Men diagnosed with prostate cancer find assurance in discussing the state of their disease and treatment options in detail. Understanding grade, stage, prognosis and treatments prepares the patient for making an informed treatment decision, and can actually bring comfort and confidence, since most prostate cancers are very curable.
While three choices have dominated treatment — active surveillance, or radical prostatectomy or radiation — other treatments like minimally invasive high-intensity focused ultrasound (HIFU) might be an suitable alternative for some men with localized prostate cancer.
Here is what patients can expect from a follow up visit with a urologist following the results of an MRI, if done, and a biopsy indicating the presence of cancer:
- The Grade of Your Prostate Cancer
The urologist will first discuss the grade and stage of the patient’s cancer. The grade is a number that is assigned by a pathologist, who looks at the cancerous tissue sample and assigns a grade using the Gleason grading system, which measures how aggressive the cancer is. Gleason grades go from 1 (least aggressive) to 5 (most aggressive). Grade 1 looks a lot like normal prostate tissue but has distinguishing features that make it identifiable as cancer. Grade 5, on the other hand, looks unlike normal prostate tissue and is almost not identifiable as such.
Oftentimes because of subtleties in the Gleason system it is possible for the pathologist to see more than one grade. Dr. Gleason’s score, which is used to solve this problem, is the sum of the two most common grades, with the primary grade being the most common and the secondary grade being the next most common. The order of the grades is significant. For instance, a score of 4 + 3, where 4 is more predominant than 3 tends to be a more aggressive cancer than 3+4.
However, not every patient has multiple grades. It is possible for the patient to have only one grade, but the Gleason score always has two numbers. So in this case the grade number is repeated. For instance if the cancer is all grade 4 and no other grade is seen, the Gleason score would be 4+4. So grades go from 1 to 5, but scores go from 2 to 10.
- The Stage of Your Prostate Cancer
Staging allows doctors to tell how advanced the cancer is at the time of diagnosis. Most cancers are clinically localized to the prostate. That is, there is no evidence, by different tests that the cancer has spread beyond the prostate. Common tests used to identify this might include a bone scan and a CT or MRI scan of the pelvis. Most cancers are T1c, meaning that the cancer is not palpable and was only identified because a patient presented with an elevated PSA. If the cancer can be felt it’s a T2 tumor.
- T2a: the tumor is small and localized to one side.
- T2b: it’s either a big tumor or palpable on both sides.
- T3: the tumor is palpable beyond the limits of the prostate.
- T3 or T4: the cancer is clearly outside the prostate and has gone to a pelvic sidewall or to the base of the bladder.
- Prognosis
Prognosis is largely based on your Gleason score, PSA and stage. Most prostate cancers are very curable. Only a minority of patients present with disease that is already incurable.
- Treatment Options
It’s important that men diagnosed with prostate cancer understand their treatment options and the side effects associated with each, so they make an informed decision with a full understanding of what’s behind their doctor’s recommendation.
More than 90 percent of men diagnosed with prostate cancer, have localized disease, defined as cancer that hasn’t spread outside of the prostate. These patients are typically given the options of active surveillance, radical (complete removal) prostatectomy or radiation therapy. For men with localized prostate cancer other treatment options are available. Here is an overview of all potential treatments:
High Intensity Focused Ultrasound (HIFU)
HIFU, which stands for High Intensity Focused Ultrasound, is a minimally invasive option for prostate tissue ablation through heating with a low occurrence of side effects. Using real-time image guidance — and sometimes paired with additional magnetic resonance imaging (MRI) and/or location of the biopsies in 3D — the doctor directs a focused beam of ultrasound energy at the target area within the prostate through an ultrasound probe inserted into the rectum. No incisions are required to reach the targeted zone and ablate the prostate tissue at the focal point.
HIFU’s precise targeting minimizes damage to the surrounding healthy tissue, and has a low risk of post-procedure impotence and incontinence. Unlike radiation therapy or surgery, it is possible to repeat a HIFU procedure because it does not remove the prostate altogether.
Risks and Side Effects
Rectal wall injury from probe
- Catheter required following treatment
- Potential ejaculation problems
- Low rate of urinary incontinence
Recovery after a HIFU procedure is much faster compared to prostatectomy and radiation therapy. Patients can return to work and the activities of normal life by the next day.
Prostatectomy
Prostatectomy is a surgical approach to treating prostate cancer involving the removal of the entire prostate and seminal vesicles. It requires one-to-two night stay in a hospital.
Risks and Side Effects
- Urinary incontinence (inability to control the flow of urine from the bladder)
- Erectile dysfunction
Recovery after a prostatectomy usually occurs slowly over time. Each patient’s situation is different, so the doctor’s success rates and his/her personal evaluation is the best way to predict recovery outcomes.
Radiation Therapy
Radiation therapy uses high-energy rays or particles to kill cancer cells. Radiation is common, and often used as the initial treatment for cancer that is still in the prostate gland. Cure rates for men with these types of cancers are about the same as those for men treated with prostatectomy.
Risks and Side Effects
- Bowel problems
- Radiation can irritate the rectum and cause a condition called radiation proctitis (leading to diarrhea, sometimes with blood in the stool and rectal leakage)
- Urinary problems
- Radiation can irritate the bladder and lead to a condition called radiation cystitis (urinating more often, burning sensation while urinating and/or blood in urine)
- Urinary incontinence (no control of urine)
- Erection problems, including impotence
- Problems with erections usually do not occur right after radiation, but slowly develop over time
- After a few years, the impotence rate after radiation is about the same as that after surgery
- Lymphedema
- If the lymph nodes around the prostate are damaged by radiation, fluid may collect in the legs or genital region over time, causing swelling and pain
Most of these problems go away over time, but in rare cases normal functions do not return.
Cryotherapy
Cryotherapy is the use of very cold temperatures to freeze and kill prostate cancer cells. This treatment is sometimes used for early-stage prostate cancer, and is often an option if the cancer comes back after radiation therapy.
The doctor uses transrectal ultrasound (TRUS) that goes into the anus to guide hallow probes (needles) through the skin. Very cold gases are passed through the needles to freeze and destroy the prostate. A catheter is left in place for several weeks afterward to empty the bladder while recovering.
Risks and Side Effects
For men who have already had radiation therapy, side effects from cryotherapy tend to be worse, as opposed to men who have it as the first form of treatment.
- Blood in urine
- Soreness in the area where the needles were placed
- Swelling of the penis or scrotum is common
- Freezing may affect the bladder and rectum, leading to pain, burning sensations and frequent bowel movements
- Erectile dysfunction
- Freezing often damages the nerves near the prostate
- More common after cryotherapy than after a prostatectomy
- Urinary incontinence (having problems controlling urine)
According the American Cancer Society, doctors have less of an understanding of cryotherapy’s long-term effectiveness. Compared to surgery or radiation therapy, cryotherapy is not as effective for advanced prostate tumors.
It is important that men take educating themselves seriously. Knowing the options allows patients to make more informed decisions, evaluate all possible treatment options and choose the one that allows them to maintain their quality of life.
