Intermediate Risk Prostate Cancer: Treatment Options Explained (MUSC)

[00:00:06][Music] hi I'm Dave Marshall I'm a radiation oncologist at Hollings Cancer Center at MUSC and I'm going to talk today about the management of intermediate risk prostate cancer [Music] intermediate risk prostate cancer is not the slowest growing prostate cancer and it's not the fastest it's in the middle that's why we call it intermediate risk usually patients either have a Gleason score of seven that's a three plus four or four plus three or a PSA between 10 and 20 that make them intermediate risk the Gleason score is how the prostate cancer is graded by the pathologist the faster growing the prostate cancer the higher the Gleason score and so there are many management options for intermediate risk prostate cancer and so usually what we do is we talk about three different approaches we either talk about surgery or radical prostatectomy radiation therapy of some form and that is either usually in a seed implant either by itself or external beam either by itself or with the combination of a seed implant in the external beam but before I start that all of these options have a high rated cure for what you have so you're unlikely to die of prostate cancer no matter which of these options you choose in fact if you choose any of these options your chances of dying to prostate cancer in the next 10 years or around one percent [Music] this the first option is the radical prostatectomy this is an excellent option for many patients with intermediate risk prostate cancer there are multiple ways to do this surgery most of them these days are done laparoscopically with robotic assistance but basically what they do is physically remove the prostate during a surgery that's about four hours long when you wake up you have a catheter placed in your bladder while you heal up over the next week or so so this is an invasive procedure it's the most invasive of the options that I'll discuss today but it has the advantages of it's done in a one four hour setting and then after that you're healing up and basically your treatment is complete with surgery to remove your prostate they do have to rearrange the plumbing so they're they take out the prostate which is in between the bladder and the outside so the tube that connects the bladder to the outside called the urethra goes right through the prostate so when they take the prostate out they take a section of this tube with it so then they have to reconnect the two ends the bottom part of the bladder to What's Left of the urethra and this has to heal up so that's why they put the catheter in when they take that catheter out because they've rearranged your plumbing there is a chance that you can have some leakage issues or urinary incontinence so that somewhere between five and fifteen percent or so of men who have this procedure will have to wear a pad or diaper forever after this operation so that's definitely one thing to consider when you're choosing your treatment options [Music] external beam is the least invasive approach you lay in a table a machine moves around you and delivers radiation in the form of x-rays into your prostate in the area around your prostate you don't see or feel anything when this happens it takes about five minutes but you have to come back and forth several times up to 20 treatments or so for intermediate risk prostate cancer in order to get your treatment complete so that it's a four week commitment at our institution once a day Monday through Friday the treatment itself takes only five minutes or so but it's every day Monday through Friday that you have to come in for that treatment [Music] foreign the external beam is different from the Sedum plant in that the Ceda plant is a minimally invasive procedure done on an outpatient setting under general anesthesia takes about two hours but you go home the same day so what we do is when you're asleep we use long skinny needles to place radioactive pellets about the size of a grain of rice in and around the prostate once this is done you're taken up out of anesthesia and when you're awake and alert you can go home so you get all of your treatment done in that one Fell Swoop but it's less invasive than the surgery to remove your prostate now the difference between the external beam and the seed implant is that the external beam is the least invasive the seed implant is in the middle so you can see more bruising or swelling from the seed implant compared to what you would see with external beam which doesn't have any external bruising or swelling so you might after acetam plant pass some blood for a day or two you may have a bit of bruising after the procedure but in general we see you back in a month and most patients are doing quite well by that time with radiation therapy we have very low risk of leakage compared to surgery with surgery as I said five to fifteen percent risk of needing a pad or diaper forever with radiation therapy the risk of having to wear a pad or diapers only about one percent so it's not very likely that's because we're treating the prostate where it is we're not removing anything or rearranging your plumbing but we do have side effects the side effects from radiation are typically from the swelling if you would of the of the prostate so that the passage through the prostate could be partially blocked or obstructed so you have a weaker stream stopping and starting more often when you urinate getting up more in the middle of the night those types of symptoms you can have burning when you pee these types of symptoms are often treated with medications like tamsulosin or Flomax usually to very good effect but this is the common type of problem during the course and for a while after radiation therapy you can also have looser or more frequent bowel movements with radiation as the lining of the colon can be irritated from the radiation these side effects will peak in the first weeks or few weeks during and after the radiation and then slowly go away with time for most patients so that by several weeks to a few months or a year later most patients are back to their Baseline as far as their bladder or bowel habits the severity of these types of bladder obstructive symptoms varied between seed implant and external beams the seed implant is more invasive we place the radioactive pellets directly in and around the prostate so we're poking holes in the prostate it's causing a little bit of trauma more so than the external beam that's done with x-rays and the radiation dose is stronger with the seeds than it is with the external beam so the bladder irritation on average is a little more intense if you have a radical prostatectomy and your prostate's removed you'll have a catheter for a week or so for sure that helps you drain your bladder if you have external beam radiation we usually do not have enough swelling that requires a catheter to be placed into your bladder the risk of that with external beam is only about one percent the seed implant is in the middle there can be more swelling than with the external beam but not nearly as much trauma as we see with the radical prostatectomy so with the seed implant it's about a one in ten or ten percent risk that you might need to have a catheter placed at some point after the seed implant so again in terms of invasiveness the radical prostatectomy to remove your prostate is the most invasive seed implant is in the middle and the least invasive is external being the time commitment is different the radiation whether it's a seed implant or external beam is more of a process so you have the one day surgery to remove your prostate you have the seed implant that's done in a day but the radiation is delivered over a few weeks with the seeds inside you or the external beam radiation which requires usually about 20 trips back and forth for daily treatments now with radiation therapy most patients as I said their bladder irritation looser more frequent bowel movements will decrease over time and go away some patients may see blood in their urine or blood in their stool as the weeks or months go by after radiation and most the time this is from a benign process we don't have to do anything about but if it's persistent we need to check it out and make sure we're not missing something like a polyp so we'll do a scope if this happens and most of the time what we see if there's an injury from the radiation is a little bit of scarring that can bleed especially if patients strain or have constipation so if we can avoid constipation after that usually it'll resolve spontaneously we usually do not have to do anything about this problem and as long as we're aware that there's nothing else going on that needs to be taken care of we leave you alone some patients may have problems with erections after any treatment for prostate cancer whether it's radiation surgery seed implant what have you any treatment for prostate cancer can increase the risk of having problems with sexual function or changes in erectile function the good news is that there are multiple ways to help so we have pills that everybody's familiar with but in addition to that there's three or four or even more other things that we can do to help a gentleman who has problems with erectile dysfunction regardless of the cause these types of situations are best handled by a specialist we have Specialists who focus on erectile dysfunction that we are happy to refer patients to as needed to help with this problem very rarely surgery or radiation can result in a severe injury the good news is it's very unlikely to happen to you if you have radiation it's possible that you could have a severe reaction that could result in a sore that doesn't heal requiring chronic pain medicine or you could have bleeding that requires transfusion or you could have a severe injury that could require surgery to fix even a colostomy bag the good news is that the chances of this happening to you are less than one percent about the same risk as having a catastrophic event during anesthesia for prostatectomy so it's not very likely to happen it's possible but not very likely and we do everything we can to minimize that risk with radiation exposure theoretically it's possible to increase your risk of getting another cancer down the road we know that radiation in general is not good for you we know that from the exposure of patients or people from Chernobyl or the atomic bomb survivors exposure to radiation with that type of uncontrolled exposure can increase your risk of of getting a secondary cancer like leukemias or thyroid cancer this situation is different this is a very controlled precise and accurate delivery of radiation but theoretically it could increase your risk of getting another tumor in your pelvis 5 10 or 20 years after radiation the good news is that this increased risk is very low so if your risk without radiation of getting another cancer in the next 5 10 20 years is X with radiation to treat your prostate cancer that risk may go up by one or two percentage points so it's a small increase in absolute risk you probably will not get another cancer but radiation theoretically could increase that risk slightly so these are the options for treating intermediate risk prostate cancer radical prostatectomy seed implant or brachytherapy or external beam radiation therapy in some cases though we may need to add other things to the mix or combine these modalities together particularly for unfavorable intermediate risk patients so intermediate risk patients are subdivided into favorable intermediate risk and unfavorable intermediate risk if you have a Gleason 7 and your first number is a four so if you have a four plus three Gleason prostate cancer that bumps you into the unfavorable intermediate group if you have a PSA above 10 and a Gleason score of seven two intermediate risk factors that bumps you into the unfavorable intermediate risk group if you have more than half of your biopsy cores with cancer in them that will increase your risk and bump you into the high risk group these higher risk intermediate risk patients are referred to as unfavorable intermediate risk with unfavorable intermediate risk we have studies that have been done over the years that show us if you choose radiation your outcome will be better if we combine agents so we might not just do a seed implant or not just do four weeks of external beam we might combine the two we might do a seed implant and some external beam or we might add what we call a short course four to six months of hormonal therapy hormonal therapy are medications that tell your body to stop making testosterone so we give put you in a low testosterone State on purpose the reason we do that is because prostate cancer can be driven by testosterone so if we take the testosterone away we'll kill prostate cancer cells we don't kill all of them without adding radiation to it so that's why we need the combination with unfavorable intermediate risk prostate cancer sometimes we can do a seed implant or the external beam with hormonal therapy typically in this setting the medication is a pill or a once a month injection that lowers your testosterone we usually start this treatment first and let it work for two months or so before we initiate the radiation treatments so we start the hormone therapy and we let it beat up on the cancer and then we'd start the radiation about two months later the radiation is done in the middle of the hormonal therapy the hormonal therapy then continues for a few months after the radiation is over for a total of four to six months the benefits of adding hormonal therapy are that it makes the radiation more effective so it softens up the cancer in the prostate if you would and makes it more susceptible to the radiation makes it more likely that the radiation will kill all the cancer cells in the prostate the second thing it does is it has effects all throughout your body so if these prostate cancer cells are trying to go other places in your body and set up shop the hormone therapy decreases the chances that that'll be successful so it decreases the likelihood that the cancer spreads somewhere else in your body this one-two punch of the hormonal therapy has been shown in multiple studies in patients with unfavorable intermediate risk prostate cancer to improve the chances of the cancer going away completely and never coming back in fact in multiple studies they improve the chances of you being alive 10 years after the treatment if you do the hormonal therapy compared to if you do radiation without the hormonal therapy so it's an important part of treatment for patients with unfavorable intermediate risk prostate cancer now again hormonal therapy is not without its side effects as I said we put you in a low T State if you would low testosterone on purpose to help us kill the prostate cancer the side effects are that you have low testosterone how does that affect you most men with low testosterone on these medications will have hot flashes they'll go hot and sweaty for five or ten minutes and it goes away like what was that how did that happen that was a hot flash just like women complain about when some of them go through menopause so you can have hot flashes now the second thing that you'll notice uh gentlemen with low testosterone may have decreased sex drive the hormone that has been circulating in your brain telling your body to think about sex since you were eight years old is no longer doing that temporarily so you may have decreased interest in sexual activity that can lead to problems with erections temporarily as well when you're low on testosterone it's hard to build muscle mass so it's easier to put on fat on your chest and belly and harder to keep muscle so these are the things that guys notice when they're on this hormonal therapy the good news is that most of these things if not all of these things will go away once we're done with the hormonal therapy and your testosterone levels come back over time so it's important that if you have intermediate risk prostate cancer that's unfavorable intermediate risk that if you choose radiation you need to understand the importance of hormonal therapy in addition or with the radiation and again this is something that's different than surgery with these options every gentleman who has unfavorable or favorable intermediate prostate cancer for that matter the chances of being cured are the same whether you choose surgery radiation with a seed implant or radiation with external beam especially if you add the hormonal therapy in with the radiation the chances of being cured are very high somewhere in the order of 80 to 85 percent of all patients will be cured of their prostate cancer with any of these treatments so you do have multiple treatments but one of the problems with prostate cancer is that you have to pick which one because none of these three options that we've talked about today are necessarily better than any of the others they just have different side effect profiles for prostate cancer it's very important that every patient hear about all these different options that you have because there's not one best way to treat prostate cancer some patients may be best treated with surgery some with radiation some with a combination of seed implant Etc so make sure that you talk to your urologist and you talk to a radiation oncologist about all these different options you need to be an educated consumer when it comes to figuring out how you're going to manage your prostate cancer at Holly's Cancer Center we truly believe that the best Cancer Care comes in the context of a clinical trial no matter where you get treated ask your provider how can I participate in a clinical trial because that's how we improve Cancer Care for ourselves and for our future if you need more information about how to care for your prostate cancer reach out to Highlights Cancer Center we're here to help [Music] foreign