:
- Signs of obstructed urine outflow (infravesical obstruction). These symptoms are similar to manifestations of prostate adenoma:
- weak intermittent stream of urine,
- feeling of incomplete emptying of the bladder,
- stress urinary incontinence
- imperative (sudden and irresistible) urination,
- frequent urination.
- Manifestations caused by local tumor growth:
- the appearance of blood in semen,
- the appearance of blood in the urine,
- erectile disfunction,
- pain in the perineum and suprapubic region.
- Manifestations of distant metastases:
- bone pain
- if the tumor compresses the ureter - lower back pain,
- with compression of the spinal cord - paresis of the lower extremities,
- swelling of the legs due to lymphostasis,
- causeless weight loss.
Screening tests designed to quickly identify the possibility of cancer at an early stage are not recommended for everyone, but only for men with existing risk factors, including:
- Genetic predisposition: Up to 10% of all prostate cancers are familial forms.
- Food preferences: The risk is increased in men whose diets are high in animal fats. Increases the likelihood of illness and obesity.
- Hormonal imbalance: increased levels of testosterone, dihydrotestosterone and luteinizing hormone.
- 5-alpha reductase inhibitors. This is an enzyme that transforms testosterone to dihydrotestosterone. 5-alpha reductase inhibitors (finasteride, dutasteride) are prescribed for benign prostatic hyperplasia (adenoma) to reduce organ volume.
- Negroid race.
It used to be that smoking, alcohol, chronic (especially untreated) prostatitis and a deficiency of certain vitamins also increased the risk of prostate carcinoma. Now these ideas are disproved.
Patients with existing risk factors are advised to measure the level of prostate-specific blood antigen once a year after 50 years (those with blood relatives who died from prostate cancer at a young age, after 40 years). Without risk factors, you can begin to be examined after 70 years. Regular measurement of prostate-specific antigen levels reduces the risk of death from prostate cancer by 25–31%.
Tumors T1-2Nx-0M0 (localized prostate cancer)
When choosing a method of dynamic observation (delayed treatment), the degree of differentiation of the tumor and the expected life expectancy are of primary importance. The prognosis for low-grade tumors is very poor: 10-year survival rate is 30–34%. The effect of the degree of tumor differentiation on the prognosis is confirmed by the analysis of the SEER database of the National Cancer Institute (USA). With a high, moderate, and low degree of differentiation, the risk of death from a tumor within 10 years was 8, 24, and 57%, respectively. In order not to miss tumor growth and a decrease in the degree of differentiation, some experts recommend conducting an examination every 3-6 months (ultrasound, level determination prostate-specific antigen (PSA) and biopsy), especially with a high life expectancy.
Albertsen et al. (1998) studied the effect of the degree of differentiation on prognosis using the Gleason index. The risk of death was very high at an index of 7-10, intermediate at an index of 6, and low at an index of 2-5 (Table 4-3). In addition, this study showed that with a Gleason index of about 6-10, the risk of death from a tumor constantly increases within 15 years from the start of the observation.
Table 4-3. Localized Prostate Cancer Risk of Death for 15 Years
There are relatively few publications on changes in PSA levels in the absence of treatment. It was shown that when the PSA content is less than 3 ng / ml, the tumor does not threaten life for 10 years, however, the dynamics of changes in the PSA level weakly reflects the risk of disease progression.
Thus, dynamic observation in a localized process in some cases increases the risk of progression. If life expectancy exceeds 10 years, then the risk of death from a tumor in the absence of radical treatment increases. Long-term follow-up for highly and moderately differentiated tumors confirmed a higher risk of death in patients who lived more than 15 years. A randomized trial showed a significant reduction in the risk of death during prostatectomy compared with dynamic observation.
The risk of death depends on the age at which the diagnosis was made, since possible death from concomitant diseases must be taken into account, but mortality shows how this risk would be if there were no other causes of death. According to a randomized study over 15 years, survival in patients with localized tumors (excluding PSA levels) increased with immediate hormone therapy.
Observation and Waiting Tactics
Since prostate cancer usually develops very slowly, some men (especially older men or those who have other health problems) may not need any treatment. Instead, the doctor can choose the so-called tactics of observation and waiting.
This means that the doctor will closely monitor (monitor the PSA level in the blood) for the cancer, but will not use any method of treatment, for example, surgical or radiation therapy. This can be a good solution if the cancer does not cause any complaints and may develop very slowly and is located in only one part of the prostate gland. If the patient is at a young age, does not have side diseases, and if the tumor grows very quickly, this method is rarely used.
Observation tactics are a reasonable decision if the patient has a slowly growing tumor, since it is not known for sure whether active treatment will prolong his life. Many men choose the tactics of observation, because, in their opinion, the side effects of treatment clearly exceed the possible benefits from it. However, others are prepared to tolerate possible side effects in order to overcome the cancer or reduce its development and / or symptoms.
Observation tactics do not mean that they will forget about you. On the contrary, the doctor will carefully monitor the development of cancer. Every three or six months, you will need to conduct PSA tests and palpation of the prostate, and a biopsy of the prostate will be required annually. If you have any complaints or the tumor begins to grow faster, you should discuss the possibility of active treatment. The weak point of the observation method - you can skip the moment when the cancer begins to sharply progress, and this can reduce the effectiveness of the treatment.
The diagnosis of prostate carcinoma is carried out by a urologist, who, if necessary, directs the patient to an oncologist. For the diagnosis of prostate cancer are used:
- Medical history, or a conversation with the patient, allowing to identify risk factors and characteristic complaints.
- Digital rectal examination - palpation of the prostate through the rectum. Allows you to detect a tumor with a diameter of 2 mm, provided that it is located on the side adjacent to the intestine.
- Determining the level of prostate-specific antigen. The level at which a prostate biopsy is recommended for men under 60 years old is 4 ng / ml, after 60 - 2.5 ng / ml.
- Transrectal Ultrasound (TRUS) allows not only to detect characteristic changes in the gland, but also to accurately take a biopsy of the changed area. The material obtained by biopsy is intended for histological examination - the only final way to confirm or refute prostate carcinoma.
- Ultrasound of the abdomen, CT and MRI allow to identify the prevalence of the tumor, the presence of distant metastases.
Selecting a Country for Prostate Cancer Therapy
As you know, the oncological branch of medicine is very developed in many countries of Asia and Europe. But the best choice is Israel. This is due to the high level of health care, which is controlled by the state, and at the same time relatively low prices (30-50% lower than in America and Europe).
However, organizing a trip for treatment in Israel on your own is not easy. Especially considering that you can not lose precious time. The Top Ichilov Clinic is ready to take on the entire organization of the trip: the staff themselves will purchase tickets, provide a transfer, offer convenient accommodation options, including near the clinic, arrange consultations and examinations, and help throughout the treatment. And it’s possible to go to Israel for treatment as soon as possible after contacting the “Top Ichilov”.
Another advantage of the clinic is the availability of modern high-tech equipment and, as a result, the high accuracy of cancer diagnosis. Top Ichilov’s specialists, including professors, presidents and board members of professional associations in Europe and the USA, are attentive to each patient and are ready to continue the accompaniment after completing the course of treatment. The team of specialists "Top Ikhilov" has doctors of various profiles who have achieved high results in their field.
The degrees and stages of prostate cancer
Diagnosis allows you to determine the stage of the tumor and the degree of malignancy.
Grade of malignancy according to the WHO scale characterizes the aggressiveness of the tumor. The less differentiated the tumor (the more its cells differ from the norm), the more actively it grows and earlier metastases. In total, 4 degrees of malignancy are distinguished:
- G1 - a high degree of differentiation of cells,
- G2 - moderate
- G3 - low
- G4 is an undifferentiated tumor.
Tumor Stage describes the volume of the neoplasm, the defeat of the lymph nodes and the presence of distant metastases. To do this, use the TNM system, where:
- T is the size of the original node,
- N - lymph node involvement,
- M - the presence of distant metastases.
More familiar to the average person 4 stages of cancer in the description of prostate carcinoma are composed of stages by TNM and tumor grade. At the same time, the 1st stage involves a clinically undetectable tumor with a volume of not more than 5% of the gland of the first degree of malignancy in intact (intact, uninvolved) lymph nodes. At the 2nd stage, the neoplasm still does not extend beyond the prostate, at the 3rd stage it grows outside the capsule of the gland. Germination of neighboring organs and tissues, or damage to lymph nodes, or the appearance of distant metastases means the 4th stage of prostate cancer, when it is impossible to remove the neoplasm at the same time.
Prostate Cancer Treatment: Official Medicine Methods
Clinical guidelines for the treatment of prostate cancer offer the following methods:
- radiation therapy,
- hormone therapy
- minimally invasive methods: cryoablation and ultrasound ablation - are experimental and do not yet have a long (over 10 years) observation period.
The choice of technique or combination of methods depends on the stage of the tumor and the condition of the patient.
Surgery. Radical prostatectomy - that is, removal of the prostate, seminal vesicles and part of the urethra - is the method of choice for localized prostate cancer (the tumor is limited to an organ capsule). The operation allows you to completely remove the neoplasm. Either traditional open access is used, or less traumatic - laparoscopic, including one of its options - robot-assisted radical prostatectomy, which is becoming more popular. It allows you to reduce the amount of blood loss, and in the recovery period after a robot-assisted intervention, urinary incontinence and erectile dysfunction are less common.
Radiation therapy. It is used for locally advanced cancer, when the tumor has gone beyond the capsule of the organ, but does not yet have distant metastases. It can be remote when the radiation source is outside the body (the method of choice), and interstitial, when the radioactive source is implanted directly into the gland tissue. Sometimes both methods of radiation therapy are combined.
Hormone therapyor androgen deprivation. Most often used as part of combination antitumor therapy. As an independent treatment, it is used only with palliative goals - to improve the quality of life. Since testosterone stimulates tumor growth in order to slow it down, you need to reduce the level of this hormone in the cells of the prostate. There are two ways to achieve this goal: to reduce the synthesis of hormones by the testes or to block their production at the level of regulatory mechanisms. Possible methods of hormone therapy:
- Bilateral orchidectomy (testicular removal). It allows you to quickly reduce the concentration of testosterone (by 95% during the first 12 hours after surgery). The method is considered the "gold standard."
- Medical castration. Prescribe drugs (agonists or antagonists, releasing factors of the luteinizing hormone - LHRH), which act on the hypothalamus - the part of the brain that "conducts" all the endocrine glands. Under the influence of these agents, the hypothalamus ceases to secrete substances that stimulate the synthesis of androgens by the testes.
Antiandrogens (substances that block the effects of male hormones) and estrogens (female sex hormones) can be prescribed as additional therapy.
Chemotherapy used only for metastatic prostate cancer and only as part of combination therapy (most often in combination with hormone therapy plus chemotherapy).
In some men, due to age or related health problems, treatment can lead to complications and side effects that are more serious than problems caused by the cancer itself. In such cases, the doctor may adhere to active observation. Such tactics are possible in the following cases:
- The patient does not experience symptoms.
- The tumor is projected to grow slowly.
- The tumor is small.
- Cancer does not spread beyond the prostate gland.
The tactics of active observation involves examinations by a doctor and blood tests for prostate-specific antigen every six months. Once a year, a doctor may prescribe a prostate biopsy.
The following methods of radical prostatectomy are available.
- Radical prostatectomy with access above the pubic bone
Most surgeons choose this method. The incision is made in the lower abdomen. The patient is under general anesthesia (euthanized) or he has been given medications that make the lower body insensitive (epidural anesthesia) and sedatives.
First, the doctor removes the lymph nodes near the prostate and sends them to the laboratory, where they are examined under a microscope. If cancer cells are found in one of the lymph nodes, this means that the cancer has already spread beyond the prostate gland. Since surgery can no longer cure cancer, the doctor may decide not to continue the operation.
The nerve, which is responsible for erection, is very close to the prostate gland. Sometimes during the operation it is possible to maintain this nerve (this is called the method that spares the nerve). This reduces, but does not completely reject, the possibility of impotence (inability to achieve an erection) after surgery. If you still have the ability to have an erection before surgery, your doctor may try to preserve this nerve. Of course, if the cancer has already touched this nerve, then the doctor must remove it. Even if you manage to maintain the nerve, it may take many months after the operation before your ability to erect is restored. This is due to the fact that during the operation, the nerve is still slightly affected, and for some time it is not able to function normally.
- Perineal Radical Prostatectomy
During this operation, the surgeon makes an incision in the perineum - in the space between the anus and scrotum. This method does not allow you to remove the lymph nodes and save the nerve. Since this operation requires less time than the above, it can be performed in men who do not need to preserve the nerve or in those who have other health problems, because of which it is difficult to transfer the operation of the first type.
The operation with access to the pubic bone lasts from about one and a half to four hours. Perineal surgery requires less time. After the operation, it is necessary to spend about three days in the hospital; you can get to work in about three to five weeks.
Usually, after surgery, a tube (catheter) is inserted through the penis to urinate. This is done while you are still under general anesthesia. The catheter remains in the bladder for one to three weeks and during the cure period will help urine to drain. After removing the catheter, you can lower your urine yourself.
- Laparoscopic radical prostatectomy
Both of the above methods of surgical intervention are “open” methods, since the doctor makes a longitudinal incision in the skin to remove the prostate. The latest technology allows the surgeon to make only small incisions and use special long instruments to remove the prostate. This is called laparoscopic radical prostatectomy, and this method is being used more and more often.
Advantages of laparoscopic surgery: slight bleeding, less pain, short hospital stay, short postoperative period. With laparoscopic surgery, you can save the nerve that is responsible for erection, this operation can cause the same side effects associated with nerve damage, as well as the operation of the "open" type.
- Transurethral resection of the prostate
Transurethral resection of the prostate is performed in order to reduce problems (for example, problems with urination) in men whose other operations are contraindicated. This method does not cure or completely remove the entire tumor. This method of surgery is usually chosen to alleviate the problems of patients with benign prostatic adenoma.
During the operation, a special instrument is inserted into the urethra through the penis, at the end of which there is a wire loop. This wire is heated, and with it, that part of the prostate gland that presses on the urethra is removed. With this operation, large incisions are not made on the skin. During surgery, spinal anesthesia is used (the lower body, starting at the waist, becomes insensitive) or general anesthesia (anesthesia).
The operation lasts approximately one hour. Typically, the patient is discharged from the hospital within one to two days after surgery, you can go to work after about one to two weeks. After surgery, a tube (catheter) must be inserted into the urethra for urination, which remains there for two to three days. Some time after surgery, a slight admixture of blood may appear in the urine.
Integrative medicine approaches to the treatment of prostate cancer
Clinical guidelines and guidelines describe Western medicine approaches. But in the countries of the East, where their own traditions are strong, an integrative approach is widespread, when several specialists work with one patient, using both the approaches of official medicine and traditional methods. The ratio of traditional and modern methods of treatment varies in different countries: if in China the main emphasis is on eastern methods, then in South Korea the leading role is played by the western approach, but they use as auxiliary methods:
A successful combination of Western and Eastern techniques improves the effect of treatment. In particular, that is why there are so many patients from Western countries in South Korea: the quality of the medical services provided and the drugs used for treatment are under the control of the government. And the largest and most serious centers, such as Quims, are equipped with high-tech robotic devices for the treatment of cancer. For example, Rapid Arc system with radiation therapy technology with the possibility of visual control and others.
Of course, not all eastern, including Korean, clinics are the same. As in our country, a lot depends on the qualifications and experience of the staff, the level of equipment of the clinic. Therefore, before making the final choice, you need to know about the medical institution as much as possible.
Surgical treatment of prostate cancer
In prostate cancer, radical prostatectomy is performed - an operation during which the prostate gland and surrounding tissues, including seminal vesicles, are removed.
Radical prostatectomy can be performed in various ways:
- Postpartum prostatectomy performed through a longitudinal section from the navel to the pubis. Usually the patient is discharged from the clinic a few days after surgery, the recovery period lasts several weeks.
- With perineal prostatectomy make an arcuate incision between the scrotum and anus. This operation is faster compared to the posterolateral prostatectomy, but during it access to the lymph nodes is difficult, and it often leads to problems with erection.
- Laparoscopic prostatectomy performed using special tools through punctures in the abdominal wall. It is accompanied by less bleeding and less tissue trauma compared to open interventions, and the recovery period is shortened. But the risk of complications is about the same.
- Robotic prostatectomy conducted using the da Vinci robot. In fact, this is the same laparoscopic intervention, but the surgeon does not hold the instruments himself, but controls the movements of the robot through a special remote control. Thanks to this, the movements of the instruments are more accurate. But there is no evidence that this helps reduce the risk of complications.
Possible complications after radical removal of the prostate: urinary incontinence, erectile dysfunction, slight shortening of the penis, inguinal hernia, infertility, lymphedema (edema due to removal of the lymph nodes).
Risks and side effects of radical prostatectomy
Any prostate cancer surgery can have different risks and side effects.
This surgery may have the same surgical risk as any other surgery. Problems with anesthesia, a slight risk of a heart attack, stroke, blood clots in the legs, infection and bleeding may occur. What complications you can expect depends on your age and the general state of your health.
The most significant adverse events after radical prostatectomy are urinary incontinence (incontinence) and inability to achieve an erection (impotence). But the same side effects can cause other methods of treatment.
Urinary incontinence Urinary incontinence means that you cannot control the leakage of urine or you constantly have a small flow of urine. There are different types of urinary incontinence. If you have such a problem, then it can affect both your physical and emotional state.
- Stress incontinence is the most common type of urinary incontinence after prostate surgery. In men with stress incontinence, urine leakage can occur when coughing, exercising, laughing or sneezing.
- Incontinence with a crowded bladder - in this case, men urinate for a long time, urine flows in a weak stream and for a long time.
- Urgent incontinence or overactive bladder is a sudden and unstoppable need to empty the bladder, having no way to control this process. The need to empty urine depends on the volume of urine in the bladder.
In rare cases, a man may lose all ability to control bladder function. This is called persistent incontinence.
In most men, the ability to fully control bladder function is restored within a few weeks or months after surgery. The doctor cannot anticipate your body's reaction to surgery.
If you have urinary incontinence, tell your doctor. Your doctor should get information about your problems and help you solve them. There are special exercises that help strengthen the muscles of the bladder. Urinary incontinence can be prevented with medication or surgery. There are also many hygiene products that will make you feel dry and comfortable.
Impotence - the inability of a man to achieve a sufficiently strong erection for sexual intercourse. During surgery or radiation therapy, nerves that are responsible for erection can be damaged. Within 3 to 12 months after the operation, you may have problems with an erection, and you cannot achieve it without the help of medications. In most boughs, this ability is later restored, but in some men this problem may persist longer. The ability to erection is also associated with the age and type of surgery you have performed.Men at a young age are more likely to recover.
If you are concerned about possible erectile dysfunction, discuss this with your doctor. There may be ways to help you. There are various medications and devices, for example, vacuum pumps or penile implants.
Sterility During radical prostatectomy, the ducts that connect the testicles (which produce sperm) to the urethra are cut. This means that a man cannot become a father naturally. This usually does not matter much, since prostate cancer develops in older men. But if it matters to you, before the operation, discuss with your doctor the opportunity to donate your sperm to a “sperm bank”.
Lymphedema If the lymph nodes located next to the prostate gland are removed during surgery, lymphedema (increased accumulation of lymph) can occur, it causes burning and pain. Lymph nodes provide the flow of excess fluid from the organs of the body back to the heart. After removal of the lymph nodes, excess fluid can accumulate in the legs and in the genital area. Most often, lymphedema is treated with physiotherapy, but it may not completely disappear.
Penis length changes Another side effect of the operation is that the penis may contract.
Which medical center can I go to?
We asked an expert at MEDUNION to tell you which medical center you can go to treat prostate cancer:
“Domestic medicine is still free. Shareware: if you don’t have the opportunity to wait for months for a line of high-tech examination, you will have to pay. But if there is an opportunity to pay for the speed and level of treatment, it is better to contact one of the hospitals in South Korea. In this country, the development of medicine is one of the state priorities, and most clinics are equipped to the latest standards. We recommend Quims Hospital, one of the largest accredited multidisciplinary centers of integrative medicine. The hospital is among the ten best clinics in South Korea. The medical center is located at Gyeonggi University, famous for its faculty of traditional Korean medicine. The clinic has 30 departments of various profiles, equipped with the most modern equipment. More than half a million patients undergo treatment at the center annually. The Coordination Center combines the efforts of specialists in the field of oriental medicine and doctors who have the latest developments in cancer treatment.
MEDUNION can help organize treatment in South Korea and make your stay in this country as comfortable as possible for the patient. The company’s representative office in Seoul has coordinators and translators who support patients throughout their stay in the clinic. The trip is organized for free: treatment and diagnostics are paid directly at the cash desk of the hospital. ”
Issuance number T902-277-5545-596 Business registration 206-31-696010
License No. T902-277-5545-596, Registration Certificate No. 206-31-696010
Radical Prostatectomy (RPE) - removal of the prostate gland and seminal vesicles by the posterolateral or perineal access. Laparoscopic and robot-assisted laparoscopic prostatectomy is becoming increasingly common. The use of minimally invasive methods of prostatectomy allows you to activate the patient earlier and reduce the period of hospitalization.
RPE was first performed in 1866, and at the beginning of the XX century. when performing it, perineal access was applied. Lateral access was later proposed. In 1982, the anatomy of the venous plexus and neurovascular bundles of the prostate gland was described, which significantly reduced blood loss, the risk of impotence and urinary incontinence.
Prostatectomy - the only treatment method that showed in a randomized trial a decrease in the risk of death from a tumor compared with dynamic observation. Its main advantage is the possibility of a complete cure for the underlying disease. When performed by an experienced doctor, the operation is associated with a minimal risk of complications and gives a high chance of recovery. However, it should be borne in mind that RPE is a complex operation with a very long “learning curve”.
Postpartum access is used more often, since it allows you to remove the pelvic lymph nodes. Given the anatomical features of the fascial cover of the gland (thinning in the anterior sections), with perineal access, the possibility of maintaining tumor cells in the resection zone is great. Probably, with perineal prostatectomy and laparoscopic lymphadenectomy, complications occur less frequently than with operations with posterolateral access. In recent years, some European centers have mastered laparoscopic prostatectomy. Despite the fact that data on long-term results have not yet been obtained, this method is gaining popularity. Advantages and disadvantages of the post-RPM RPE are shown in table. 4-4.
Table 4-4. Advantages and disadvantages of post-pulmonary radical prostatectomy
With a localized tumor and an expected life expectancy of about 10 years or more, the goal of the operation (regardless of access) should be a cure. In case of refusal of treatment, the risk of death from an underlying disease within 10 years is 85%. The patient’s age cannot be an absolute contraindication to surgery, however, with an increase in age, the number of concomitant diseases increases, so after 70 years the risk of death directly from localized prostate cancer is markedly reduced.
An important problem is the preservation of potency after surgery. The task of the urologist is to assess the degree of risk and the need to preserve the neurovascular bundles responsible for erectile function. Nerve-saving surgery is indicated for a limited number of patients who satisfy the following requirements before surgery: initially preserved potency and libido, low oncological risk (PSA level less than 10 ng / ml, Gleason index - more than 6). Otherwise, the risk of local recurrence is high. At high oncological risk, such patients are shown postoperative remote radiation therapy, therefore, preservation of the neurovascular bundles is impractical.
To resume sexual activity after surgery, it is possible to use type 5 phosphodiesterase inhibitors (sildenafil, tadalafil), the use of intracavernous injections (alprostadil), vacuum erectors. With a complete loss of function, prosthetics of the penis is possible. If the patient insists on the preservation of the neurovascular bundles, it is necessary to inform him about the timing of the restoration of potency (6-36 months), the risk of developing Peyronie's disease with incomplete rigidity of the penis and the possibility of complete loss of erectile function.
Radiation therapy for prostate cancer
Radiation therapy may be prescribed as an alternative to surgical treatment. In terms of effectiveness, it is often not inferior to surgery. Other indications:
- In combination with hormone therapy for cancer that has spread beyond the prostate gland.
- With a relapse of cancer.
- As a palliative treatment in the later stages. This helps inhibit tumor growth and increase the patient's lifespan.
In prostate cancer, two types of radiation therapy are used: external and internal (brachytherapy). External exposure is of various types:
- Three-dimensional conformal radiation therapy uses computer technology to determine the exact location of the prostate and tumor. This helps reduce damage to surrounding healthy tissue.
- Intensively Modulated Radiation Therapy - A more advanced form of 3D conformal radiation therapy. The device not only irradiates the tumor at different angles, but also regulates the radiation intensity. This allows you to apply an even larger dose to the prostate, avoiding irradiation of healthy tissues.
- Stereotactic therapy uses modern technology to deliver the entire dose of radiation to where the cancer is located. It allows you to reduce the course of radiation therapy, as a result, it lasts days instead of weeks.
With brachytherapy, a small granule, which is the source of radiation, is placed directly in the prostate gland. This treatment is used in men with early-stage prostate cancer, which is slowly growing. In the later stages, brachytherapy is sometimes used in combination with external radiation therapy.
On the eve of the operation, fluid intake is limited; in the morning before the operation, a cleansing enema is performed. 1 hour before the operation, a single administration of antibiotics is indicated (fluoroquinolones or cephalosporins of the 3rd-4th generation). The operation can be performed under epidural anesthesia or endotracheal anesthesia. A prerequisite is compression bandaging of the lower extremities for the prevention of thromboembolic complications.
The main stages of the recessed RPE:
- Pelvic lymphadenectomy.
- Dissection of the pelvic fascia.
- Intersection of the pubic-prostatic ligaments (possible after flashing dorsal venous complex - DVK).
- Flashing, ligation and intersection of the DCK.
- The intersection of the urethra.
- Isolation of the prostate gland, seminal vesicles and vas deferens.
- Cutting off the prostate from the bladder.
- Reconstruction of the neck of the bladder.
- An anastomosis between the bladder and the urethra.
- Drainage of the perivascular space.
The duration of the operation is 2-3 hours. Patients are activated the day after the operation. Drainage is removed as wound discharge decreases (less than 10 ml). The urethral catheter is removed on the 8-12th day. To restore full retention of urine, Kegel gymnastics is recommended. In the early postoperative period, in case of instillation of urine, absorbent pads are used. PSA level control is carried out every 3 months after surgery.
Chemotherapy for prostate cancer
Chemotherapy is not the main treatment for prostate cancer, but it can sometimes be useful. Chemotherapy is prescribed in combination with hormonal drugs or in cases where hormone therapy does not work.
In prostate cancer, drugs are used: docetaxel, cabazitaxel, mitoxantrone, estramustine.
Morphological study of a macrodrug
A full-fledged study of an organ removed during radical prostatectomy requires a large number of blocks, which leads to significant economic costs. However, non-observance of the research protocol significantly complicates the specification of the stage of the disease and the solution of the question of tactics for further treatment. The description of the macrodrug should contain the following information: description of the removed organ or tissue, weight (g), dimensions (cm) and number of samples, description of the tumor node (localization, size, type, edge). In the histological conclusion, it is necessary to indicate: the histological type, the degree of Gleason differentiation, the degree of tumor spread, lymphatic and venous invasion, damage to the seminal vesicles and lymph nodes.
Extraprostatic distribution - germination of the tumor in the adjacent non-gum tissue. Criteria for the spread of prostate cancer per capsule of the gland are based on the detection of components that form the extraorganic tumor focus: tumor cells in adipose tissue, anterior muscle group, carcinoma in the perineural spaces of the neurovascular bundles. The extent of the lesion (has important prognostic value) can be focal (several foci of the tumor outside the prostate gland) and diffuse (all other cases).
Removal of seminal vesicles, despite the data of a preoperative examination, is carried out in full, which is associated with the mechanism of tumor spread. It can occur by direct germination upward, into the complex of seminal vesicles, by spreading from the base of the gland or surrounding adipose tissue, isolated in the form of a single metastasis without communication with the primary focus.
External radiation is similar to an ordinary x-ray, but it lasts much longer. Each exposure session lasts only a few minutes. Usually outpatient in the period from seven to nine weeks spend five sessions per week. The treatment itself is quick and painless.
At present, external irradiation is chosen much less frequently than before. The latest technology allows the doctor to more successfully treat the prostate gland itself without exposing the surrounding healthy tissue to radiation. These methods can improve the effectiveness of treatment and reduce side effects.
Hormone therapy for prostate cancer
It is known that male sex hormones - androgens - stimulate the growth of prostate cancer. The goal of hormone therapy is to lower the level of androgens in the body or to prevent their interaction with cancer cells.
Hormone therapy stops the growth of the tumor for a while. As a monotherapy, she is not able to cure. Indications for her appointment:
- The presence of contraindications for surgical treatment and radiation therapy.
- Common prostate cancer when surgery and radiation therapy are ineffective.
- In aggressive tumors, when the risk of relapse is high, hormone therapy is prescribed along with radiation therapy.
- It can also be prescribed before radiation therapy to inhibit tumor growth and improve treatment outcomes.
The treatment for prostate cancer is constantly being improved. More recently, as a result of a large study, the negative effects of hormone replacement therapy have been shown to patients with a recurring process and low PSA levels. Doctors at the European Clinic closely monitor such changes and offer their patients only treatment that meets modern standards.
T1a-2c tumors (localized prostate cancer)
The most commonly diagnosed tumor is T1c. In each case, it is difficult to predict the clinical significance of the tumor. According to most studies, T1c tumors usually require treatment, since about a third of them are locally distributed. The proportion of clinically insignificant tumors is 11-16%. With an increase in the number of biopsy samples, this indicator may increase, although taking 12 biopsy samples usually does not increase it.
Prostatic dysplasia is not considered an indication for treatment, but after 5 years, cancer is found in 30% of patients with severe dysplasia, and after 10 years - in 80%. Mild dysplasia is also dangerous: the risk of cancer during subsequent biopsies is comparable to that for severe dysplasia. However, in the absence of cancer, radical prostatectomy is not recommended, as dysplasia may be reversible.
It is important to determine which T1c tumors can avoid prostatectomy. The biopsy data and the level of free PSA make it possible to predict the significance of the tumor; Partin nomograms can be of great help. Some doctors prefer to focus on the results of a biopsy: if cancer is detected in only one or a single biopsy specimen and occupies a small part of the biopsy specimen, the tumor is most likely not clinically significant (especially with a low Gleason index). In some such cases, dynamic observation is warranted. However, usually with T1c tumors, prostatectomy should be recommended, since most of these tumors are clinically significant.
Radical prostatectomy - One of the standard methods for the treatment of T2 tumors with an expected life expectancy of more than 10 years.If in a morphological study the tumor is limited to the prostate, the prognosis is favorable even with a low degree of differentiation (although usually such tumors extend beyond the gland). With a high degree of differentiation, dynamic observation is also possible, but remember that a biopsy often underestimates the Gleason index.
T2 tumors tend to progress. Without treatment, the median time to progression is 6-10 years. Even with T2a tumors, the risk of progression for 5 years is 35–55%, therefore, with an expected lifespan of about 10 years or more, prostatectomy is indicated. With T2b tumors, the risk of progression exceeds 70%. The need for surgery is confirmed by comparing prostatectomy with follow-up (most patients in this study had T2 tumors).
In relatively young patients, prostatectomy is the optimal treatment method, however, in elderly patients with severe concomitant diseases, it is better to use radiation therapy. The experience of the surgeon and adherence to the technique of surgery can improve the results of surgical treatment of prostate cancer.
Possible side effects of external exposure
Possible side effects of external exposure are the same as when irradiating other organs. Using the latest treatment methods, the risk of side effects is also reduced.
- Disorders of the intestines. In the period of external exposure, as well as some time after the treatment, you may have diarrhea, an admixture of blood in the feces, fecal incontinence (it is very rare) and irritation of the colon. Most of these problems disappear over time, but in some cases, after the end of therapy, bowel function does not return to normal.
- Bladder problems. It may be necessary to lower urine more often, pain during urination and a slight admixture of blood in the urine may appear. Bladder functioning problems occur in one in three patients. Most often, there is a need to often lower urine.
- Urinary incontinence. Urinary incontinence means that you cannot control the functioning of the bladder or you are leaking urine. In the case of radiation therapy, urinary incontinence is much less common than after surgical treatment. For more information on urinary incontinence, see the section on side effects of surgery.
- Impotence. Impotence means that you have problems with an erection, and you may have problems in your personal life. After radiation therapy, impotence is as common as after surgical treatment. Usually it does not appear immediately during therapy, but builds up gradually over several years. The same process is observed after surgical therapy. If you are in old age, it is more likely that you will have problems with an erection. These problems can be solved with the help of medications and various devices (see the section on surgical therapy).
- Fatigue. Radiation therapy can cause fatigue and weakness. This can last even several months after the end of radiation therapy.
- Lymphedema. Accumulation of excess fluid in the legs or genitals (see the section on side effects of surgical therapy) can occur if the lymph nodes die during radiation therapy.
Stage 4 Prostate Cancer Treatment
In stage IV, prostate cancer spreads to the bladder, rectum, lymph nodes, distant metastases appear in the bones and various organs. But even at this stage, depending on the prevalence of the process, remission can sometimes be achieved. In cases when the cancer is incurable, palliative treatment will help to restrain its growth for a while and prolong the patient's life.
Typically, treatment for stage 4 prostate cancer includes the following:
- Hormone therapy, in some cases, in combination with chemotherapy.
- Surgery. If the cancer has not spread to the lymph nodes and there are no metastases removed, a radical prostatectomy can be performed. Other times for fighting
- with symptoms resort to palliative intervention - transurethral resection of the prostate (TURP).
- If the patient is contraindicated in all types of treatment, and he has no pronounced symptoms, active observation is possible.
Internal exposure (brachytherapy)
For brachytherapy with a low dose of radiation, radioactive microcapsules are used (each about the size of a grain of rice), which are injected into the prostate. These capsules are also called "grains." Since they are very small, they do not cause discomfort, and after treatment they are often left in the prostate.
In practice, short-term brachytherapy or high-dose brachytherapy are also used. In this case, needles are used with which soft tubes (catheters) are inserted. For 15 minutes, material with strong radioactive radiation is introduced into these tubes, then it is removed. During this treatment, you must stay in the hospital. Usually, three treatment sessions are carried out over several days. After the last session, the catheters are removed. This type of therapy is often combined with external exposure, in which the radiation dose is lower than when only external exposure is used. A few weeks after the course of treatment, you may feel pain in the area between the testicles and the anus, the urine may be brown-red.
T3 Tumors (locally advanced prostate cancer)
The proportion of locally advanced tumors is currently gradually decreasing (before there were at least 50%), but the optimal tactics in detecting them still causes discussion. Prostatectomy often does not completely remove the tumor, which dramatically increases the risk of local relapse. In addition, surgical complications with prostatectomy occur more often than with localized tumors. Most patients have metastases to the lymph nodes and distant metastases. Thus, surgery for T3 tumors is usually not recommended.
A combination of hormone therapy and radiation is increasingly being used, although it has not been proven that such tactics are better than performing a prostatectomy. A randomized trial showed the benefit of combination treatment over isolated radiation therapy, but there was no surgical control group in this study. Evaluation of the results of prostatectomy is also complicated by the frequent administration of concomitant adjuvant radiation therapy and immediate or delayed hormone therapy.
About 15% of tumors clinically regarded as T3 turned out to be localized (pT2) during surgery, and only 8% were common (pT4). In the first case, the prognosis is favorable, but in the majority of patients with pT3b tumors, early relapses were noted.
Relapse-free survival for 5 years (zero PSA level) in T3 tumors is about 20%. The prognosis depends on the Gleason index. A histological examination of the removed prostate often reveals moderately and low-differentiated cells. In addition to the degree of cell differentiation, other independent adverse prognosis factors include invasion of seminal vesicles, metastasis to the lymph nodes, detection of tumor cells in the resection margin, and a high level of prostate-specific antigen (more than 25 ng / ml).
With T3a tumors and PSA levels of less than 10 ng / ml, 5-year relapse-free survival usually exceeds 60%. Thus, the operation can help not only those patients in whom the clinical stage was overestimated, but also with true T3a. The operation is ineffective in patients with metastases to the lymph nodes and invasion of seminal vesicles. Partin nomograms are used to detect this data. In addition, it helps to assess the condition of the lymph nodes and seminal vesicles. Magnetic resonance imaging (MRI).
Surgery for T3 tumors requires a highly qualified surgeon, which reduces the risk of complications and improves functional results.
Treatment of metastases of prostate cancer in the bone
If bone metastases are detected, hormone therapy, radiation therapy, chemotherapy are prescribed. In addition, in the treatment of bone metastases in prostate cancer, bisphosphonates (drugs that slow bone destruction), denosumab (the same effect as bisphosphonates, but a different mechanism of action), drugs of the adrenal cortex hormones (reduce pain), painkillers are used.
Possible risks and side effects of internal exposure
The microcapsules introduced inside your prostate within a few weeks produce a small amount of radioactive radiation. Although this radiation is far from spreading, you should avoid contact with pregnant women and children during these weeks. You should be cautioned in other situations, for example, during intercourse you should use a condom.
About a week after the introduction of the microcapsules, you may feel pain in this area, the urine may be brown-red. There is a risk that some capsules may extend beyond the prostate, but this is very rare. Also, as with external exposure, problems may occur in the functioning of the intestines and bladder and problems of potency. If you have any problems, tell your doctor. In most cases, you can be helped with medication or other means.
Lymphadenectomy can not be performed at low cancer risk, but its implementation allows you to more accurately establish the stage of the disease and detect micrometastasis. Lymph node metastases are precursors of distant metastases. After surgery, relapse usually occurs in such patients. The significance of the study of freshly frozen sections of the lymph nodes (frozen-section) during the operation is not clearly defined, but most urologists strive to perform advanced lymphadenectomy, refuse prostatectomy with a pronounced increase in lymph nodes (usually these are disseminated tumors that are only subject to hormone therapy) and stop the operation if an urgent histological examination revealed metastasis.
It has been observed that a routine examination of distant lymph nodes can help detect micrometastases. With single metastases to the lymph nodes or micrometastases, the risk of relapse is lower. In the case of metastases to the remote lymph nodes, adjuvant hormone therapy is possible, but since it is associated with side effects, you can sometimes limit yourself to observation, postponing hormone therapy until the PSA level rises.
Some surgeons always perform advanced pelvic lymphadenectomy (including, in addition to the obstructive, external and internal iliac and sacral lymph nodes), but this approach requires randomized studies. In recent years, lymphadenectomy is increasingly giving not only diagnostic, but also therapeutic value.
Benefits of Prostate Cancer Treatment at the European Clinic
The main differences of the European clinic:
- We always act in the interests of the patient. When a doctor chooses treatment methods, he strives to achieve the maximum effect with minimal risks for the patient.
- In the European Clinic, a team of doctors works with the patient: a clinical oncologist, oncourologist, chemotherapist, and oncologist-radiologist.
- Prostatectomy is a serious intervention. We care about the safety of patients, therefore, before a surgical procedure, a thorough examination is carried out, the patient is consulted by a therapist, neurologist, cardiologist, resuscitation anesthetist.
- You can get a second opinion from reputable doctors from Europe, Israel, and the USA.
- We treat prostate cancer in Moscow according to international protocols, in accordance with the principles of evidence-based medicine.
In further monitoring of cancer patients, the pathological stage (RT) indicating the purity of the surgical margin, postoperative PSA level (biochemical relapse), local relapse, metastasis, cancer-specific survival, and overall survival are of great importance. The relapse-free course of the disease depends on the clinical and pathomorphological data. Independent prognostic factors include the clinical stage, Gleason gradation, and PSA level.
Additional factors: capsule sprouting (extracapsular extension), perineural and / or lymphovascular invasion, damage to lymph nodes and seminal vesicles. Long-term RPE results are presented in table. 4-5.
Table 4-5. Long-term results of radical prostatectomy
* Patients with adjuvant radiation therapy were excluded from the study (Walsh).
** Patients with adjuvant radiation therapy included in the study (Catalona).
Patient Testimonials on Prostate Cancer Treatment at the European Clinic
I have been under observation at the district clinic for many years and was ready for the fact that sooner or later I will find prostate cancer. He was with my grandfather and father. They both died not from him, but still quite alarming. So, six months ago, tumor markers did show a tumor. I chose the clinic exclusively on the Internet, compiled a list of five, in my opinion, the best, and then phoned. As a result, he stopped at the European clinic. When I arrived at the reception, it immediately became somehow calm. I was received by Avetis Agvanovich, very thoroughly and in detail explained my diagnosis, his prospects and methods of treatment. It’s immediately obvious that the specialist knows the question “perfectly”. Did some tests and procedures. They didn’t cut it yet. It may not have to. Now I am completely in control of the situation, I know for sure what is going on there, and most importantly, I know for sure that there is an excellent doctor who remembers me personally and is ready to respond at any moment. Thank you, Avetis Agvanovich, and until the next inspection! Igor A. Shch.
Hormone therapy is usually chosen in the following cases:
- in men whose surgical and radiation therapy are contraindicated,
- in men whose cancer cells have spread throughout the body, or in those who have relapsed after the initial treatment,
- in case of an increased risk of a possible cancer recurrence after therapy, this method is used together with radiation therapy,
- sometimes it is used before surgical or radiation therapy in order to reduce the size of the tumor.
Since almost all types of prostate tumors become insensitive to hormone therapy over time, they choose this method of treatment when hormonal drugs are used for a while, then they take a break, and then hormone therapy is continued again after a while (this is called intermittent treatment). This helps to avoid some side effects (impotence, deprivation of interest in sexual life, etc.).
The overall level of complications after a post-ciliary radical prostatectomy (with sufficient experience of the surgeon) is less than 10%. Among the early complications, bleeding, damage to the rectum, ureters, obturator nerves, anastomotic failure, vesicoureteal fistula, thromboembolic complications, pathology of the cardiovascular system, ascending urinary infection, lymphocele, and postoperative wound failure are possible. Late complications include erectile dysfunction, urinary incontinence, urethral stricture or anastomosis, inguinal hernias (Table 4-6).
Table 4-6. Complications of Radical Prostatectomy
Careful observance of indications for surgical intervention reduces the risk of postoperative mortality to 0.5%. Typically, the amount of blood loss does not exceed 1 liter.An infrequent, but severe complication is considered damage to the ureter. With a minor defect, wound closure and drainage by a catheter (stent) are possible. With more extensive injuries or crossing the ureter, ureterocystoneostomy is indicated. A minor rectal defect can also be sutured with a two-row suture after anus deviation. Anus preater naturalis is applied in cases of severe defect or previous radiation therapy.
The function of urine retention is restored faster than erectile. About half of the patients immediately after surgery retain urine, while the rest recover within a year. The duration and severity of urinary incontinence directly depends on the age of the patient. 95% of patients under the age of 50 are able to retain urine almost immediately, and 85% of patients over the age of 75 suffer from incontinence of varying severity. With total urinary incontinence, the establishment of an artificial sphincter is indicated. Erectile dysfunction (impotence) previously occurred in almost all patients.
In the early stages, it is possible to perform an operation to preserve the cavernous nerves, however, it increases the risk of local recurrence and is not recommended for low-grade tumors, invasion of the apex of the prostate gland and for palpable tumors. One-sided preservation of the cavernous nerve also gives good results. Injections of alprostadil into the cavernous bodies in the early postoperative period help to reduce the risk of impotence.
Types of hormone therapy
There are many types of hormone therapy, including surgery or medications that lower blood testosterone or block the body’s response to androgens.
- Testicular removal. Although the removal of the testicles is a surgical operation, hormonal changes occur as a result of it. During the operation, the surgeon removes the testes, which produce 90% of androgens, including testosterone. Although this operation is quite simple and cheap, the consequences are irreversible, and most men cannot put up with it. After this operation, men mostly lose interest in sexuality and they can no longer achieve an erection.
- Luteinizing releasing hormone analogue (LHRH analogue). These medications lower testosterone levels as well as testicular removal. The LHRH analog (or agonist) is injected once a month or once every 4, 6 or 12 months. Although this treatment is more expensive, and more often than when removing the testicles, you need to visit a doctor, men still most often choose this method. After the first dose of the LHRH analogue is administered, the testosterone level rises sharply for a short time, but then decreases. This is called the flash effect. If the cancer cells have spread to the bones, then during this “outbreak” the bones may hurt. To reduce the effect of the “outbreak” several weeks before the therapy of the LHRH analogue, it is necessary to take medications - antiandrogens.
- Antagonists of LHRH. These medications significantly lower testosterone levels and do not cause a “flash” effect. However, in some men, this medication causes an allergic reaction. Therefore, it is prescribed only to those men who can not use other types of hormone therapy. The medicine is injected only in the doctor’s office. In the first month, the medication is administered every two weeks, then every four weeks. You should stay in the doctor’s office for about 30 minutes so that the doctor can make sure that you do not have an allergic reaction.
- Antiandrogens. These medicines block the action of androgens in the body. After an operation to remove the testicles, or during LHRH therapy, a small amount of androgen is produced by the adrenal gland. Antiandrogens can be used together with LHRH analogues or after removal of the testicles, then this is called combined androgen blockade to completely block the production of androgens and their action in the body. So far, experts have no consensus on whether combination therapy has advantages over any of the monotherapy.
Clinical guidelines for performing radical prostatectomy
- stage T1bNx-0M0 with an expected life expectancy of more than 10 years,
- T1a tumors with a very large (over 15 years) life expectancy,
- T3a tumors with a Gleason index of more than 8 and a prostate-specific antigen level of more than 20 ng / ml.
In stage T1-2, a 3-month course of neoadjuvant therapy is not recommended. Preservation of the cavernous nerves is possible only with low oncological risk (T1c, Gleason index less than 7, PSA level less than 10 ng / ml). In stage T2a, prostatectomy with unilateral conservation of the cavernous nerve is possible. The feasibility of prostatectomy with a high risk of distant metastasis, with metastasis to the lymph nodes, as well as in combination with long-term hormone therapy and adjuvant radiation therapy is not well understood.
Side effects of hormone therapy
Since the hormonal level of the body changes, all means and methods - removal of the testicles, analogues and antagonists of LHRH - cause similar side effects. It could be:
- decreased sex drive,
- impotence (erectile problems),
- hot flashes (over time this phenomenon decreases or disappears completely),
- breast tenderness and growth
- decrease in bone mass (osteoporosis), which with prolonged life can lead to bone fractures,
- low red blood cell count (anemia),
- memory impairment
- muscle mass reduction,
- weight gain
- severe weakness and fatigue,
- high blood cholesterol,
The risk of high blood pressure, diabetes and heart attack also increases.
Most side effects can be prevented or treated. For example, by applying certain antidepressants, hot flashes disappear. A short course of radiation therapy for the breast prevents its enlargement. Medicines are available to prevent and treat osteoporosis. Depression is treated with antidepressants or psychotherapy. Adequate physical activity helps prevent some side effects (including rapid fatigue, weight gain) and reduces muscle and bone mass loss. If anemia occurs, it is usually mild and does not cause any problems.
Neoadjuvant hormone therapy
Prostate cancer - androgen-dependent tumor, so neoadjuvant hormone therapy is of great interest. An attempt to reduce the size of the tumor using an orchiectomy before prostatectomy was first described as far back as 1944. With T2-T3 tumors, hormone therapy can reduce the size of the tumor and lower the PSA level.
Neoadjuvant hormone therapy showed a significant decrease in the frequency of detection of tumor cells in the resection margin compared to that after operations with the previous short (1.5–4 month) course of hormone therapy; the relapse-free survival is the same in both cases. However, large studies evaluating overall survival were not performed.
According to some reports, hormone therapy somewhat complicates the surgical allowance, although it does not increase the time of surgery, blood loss and the need for blood transfusion. The hopes for a high efficiency of longer hormone therapy are also not justified: an 8-month course did not show advantages over a 3-month course of treatment. Further studies are needed to develop neoadjuvant hormone therapy regimens (and possibly chemotherapy) for localized and locally advanced tumors. Currently, it is impossible to recommend it as a standard preparation for prostatectomy.
Hormone therapy discussions
Many questions regarding hormone replacement therapy have not yet been fully resolved, for example, when is the best time to start and end hormone replacement therapy. Research is still ongoing in this area. If you are offered to start hormone therapy, ask your doctor to familiarize you with the process of hormone therapy and possible side effects.
Side effects of chemotherapy
Although chemotherapeutic drugs kill cancer cells, they can damage normal cells, and this causes various complications. The types of side effects depend on the medication, dose and duration of treatment. When applying the main treatment regimen, observe:
- peripheral neuropathy
- hair loss,
- nausea and vomiting (rarely)
- loss of appetite (rarely).
Since normal cells are damaged, your blood cell count may decrease. This causes the following problems:
- increased risk of infectious diseases (due to reduced white blood cell count),
- the possibility of bleeding or bruising even after minor injuries and scars (due to a reduced platelet count),
- rapid fatigue (due to a reduced number of red blood cells).
After treatment, most side effects disappear. If you experience any side effects, discuss with your doctor how to prevent them. There are many ways to deal with side effects. For example, medications are available to reduce nausea and prevent vomiting. Other medicines can increase the number of blood cells.
Fighting pain and other symptoms
This material focuses on the destruction and weakening of tumor cells or methods by which their development can be slowed down. But the main goal of treatment is to improve the quality of human life. Inform your doctor or nurse about the pain and any other problems that you encounter. They can be prevented in many ways. With the right treatment, you will feel better and you will be able to pay attention to more important things in your life.
Pain Relief Medicines
Painkillers are very effective. When using medications to reduce pain caused by cancer, you don’t have to worry about their harmfulness or addiction. Drowsiness or itching may appear at first, but then they disappear. Constipation may occur, but there are different methods to prevent it. Side effects can often be prevented by changing the medication or adding another medication.
Biophosphonates are a group of medicines to reduce bone pain. In men who are prescribed hormone therapy, these medications slow down the development of the tumor and increase bone mass.
Biophosphonates can cause side effects, such as flu-like symptoms or bone pain. In very rare cases, these medications can cause the opposite effect and affect bone tissue.
Which of these methods is the most suitable for me?
If you have prostate cancer, you need to weigh many aspects before choosing a treatment method, namely, your age, general health, purpose of treatment, and your attitude to side effects. For example, some men cannot even imagine that they will have to put up with urinary incontinence or impotence. However, others are not concerned about possible side effects because they want to completely free themselves from cancer cells.
If you are 70 years old or older and you already have health problems, you can take prostate cancer as another chronic disease. Perhaps it does not affect the duration of your life. But cancer can cause problems that you wish to avoid. In this case, the goal of treatment is to reduce symptoms and avoid side effects caused by the medicine. Therefore, you can choose the tactics of observation or hormone therapy. Of course, when choosing treatment tactics, age should not be a decisive factor. Many men over the age of 70 will have a fairly good physical and spiritual condition, but young men sometimes have serious health problems.
If you are relatively young, it is possible that for a greater likelihood of complete healing, you will be ready to endure the side effects of treatment. In the early stages of prostate cancer, choosing external radiation, or radical prostatectomy or radioactive implants, the probability of cure is the same in all cases. But each situation is unique in its own way, and different factors can affect it.