There are several treatment options to consider.
Remember that I’m not giving a specific recommendation for your particular treatment.
I’m just giving an outline of the treatment options that are available.
You must play a critical role in deciding which treatment is best for you.
The first treatment approach we talk about is observation.
Under certain circumstances, such as with a very elderly man with multiple medical problems
and a very slow growing cancer, it may be appropriate not to deliver any treatment at
the time.
For a 72 year old man with multiple medical problems, a PSA of 5 and a Gleason’s score
of 2 plus 3 and only one positive biopsy, the cancer may pose much less of a threat
than his other medical problems.
Instead of aggressive treatment, his PSA can be followed on a regular basis and he can
be observed by his physicians until such time as there’s evidence of growth of the disease.
On the other hand, if a person has a high Gleason score or a high PSA, or is a younger
individual with a long life expectancy, then observation is not necessarily the best route,
and serious consideration should be given to other treatment options.
Researches are working diligently to identify genetic markers that are superior to PSA in
being able to differentiate between slower growing tumors, that may not require any treatment,
and more aggressive cancers that do require treatment.
These tests may someday soon add critically important information to the existing prognostic
factors.
Since many patients may have been diagnosed with extremely early and non-aggressive cancers,
a path of Active Surveillance may be considered.
Patients who may be reasonable candidates for active surveillance include those who
have very slowly rising PSA levels less than 10, no palpable tumor, stage T1c disease,
and only one or two biopsies out of 16 or more that show small areas of cancer with
Gleason score of 6 or less.
If the patient has more extensive disease or higher grade disease or a higher PSA, active
surveillance may not be appropriate.
Under Active Surveillance, the patient will get PSA tests and digital rectal examaminations
three times a year, and repeat biopsies of the prostate every one or two years.
If the PSA continues to rise, or is rising at an increased rate, or if the digital exam
changes, or if the repeat biopsies show more disease, then a definitive form of treatment
should be undertaken.
The benefit of a path of active surveillance is that it allows a patient to avoid any of
the risks associated with the treatments for prostate cancer, possibly for several years.
The risk, however, is that while being observed, the cancer may change to a more aggressive
grade that would require more intensive treatment.
Active Surveillance is clearly not appropriate for every patient, but can be considered in
very early disease cases.
The first treatment option to discuss is surgery.
Once the patient is under anesthesia, the first step is to examine the pelvic lymph
nodes.
These lymph nodes are immediately examined by the pathologist in most cases.
If the pathologist sees no evidence of cancer in the lymph nodes, the next step is to proceed
with the prostetactomy.
There are different surgical approaches that the surgeon can use to get to the prostate.
They fall into two main categories: the open radical prostatectomy (either perineal approach
or retropubic approach) and the robotic prostatectomy.
The pros and cons of each approach should be discussed with your surgeon.
With the perineal approach, entry is made below the scrotum and in front of the anus.
With the retropubic approach, entry is made just below the belly button.
The robotic approach is performed by introducing small fiberoptic scopes and robotically controlled
arms through tiny incisions in the abdomen.
Your surgeon will discuss these different surgical approaches in much more detail.
On either side of the prostate gland are a combination of nerves and blood vessels, called
the neurovascular bundle.
If possible, these are spared in an effort to save the patient’s sexual potency.
It is not always clear pre-operatively whether these can be preserved, due to the effect
of the tumor on these structures.
If the tumor is adjacent to the neurovascular bundle on one side or if the biopsies pre-operatively
were extensively involved on one side, then the surgeon does not attempt to spare that
neurovascular bundle.
A person can therefore have a procedure in which both neurovascular bundles are spared,
only one is spared, or neither is spared.
This is important because the chance of maintaining sexual potency varies depending on how much
of their neurovascular tissue can be left behind.
If the cancer is confined to the prostate gland, that is there is no spread through
the capsule or into the seminal vesicles, or pelvic lymph nodes, then the patient has
an excellent chance for cure with the surgical approach.