Consists of the application of the suitable treatment according to the patient’s age, life expectancy, associated illnesses, Gleason, PSA level, TNM, symptoms, side effects of therapies and an informed choice made by the patient himself.
We must start from the base that, in general, prostate cancer is a disease with a long and almost chronic evolution.
Due to this, many factors must be taken into consideration. Except for exceptions, the decision to treat prostate cancer is not an urgent matter; nothing of the typical ‘come back Monday and we’ll operate’.
Firstly, assure that the patient has all information and that he has understood all of its content.
Age is a factor of great importance, given that aggressive treatments are not good for people of an advanced age and less aggressive ones are better, paying special attention to combating possible symptoms.
Even more than the actual chronological age, consider the life expectancy that depends on the age but also on the general state of health and the presence or lack of other associated diseases (diabetes, hypertension, cardiopathy, respiratory insufficiency, etc.).
The Gleason score allows the aggressiveness of the tumour to be known and lower Gleason scores lead to more conservative treatments.
The PSA level indicates the quantity of active cells in the prostate cancer. The TNM is essential for assessing the need or lack of immediate treatment or differed treatment.
Treatments, especially surgery and hormone therapy, severely alter the quality of life of the person affected by the illness. Impotence and urinary incontinence, feminisation, etc. are important enough issues for doctors to explain them in detail and their incidence depending on the treatment chosen.
Finally, with all the information available, it is often suitable to request a second opinion in order to compare different viewpoints. And even a third opinion if deemed necessary.
The basic treatments for prostate cancer located in the gland are surgery (prostatectomy) and radiotherapy. Hormone therapy is suitable for recidivist cases (the disease returns after the initial healing attempt) and when there is in metastasis.
There will be patients who, after considering the information about the disease that their doctor has given them, will want to decide upon their future taking the following priorities into consideration:
a) Treatment: Some men will not want to run the risk of losing control of urination or becoming impotent, in order to control cancer that is potentially (not always) mortal, including without treatment.
b) Urinary incontinence and/or sexual impotence are the greatest risk factors when deciding on treatment, taking into account that they seriously affect the person’s quality of life.
c) Quality of life: many men cannot endure the idea of having prostate cancer and prefer for it to be removed, while others do not want to risk suffering from urinary incontinence and/or sexual impotence and thus select non-surgical treatment.
WAIT AND SEE
This is the situation where, after diagnosing prostate cancer, it is decided to abstain from treating the patient and move to its observation to see how events develop.
And observation means….?
Deciding not to treat the prostate cancer.
But this isn’t done with other cancers, right?
Practically never. Prostate cancer, due its non-aggressive growth, means that observation without treatment is a viable option under certain circumstances.
When it is more likely that you will die due to other causes before the cancer can start growing and cause serious problems or death.
To establish this, many factors are taken into consideration: age (the older the patient, the greater the chance that a slow-growth cancer will not end up developing); individual life expectancy (depends on chronological age, but also on the person’s general state of health and the associated diseases he has, the lower the life expectancy, the less chances that the prostate cancer will be lethal).
Taking exclusively age and life expectancy into consideration, the best candidates for observation are men older than 75 years of age, with limited life expectancy or men between 60 and 75 years of age with associated diseases that are life-threatening.
However, many factors about the cancer itself must be evaluated (low Gleason scores develop slower than high ones; initial TNMs, for example T1 and T2, without ganglions or metastasis, also).
After evaluating these factors, patients often may decide against treatment.
On the other hand, there are many people with prostate cancer that don’t even know they have it during their lives (autopsies on the elderly who died in traffic accidents reveal this, as well as other autopsies where prostate cancer is discovered that never was manifested).
If I decide ‘to wait and see’, what do I have to do?
The ‘wait and see’ approach still requires periodic checkups to detect symptoms, problems or PSA increases that may lead to the conclusion that the cancer is growing too quickly.
Therefore, the PSA should be regularly taken during the observation period (every four or six months). After determination, the doctor will assess possible symptoms and, if considered necessary, perform a rectal probe.
And if the cancer starts to grow?
If it grows slowly, you may wait a little while longer, following the PSA.
If it grows quickly (for example, the PSA increases a lot and/or the doctor notices an increase in the tumour size in the prostate with urinary symptoms), treatment can be started (this is why ‘deferred treatment’ is known as ‘wait and see’).
A good rule to know the importance of an increase in PSA is, starting when a significant increase is detected: repeat the exam monthly two or three times. Clear increases month after month may indicate the need for some type of treatment.
Are the treatments different at this time than if I would have selected treatment from the beginning?
Probably not and treatment choices will be the initial ones, according to the TNM.
However, sometimes there may have been an increased quantity of tumour that has extended to ganglions or bones.
Although the tumour is growing, can I continue under observation, since prostate cancer grows extremely slowly?
Yes, this is possible at times. The chance of dying from this cancer is low, although it continues to increase with the passing of the years.
Radical prostatectomy consists of cutting out the entire prostate gland and adjacent glands for the treatment of prostate cancer.
It is utilised when the cancer is located in the prostate.
It is done either with general anaesthesia (patient totally asleep) or with epidural anaesthesia (where the lower part of the body is anaesthetised).
There are two types of prostatectomy:
*Retropubic prostatectomy, which is the most common. An incision is made in the abdomen in order to explore the lymphatic ganglions. If they are affected, the prostate is not removed and other treatments are considered; if they are not affected, the prostate is removed.
One type of retropubic prostatectomy is where the doctor tries to avoid cutting the nerves on both sides of the prostate, since these nerves are essential for erection, letting the risk of impotence decrease (although not always), in favourable cases recovering erection capability 12 or 18 months after the prostatectomy.
*Perineal prostatectomy, where the prostate is removed by making an incision between the anus and the scrotum. The ganglions are not removed. To perform the procedure, a small incision must also be made in the abdomen or a laparoscope used.
This does not facilitate the conservation of the nerves that participate in erections.
However, perineal prostatectomy is less traumatic to the body, permitting the patient to recover more quickly and with less pain.
Which do urologists prefer?
They tend to prefer retropubic prostatectomy due to the advantages described.
How long is the prostatectomy process?
Surgery takes between 2 and 4 hours, since the prostate is located very deep and there is a large risk of haemorrhaging.
Does prostatectomy endanger my life?
The consequences of prostatectomy have been minimised. Blood transfusions are not normally necessary and mortality is less than 0.05% in hospitals with experience and good technology.
Hospital stays tend to be between 3 and 6 days, with a recovery period at home from between 4 and 8 weeks.
Recovery is facilitated by physical exercise, where the most suitable exercise is walking, gradually increasing the distance covered. If you become exhausted, sweat excessively or are nauseous, you have overexerted yourself and should moderate the distance.
We recommend breaking up the walks and doing them 4 to 6 times a day.
Bicycling should be avoided until after total recovery in order to prevent any type of pressure on the perineal zone, the area where the bladder and urethra connect. If you want to practice this sport, do it step by step. A soft and wide seat is recommended and hard, narrow seats should be avoided.
Heavy objects should not be lifted until you have recovered and you should not drive a car until at least three weeks after surgery. Even when you are simply a passenger, avoid long trips for a few weeks.
People who regularly played other sports before surgery (golf, tennis, ninepins, etc) should consult their doctor for advice about starting to play them again.
To make it easier for patients to urinate, a catheter is placed through the penis to the bladder, which is kept in for two or three weeks.
As regards hygiene, there is no restriction as regards the number of showers you may take, although showers are more preferable than baths, which may involve counterproductive positions.
There are no dietary restrictions. Eat whatever you like, although the best is always a Mediterranean diet. However, since constipation may occur for a period after surgery, you should try to eat abundant fibre (cereals, fruits, vegetables, etc.) and drink a lot of water and other liquids.
If constipation is pronounced, consult your doctor.
Surgical scarring tends to heal after about 6 weeks, although the total process can take up to one year.
I want to know the possible complications from prostatectomy.
They are the following:
The main complications are sexual impotence and incontinency. However, we will first speak of the two most immediate, possible consequences – haemorrhaging and narrowing of the neck of the bladder.
a) Haemorrhage: this occurs because the structures around the prostate are rich in multiple and thick blood vessels (arteries and veins). When the gland is removed, a vessel may be sectioned, although this is infrequent.
b) Narrowing of the neck of the bladder due to scarring there, which can lead to urinary problems. This is seen in one of every 20-30 prostatectomies.
This problem tends to be resolved by using metal dilators or, if it continues, removing the scar surgically.
c) Sexual impotence: We must first distinguish between impotence (inability to get or keep an erection in order to have sexual relations) and erectile dysfunction (able to get an erection, although it may not be adequate for sexual relations. For example, it does not last enough time).
This is due to the surgical damage occurring when removing the prostate after the prostatectomy. Patients may experience erection problems for up to a year after the surgery. Finally, and depending on the age (the younger the patient is, the less problems there are), between 65% and 90% of men will remain impotent after surgery.
The type of prostatectomy that tries to avoid cutting the nerves that enable erections in patients with small tumours, 50% of whom were sexually effective before the surgery recover erection ability. However, their quality tends to not be the same as before the procedure. This 50% of patients recover their sexual effectiveness between 2 and 24 months after the operation.
Patients should see specialists in impotency for further information.
d) Urinary incontinency: is the loss or involuntary escape or urine or the inability to control the flow of urine.
There are three basic types of urinary incontinency:
*Stress: the urine escapes when making an effort, such as coughing, sneezing, laughing or doing exercise. It is most frequent after prostatectomy.
* Urge (irresistible need to urinate) and dribble (takes time to urinate with a weak flow of urine). The latter case occurs when the surgery causes the narrowing of the neck of the bladder.
Urinary incontinence occurs because surgery can affect the sphincter of the bladder or the muscular valve that keeps urine inside the bladder or because the nerves are damaged that are essential for the functioning of the sphincter.
In general, patients recover from post-surgery incontinence from several weeks to a few months after the operation. Within a year, most patients can control their bladder.
However, it may be permanent in up to 35% of patients operated on for prostate cancer (in a light form, such as stress incontinence). And between 2 and 15% of men have more severe stress incontinence, which can be permanent.
One way of preventing incontinence and combating it is to practice Kegel exercises.
This exercise should be started before the prostatectomy and continued after, until recovery from incontinence.
It consists of strengthening the musculature in the pelvis by doing an exercise similar to what we can normally do when urinating and voluntarily stop the urine flow or by squeezing together the buttock cheeks, as if we wanted to hold something between them.
It is recommended that these exercises are done before the prostatectomy and after surgery when the catheter is removed from the penis.
Five minutes an hour during the day should be enough. The best way to do the exercise is to tighten the muscles in the pelvis and then not loosen the grip all at once, but rather letting it out slightly and continuing to repeat for 5 minutes.
If the condition does not improve, you will have to consult a specialist.
What is cryotherapy?
It is the freezing of the prostate to try to cure cancer in this gland. This technique is also known by the name of cryosurgery.
The objective is to kill the cancerous cells.
Advantages include simplicity, ease and the quickness of the procedure, as well as the low cost.
However, it is still considered an experimental treatment because there are no long-term studies showing its real effectiveness. Thus, it is still unknown if it is as effective as surgery or radiotherapy.
How is it done?
The patient is given anaesthesia.
Under control via transrectal ecography, special probes are inserted into the prostate and liquid nitrogen is circulated through them, which freezes the prostate tissue.
To prevent the urethra from freezing, hot liquid is circulated there during the cryotherapy procedure.
What side effects can it cause?
There may be temporary discomfort due to the irritation of the urethra or bladder.
They basically consist of a burning sensation when urinating, frequent urinations many times without prior warning, hematuria –blood in the urine-, pain when urinating and similar irritation while defecating and swelling of the penis and/or scrotum.
Very few men have more serious problems like scarring on the urethra and/or more serious difficulties urinating (which could require the placement of a catheter).
One other rare and more severe complication is the formation of a fistula in the area between the urethra and rectum.
Impotence and urinary incontinence?
Impotence is a serious complication of cryotherapy affecting 75-80% of patients.
Conversely, urinary incontinence is quite rare.
It is an interesting option, although it cannot be your first choice, since its long-term effectiveness has not been scientifically proven.
Over time, it may become a good and viable option.
This is a technique for destroying tumours in which high-energy rays (similar to x-rays) or particles (electrons or protons) are used.
The tumour is surrounded by normal cells that the irradiation may also destroy and thus it should be avoided wherever possible.
The difference between normal and cancerous cells with respect to radiotherapy is that the first ones have a large capacity to repair or correct the damage caused to them from irradiation.
Conversely, cancerous cells have less reparative capacity.
In this way, it is possible to destroy more of the tumour than normal cells. Although some of the normal cells do die through irradiation, they can be replaced through the development of new and normal cells.
How many different ways can radiotherapy be done?
Basically, there are two types of radiotherapy that are applied to prostate cancer: external radiotherapy and internal radiotherapy, or brachytherapy.
External radiotherapy comes from a machine (cobalt pump, linear accelerator, etc.) located outside of the patient. Irradiation is then directed at the area where the tumour is located, in this case the prostate.
Internal radiotherapy or brachytherapy or interstitial radiotherapy is when radioactive materials are placed in the prostate, in the shape of small ‘shot’ or ‘seeds’. These subsequently emit radioactivity for weeks or months that is not damaging to the patient or his family.
Can you tell me more about external radiotherapy?
Specialists that apply this treatment are known as radiotherapists or radiotherapeutic oncologists. Radiotherapy is a local treatment (for T1 and T2), equivalent to surgery, although radiotherapy is also useful in treating localised but widely-extended cancers (T3,T4) that surgery cannot successfully eliminate due to the spreading.
It is also suitable for patients who, for other reasons, do not want or cannot have surgery.
How is it applied?
Firstly, simulation is performed. Using special x-rays, treatment is simulated in order to determine the dose and the exact zone to treat. This simulation does not irritate the patient in any way.
After the simulation is done, authentic treatment is initiated.
I was told that it is an extremely prolonged treatment. Is that true?
The entire treatment lasts 6 or 7 weeks. It is performed five days a week, generally from Monday to Friday. The two-day break is necessary for the normal cells around the tumour to recover.
How long does a session last?
Around 10 minutes.
Does radiotherapy have advantages compared to prostatectomy?
Firstly, it prevents the need for anaesthesia and hospitalisation and the side effects of surgery.
There is no risk of haemorrhaging or pain or heart problems or embolisms due to blood clots.
So what are the possible side effects from radiotherapies?
Tiredness until the end of treatment is very common and some 15% of patients also develop cystitis (irritation when urinating) and/or rectitis (rectum inflammation causing trouble during defecation, pain, urgent need to defecate).
Are these problems permanent?
They disappear in the majority of patients after radiotherapy has finished and a maximum of some two or three months after.
In very rare cases, these problems could persist and require treatment.
Does radiotherapy cause urinary incontinence?
Only in 5% of patients.
Radiotherapy can cause impotence if blood vessels or nerves required for erection are damaged.
Due to this, between a third and a half of men treated with radiotherapy will experience some degree of lessening of erection hardness. If it does occur, it is not immediate but rather is delayed a minimum of 1 or more years before occurring.
Is radiotherapy curative?
It is the same as prostatectomy, with a similar level of effectiveness.
After radiotherapy, when can I go back to work?
Except for those patients suffering from fatigue (whose recovery after treatment may last very few weeks), others may continue with normal physical activities (for example, sports) during and after treatment.
Can you tell me more about internal radiotherapy?
Internal radiotherapy or brachytherapy uses several small masses, approximately the size of grains of rice, prepared to be radioactive.
Using thin needles that are inserted into the prostate, treatment is planned so that radioactivity affects the entire tumour.
How are the needles with the seeds introduced into the prostate?
The needles are introduced through the skin of the perineum (below the scrotum and in front of the anus).
Its largest advantage with respect to external radiotherapy is how short the treatment is – only one day.
What radioactive elements are used?
In the beginning, radioactive iodine 125 was used more, although currently, palladium 109 is generally used, which is more powerful and offers greater assurance about the death of the tumour cells.
Is brachytherapy as effective as radiotherapy or prostatectomy?
It is possible although there are still no long-term results as the process is relatively new. Until this time, there have been long-term and proven studies done for patients treated with radiotherapy and surgery.
Are the side effects caused by brachytherapy like the ones from radiotherapy?
Yes, they are the same and in the same proportion.
Its objective is to decrease the levels of male hormones, with the principal one being testosterone.
Prostate cancer is sensitive to the effect of testosterone, which causes its growth and development.
Cancer stops developing in the majority of patients when testosterone is eliminated.
In what situations is hormone therapy recommended?
In five situations:
1. The most common is when the disease has spread (metastasis). The cander may stop for long periods of time, although it is never fully cured.
2. When the patient’s disease has repeated locally, after having been treated successfully when there is no chance of new local treatment.
3. Before surgery or radiotherapy to decrease the size of the tumour and make it easier to remove or irradiate. This is called neoadjuvant hormone therapy.
4. In some cases, for application after the local treatment to improve the results of surgery or radiotherapy.
5. In elderly patients when the treatment is required because the cancer is progressive, but local treatments are not recommendable (especially surgery, due to its greater risks).
Is hormone therapy applied via surgery or by medicines?
The most frequent therapy uses medicines. However, hormone therapy started as a surgical procedure through the performance of orchiectomy or removal of the testicles.
Orchiectomy is part of ablative hormone therapy.
But why do they remove the testicle(s)?
Because the testicles produce 95% of testosterone. There are still urologists who support orchiectomy as a type of hormone treatments for prostate cancer, although its enormous psychological effect must be taken into consideration. It can destroy the self-image and self-esteem. It is very effective since it decreases the largest production source of testosterone all at once, although the gentler effects of hormone medicines have relegated the former procedure to second place.
Is orchiectomy used for any specific patients in the present day?
It continues to be important for certain cardiopath patients (with heart problems) that require hormone treatment for prostate cancer. In these cases, hormone treatment is not recommended with medicines because it could aggravate the cardiopathy.
Another advantage of orchiectomy is that testosterone levels drop almost to zero between 3 and 12 hours after performing the operation. Men with bone pain from metastasis can note the pain disappearing in a few short days.
However, orchiectomy does not produce these effects for which the situation is recommended.
What can you tell me about hormone medicines?
They are part of what is called additive hormone therapy because medicines are added that will change the patient’s hormone state. Most of these drugs are aimed at producing a chemical-type castration, cancelling the sources of androgen production (principally testosterone).
You said that 95% of androgens are produced in the testicles. What about the remaining 5%?
In the adrenal glands (called this because they are located above each kidney). These androgens are not eliminated by either castration or by hormone treatments that produce chemical castration. If they need to be eliminated, special treatment is required with drugs called antiandrogens.
Tell me about the medicines that are used in additive hormone therapy.
Firstly, DES or dietilestilbestrol, which is like an oestrogen (female hormone).
Is it currently used?
Not very much. Many years ago, it was the only hormone treatment, but new medication was searched for due to the increased risk of heart attacks it caused, as well as cerebral haemorrhaging and mortal blood clots.
It is a great disadvantage because it is an extremely cheap and easy to use medicine (one pill a day).
But it had to be abandoned.
So what medicines are currently used?
Luteinizing hormone-releasing hormone (LHRH) analogues. They are basically copies of natural hormones produced in our body that stimulate the production of testosterone.
The most widely-used are leuprolide acetate and goserelin acetate. They decrease testosterone levels as efficiently as physical castration and thus cause a type of chemical castration.
How are they applied?
A deep intramuscular injection or an injection below the skin (subcutaneous) of the abdomen, once a month (in depot form). There is also another depot form available now, which is applied once every three months.
How do they act?
After being administered, they stimulate testosterone production for 2 weeks. The body interprets this increase as if excessive testosterone has been produced, due to which it stops production of the hormone stimulating testosterone production.
Our body is ‘tricked’ in a certain way by the hormone analogue.
Isn’t this increased level of testosterone for 2 weeks dangerous?
In short, it is not recommended. In order to counteract it, before starting treatment with an LHRH analogue, 2 weeks of antiandrogens are administered in order to neutralise the increased testosterone levels.
Can you clarify that for me?
First, let’s look at the definition of an antiandrogen. As mentioned, a small proportion of androgens are produced in the adrenal glands.
In order to block their action, medicines were synthesized that are called antiandrogens, whose action consists of blocking, at the level of the prostate, the action of the androgens.
There are two different principal uses for antiandrogens:
*In prostate cancer treatment associated with the LHRH analogue, as part of what is known as total hormone blockade, which will be defined later.
*To prevent increased testosterone the first two weeks after the application of an LHRH analogue.
What are the most commonly-used antiandrogens?
They are flutamide and bicalutamide.
How and when are they taken?
They are tablets that are orally administered through the mouth. Flutamide is taken three times a day while bicalutamide is taken once every 24 hours.
What does total hormone blockade consist of?
Some authors believe the best hormone treatment is based on the association or combination of an LHRH analogue with an antiandrogen or total hormonal blockade. In this way, 100% of androgen production will be controlled.
There is a great deal of polemic about whether the elimination of the 5% of androgens produced by the adrenal glands really increases benefits as regards treatment failure levels when only the analogue is used or whether total blockade would increase patient survival.
There are no definitive data, due to which some doctors prefer total hormone blockade and others treat using only the analogue.
Is there any patient group where total hormonal blockade has been shown to be better than only analogue?
Yes, the group comprised of patients with prostate cancer, with very little spreading to the bones (metastasis) and with minimum symptoms.
Does hormone treatment increase the chances of survival of patients with metastasis?
This has not been proven. What it does do is improve the quality of life of patients and decrease the risk of complications.
How long will a patient with metastasis from prostate cancer have to take hormone treatment?
There are always trends and polemics in medicine.
For the majority of doctors, hormone treatment is taken forever. It is called ongoing hormone treatment and it is believed that the disease is better controlled in this way.
Others however prefer what is known as intermittent hormone treatment.
This consists of starting with hormone treatment and continuing until the PSA and symptoms have been reduced to minimum levels and then stabilised. Then treatment is stopped and not reinitiated until the PSA increases again, performing analyses two or three times a month. Thus treatment is given or not depending on the patient’s development.
Intermittent treatment, studied in laboratory animals, has been shown to be better than ongoing treatment and, furthermore, does not cause problems.
Intermittent treatment is cheaper than continual treatment and has another further advantage, which is to give the patient rest periods that give the disagreeable symptoms produced by the hormones time to disappear.
Some studies on humans have shown favourable results with intermittent treatment.
What are the toxic or side effects of these medicines?
Orchiectomy, previously explained as a type of hormone treatment, causes decreased sexual desire (libido) or absence of desire and impotence in over 90% of men and even hot flashes at times. These tend to lessen over time.
LHRH analogue effects are similar to those from orchiectomy. Perhaps the most frequent is hot flashes (10 to 15% of men), which are like waves of heat and sweating, which come and go. They also tend to decrease over time.
These drugs can also cause sensitivity in the mammary glands and at times an increase in their size (ginecomasty). In very infrequent cases, painful sensitivity may require low doses of radiotherapy or surgery to resolve the problem.
Weight gain tends to occur while taking these drugs.
As regards antiandrogens, the most pronounced effect is diarrhoea, especially with flutamide. If it continues, the antiandrogen dose must be lowered, suspended or replaced. It can also cause nausea and fatigue.
The continued use of these medicines can damage the liver and, thus, periodic checkups should be done by analysis to assess the liver.
There is also danger of calcium deficiency (osteoporosis), due to which calcium supplements are recommended, as well as vitamin D and sunbathing.
If the metastasised cancer becomes resistant to all of these hormone treatments, are there any other hormone medicines available?
One medicine used in cases where there is resistance to hormone therapy is Estramustine. It is a drug located halfway between hormone therapy and chemotherapy.
In short, Estramustine combines a female hormone, oestrogen, with a chemotherapy drug, nitrogenous mustard.
Estramustine is used alone or in conjunction with other chemotherapeutical drugs (mitoxantron, etoposide, vinblastine, paclitaxel).
This is another option for patients who are resistant to all types of hormonal treatment.
Two types of medicines are used:
*cytotoxics, which interfere with the development of the cancerous cell and cause it to die.
*cytostatics, which promote cellular aging and make cellular multiplication difficult. They do not directly kill cells, but cause their gradual disappearance, since they stop them from reproducing.
The majority that are used belong to the first group.
Most cytotoxics affect the cells that are multiplying at the time the drug is administered. Due to this, and even when they affect more cancerous cells, they have unpleasant side effects owing to the normal cells being affected that are in division and multiplication processes, basically in the blood, the alimentary canal and skin.
Furthermore, through the present, chemotherapy has not produced good results.
The most widely used cytotoxic drugs are taxotere, etoposide, vinblastine, paclitaxel and mitoxantrone, besides estramustine, which was already mentioned in the section about resistance to hormone therapy.
TREATMENT RECOMMENDATIONS ACCORDING TO TNM AND OTHER FACTORS
Treatment is individualised depending on personal characteristics (age, general state of health, life expectancy), on the tumour (Gleason) and its extension (TNM).
Let’s consider these different situations.
T1. We must consider the T1a and T1b, T1c, T2aA and T2b separately:
T1a. Three fundamental aspects must be considered, life expectancy, PSA level after the excision of the tumour and the Gleason score.
SITUATION A. *If life expectancy is greater than 20 years (for example, young men between 40 and 50 years of age),
*and/or the PSA continues to be higher than 1 ng/ml and,
*Gleason higher than 6,
CONSIDER TREATMENT WITH RADIOTHERAPY OR RADICAL PROSTATECTOMY, without totally ruling out deferred treatment.
SITUATION B. *Life expectancy less than 20 years,
*PSA less than 1ng/ml after removing the tumour,
*Gleason of 6 or less,
NO TREATMENT UNTIL THERE ARE SYMPTOMS (deferred treatment).
T1b, T1c, T2a and T2c. There are the following possibilities:
1. Gleason between 2 and 4,
With life expectancy less than 10 years,
NO TREATMENT UNTIL SYMPTOMS APPEAR OR RADIOTHERAPY.
With life expectancy between 10 and 20 years,
NO TREATMENT UNTIL SYMPTOMS APPEAR OR RADIOTHERAPY OR PROSTATECTOMY RADICAL.
With life expectancy greater than 20 years,
RADIOTHERAPY OR PROSTATECTOMY RADICAL.
2. Gleason 5 or 6,
With life expectancy greater than 10 years,
NO TREATMENT UNTIL SYMPTOMS APPEAR OR RADIOTHERAPY.
With life expectancy greater than 10 years,
RADIOTHERAPY OR PROSTATECTOMY RADICAL.
3. Gleason 7 a 10,
With life expectancy less than 5 years,
NO TREATMENT UNTIL SYMPTOMS APPEAR OR RADIOTHERAPY.
With life expectancy greater than 5 years,
RADIOTHERAPY OR RADICAL PROSTATECTOMY
T3a. Depends if the tumour has spread to one of both sides of the prostate lobes (parts):
If the tumour spreads beyond the prostate, but only on one side,
RADIOTHERAPY OR HORMONE TREATMENT OR BOTH (prostatectomy may be required if the Gleason is 6 or less and the tumour has not spread).
If the tumour spreads beyond the prostate, but in both parts,
RADIOTHERAPY OR HORMONE TREATMENT OR BOTH
T3b and T4NOMO:
RADIOTHERAPY OR HORMONE TREATMENT OR BOTH
Ganglions affected (N1, N2, N3),
Can select HORMONE TREATMENT, with or without radiotherapy, or NO TREATMENT UNTIL SYMPTOMS APPEAR