Curing prostate cancer

Depending on the individual patient and the progression of cancer of the prostate, urologists and radiation oncologists and their patients can choose from three treatment options:

Wait and see means what it says: Watch early cancers to see if and how quickly they spread. Advocates maintain that, in slowly progressing tumors, particularly in patients who are quite elderly, survival rates still will be high--that is, these patients are likely to die of something else before the prostate cancer reaches a fatal stage.

Radical prostatectomy (surgery to remove the prostate). "A new `nervesparing' surgery preserves sexual potency in 50-70% of patients, depending on the patient's age, sexual history, and stage of the tumor," notes Carlos Perez, professor and director of the Radiation Oncology Center, Mallinckrodt Institute of Radiology, St. Louis, Mo. Traditional surgery usually results in impotency.

However, after surgery, "25% of patients will have stress incontinence (involuntary release of urine when a man coughs, for instance) and six percent will have total incontinence," indicates Gerald Hanks, chairman of the Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pa. "This is a real problem for a man in his late 50s who still works."

Up to 20% of surgery patients also will receive radiation therapy after surgery if the cancer has spread into adjacent tissue or, after prostatectomy, prostate specific antigen (PSA) tests show an increase in glycoprotein in the blood, which normally is elevated when cancer is present.

Radiation therapy alone. Treatment can be delivered with external beam X-ray, a radioactive implant, or both. About 30% of patients opt for radiation therapy The cure rate is comparable to surgery, and the incidence of impotence is reduced to about 15-30%. Incontinence is a rare complication, occurring around two percent of the time. Radiation therapy means no general anesthesia or other risks of surgery, plus it is less expensive.

The optimal radiation dose for curing prostate cancer, as documented in 20-year outcome studies, is delivered over 30 to 40 treatments five days a week for six to seven weeks. Each treatment takes a few minutes.

Conformal therapy is a newer technique being used to "shape" the healing radiation beam to the size and contours of the tumor--circular, pear-shaped, or irregular. The technique enables a higher dose, necessary for better cures, to be delivered right to the cancer site, sparing nearby healthy tissue.

"Conformal therapy is planned in three dimensions on a computer," Perez explains, and is sometimes called "throwing a net around the cancer." It is made possible by fast, versatile computers that pinpoint the cancer and calulate precisely the radiation beam direction and dose. Conformal therapy makes it possible to study the effectiveness of higher doses

Current clinical trials are investigating ways to improve existing treatment options. These include:

* Hormone treatment. Suppressing male hormones with female hormones or drugs that induce total androgen depletion, used in conjunction with radiation therapy, are promising in improving cure rates. Male hormones in the prostate may stimulate cancer growth.

* Implanted radiation (brachytherapy). Radjoactive "seeds" are implanted directly into the prostate. "Some early studies suggest that it can reduce the sexual impotence rate to 15-25%; however, not enough well-controlled studies have been done," Perez points out.

* Cryroablation. The prostate harboring the tumor is frozen by a urologist with the help of ultrasound, killing the cancer cells.

* Ultrasound. Images using sound waves, not X-rays, may be helpful when combined with PSA tests in detecting prostate cancer. In one study, transrectal ultrasound found some abnormal prostate images in men with normal PSA levels.