by Science Writer Heather Schmidt and Ernesto Cullari ….
Prostate cancer is the second most common form of cancer diagnosed in men in the United States. In America, 1 in 39 men will die of prostate cancer, according to cancer.org.
Yet many patients, clinicians and families alike are beginning to demand better treatment options, including in some cases, no treatment at all, because recent research cites the ‘over-diagnosing’ and the ‘over-treating’ of prostate cancer, coupled with the harrowing, often permanent side-effects, associated with the current standard of care.
Believe it or not, prostate cancer has been over diagnosed. In the desire to reduce mortality rates from prostate cancer, early detection and more advanced screening technologies has led to the treatment of patients who never would have been diagnosed with cancer, because the disease in many was clinically insignificant and never would have been detected in the patient’s lifetime, without the more advanced screening methods available now.
Otis Brawley, writing for CNN cites, “The phenomenon of cancers that can be diagnosed but will never progress and cause harm is the end result of dramatic improvements in our diagnostic and imaging technologies. The technical term for this phenomenon is “overdiagnosis.” It has been estimated that overdiagnosis occurs in half of all patients with prostate cancer, perhaps 30% to 40% of those with thyroid cancer, 10% to 30% of breast cancer patients and even some with screen detected lung cancer.”
This is a major revelation, considering the ways prostate cancers are treated. It is well established that cancer therapies can be toxic, drastic, invasive, painful, debilitating and emotionally devastating. The treatments are often as damaging as the disease.
Case in point, while the most common forms of prostate cancer diagnosed are deemed ‘non-aggressive’ the standard of care can be very impactful upon a patient’s overall quality of life. The first intervention is usually hormone therapy – androgen deprivation therapy being the most common. This treatment decreases the amount of testosterone and is also known as chemical castration. And while there are several types of hormone therapy that work to decrease the levels of androgens available in the body in different ways, almost all the treatments carry the risk of urinary incontinence, diminished libido and erectile dysfunction – which can be permanent.
Other side effects can include: loss of bone density, which can lead to bone fractures, loss of muscle tone and strength, which can lead to further bodily injury. There can be other physiologic changes such as dangerous changes in blood lipids and insulin resistance. Many of these symptoms are commonly encountered and can be permanent.
Such drastic physiologic changes can be demoralizing to a patient and can be harder to cope with than the cancer, impacting one’s self-esteem, psychological well-being and intimate relationships.
There are other current treatment options including; radical prostatectomy, EBRT (external beam radiation therapy), brachytherapy (implanting a radioactive seed near a tumor) as well as chemotherapy. However, chemotherapy is typically only considered if the cancer has spread or if used in conjunction with another treatment.
Radical prostatectomy removes the entire prostate as well as the seminal vesicles. There are three types of radical prostatectomy including retropubic, laparoscopic/robotic assisted and perineal.
The retropubic and the perineal procedures are open surgeries and are not as commonly performed today as they once were. Open surgery is just like it sounds, the body is opened via creating large incisions. There is a longer healing time associated with open incision type surgeries.
The retropubic surgery is done by dissecting through the abdominal wall. This surgery effectively weakens the abdominal wall and can include a painful recovery period. It has been reported that in 15 to 20% of cases, patients have developed inguinal hernias, which may lead to an additional surgery to correct or to support the abdominal wall.
During the retropubic surgery, the surgeon makes an incision in the lower abdomen, from the belly button down to the pubic bone. The patient may be anaesthetized under general anesthesia, where they are asleep or the patient will be given spinal or epidural anesthesia, which numbs the lower half of the body, combined with sedation during surgery. It is very common during this procedure for the physician to examine the lymph nodes to determine if the cancer has spread.
If this is the case the prostate gland will not be removed, because it is unlikely the procedure will cure the cancer and the post-surgical side-effects are too debilitating, with the most common side-effect being urinary incontinence, followed by sexual dysfunction.
The perineal procedure is a shorter procedure. It is somewhat less invasive, with a shorter recovery period. It may be recommended if the patient is obese, where weakening the abdominal wall is likely to cause herniation. Nonetheless, there is a high incidence of erectile dysfunction, but it may be performed if the patient is not concerned with erectile function and it has been determined that the lymph nodes do not need to be removed.
Laparoscopic radical prostatectomy is now the most commonly recommended surgical intervention for prostate cancer, because it is among the least invasive of the surgeries, with less blood loss and an easier recovery period. It can be done with robotic assistance or without, but both a monitor screen, where the surgical team can view what is going on inside the body. Small incisions are made in the abdominal wall, where both the instruments and the camera are inserted into the body. Despite the less invasive nature of laparoscopic surgery the success rate of curing prostate cancer is nearly the same as that of the open procedures and the long-term side-effects are nearly the same as well.
In addition to surgical procedures for prostate cancer there are other interventions:
- EBRT (external beam radiation therapy) is a form of radiation targeted to a specific region that is delivered by a machine such as a cyberknife, a linear accelerator. There are several types of EBRT as well including IMRT, Protons and Tomotherapy.
- Brachytherapy, commonly referred to as radioactive seed implantation – is defined as any procedure in which a source of radioactive material is placed near a neoplasm (tumor).
“Complications following Prostate Cancer treatment are relatively common regardless of treatment approach. These include the commonly identified issues of urinary incontinence and erectile dysfunction, and others including hospitalization and invasive procedures to manage complications and secondary malignancies.1” While not all therapies carry the risks of urinary incontinence and sexual dysfunction, most do, and for some these effects are long-lasting, if not permanent.
New evidence indicates that the first order of treatment for prostate cancer should be observation in nearly half the patients. For progressive cancers, the first intervention should not be chemical castration via androgen deprivation. Therapies that disrupt cancer’s metabolism and that do so in ways that are neither toxic nor known to induce erectile dysfunction or incontinence should be given both serious consideration and priority over hormonal, chemo, radiological and surgical interventions.
Wallis CJD, Glaser A, Hu JC, Huland H. Survival and Complications Following Surgery and Radiation for Localized Prostate Cancer: An International Collaborative Review. European Urology. June 2017.
Smith MR, Finkelstein JS, McGovern FJ, Zietman AL, Fallon MA. Changes in Body Composition During Androgen Deprivation Therapy for Prostate Cancer. The Journal of Clinical Endocrinology & Metabolism. 2002;87(2):599-603.