Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
In this video, we're going to cover the four main types of treatment for men with prostate
cancer.
There are four broad categories: Observation alone, local treatments where the therapy
is administered to the gland alone, systemic treatments where medicines circulate throughout
the whole body, and then combinations of local plus systemic therapies.
Men who have prostate cancer and want to pursue active surveillance need to have certain specified
criteria. A Gleason 6, possibly certain types of Gleason 7, for their grading which comes
from the biopsy. A PSA that is less than 10 and if the doctor has done a finger exam he
shouldn't be feeling any hard lumps or bumps. Active surveillance for prostate cancer is
a very attractive approach because the standard treatments like surgery or radiation can cause
very serious side effects—impotence, incontinence, rectal damage—that is often irreversible.
Men undergoing active surveillance have their blood tested for PSA every three months or
so and if the PSA were to go up to a dramatic degree then that could suggest there was a
problem. More importantly, men are either going to need a periodic prostate biopsy,
perhaps every other year, or annual scans with multiparametric MRI. Many men can remain
on active surveillance for the remainder of their lives and that's because the type of
cancer that's selected for surveillance is so low-grade it's very unlikely that it will
grow or change during a man's normal life expectancy. Men can continue on active surveillance
as long as certain things, especially the biopsy, doesn't change. It is possible for
men to develop new cancers that have a higher grade—a Gleason score of 8 or higher, for
example—and that is the sort of thing that typically would lead to a man stopping active
surveillance.
When we start talking about localized treatment, that means a treatment that's directed directly
at the prostate gland, we're talking about things like radiation treatments, surgery,
or high intensity focused ultrasound, cryotherapy which is a type of freezing. The unifying
thought is that all the treatments are directed exclusively at the prostate. Local treatments
are for men who we consider to have curable cancer, but also have a cancer serious enough
to require treatment. Curable cancers are defined by having a PSA of less than 20 or
so and in men who have had scans—bone scans and PET scans—that don't show any enlarged
lymph nodes or metastases in the bones. Although it's often very slow-growing, over a period
of many years it can spread and become incurable. The threat is not as immediate as it is with
other cancers, but there is a threat.
Surgery of the prostate is an intricate and challenging operation that's usually done
robotically these days. The short-term side effects from the operation itself are pretty
tolerable; however, there can be some long-term issues related to recovery of sexual and urinary
function.
So radiation therapy for prostate cancer comes in two broad categories: Beam radiation and
seed implant radiation. Seed implant radiation involves putting radioactive seeds inside
the prostate in an operative procedure. Beam radiation involves going to a specialized
facility where they transmit the beam sort of like a regular x-ray, but it's aimed at
the prostate in high doses requiring multiple visits to the facility over a period of weeks
or even a couple of months.
Systemic therapy for prostate cancer is superior to systemic therapy for any other type of
cancer. Hormone treatments alone can put a man into remission for an average of 10 years,
even when they have the relapsed type of prostate cancer. That's quite remarkable, but we have
a number of other systemic therapies that are also very effective: Injectible radiation,
immunotherapy, and a variety of different types chemotherapies—chemotherapies that
on the whole are generally quite well-tolerated.
Combination therapy for prostate cancer involves both treatment with radiation or surgery—a
local treatment—to cure the cancer inside the prostate, and a systemic treatment that
circulates in the bloodstream to cure any potential cancer outside the prostate. This
type of treatment is used for men that are considered to be high risk, in other words,
they have PSAs over 20 or Gleason scores that are 8 or higher. When men have high-risk prostate
cancer, combination therapy improves their chance for cure, perhaps as much as 15-30%.
So if they were to have only surgery or only radiation without any systemic treatment—without
any hormone treatment for example—their cure rates would be lowered. The most common
combination therapy is some form of radiation with some form of hormone treatment. Typically,
the hormone treatment starts a couple months before the radiation, the hormone treatment
continues through the radiation and beyond depending on how serious the cancer is the
hormone therapy may continue for only a couple months or it may go on for a full year after
the radiation.
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