Treatment for prostate cancer may involve active surveillance, surgery, radiation therapy including brachytherapy (prostate brachytherapy) and external beam radiation therapy, high intensity focused ultrasonography (HIFU), cryosurgery, hormonal therapy, chemotherapy, or some combination. Which choice is best depends on the stage of the disease, Gleason score, and PSA level. Other important factors are male age, general health, and his feelings about potential care and possible side effects. Because all treatments can have significant side effects, such as erectile dysfunction and urinary incontinence, treatment discussions often focus on balancing therapeutic goals with lifestyle change risks.
Selection of treatment options may be a complex decision involving many factors. For example, radical prostatectomy after primary radiation failure is a very technically challenging operation and may not be an option. This can be incorporated into the treatment decision.
If the cancer has spread beyond the prostate, treatment options change significantly, so most doctors who treat prostate cancer use various nomograms to predict the possibility of spreading. Treatment with active watchful surveillance, HIFU, external beam radiation therapy, brachytherapy, cryosurgery, and surgery are, in general, offered to men whose cancer remains in the prostate. Hormonal therapy and chemotherapy are often reserved for diseases that have spread beyond the prostate. However, there are exceptions: Radiation therapy can be used for some advanced stage tumors, and hormonal therapy is used for some early stage tumors. Cryotherapy (tumor-freezing process), hormonal therapy, and chemotherapy can also be offered if initial treatment fails and the cancer develops.
Video Management of prostate cancer
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Active surveillance is routine observation and monitoring without invasive treatment. In the context of prostate disease this usually consists of regular PSA blood tests and prostate biopsy. Active surveillance is often used when the early stages, slow-growing prostate cancer is suspected. However, waiting with caution can also be advised when the risks of surgery, radiation therapy, or hormonal therapy outweigh any possible benefits. Other treatments can be started if symptoms develop, or if there are signs that cancer growth is accelerating (eg, rapid increase in PSA, increased Gleason score on re-biopsy, etc.).
About a third of men who choose active surveillance for early-stage tumors eventually have signs of tumor progression, and they may need to start treatment within three years. Men who choose active supervision avoid surgical risks, radiation, and other treatments. The risk of disease progression and metastasis can be increased, but the increased risk appears to be small if surveillance programs are followed closely, generally including serial PSA assessment and repeat prostate biopsy every 1-2 years depending on PSA trends.
The results of the study in 2011 show active surveillance is the best option for older 'low risk' patients.
Maps Management of prostate cancer
Surgery
Prostate removal surgery, or prostatectomy, is a common good treatment for early-stage prostate cancer or for cancer that fails to respond to radiation therapy. The most common type is a radical retropubic prostatectomy, when the surgeon lifts the prostate through the abdominal incision. Another type is a radical perineal prostatectomy, when the surgeon lifts the prostate through an incision in the perineum, the skin between the scrotum and the anus. Radical prostatectomy can also be done laparoscopically, through a series of small incisions (1 cm) in the abdomen, with or without the aid of a surgical robot.
Radical prostatectomy
Radical prostatectomy is effective for tumors that have not spread beyond the prostate; the healing rate depends on risk factors such as the PSA level and the Gleason class. However, it can cause nerve damage that can significantly alter the quality of life of prostate cancer survivors.
Radical prostatectomy has traditionally been used alone when the cancer is localized to the prostate. In the case of a positive margin or advanced local disease found in pathology, adjuvant radiation therapy may offer improved survival. Surgery may also be offered when the cancer does not respond to radiation therapy. However, because radiation therapy causes tissue changes, prostatectomy after radiation has a higher risk of complications.
Laparoscopic radical prostatectomy, LRP, is a new way to approach prostate surgery with a view to healing. In contrast to open surgery from prostate cancer surgery, laparoscopic radical prostatectomy requires smaller incisions. Relying on modern technology, such as miniaturization, optical fiber, and the like, laparoscopic radical prostatectomy is a minimally invasive prostate cancer treatment but technically demanding and rarely performed in the United States.
- Robotics help Some believe that in the hands of experienced surgeons, robotic laparoscopic prostatectomy (RALP) may reduce positive surgical margins when compared with radical retropubic prostatectomy (RRP) among patients with prostate cancer according to retrospective studies. The relative risk reduction was 57.7%. For patients at the same risk as those in this study (35.5% of patients had positive surgical margins after RRP), this led to an absolute 20.5% risk reduction. 4.9 patients should be treated for one benefit (the amount needed to treat = 4.9). Other recent studies show that RALP produces a significantly higher level of positive margins. Another study showed no difference in robots to open operations. A 2009 French study comparing standard laparoscopes for robotics to open prostatectomy showed no difference in margin status or biochemical recurrence at 5 years. The relative merits of RALP and the potential benefits of open radical prostatectomy today are an area of ​​intense research and debate in urology. The only proven and accepted benefit for RALP is intraoperative blood loss. Other advantages are suggested in addition to data that are uncertain and not yet widely accepted by the wider urological community.
Transurethral rescue
Transurethral resection of the prostate, commonly called "TURP," is a surgical procedure performed when the tube from the bladder to the penis (urethra) is blocked by prostate enlargement. In general, TURP is for benign disease and is not intended as the definitive treatment for prostate cancer. During TURP, a small instrument (cystoscope) is placed into the penis and the blocking prostate is cut off.
Cryosurgery
Cryosurgery is another method of treating prostate cancer in which the prostate gland is exposed to freezing temperatures. Cryosurgery is less invasive than radical prostatectomy, and general anesthesia is less commonly used. Under ultrasound guidance, the method invented by Dr. Gary Onik, a metal rod is inserted through the perineal skin into the prostate. The highly purified argon gas is used to cool the stem, freezing the surrounding tissue at -186 ° C (-302 ° F). When the water inside the prostate cells freezes, the cells die. Urethra is protected from freezing by a catheter filled with warm liquid. Impotence occurs up to ninety percent of the time.
Scrub removal operation
In metastatic disease, where the cancer has spread beyond the prostate, removal of the testicles (called orchiectomy) can be done to lower testosterone levels and control the growth of cancer. (See hormonal therapy, below).
Operating complication
The most common serious complications of surgery are loss of urinary control and impotence. Reported rates of both complications vary widely depending on how they are assessed, by whom, and how long after surgery, as well as arrangements (eg, academic series vs community-based or population-based data). Although the sensation of the penis and the ability to achieve orgasm usually remains intact, erection and ejaculation are often impaired. Drugs such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) can restore some degree of potential. For most men with organ-limited disease, more limited "nerve-sparing" techniques can help reduce urinary incontinence and impotence.
Postoperative urinary incontinence has been reported at 16% among patients at 12 months after radical prostatectomy. Although pelvic floor muscle training has been prescribed to increase urine continuity, evidence for efficacy in men after radical prostatectomy has been a recent question. According to information from randomized controlled trials of Men After Prostate (MAPS), pelvic floor muscle training is not proven to be a therapy or cost effective in improving urine continuity. Of patients in the intervention group, 148 of 196 patients reported some form of incontinence at 12 month mark. In the control group, 151 of the 195 patients reported some urinary incontinence (EER = 0.755, CER = 0.774, RRR = 0.045, ARR = 0.019, NNT = Not Significant).
Radiation therapy
Radiation therapy, also known as radiotherapy, is often used to treat all stages of prostate cancer. It is also often used after surgery if surgery does not successfully cure cancer. Radiotherapy uses ionizing radiation to kill prostate cancer cells. When absorbed in the tissues, ionizing radiation such as gamma and x-rays damage DNA in cancer cells, which increases the likelihood of apoptosis (cell death). Normal cells can repair radiation damage, while cancer cells do not. Radiation therapy makes use of this fact to treat cancer. Two different types of radiation therapy are used in the treatment of prostate cancer: external beam radiation therapy and brachytherapy (special prostate brachytherapy).
External beam radiation therapy
External beam radiation therapy uses linear accelerators to produce high-energy x-rays directed at the light toward the prostate. A technique called Intensity Modulated Radiation Therapy (IMRT) can be used to adjust the radiation emission to suit the tumor shape, allowing higher doses to be given to the prostate and seminal vesicles with minimal damage to the bladder and rectum. External radiation beam therapy is generally given for several weeks, with daily visits to the radiation therapy center. New types of radiation therapy such as IMRT have fewer side effects than traditional treatments. Eleven centers in the United States are now using proton therapy for prostate cancer, which uses protons rather than X-rays to kill cancer cells. Researchers also studied the type of stereotactic body radiotherapy (SBRT) to treat prostate cancer.
Brachytherapy
Permanent implant brachytherapy is a popular treatment option for patients with low to moderate risk features, may be performed on outpatients, and is associated with a good 10-year outcome with relatively low morbidity. This involves placing about 100 small "seeds" containing radioactive material (such as iodine-125 or palladium-103) with a needle through the perineal skin directly into the tumor when under general or spinal anesthesia. These seeds emit low energy X-rays that can only travel short distances. Although the seeds eventually become inert, they remain in the prostate permanently. The risk of exposure to other people from men with commonly planted seeds is accepted to be insignificant. However, men are encouraged to talk to their doctor about special precautions while around small children and pregnant women.
Usage
Radiation therapy is commonly used in the treatment of prostate cancer. It can be used instead of surgery or after surgery on early stage prostate cancer (adjuvant radiotherapy). Radiation treatments can also be combined with hormonal therapy for medium risk diseases, when surgery or radiation therapy alone is less likely to cure cancer. Some radiation oncologists combine external beam radiation and brachytherapy for medium to high risk situations. Radiation therapy is often used in conjunction with hormone therapy for high-risk patients. Others use a combination of "three modalities" of external beam radiation therapy, brachytherapy, and hormonal therapy. In advanced stages of prostate cancer, radiation is used to treat painful bone metastases or reduce compression of the spinal cord.
Radiation therapy is also used after radical prostatectomy is good for cancer recurrence or if some risk factors are found during surgery. Radiation therapy is delivered immediately after surgery when risk factors are present (positive surgical margins, extracapsular extensions, seminal particles involvement) have been shown to reduce cancer recurrence, lower distant metastases, and improve overall survival in two separate randomized trials.
Side effects
Side effects of radiation therapy may occur after several weeks of treatment. Both types of radiation therapy may cause diarrhea and mild rectal bleeding due to radiation proctitis, as well as potential urinary incontinence and impotence. Symptoms tend to improve over time except that erections usually worsen over time.
The new method of reducing rectal radiation injury in prostate cancer patients involves the use of an absorbable spacer placed between the prostate and rectum.
Spacers are commercially available in some areas, and are undergoing clinical trials on others. By altering temporary anatomy these products have the potential to enable enhanced cancer targeting while minimizing risk to neighboring healthy tissue. Prostate Rectum Spacer should be compatible with all radiotherapy treatments of prostate cancer including conformal 3D, IMRT and stereotactic radiation and brachytherapy.
Comparison with operations
Several retrospective analyzes have shown that overall survival and disease-free survival outcomes are similar between radical prostatectomy, external beam radiation therapy, and brachytherapy. The price for impotence when comparing radiation with similar nerve-sparing operations. Radiation has a lower incontinence rate than surgery, but has a higher rate of mild rectal bleeding. Men who have undergone external beam radiation therapy may have a slightly higher risk then develop colon cancer and bladder cancer.
Since prostate cancer is generally a multifocal disease, traditional prostatectomy removes all local lesions by removing the entire prostate. However, it has been hypothesized that "index lesions" may be responsible for disease progression. Therefore, focus therapy aimed at index lesions may be effective in treating prostate cancer while maintaining the rest of the gland. Intervention radiologists have begun to treat prostate cancer with minimally invasive therapies such as cryoablation, HIFU, radio frequency ablation, and photodynamic therapy that enable focal therapy by utilizing image guidance. These therapies are still in their early stages or experimental stages; However, as they preserve the tissues, they potentially reduce adverse treatment outcomes such as impotence and incontinence. A small prospective study published in the European Urology in February 2015 assessed the treatment of focusing index lesions with HIFU in patients with multifocal prostate cancer and found that the majority of men returned to genitourinary function early and 86% of men were free of clinically significant prostate cancer. in one year. A small, non-randomized cohort study with a median follow-up range of 17-47 months showed that cryoablation, HIFU, and phototherapy were associated with low rates of adverse events and initial disease control rates of 83% -100% based on negative biopsy.
Patients who may benefit specifically from focal therapy with HIFU are men with recurrent cancer once the gland is removed. The rate of cancer recurrence after surgical resection can be as high as 15-20%. MR imaging improves early cancer detection, so MR-guided therapy can be applied to treat recurrent disease. In addition, for men who have failed to save radiation treatment and have limited remaining therapy options, intervention therapy may offer more opportunities to potentially cure their illness. While recent studies have demonstrated the feasibility of this treatment, additional work is needed to further evaluate which patients are most suitable for this procedure and determine long-term efficacy.
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High intensity focused ultrasound (HIFU) was first used in the 1940s and 1950s in an attempt to destroy tumors in the central nervous system. Since then, HIFU has been shown to effectively destroy malignant tissue in the brain, prostate, spleen, liver, kidney, breast, and bone.
HIFU for prostate cancer uses ultrasound to erode/destroy prostate tissue. During the HIFU procedure, sound waves are used to heat the prostate tissue, thus destroying cancer cells. In essence, ultrasonic waves are focused on certain areas of the prostate to remove prostate cancer, with minimal risk of affecting tissues or other organs. The temperature at the focal point of the sound wave may exceed 100 Ã, Â ° C (212 Ã, Â ° F). However, much research on HIFU is done by HIFU device manufacturers, or members of the factory advisory panels.
Contraindications to HIFU for prostate cancer include a prostate volume greater than 40 grams, which can prevent targeted HIFU waves from reaching the anterior and anterobasal areas of the prostate, anatomical or pathological conditions that may interfere with the introduction or displacement of HIFU probes into the rectum, and calcification of volumes high inside the prostate, which can lead to HIFU scattering and transmission interference.
The 2012 HIFU UK trial in 41 patients reported no histologic evidence of cancer in 77% of treated men (95% confidence interval: 61- 89%) in biopsies targeted at 12 months, and low rates of genitourinary side effects. However, this does not necessarily mean that 77% of men definitively recover from prostate cancer, because systematic and random sampling errors are present in the biopsy process, and therefore recurrent or previously undetectable cancers can be missed.
Lifestyle changes
Prostate enlargement can cause difficulty emptying the bladder completely. This situation, where there is a residual volume in the bladder susceptible to complications such as cystitis and bladder stones, is also commonly found in patients with benign prostate hyperplasia. It is often recommended to change the urinary position of symptomatic men, but the results show heterogeneity. A meta-analysis of people with prostate enlargement and healthy men showed a significant decrease in residual volume, while a trend toward increased urinary flow rates and decreased urinary time was found. The effects of a person's position change are thought to arise from the relaxation of the pelvic muscles, contracted in a standing position thereby affecting the urodynamics.
Frequent exercise such as brisk walking can delay prostate cancer development
Hormonal therapy
Androgen deprivation therapy
Hormonal therapy uses drugs or surgery to block prostate cancer cells from getting dihydrotestosterone (DHT), a hormone produced in the prostate and necessary for the growth and spread of most prostate cancer cells. Blocking DHT often causes prostate cancer to stop growing and even shrinking. However, hormonal therapy rarely cures prostate cancer because the cancer that initially responds to hormonal therapy usually becomes resistant after one to two years. Hormonal therapy, therefore, is usually used when the cancer has spread from the prostate. It can also be given to certain people who undergo radiation therapy or surgery to help prevent the return of their cancer.
Hormonal therapy for prostate cancer targets the path the body uses to produce DHT. A feedback involving testicles, hypothalamus, and pituitary, adrenal, and prostate gland controls blood levels of DHT. First, low levels of DHT in the blood stimulate the hypothalamus to produce a hormone that releases gonadotropin (GnRH). GnRH then stimulates the pituitary gland to produce luteinizing hormone (LH), and LH stimulates the testicles to produce testosterone. Finally, testosterone from testicles and dehydroepiandrosterone from the adrenal gland stimulates the prostate to produce more DHT. Hormonal therapy may decrease the level of DHT by disrupting this pathway at any point. There are several forms of hormonal therapy:
- Orchiectomy, also called "castration," is an operation to lift the testicles. Because the testes make up most of the body's testosterone, after the level of testosterone orchiectomy decreases. Now the prostate not only lacks a testosterone stimulus to produce DHT but also does not have enough testosterone to turn into DHT. Orchiektomi is considered a gold medication standard.
- Antiandrogens are drugs such as flutamide, nilutamide, bicalutamide, enzalutamide, apalutamide, and cyproterone acetate that directly block the action of testosterone and DHT in prostate cancer cells.
- Drugs that inhibit adrenal androgen production such as DHEA include ketoconazole and aminoglutethimide. Since the adrenal glands only make up about 5% of the body's androgens, these drugs, in general, are only used in combination with other methods that can block 95% of the androgens made by the testes. This combined method is called total androgen blockade (TAB). TAB can also be achieved by using antiandrogen.
- GnRH actions can be interrupted in one of two ways. GnRH antagonists such as abarelix and degarelix suppress LH production directly by acting on the anterior pituitary. GnRH agonists such as leuprolide and goserelin acetate suppress LH through a downregulation process after the initial stimulatory effects that may cause early tumor flares. To prevent stimulation of tumor growth during initial LH surge, antiandrogens such as cyproterone acetate are prescribed a week before and three weeks after GnRH agonists are administered. Abarelix and degarelix are examples of GnRH antagonists, whereas GnRH agonists include leuprolide, goserelin, triptorelin, and buserelin. Initially, GnRH agonist increased LH production. However, because the constant supply of drugs is incompatible with the body's natural production rhythm, the production of LH and GnRH decreases after several weeks.
- Abiraterone acetate was approved by the FDA in April 2011 for the treatment of prostate cancer resistant to castration for patients who have failed docetaxel therapy. Abiraterone acetate inhibits an enzyme known as CYP17, which is used in the body to produce testosterone.
The most successful hormonal therapy is the orchiectomy and GnRH agonist. Although the cost is higher, GnRH agonists are often chosen more than orchiectomy for cosmetic and emotional reasons. Finally, total androgen blockade proved to be better than a self-employed GnRH orchiectomy.
Each treatment has a loss that limits its use in certain circumstances. Although orchiectomy is a low-risk operation, the psychological impact of removing testicles can be significant, and sterility is certain. Loss of testosterone can cause hot flashes, weight gain, loss of libido, breast enlargement (gynecomastia), impotence, penile atrophy, and osteoporosis. GnRH agonists eventually cause the same side effects as orchiectomy but may cause worse symptoms at the start of treatment. When GnRH agonists are first used, testosterone waves can cause increased bone pain due to metastatic cancer, so antiandrogens or abarela are often added to collect these side effects. Estrogens are not commonly used because they increase the risk of cardiovascular disease and blood clots. In general, antiandrogens do not cause impotence, and usually lead to reduced bone and muscle mass. Ketoconazole can cause liver damage with long-term use, and aminoglutethimide can cause skin rashes.
Estrogen therapy
Estrogen has been used in the treatment of prostate cancer. Used estrogens include diethylstilbestrol, phosphestrol (diethylstilbestrol diphosphate), ethinylestradiol, ethinylestradiol sulfonate, polyestradiol phosphate, and estradiol undecylate, and a combined estrogenine and nitrogen mustard alkylating antineoplastic agent estramustine phosphate. New estrogens with better tolerance and safety such as GTx-758 have also been studied. Estrogens are effective in the treatment of prostate cancer because they are functional antiandrogens. They both suppressed the concentration of testosterone to castrate levels through their antigonadotropic activity and they reduced the percentage of free and bioavailable testosterone by increasing the production and globulin levels of hormone-binding globulin. Estrogens have been found to be equivalent in their effectiveness to androgen deprivation therapy with nonsteroidal castration and antiandrogens. However, they significantly increase cardiovascular mortality, and for this reason, are now little used in prostate cancer. Although the most commonly used estrogens such as diethylstilbestrol and ethinylestradiol are associated with increased cardiovascular mortality, it should be noted that certain estrogens, ie polyestradiol phosphates, have been found not to do so; this is associated with varying degrees of effects of various estrogens on hepatic protein synthesis.
Broad disease
Palliative care for advanced prostate cancer focuses on prolonging life and reducing symptoms of metastatic disease. As mentioned above, abiraterone shows some promise in treating advanced stage prostate cancer. This led to a dramatic decline in PSA levels and tumor size in advanced, aggressive prostate cancer for 70% of patients. Chemotherapy may be offered to slow the progression of the disease and delay the symptoms. The most commonly used regimen combines docetaxel chemotherapy drugs with corticosteroids such as prednisone. One study showed that treatment with docetaxel with prednisone prolonged the life of 16.5 months for those taking mitoxantrone and prednisone up to 18.9 months for those taking docetaxel prednisone. Bisphosphonates such as zoledronic acid have been shown to delay skeletal complications such as fractures or the need for radiation therapy in patients with hormone-refractory prostate cancer metastasis. Xofigo is a new pharmaceutical bone targeting metastasis that emits alpha. Phase II testing shows the long-term survival time of the patient, reduces pain, and improves quality of life.
Bone pain due to metastatic disease is treated with opioid pain relievers such as morphine and oxycodone. External beam radiation therapy directed at bone metastases can provide pain relief. Certain radioisotope injections, such as strontium-89, phosphor-32, or samarium-153, also target bone metastases and may help relieve pain.
Alternative therapy
As an alternative to active supervision or definitive treatment, other therapies are also being investigated for prostate cancer management. PSA has been shown to be inherited in men with localized prostate cancer using a vegan diet (fish allowed), regular exercise, and stress reduction. These results have so far proved durable after two years of treatment. However, this study does not compare the vegan diet with active surveillance or definitive treatment, and thus can not comment on the comparative efficacy of the vegan diet in treating prostate cancer.
Many other sole agents have been shown to reduce PSA, slow PSA times, or have a similar effect on secondary markers in men with localized cancer in short-term trials, such as pomegranate or genistein juice, isoflavones found in various legumes.
The potential of using some such agents in concert, let alone combining them with lifestyle changes, has not been studied. A more thorough review of the natural approach to prostate cancer has been published.
Neutrons have been shown to be superior to X-rays in the treatment of prostate cancer. The reason is a tumor containing hypoxic cells (cells with enough oxygen concentration to survive, but not enough for X-ray-radiosensitive) and oxygen-deficient cells that are resistant to X-ray killing. Thus, the lower the Oxygen Enhancement Ratio (OER) of the neutrons provides an advantage. Also, neutrons have higher relative biological effectiveness (RBE) for slow-growing tumors than X-rays, allowing for the advantage of killing tumor cells.
Prevention
Both selenium and vitamin E have been found to be effective in preventing prostate cancer.
Trade-off
The trade-off dilemma refers to the choice between beneficial and harmful effects expected in terms of survival and quality of life for a particular treatment. Examples of the trade-offs in the treatment of prostate cancer include urinary and bowel symptoms and waning of sexual function. How common these symptoms are and the difficulties they generate vary between treatments and individuals.
One option is to trade a complete sexual function for the possibility of a long life expectancy with no curative treatment. This option involves a trade-off so it is important for people and doctors to have access to information about the benefits of established care and side effects. A study in Sweden found that the desire to make this kind of trade-off varies greatly among men. While six out of ten are willing to consider a trade-off between life expectancy and full sexual function, given the current knowledge of treatment benefits for clinically localized prostate cancer, four out of ten state that they will in all circumstances choose treatment regardless of the risk for waning sexual function. Access to valid empirical information is essential for such decision-making. The main factors here are the individual's feelings towards the disease, their emotional values ​​and religious beliefs. Most people and doctors, experiencing stress in assessing the trade-off between different treatment options and the side effects of treatment that add stress to cancer are diagnosed, a deteriorating situation in eight out of ten people with prostate cancer have no one to confide except for their partner and one from five people live in total emotional isolation.
See also
- Prostate cancer # Research
References
Source of the article : Wikipedia
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