William Aiken

There seems to be a great deal of misunderstanding and apprehension among men regarding the treatment of prostate cancer. The concern relates mainly to available options and their potential side-effects.

There is a misconception on the part of a lot of men that treatment of prostate cancer will invariably render them impotent and incontinent. While this is true in some cases, it is definitely not the case for the majority of men. Unfortunately, these fears are a strong factor in preventing some men from having the necessary tests to determine whether they have prostate cancer. They feel that life will not be worth living if these presumed side-effects were to afflict them.

Many factors are taken into consideration when determining how a specific patient with prostate cancer ought to be treated. These factors may be categorised into tumour factors, patient factors, and logistical factors.

Tumour factors

Tumour stage, that is, the extent of spread of the tumour, and tumour grade, that is, a measure of the degree of likely aggressiveness of the tumour, are the most important tumour factors used to guide treatment and determine prognosis. The stage is determined by a careful evaluation of the patient, while tumour grade is assessed by microscopic examination of tissue submitted to the pathologist.

A tumour that is confined to the prostate is potentially curable by removal of the prostate, radiotherapy or cryotherapy.

When the tumour has directly spread outside of the prostate but is not involving lymph nodes it is called locally advanced; when spread to the pelvic lymph nodes is present, this is called regional metastasis and when spread to distant sites such as the bones or non-contiguous organs is involved it is called distant metastasis.

Patient factors

Patient factors determining treatment include age, life expectancy, presence and severity of other illnesses, symptoms as well as complications that are present as a consequence of the cancer, quality of life issues and patient wishes/expectations regarding treatment.

The options for treating prostate cancer when it is still confined to the prostate and therefore curable include watchful waiting, radical prostatectomy, external beam radiotherapy, brachytherapy (implantation of radioactive seeds in the prostate), and cryotherapy (freezing the prostate).

Watchful waiting involves regularly checking the patient's PSA, a surrogate marker for tumour volume, and is indicated in patients with low-grade tumours that are unlikely to pose a threat to the patient's life because of their slow-growing nature.

Removal of prostate

Radical prostatectomy (RP) involves complete removal of the prostate and an adjoining gland called the seminal vesicles, followed by reconstruction of the bladder neck and reattachment of the urine passage to the bladder over a catheter for three weeks while the junction heals. This may be done by an abdominal, perineal (between scrotum and anus) or laparoscopic (keyhole surgery) approach.

Nerve-sparing RP refers to preservation of the nerves on either side of the prostate that convey impulses to the penis and are responsible for erections. An attempt to spare these nerves is routinely done unless it is clear that the tumour is encroaching on them.

Potential side-effects of surgery include a very low incidence of urinary incontinence, erectile dysfunction, and a stricture of the bladder-urethral junction. Erectile dysfunction is more likely to occur in older patients and in those whose erectile function is suboptimal prior to surgery. Erectile function may take up to 18 months to recover and during this period oral agents (Viagra, Levitra or Cialis) or injections directly into the penis are useful in maintaining the viability of the tissues of the penis and allowing for intercourse to take place.

Dr. William Aiken is the head of Urology at the University Hospital of the West Indies and president of the Jamaica Urological Society; email: yourhealth@gleanerjm.com.