Health

Treatments for Prostate Cancer

By CBSNews.com staff CBSNews.com staff

January 31, 2002 / 8:40 AM EST / CBS

Mayor Rudy Giuliani of New York City recently said he was getting anti-hormone shots and was considering radiation to treat his prostate cancer. CBS health correspondent Dr. Emily Senay tells us about the most common treatments for prostate cancer and their side effects.

Shortly after New York Mayor Rudolf Guiliani was diagnosed with prostate cancer in April, questions arose about the type of treatment he would choose to combat the disease. The Mayor's cancer, caught in the early stages, was diagnosed through a blood test, a PSA test, (prostate specific antigen). Generally reluctant to talk about his treatment, the mayor recently admitted to receiving injections of a hormone-blocking drug called LUPRON, and said he was leaning toward radiation treatment rather than surgery as the second course of treatment. Recent high-profile prostate cancer surgery survivors are Yankees manager Joe Torre and former Senator Bob Dole.

Giuliani, 56, has admitted to having difficulty reaching a decision about treatment. His indecision may be compounded by the fact that his father died of the disease. The mayor is reported to be seeking treatment from Dr. Richard Stock, a radiologist at Mount Sinai and an expert in radioactive seed implantation.

Giuliani's predicament is typical of men considering treatment options. In short, they are trying to save their lives without destroying the quality of their lives. The side effects of the treatments are considerable.

Hormone blocking drugs can sometimes hold the disease in check, even reduce the tumor for a time, but it doesn't kill the disease or treat the cancer. The side effects of hormone blocking drugs can be unpleasant. Radical prostatectomy can lead to incontinence and impotency, however in some cases the nerves that result in erection can be spared. External beam radiation can be used in combination with internal radiation therapy, called brachytherapy (implantation of radioactive seeds). High dose brachytherapy can implant seeds that continue to deliver and can be done in a day.

Approximately 180,000 men were diagnosed with prostate cancer last year. It develops as a result of both inherited and environmental factors. And is associated with aging. Approximately 60% of all men have latent or clinically silent prostate cancer. Slightly less than 3% of men will ever actually die from prostate, that's less than 1/10th of the total population thought to be affected. However, it is the second leading cause of cancer deaths of men in this country, surpassing deaths from lung cancer. The difficulties in dealing with prostate cancer are many, starting with diagnosis. Since many men live long and productive lives never knowing that they have a low-grade form of the disease, it is important for all men to be tested. Early detection saves lives. All forms of treatment have considerable complications, though many of these: incontinence, sexual dysfunction, loss of libido can be treated and sometimes reversedNo one treatment is appropriate for everyone. Many factors must be considered, and still the answers are imperfect.

A person's risk more than doubles if a close relative has prostate cancer. African-Americans are more than twice as likely to be diagnosed with prostate cancer and have a mortality rate more than double that of white males. A high fat diet changes hormone levels; a direct link between obesity and prostate has been demonstrated.

HORMONE THERAPY (androgen deprivation)

Essentially, there are just two hormone-blocking medications (luteinizing hormone-releasing hormone analogs or LHRH) used today: Lupron and Zoladex, interchangeable except for the brand names. These drugs work through the hypothalamus, sending a message to the testicles to cease testosterone production. Since testosterone encourages the growth of prostate cancer, the hormones effectively cut off the food supply to the tumor.

Hormonal therapy is not meant to be curative. It is designed to palliate r slow the cancer's growth, though it sometimes is the sole treatment in older men--80 to 85 --who have symptomatic disease and in some men whose cancer has metastasized. In the mayor's case, however, the drug has allowed him to remain in a holding pattern, while he decides on his next course of treatment. The hormone blocker will probably reduce the size of his tumor but it does not kill cancer cells.

Three types of prostate cancers:

1.Those dependent on male hormone
2.Those sensitive to male hormone (these can actually be killed through hormone therapy)
3. Those independent of the male hormone

In a neo adjuvant setting (meaning used in combination with another type of treatment) hormone-blocking drugs are administered for 3 to 6 to 9 months.

But the use of the hormone blocker may be an indication that Giuliani has chosen radiation treatment over surgery, since the drugs' effectiveness prior to surgery is limited, even redundant. Because the cancer will be made smaller (eliminated) by surgery, there's little need for the tumor-reducing hormone blockers. And if there are cancer cells outside the prostate, the hormonal block doesn't affect them at all.

Hot flashes, weight gain and impotence are common side effects. They last as long as the patient is on medication. It also tends to suppress the libido.

Removal of the prostate, or radical prostatectomym, may also include removal of the lymph nodes, depending on the size and progress of the tumor. (Based on the PSA results and other tests, prostate cancer is assigned a numerical score, called a Gleason's score. This score acts as the foundation for treatment choices). Given certain parameters, surgery is the best treatment for men below the age of 70 or less who have a life expectancy of at least 10 years.

Recovery time is three to five weeks, including a three to four day hospital stay.

Downside: It causes incontinence in 10% of patients. Treatment for incontinence is collagen injections, oan artificial sphincter. Impotency, which can be treated in a host of ways: Viagra, an erect aide device, injections into the penis, urethral insert and prosthesis. However, the surgical procedure can be modified: In a nerve sparing radical prostatectomy, the surgeon can spare one or both of the nerve bundles that allow for erection. The chance of leaving someone potent, depends on the person's age and ability to experience a pre-surgery erection, is 20% to 60%.

Patients' decision on treatment may be influenced by a family member's death of the disease. Often those patients opt for surgery, not because it's indicated but for purely emotional reasons: "I want it all out."

In all forms of radiation therapy, higher doses of radiation are now being used. As techniques for focusing the radiation have improved, limiting damage to surrounding tissue, radiation dosage has increased.

External beam radiation (from a source outside the body, focused on the tumor area) is administered five days a week for eight to nine weeks. Side affects of acute radiation toxicity include burning on urination and/or frequent urination or defecation, and bleeding from rectum or bladder. Risk of incontinence is 1% to 2%. Risk of impotency is about 25% to 30 %.

There are two major problems of radiation. It's not prophylactic, therefore doesn't prevent new cancer. Biopsy results show radiation doesn't sterilize the cancer cells in 25% to 75% of patients. However, many prostate cancer cells can be rendered dormant for extended period of time.

Internal radiation therapy (brachytherapy) uses small radioactive pellets (each about the size of a grain of rice) that are directly implanted (permanently or temporarily) into the prostate. Imaging tests such as transrectal, ultrasound, CT scans, or MRI are used to guide placement of the radioactive material into the prostate gland. The radioactive materials (isotopes such as iodine 125 or palladium 103) are placed inside thin needleswhich are inserted through the skin of the perineum (area between scrotum and anus) into the prostate. The permanent pellets, sometimes called seeds, give off radiation for weeks or months. Once the radiation expends itself the seeds can be left in place.

High-dose brachytherapy uses needles to deliver even more radioactive material. The material can be placed for less than a day.

Side effects: Also incontinence, (1% to 2%), impotency (about 25%), irritative symptoms (soreness and urination and defecation difficulties, bleeding from rectum) (about 60%), can last about six months. Results with seeds for patients with Gleason scores of six or less, PSA less than 10 is the group that responds best.

Results are not quite as good as surgery in same set of patients, but is reasonable. Surgery will render 90% to 94 % of patients biochemically free of cancer.

Sometimes internal beam radiation is combined with external radiation that zeroes in on the imbedded seeds using them as targets fo additional radiation treatment from outside the prostate. The combination can cause some surrounding tissue damage, but the bulk of the tissue damage is focused in the range of the prostate.

Some experts feel that using combination treatment extends the criteria of the tumors that can be treated effectively, and more high-grade tumors and those that are not well differentiated. Argument is that it's better than just interstitial, you can treat bigger field. With seeds you treat what you plant.