While a wide array of treatment options exist, it can be difficult for patients to determine what’s best for them when considering side effects such as incontinence and erectile dysfunction. This section exists not to examine all potential options, but rather to direct the patient toward resources that will improve their experience when researching treatment options and navigating the medical system.
Researching treatment options can empower the patient to make more informed decisions, further their understanding of potential side-effects and after-effects, and enable them to actively participate in the treatment process. Yet being unfamiliar with medical literature or statistics can make it an intimidating task; below are resources to use as an easy starting point for research:
Canadian Cancer Society – The Canadian Cancer Society (CCS) provides a brief summary of many treatment options.
myProstate – A Swiss site that allows patients to create and compare outlines of their treatments with other users. When considering a treatment option, patients can view how that treatment has impacted other patients.
Prostate Cancer Information Service – A service run by Prostate Cancer Canada (PCC) that provides information and support throughout the cancer journey; services include a phone line, email response, distribution of resources, and referral to programs run through PCC.
You Are Not Alone (YANA) – A prostate cancer support site that gives an in-depth walkthrough of choosing treatments, general information about options, and useful links.
Conversations with your doctor
A meaningful conversation with a health care provider can make a world of difference for those diagnosed with prostate cancer. Prostate Cancer Canada (PCC) suggests these questions when talking to a healthcare professional about potential treatment options:
- What are the risks if my cancer is not treated soon?
- What treatment options might be right for me?
- What are the major side-effects of the treatments available to me?
- What are the chances I will have problems with incontinence, erectile dysfunction or rectal issues?
- How would various treatments affect my quality of life?
- What is your experience with this treatment?
- How frequent are complications?
- What happens if the cancer spreads beyond my prostate?
- When will my treatment begin and how long is it expected to last?
- What if the first line of treatment doesn’t work?
- How will I be monitored after treatment or during active surveillance?
Available for download is a Personal Decision Form from the Saskatoon and Regina Prostate Assessment Centres. This can be filled out before meeting with a doctor and serve as a helpful tool for the patient when discussing treatment options.
Treating Advanced Prostate Cancer
Age as a factor in treatment decisions
Two-thirds of prostate cancer-related deaths occur in men aged 75 years and over ; so while localized and regional prostate cancer can be cured with procedures such as radical prostatectomy or radiation therapy, treatment options for advanced stages of prostate cancer become palliative in order to avoid impact on the quality of life of older patients.
Treatment at a glance
The primary treatment given to advanced or metastatic prostate cancer patients is hormonal therapy, or androgen suppression therapy (ADT), which slows the growth and spread of the prostate cancer by suppressing male hormone levels in the body. Hormonal therapy is not a long-term solution; the majority (seventy to eighty percent) of patients respond positively to hormonal therapy for around two to three years, but as the response decreases, the prostate cancer begins to spread again. Secondary line hormonal therapy is often used when the first line hormones cease to be effective.
Hormonal therapy can be administered in a variety of different ways: orchiectomy (removal of the testicles), luteinizing hormone-releasing hormone (LHRH) agonist and antagonists and anti-androgens.
Other treatments such as radiation therapy, transurethral resection of the prostate (TURP) surgery, biological therapy, bisphosphonates or RANK-Ligand inhibitors may be offered to the patient in order to relieve symptoms of the disease and treatments such as urinary symptoms, bone pain and fractures.
Side effects of hormonal therapy
Hormonal therapy causes side effects because it reduces the levels of male hormones in the body. These side effects can include:
- Breast tenderness and growth of breast tissue
- Decreased mental sharpness
- Hot flashes
- Increased cholesterol
- Loss of muscle mass
- Reduced or absent libido
- Shrinking of testicles and penis
- Weight gain
For more information about the treatment of metastatic prostate cancer, click here.
Not all patients with advanced prostate cancer experience pain; pain levels can vary from person to person, and more than 25% don’t experience any pain at all . If you’re experiencing pain, or if your pain relief isn’t working, it’s important to speak to your primary health care provider to find a treatment more suited to you. Listed below are types of pain typical in metastatic prostate cancer:
Complementary and Alternative Therapies
Complementary and alternative medicines (CAM) are alternate medical products and practices that do not make up a part of conventional medical practice; CAM therapies can include acupuncture, chiropractic, and herbal therapies. They can be used in conjunction with a conventional medical practice or on their own; sometimes to ease the physical and psychological side effects of cancer treatment or to treat the cancer itself. While there is no guarantee these treatments will work, they may provide relief and comfort for some patients.
Cancer Wellness Centers often offer complementary and alternative medicines, such as yoga, and other healthful practices for patients and their caregivers. Researching the programs and services available at a local Cancer Wellness Centre may give an idea of the alternative treatments that can be beneficial to a patient.
- Canadian Cancer Society – Complementary and alternative therapies – Contains useful definitions pertaining to CAM that will help patients determine whether it would be useful to them
- Inspire health – Integrative cancer care – Inspire Health, based in British Columbia, offers health care for cancer patients which incorporate both conventional and complementary therapies surrounding cancer care; they also offer an online program
Managing Pain with Metastatic Prostate Cancer
Bone metastases (when the cancer has spread to the bone) is a common source of pain in patients diagnosed with advanced prostate cancer. Bone metastases can cause fractures and in rare cases hypercalcemia, a condition that weakens bones and creates kidney stones due to excess calcium in the bloodstream. The areas of bone likely to be first affected are those close to the prostate such as the pelvic bone, lower spine, hips and upper thighs.
Bone pain is a very specific feeling. Some men describe it as feeling similar to a toothache but in the bones, or like a dull aching or stabbing. It can get worse with movement and can make the bone tender to the touch. Every man’s experience of bone pain is different, the pain may be continuous or it might come and go.
Bisphosphonates and RANK-Ligand inhibitors are the two drug classes that are currently available to treat bone pain and can be used to improve the quality of life for patients suffering from bone metastases.
Other treatments such as radiation therapy, transurethral resection of the prostate (TURP) surgery, and biological therapy may be offered to the patient in order to relieve symptoms.
Neuropathic pain is caused by damage in the nerve. If the cancer presses against a nerve ending on a bone, it can lead to pain described as a stabbing, burning or tingling sensation. Some patients may also experience numbness in the damaged areas.
Reflective or referred pain is when the neuropathic pain is felt in areas of the body that aren’t damaged. In advanced prostate cancer, the most common type of referred pain is known as sciatica. When the nerve damage is in the spine and runs down the legs, pain is normally felt in the lower back, buttocks, legs, and feet; though sciatica usually only affects one side of the body. Symptoms of sciatica are pain, numbness, tingling, fatigue and limited mobility.
Lymphedema is caused when the cancer spreads to the lymph nodes. The cancer creates a blockage in the lymphatic system which leads to fluid buildup and causes swelling, typically in the legs. Lymphedema may also be developed as a side effect to treatments such as radiotherapy and surgery.
There are a number of factors your doctors will take into consideration when the time for treatment comes along:
- The type and stage of the cancer
- The grade or Gleason score
- The possible side effects of treatments
- Your personal preferences
- Your overall health
- Your age and life expectancy
Men in the high-risk group are usually offered aggressive treatment. Those in the low-risk group may be offered active surveillance without immediate treatment.1
Active surveillance is when the healthcare team routinely follows up on a patient and monitors them closely for any symptoms that the cancer is growing or spreading. The follow-up exams are performed every three to six months and the patient will have to undergo treatment if there are any signs the cancer is progressing.
Surgery will depend on how advanced the disease is. A radical prostatectomy will remove the prostate and some tissues around it, including the seminal vesicles. There are different types of radical prostatectomy including:
- Retropubic or behind the pubic bone in the abdomen;
- Perineal which is done through the perineum between the testicles and the anus;
- Laparoscopic which consists of a laparoscope reaching through a small incision into the abdomen;
- Robotic or guided by a robotic instrument that is highly precise;
- Nerve-sparing and transurethral resection of the prostate (TURP). A TURP removes part of the prostate through the urethra in the penis in order to help relieve urinary problems caused by an enlarged prostate pressing on the urethra. TURP is used to treat men with advanced prostate cancer or those who aren’t healthy enough to have a radical prostatectomy.2
Cryosurgery uses extremely cold elements such as liquid nitrogen and liquid carbon dioxide to freeze and destroy abnormal cells. For the time being, cryosurgery is only an experimental treatment for prostate cancer.
Pelvic lymph node dissection (PLND)
A pelvic lymph node dissection (PLND) removes the lymph nodes in the pelvis, usually at the same time as a radical prostatectomy. This is done to prevent cancer cells from spreading to other organs and to determine how advanced it is.
External beam radiation therapy
Doctors use high-energy x-rays focused on the prostate tumours to destroy them. The painless radiation is given in short bursts so that normal cells have time to recover. However, some healthy cells around the prostate may also be affected. This treatment requires sessions of five days a week for seven to eight weeks.
Brachytherapy is a procedure that surgically implants tiny radioactive “seeds” to help shrink the prostate gland by administering doses of highly concentrated radiation. The radiation from the seeds travel a very short distance and are focused into a small area, limiting the amount of damage to healthy tissues nearby. Low dose rate brachytherapy emits low levels of radiation for several weeks or months while high dose rate brachytherapy emits higher doses of radiation for up to 20 minutes over the course of a few days. Because the seeds are so small, they rarely cause discomfort and are left in place after their radioactive material has been exhausted.
Hormonal therapy or androgen deprivation therapy (ADT) is most often used to treat advanced prostate cancer and recurrent prostate cancer. The hormone, testosterone, is responsible for prostate cancer cell growth, making it a common target for deprivation therapy. The goal of ADT is to deprive the cancer cells the testosterone they need to grow by reducing the overall levels of testosterone or by blocking them from getting into cancer cells. Hormonal therapy can be used before radiation therapy or surgery to shrink the prostate cancer tumour, in conjunction with radiation as an initial treatment or in cases of recurrent disease.
Chemotherapy is used to treat advanced prostate cancer and is sometimes used in tandem with hormonal therapy to treat men with metastatic prostate cancer. The treatment can help alleviate cancer pain, slow the growth and spread of the cancer (by shrinking or eliminating tumours) and prolong life.
High-intensity focused ultrasound (HIFU)
High-intensity focused ultrasound (HIFU) uses potent ultrasound waves to create intense heat and destroy cancer cells. Sometimes doctors use it to treat recurring prostate cancer after it’s already been treated with radiation therapy. For the time being, HIFU is only an experimental treatment for prostate cancer.
Corticosteroids are hormones that act as an anti-inflammatory by reducing swelling and lowering the body’s immune response (the immune system’s reaction to the presence of foreign substances). Corticosteroids are sometimes given with chemotherapy to help chemotherapy work better and to lessen the side effects. They can help slow the growth of prostate cancer cells and alleviate cancer pains.
It is very important to follow treatment with continuous cancer care. Patients will need to attend regular follow-up visits, particularly in the first five years after the treatment has been completed. These visits will allow your doctor to better understand the progression of your disease so that they can administer the appropriate treatment.3