Active surveillance means you will not have any aggressive treatment. It is recommended for low grade, low volume cancers where the best available research to date suggests that there is little (if any) difference in long term survival between men who are treated and men who are not. It allows you to avoid the negative side effects of treatments which will have little benefit to your health at the present time.
However, prostate cancer is a serious disease and it is important to monitor your progress. Active surveillance means just that – regular testing to ensure the disease has not progressed to a point that it requires treatment.
Our active surveillance program involves regular PSA testing and, if necessary, repeat biopsies. Our use of the new multiparametric MRI prostate technology has enabled us to safely monitor men on the active surveillance program without necessarily subjecting them to regular repeat prostate biopsies. Active surveillance requires patient compliance for it to be a safe management strategy.
For men who require active management,
choice of management becomes the issue.
The choice between surgery and radiation depends on many factors including patient age, patient co-morbidities, lower urinary tract symptoms and tumour characteristics. Younger men with organ confined disease and especially men with outflow obstructive symptoms are best managed by radical prostatectomy.
Radical prostatectomy is an operation to completely remove the prostate, seminal vesicles and some of their associated pelvic lymph nodes. The goal is to completely remove any cancer contained within the prostate and surrounding tissues. For locally confined disease, this provides an excellent chance of cure.
Surgical management by radical prostatectomy involves completely removing the prostate.
In 1982 Professor Patrick Walsh popularised modern nerve sparing radical prostatectomy. His improvements allowed better control of important blood vessels to reduce bleeding and precise localisation and preservation of the nerves responsible for erectile function. This surgery remains the gold standard treatment for localised prostate cancer. It is the best management for younger men with organ confined disease and especially men with outflow obstructive symptoms. Such men need to choose between open surgery, laparoscopic or robot-assisted laparoscopic radical prostatectomy.
The approach that is best for you will be discussed at your pre-operative appointment.
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Brachytherapy: An effective alternative to radical prostate surgery
For certain men with low risk cancers brachytherapy may represent an effective alternative to radical prostatectomy surgery or external beam radiation therapy. Brachytherapy may be an option for you if you have:
- A Gleason score ≤ 6
- A PSA at diagnosis of ≤ 10 ng/mL
- ≤ 50% positive biopsy cores
There are two kinds of brachytherapy: high dose rate brachytherapy and iodine seed brachytherapy. Both involve implantation of small pellets containing radioactive iodine-125 into the prostate under transrectal ultrasound guidance. This allows the dose of radiation to be targeted to the cancer cells, reducing the impact on surrounding healthy organs and to be much lower than in external beam radiotherapy because the cancer is directly exposed.
Assessing your risk profile is critical in making the decision to undergo brachytherapy instead of radical prostatectomy.
For men with high risk disease, radical prostatectomy remains the most effective treatment to prolong disease free survival.
After brachytherapy you will not be able to have surgery.
External beam radiation therapy
For some patients, who have disease that is localised but not confined to the prostate or who are unable to undergo surgery, external beam radiation therapy may be the best treatment option. In that event, we will organise a referral to a radiation oncology specialist who will discuss the best means of management.
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Androgen deprivation therapy and biochemical failure
No treatment for prostate cancer is 100% effective; there is a risk after any form of treatment that some of your cancer will remain or recur and that you will require further treatment. For many men, this is may be many years in the future and is detected by monitoring the PSA. “Biochemical failure” is said to have occurred when your PSA rises above a certain level after radical prostatectomy or other definitive treatment. At this point, you may be treated with androgen deprivation therapy.
Androgens are “male hormones” which play an important role in male sexual development and function, the most well-known being testosterone. Androgens can also play a role in prostate cancer growth: blocking production of male hormones can cause prostate cancers to shrink or grow more slowly for a period of time, prolonging the time that you are symptom-free. Androgen deprivation therapy is not a cure for prostate cancer, and it does have a number of unpleasant side effects including reduced libido, hot flushes and fatigue.
There are several different types of drugs that block androgen production, some involve oral tablets taken daily and some involve injections given by your doctor over a much longer period. These either block the ability of the body to respond to androgens or prevent production of androgens.
Surgically, removal of the testes or orchidectomy is also an effective and permanent way to reduce androgens in the body. The testes are the site of initial androgen production.
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