Introduction To Prostate Cancer Screening, Diagnosis and Treatment

Prostate cancer is the most common cancer in men (after skin cancer). Depending on the stage of your cancer, the management options may include:

Non-metastatic prostate cancer may be treated with:

  • Watchful waiting.
  • Active surveillance. If the cancer begins to grow, hormone therapy may be given.
  • Radical prostatectomy, usually with pelvic lymphadenectomy. Radiation therapy may be given after surgery.
  • External radiation therapy (EBRT). Hormone therapy may be given before, during and/or after radiation therapy.
    • IMRT (intensity modulated radiation therapy) is the most common type of EBRT for prostate cancer treatment
    • SBRT (stereotactic body radiation therapy) uses a short course of high-dose IMRT (or proton beams) to treat the prostate (see below for more information on SBRT)
    • Proton beam radiation therapy uses high-energy protons to treat the prostate (typically through enrollment in a clinical trial)
  • Internal radiation therapy (“brachytherapy”) with radioactive seeds.
  • A clinical trial of high-intensity–focused ultrasound therapy.
  • A clinical trial of cryosurgery.

Metastatic prostate cancer may be treated with:

  • Hormone therapy.
  • Hormone therapy combined with chemotherapy.
  • Bisphosphonate therapy.
  • External radiation therapy. Hormone therapy may be given before, during and after radiation therapy.
    • IMRT
    • SBRT
    • Proton beam RT
  • Alpha emitter radiation therapy (Radium 223/Xofigo).
  • Watchful waiting.
  • Active surveillance. If the cancer begins to grow, hormone therapy may be given.
  • Orchiectomy.
  • Immunotherapy.

Dr. Lawenda discusses screening and basic information regarding prostate cancer on the health program Living Well.

Dr. Brian Lawenda’s 1-Hour Lecture on Prostate Cancer Treatment.

  • Consensus Based Guidelines for Treatment
  • MRI
  • Molecular/Genomic Testing
  • Second Opinion
  • Genetic Testing
  • AJCC TNM Staging
  • MSKCC Pre-Radical RP Nomogram
  • Radiology Studies
  • PET Scans
  • Prostate Cancer Management
  • HIFU
  • Cryotherapy
  • Radiation Techniques: IMRT and Proton Beam
  • SpaceOAR
  • Stereotactic Body Radiation Therapy
  • Brachytherapy
  • Prostatectomy
  • Testosterone (Fuel for PCa)
  • Androgen Deprivation Therapy
  • ADT with Radiation or After RP
  • Progression of Prostate Cancer
  • Androgen Receptor V7
  • Extent of Metastatic Disease
  • Castration Naive M1
  • Anti-Resorptive Bone Therapies
  • Castration Recurrent M0
  • Castration Recurrent M1
  • Radium-223 (Xofigo)
  • Castration Recurrent M1
  • Acupuncture for Hot Flashes
  • Cranberry Extract for Radiation Dysuria
  • Hyperbaric Oxygen Therapy
  • Ginseng for Cancer-Related Fatigue
  • Sleep Problems and Cancer-Related Fatigue
  • Probiotics for Radiation-Induced Diarrhea
  • Exercise and Diet
  • What to Do if Your Treatments Aren’t Working
  • Get More Opinions
  • Clinical Trials
  • Assay Directed Treatment
  • Palliative Care
  • Hospice Care

Quality of Life After Prostate Cancer Treatment:

When patients are thinking about radiation treatment options for their prostate cancer, knowing the side effects and toxicities of each option is one of the most important topics of discussion.

In a 2020 study of over 2000 patients, investigators found that modern external beam radiation therapy approaches cause the least longterm toxicities.

  • Nerve-Sparing Prostatectomy: highest probability of urinary incontinence and sexual dysfunction (Dr Lawenda wants patients to know that the risk of severe urinary incontinence is very low; less than 3% for most high-volume surgeons)
  • Brachytherapy: worst side effects relating to urinary irritative (urinary urgency, frequency, nocturia) and bowel function (rectal urgency, frequency).
  • IMRT (intensity modulated radiation therapy): best quality of life for urinary, sexual, and bowel function

Brachytherapy requires that you undergo anesthesia to get numerous large needles inserted through your perineum into your prostate in order to deliver a high dose of radiation (see images, below)

An alternative method to deliver high dose radiation to the prostate uses a non-invasive, 5-session course of IMRT (called SBRT, see below), which is a very safe and equally effective option as the more invasive brachytherapy technique or long conventional courses of IMRT.

Stereotactic Body Radiation Therapy (SBRT)

A recently published study of over 6000 prostate cancer patients treated with only 5 sessions of a non-invasive, highly-focused radiation technique called stereotactic body radiation therapy (SBRT) reported cancer control rates of 95% (5 years) and 94% (7 years)!

Furthermore, the risks of significant longterm bowel and bladder side effects are remarkably low (less than 2%).

Data from over 40 prospective studies have established that SBRT is a new standard treatment for the vast majority of patients with the most common prostate cancers (low and intermediate risk) can be treated with a fast 5-session course of stereotactic body radiation therapy (SBRT).

Even higher risk prostate cancers (unfavorable intermediate and high-risk) can be treated with a shorter course treatment using a combination of 5-weeks of IMRT followed by 3-days of SBRT, instead of 9-weeks of IMRT.

  • If you have a low risk or intermediate risk prostate cancer (most cases), SBRT is a great option.
  • Even higher risk prostate cancers can be treated using SBRT.

SBRT is the latest and most sophisticated approach in the treatment of prostate cancer. Due to many advantages, a 2020 report in JAMA notes that academic radiation oncology programs are increasingly offering patients SBRT and and treating less with brachytherapy.

SBRT benefits over brachytherapy (radioactive seeds):

  • No need for anesthesia
  • No need to go into the operating room
  • No need to traumatize the prostate with dozens of large diameter needles or catheters
  • No need to place permanent radioactive seeds in the prostate
  • If you are offered high-dose rate brachytherapy (HDR) you may require transport by ambulance 🚑 from the hospital operating room to the radiation office with needles in your prostate (twice!)
  • No Foley catheter needed
  • Lower risk of urinary obstruction
  • Less severe urinary side effects

SBRT benefits over conventional course EBRT/IMRT:

  • SBRT is only 5-treatments vs. 20-45 treatments
  • Significantly less expensive (30% less costly)

Protecting the Rectum With SpaceOAR Hydrogel

In the last few years, radiation oncologists have been using a dissolvable gel (SpaceOAR) to further improve side effect profiles.

Many patients also hear about the “seed implant” or catheter-based implant technique (called brachytherapy). While these are also established short-course alternatives for treating the prostate, SBRT has some obvious advantages over brachytherapy:

  • It is non-invasive
  • No anesthesia is required
  • There is no needle-induced trauma (brachytherapy uses many needles to deliver radiation into the prostate)
  • There is a lower risk of urinary obstruction after treatment

There are also significant advantages of SBRT over other external beam radiation regimens:

  • SBRT is a significantly shorter radiation course (5-sessions vs 20-45 sessions)
  • SBRT is less expensive

Here’s a quick video explaining how I use SpaceOAR hydrogel to reduce high-dose radiation to the rectal wall during prostate cancer treatment. Studies confirm that the use of SpaceOAR significantly reduces the risks of rectal toxicity and erectile dysfunction after prostate radiation therapy.

  • Bowel: 66% fewer SpaceOAR hydrogel patients experienced clinically significant declines in detectable bowel quality of life
  • Urinary: 65% fewer SpaceOAR hydrogel patients experienced clinically significant declines
  • Sexual: SpaceOAR hydrogel patients who had erections sufficient for intercourse at baseline were 78% more likely to retain sexual function at 3 years