Prostate Cancer Treatments in Ireland
As with many cancers, there is no such thing as “the prostate cancer”.
Every man is different, so is every prostate cancer. This combination of unique factors means that every man needs individualised treatment which recognises that every man’s prostate cancer is different. For most patients it is difficult to compare their treatments.
Below is a brief overview of the main treatments available in Ireland at the time of writing. These are subject to change and the current position should be checked by the patient or their doctor.
Some men are diagnosed with prostate cancer but they also suffering from some other life-threatening diseases (known as co-morbidities) which indicates that they have a limited lifespan. To subject such men to an active treatment programme for prostate cancer may not extend life and may adversely affect their quality of life for their remaining time for such men. This does not mean that their symptoms, such as bone pain, should not be treated as part of the patient’s overall care.
Active Surveillance – AS
Active Surveillance should be distinguished from Watchful Waiting. AS is for men who can still expect curative treatment, but who choose to defer treatment until their situation changes – either clinically, socially or psychologically. Most prostate cancers develop slowly and almost never
cause serious (life threatening) disease. For men with these kind of tumours active surveillance can be a reasonable option. These men are carefully monitored with regular PSA tests and, if needed, biopsies. The objective is to keep open the option on curative treatment, if needed. In the meantime, the man is spared the likely side-effects of radical treatment.
Depending on the age of the man and on his specific type of cancer, a total removal of the prostate can be a good treatment option. Given the
explanation above, about the location of the prostate, it is easy to understand that problems can arise. The possible and undesired side-effects of this
form of treatment may result in incontinence due to surgical damage to the sphincter muscle which controls the release of urine from the bladder. In addition, there may be impotence due to nerve damage because the nerves controlling erections are located on the exterior wall of the prostate gland.
A radical prostatectomy can be performed using one of several techniques such as conventional open surgery, laparoscopic surgery where a number of small incisions are made by the surgeon, still hands-on the patient, and robot- assisted surgery where the surgeon is physically away from the patient operating controlling the operation remotely on a screen and via his binocular microscope. Each technique may have different advantages and drawbacks and costs and not all these techniques are universally available in Ireland.
Radiation can kill tissue, both good and bad. Radiation treatment today will be administered in a very precise way so that most healthy tissue will be protected from damage. Radiation treatment can be given also with implanted radioactive seeds (low-dose brachytherapy) or with external beam radiation (EBR). The latter option has modern technical variants that limit the exposure of healthy tissue to a minimum. For radiation treatment, unwanted side effects are incontinence and impotence, but also radiation damage to bladder and rectum which may not become apparent for some years. Recent advances
in the modes of radiation delivery have allowed for effective treatment with greatly reduced side-effects.
Androgen Blockade (AB) Androgen Deprivation Therapy (ADT)
ADT is often called hormone therapy. The male sex hormone testosterone stimulates the growth of prostate tissue and of prostate cancers. Lowering testosterone in the blood slows growth of a prostate cancer.
Several drugs can be prescribed by a man’s doctor to lower his testosterone level. To monitor the effectiveness of this treatment the man’s PSA and testosterone level will be tested. ADT may affect sexual life (libido), bone density, body weight, mood, may cause fatigue and even depression.
When the ADT treatments fail and nothing else seems to be working your doctor can propose to use chemotherapy. These drugs interfere with normal reproduction of cells and impact on cancer cells that reproduce faster than most normal cells. Chemotherapy slows down the evolution of a cancer, but it cannot cure prostate cancer.
Advanced Prostate Cancers
For reasons not yet fully understood, hormone treatment (ADT) or androgen blockade (AB) often ceases to work after a period of years when the prostate cancer cells become resistant to the treatment. Clinicians describe such patients as “refractory”. When the man has been on hormone therapy his testosterone production is suppressed, and it is as if the man had been castrated – this was once the treatment for advanced prostate cancer. The refractory patient is referred to by the clinicians as having Castrate Resistance Prostate Cancer – CRPC. In most men the cancer metastasises or spreads to other locations in the body, usually bone and men with this condition are known as metatastic Castrate Resistant Prostate Cancer – mCRPC. Some CRPC men don’t appear to metastasise immediately and these are referred to as non-metatastic CRPC.
Side Effects of Treatment
One of the main reasons why urologists, radiologists and medical oncologists are now giving more emphasis to Active Surveillance to men with non-life- threatening prostate cancer is because of the concern that there may have been overtreatment of men in the past. Radical prostate cancer treatments, whether surgery or radiation, cause side effects. For some men, their treatment greatly affects their Quality of Life (QoL).
For most men the side-effects wane within a year of surgery or radiation, for others the side-effects can be more long term.
The most common side effect is urinary incontinence, especially after surgery because of the re-sectioning of the urethera.
In many instances this can be treated effectively by systematic use of pelvic floor exercises, but for some men this just doesn’t work. One of their urinary sphincters fails to recover and do its job properly. A simple procedure involving the insertion of an artificial urinary sphincter has proven a boon to men who were plagued with post-operative incontinence.
A common condition in those who had radiation treatment is an urgency incontinence – where you have the severe need to empty the bladder even if it is nowhere near full. Pelvic floor exercises help with this also.
As the more widespread use of PSA screening by GPs is leading to the discovery of prostate cancers at a younger age, the big side-effect for sexually active men is erectile dysfunction after treatment. With early stage cancers which have not spread outside the prostate gland it is also easier for the surgeon to undertake nerve-sparing surgery which can greatly increases the chances of resumption of sexual function after radical treatment. Radiation damage to the nerves can difficult to overcome but again for many men the degree of dysfunction lessens in the first year after treatment and sexual function can be assisted by the use of Viagra or Cialis and other preparations.
“Use IT Or Lose It”
One of the maxims in combatting erectile dysfunction is “use it or lose it”. After surgery or radiation treatments the sooner sexual activity is resumed (within reason) the better.
For years the side effects of cancer, including prostate cancer, were not given the degree of attention that is now developing. The Irish Cancer Society has recently taken a very important initiative in opening pilot side-effects clinics in two of the eight designated cancer hospitals to focus on patient side-effects for all cancers (Galway UH and Dublin). It is likely that, when operational, these clinics will have a fair degree of business from men who have undergone radical surgery or radiotherapy for their condition.
MAC greatly welcomes this initiative.
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