Prostate Cancer Treatments and Complications (Side Effects)

Prostate cancer patients with limited disease are grouped into low-risk, intermediate-risk and high risk for metastatic disease based on the clinical stage, Gleason score and PSA values. Read more on prostate cancer staging.

The treatment plan in limited disease is based on the risk.

  • Low-risk group includes stage T1 or T2, Gleason score less than 7 and PSA values less than 10 ng/mL.
  • Intermediate risk group is usually in stage T2, Gleason score of 7 and PSA value between 10 to 20 ng/mL.
  • High risk group includes stage T3, has a Gleason score greater than 7 and PSA greater than 20 ng/mL.

The therapeutic options available for men with limited prostate cancer include :

  • watchful waiting (wait-and-watch)
  • androgen deprivation therapy
  • radical prostatectomy with or without adjuvant radiotherapy of the pelvis
  • radiation therapy (external beam radiotherapy or brachytherapy)

Early Stage Prostatic Cancer

For information on treating high-risk prostate cancer and recurrence, refer to the article on Prostate Cancer Treatment Options.

Low-risk to intermediate-risk prostate cancer

A watchful waiting (wait-and-watch / WAW) with delayed definitive therapy may be adopted with localized prostate cancer. Active intervention is initiated when unfavorable disease status or progression is evident on the annual follow-up surveillance prostate biopsy.

Radical Prostatectomy for Prostate Cancer

Radical prostatectomy is a major surgery and is recommended only in patients with a life expectancy of 10 or more years. It is usually performed in men with T1 or T2 prostate cancer which is clinically localized and without any serious comorbidity. The aim of surgery is the entire removal of cancerous tissue with negative excision margins and minimal loss of blood and other surgery-related complications.

Open surgery involves a suprapubic incision while a laparoscopic approach is the minimally invasive alternative option. The procedure also involves the removal of surrounding connective tissue and pelvic lymph nodes from both sides.

Radical prostatectomy can also produce excellent results when performed laparoscopically by experienced surgeons. Sometimes it may be performed with robotic assistance. The average hospital stay following radical prostatectomy is less than 3 days for open radical prostatectomy and 1 or 2 days for laparoscopic radical prostatectomy.

Radiation Therapy for Prostate Cancer

Radiation therapy, or radiotherapy, in prostate cancer is administered either in the form of external-beam radiotherapy (EBRT) or brachytherapy. EBRT and brachytherapy can provide results comparable to radical prostatectomy for patients with clinically limited prostate cancer.

The sophisticated computer-aided intensity modulated three-dimensional conformal radiotherapy (3D-CRT) which is currently used for radiation therapy reduces the volume of irradiated normal tissue and helps in safely delivering a high radiation dose to the prostate. The radiation of the pelvic lymph nodes in selected high-risk patients has been found to improve the outcome. Long term outcomes are significantly improved with use of higher dose of hypofractionated regimens particularly in high-risk patients.

Brachytherapy

Brachytherapy involves placement of temporary or permanent radioactive needles directly into the prostate tissue. Iodine-125 and palladium-103 isotopes are commonly used for permanent brachytherapy. Brachytherapy needles may be placed under TRUS guidance or transperineal ultrasound guidance. Brachytherapy alone provides adequate radiation to treat low-risk tumors that are limited by the capsule of prostate.

In intermediate and some high-risk prostate cancers brachytherapy is sometimes combined with EBRT. Brachytherapy is not ideal for prostate glands larger than 60 cm3. These patients may be prescribed androgen deprivation therapy to reduce the tumor size to a degree that will allow for the use of brachytherapy. Brachytherapy is usually avoided in patients who are experiencing significant urinary obstructive symptoms as there is a high risk of developing prolonged morbidity following brachytherapy. Patients with  contraindications for EBRT (like patients who have small bowel close to the prostate or those with inflammatory bowel disease) are ideal candidates for brachytherapy.

Androgen deprivation therapy (ADT)

Androgen deprivation therapy is of value in intermediate risk patients in combination with EDRT. Improvement in the local control and prolongation of progression-free survival can be obtained with 4 months of ADT following EDRT. ADT alone is being used more frequently for patients who would like to have some therapy, but are not suitable for or decline radical prostatectomy or radiotherapy.

For information on treating high-risk prostate cancer and recurrence, refer to the article on Prostate Cancer Treatment Options.

Complications of Prostate Cancer Treatment

It is important to note that the complications below will not arise in every case. Treatment should be undertaken by a cancer specialist (oncologist) in conjunction with other specialist physicians and the patient’s family doctor. The possible complications and other side effects should not detract from the need for treatment. In advanced cases, the various treatment modalities may be used for palliative care (comfort care) to improve the quality of life but not for “curing” the cancer. Refusing treatment advised by an oncologist due to the potential side effects and complications can ultimately delay appropriate treatment and reduce the chances of total cure.

Radical Prostatectomy

  • Blood loss
  • Injury to surrounding structures like rectum
  • Deep vein thrombosis (DVT)
  • Pulmonary embolism
  • Bladder neck stricture
  • Post-operative urinary incontinence
  • Erectile dysfunction (ED)

Radiation Therapy

The radiation-related complications depend on the dose of radiation, the amount of normal tissue exposed to radiation and the field of irradiation. Acute complications of external radiotherapy usually start in the third or fourth week of treatment and often resolve with in a few days after the completion of radiotherapy.

  • Radiation proctitis (inflamed rectum) – mucus discharge, rectal bleeding
  • Fecal incontinence (mild)
  • Chronic urethritis
  • Urethral strictures
  • Urinary incontinence
  • Acute urinary retention
  • Hemorrhagic/radiation cystitis
  • Erectile dysfunction and other sexual function disruptions like decreased libido, absent ejaculate and decreased intensity of orgasm

Cryotherapy

The long term adverse effects with the current techniques of cryotherapy used for salvage therapy of prostate are :

  • Erectile dysfunction
  • Pain in rectum
  • Urinary incontinence
  • Urinary retention
  • Urethritis

Androgen Deprivation Therapy

  • Hot flashes
  • Loss of libido
  • Reduction in penile length and/or testicular size
  • Erectile dysfunction
  • Loss of facial and body hair
  • Gynecomastia
  • Breast tenderness
  • Weight gain
  • Muscle weakness
  • Anemia
  • Osteoporosis
  • Hyperlipidemia
  • Hyperglycemia
  • Fatigue
  • Depression
  • Risk of cardiovascular disease and sudden cardiac events with ADT

Various preventive measures or therapeutic interventions are employed to minimize the adverse effects of ADT. Hot flashes are controlled with estrogens. Breast irradiation may be done prophylactically to prevent breast tenderness or gynecomastia. Osteoporosis can be prevented or treated with bisphosphonates. Cardiac risk factors are screened and treated according to the problems observed in each individual.

Chemotherapy

  • Nausea
  • Vomiting
  • Abnormal taste sensations
  • Fatigue
  • Hair loss
  • Loss of appetite
  • Neuropathy
  • Neutropenia

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