Note: you will not find surgery listed here, nor will you find chemotherapy as it has not been proven to be effective for prostate cancer.
Active Surveillance is based on the concept that low-risk prostate cancer is unlikely to harm you or decrease your life expectancy. Over 30% of men have prostate cancers that are so slow growing and “lazy” that Active Surveillance is a better choice than immediate local treatment with surgery or radiation. Of the top 10 most common cancers, prostate cancer is the only one in which so many patients have a slow-growing tumor that does not warrant aggressive immediate treatment.
Active Surveillance is not “no treatment,” but rather a strategy to monitor your diagnosis.
It can feel counterintuitive to be told that you have cancer, but that the best option is to sit and wait. But studies show that men with low-risk prostate cancer who have been on Active Surveillance for 10 to 15 years after diagnosis have remarkably low rates of their disease spreading or dying of prostate cancer. In fact, a Johns Hopkins study of men on Active Surveillance found that, 15 years later, less than 1% of men developed metastatic disease. This is important because treatments used for localized prostate cancer—surgery and radiation—have side effects that can alter a person’s quality of life.
The key to these successful numbers is making sure you are monitored regularly for signs of progression. A PSA blood test and digital rectal exam (DRE) are usually done once or twice per year by your urologist, with a repeat biopsy of the prostate every 1 to 5 years. If there is evidence that the cancer is progressing, treatment may be warranted.
Active Surveillance may also be more appropriate for men who are currently battling other serious disorders or diseases—such as significant heart disease, long- standing high blood pressure, or poorly controlled diabetes. In a patient with other health issues, the patient and his doctors might feel that performing invasive tests or treatment would cause more harm than benefit. For these men, their treatment plan would of course help manage any symptoms that occur due to advanced disease. There are also some men with favorable intermediate risk who may be good candidates for Active Surveillance.
As with any treatment for prostate cancer, shared decision-making with a physician is necessary. Some physicians also administer commercial genetic tests—such as Decipher, Oncotype Dx® Prostate, and Prolaris®—that may be helpful in determining if you are a good candidate for Active Surveillance.
LDR brachytherapy uses iodine-125 and palladium-103 stored in titanium cases usually referred to as brachytherapy seeds. As the name permanent brachytherapy suggest, the seeds are permanently left inside the prostate gland. Over the course of their radioactive lives, the seeds will continuously emit low levels of radiation.
HDR brachytherapy uses a single radioactive seed made of iridium-194 which is sometimes referred to as an iridium wire. Soft flexible plastic catheters are inserted through the perineum and into the prostate gland. HDR brachytherapy entails an overnight stay in the hospital during which a patient undergoes two or three treatments with the wire through each catheter.
High Intensity Focused Ultrasound, or HIFU, is a therapy option for patients with localized, "organ confined", prostate cancer, where the tumor is still confined to the organ and has not spread to other areas of the body. HIFU is one of the few prostate cancer treatments that can be considered a minimally invasive, out-patient, radiation-free procedure where the patient does not require an overnight hospital stay. If the prostate cancer returns after initial treatment using HIFU, it does not rule out other treatment options and can be used again as needed.
During HIFU, the ultrasound waves heat up to 195-degrees Fahrenheit and target the affected prostate tissue for 2-3 seconds, leaving the healthy area around the target unharmed. Tissue Change Monitoring Software (TCM) makes it possible for surgeons to monitor changes in the prostate tissue during HIFU therapy in real time. Surgeons see how the prostate tissue is reacting to the ultrasound waves and alter treatment as needed. The precision of the Sonablate HIFU allows for flexibility in the procedure, making it possible for physicians to offer a customized treatment plan tailored to each patient's diagnosis.
For all forms of HIFU, treatments only last a few hours, and a catheter is usually worn for one to four weeks post-procedure. Patients are able to return to normal activity in a short amount of time.
Laser ablation generates intense heat that completely encompasses the targeted area. Under real-time MRI guidance, a special optical fiber is guided precisely into place at the core of the tumor. When activated, the laser emitted at the tip of the fiber destroys the tumor within minutes while special tracking called thermometry confirms the proper temperature. Afterward, multi-parametric MRI scans reveal that the destruction is complete, and the laser fiber is removed.
Prostate cryotherapy works because as cells freeze, ice crystals form inside and around them. The freezing and thawing processes destroy cells through dehydration, drastic changes in the pH levels, or prevention of the flow of red blood cells. Subjecting the prostate gland to freezing temperatures, specifically negative 40 degrees Celsius, also activates an anti-tumor response in the body. An anti-tumor response begins with the production of anti-bodies that work to eradicate the tumor.
Cryotherapy is an effective primary treatment for those who are in the early stages of prostate cancer with low risk for tumor extension. This treatment may also be an excellent alternative for those who are not good candidates for radical prostatectomy. Cryotherapy may be used if EBRT fails and the cancerous prostate cells are deemed radioresistant. Some advantages of include the one day in-hospital treatment, though some patients will stay overnight depending on their general health.
Cryotherapy can also be repeated if it fails to ablate the cancerous tissue during the first round of treatment. Patients for whom treatments fail can also pursue alternatives such as radiation therapy or prostatectomy. Because cryotherapy is minimally invasive, patients experience only minimal, if any, blood loss. One disadvantage is that the long-term data on cryotherapy is limited, due to its newness as mainstream prostate cancer treatment.
NanoKnife, otherwise known as Irreversible Electroporation (IRE) uses the NanoKnife device to pass an electrical current through the tumor. The electricity creates very tiny openings (called pores) in the tumor’s cells, leading to the death of the cells. An ultrasound or a CT scan is used to focus the current precisely on the tumor, sparing blood vessels and other tissues.
TULSA (Transurethral Ultrasound Ablation)
- TRANSURETHRAL means the procedure is done from within the prostate. There are no incisions and no cutting of the prostate tissue.
- ABLATION means the destruction or removal of tissue.
- ULTRASOUND is high-frequency sound waves often used in medicine such as pregnancy imaging. In this procedure, the power of the sound waves are increased such that they thermally heat the prostate tissue to ablate it.
THERMAL means heat, the prostate tissue is heated to the point of ablation (the heat destroys the targeted tissue). The TULSA Procedure is incision free. There are no scalpels that cut your skin or prostate tissue. Radiation free. TULSA uses sound waves to destroy tissue, not radiation. No ionizing radiation is absorbed by your tissue. The procedure can be adjusted to suit each patient’s individual needs, prostate condition and goals. A continually monitored closed-loop control of the ultrasound ensures a gentle heating is delivered to the prostate tissue. Gentle heating ensures the ablation is predictable and that the pain for the patient is low.
A radiation oncologist uses CT scans images to pinpoint the exact location of the prostate each day of treatment. Since the prostate can move around by as much as a centimeter depending on how full your bladder and rectum are. IGRT can also be modified if a man loses weight. Using the daily CT scans, doctors compare current images with prior ones and fine-tune the treatment accordingly.
Intensity-Modulated Radiotherapy (IMRT) is an advanced approach to 3-D conformal radiation therapy. The IMRT technique is very precise; it uses computer-generated images to plan and then deliver tightly focused radiation beams to prostate cancer tumors. With this capability, clinicians can vary the beam's intensity to "paint" a precise radiation dose to the shape and depth of the tumor, while significantly reducing the radiation's harmful effects on healthy tissue.
Proton therapy, also called proton beam therapy, is a type of radiation therapy. It uses protons rather than x-rays to treat cancer.
A proton is a positively charged particle. At high energy, protons can destroy cancer cells. Like x-ray radiation, proton therapy is a type of external-beam radiation therapy. It painlessly delivers radiation through the skin from a machine outside the body.
A machine called a synchrotron or cyclotron speeds up protons. The high speed of the protons creates high energy. This energy makes the protons travel to the desired depth in the body. The protons then give the targeted radiation dose in the tumor.
With proton therapy, there is less radiation dose outside of the tumor. In regular radiation therapy, x-rays continue to give radiation doses as they leave the person's body. This means that radiation damages nearby healthy tissues, possibly causing side effects.
People usually receive proton therapy in an outpatient setting. This means they do not need to have treatment in the hospital. The number of treatment sessions depends on the type and stage of the cancer.
Stereotactic body radiation therapy (SBRT), also known as stereotactic ablative radiotherapy, administers very high doses of radiation, using several beams of various intensities aimed at different angles to precisely target the tumor.
SBRT begins with one or more sessions of treatment planning with CT, MRI or other advanced imaging techniques to precisely map the position of the tumor. The images are used to design a four-dimensional, customized treatment plan that determines beam intensity and positioning. The goal is to deliver the highest possible dose to kill the cancer while minimizing exposure to healthy organs.
Tomotherapy (also called helical tomotherapy) is a type of intensity-modulated radiation therapy (IMRT) in which radiation is aimed at the tumor from many different directions. The radiation itself is delivered as a single beam divided into laser-thin “beamlets.” Tomotherapy radiation is typically used to treat hard-to-reach prostate cancer tumors that are attached or close to healthy tissues and organs. While a high dose of radiation may be used to kill tumor cells, damage to surrounding tissues is minimized.
CyberKnife is a brand name for a device that delivers stereotactic body radiation therapy (SBRT). Although it contains the word “knife” and is sometimes referred to as “radiosurgery,” there’s no knife or incision. SBRT is an image-guided technique of delivering high doses of radiation with extreme accuracy. The purpose is to kill cancer cells while limiting damage to healthy tissues and organs. The CyberKnife system has continual image guidance software that works in real time to adjust to your breathing cycle and tumor movement. SBRT allows for large doses in a specified area, so you can complete your treatment in a few days. By comparison, conventional radiation therapy takes as long as eight or nine weeks to complete.