The choices for treating prostate cancer are bewildering, especially in the disease's early stage — the stage at which 90 percent of prostate cancer is now discovered.
There's watchful waiting. There's a menu of different surgical choices, now including robotic surgery. There's a longer menu of radiation therapies, the latest involving proton beam accelerators — devices more typically found in physics labs.
More experimental techniques include cryosurgery, which kills prostate cancer cells by freezing them, and HIFU (high-intensity focused ultrasound), which cooks them to death.
A government study released this year concluded that, disappointingly, medical science still can't say which option is best.
"It puts men in a very difficult situation," says Dr. David Lee, chief of urology at Penn Presbyterian Medical Center.
In most cases, though, the slow-growing cancer allows you time to sort things out. "Don't panic," Lee says. "With PSA screening [the blood test done during men's medical checkups for prostate-specific antigen], we've almost certainly caught it early. Take your time to learn all that you can so you can make a good decision."
- With early stage cancer, watchful waiting may be an option — especially for older men — because prostate cancer grows slowly and may never hurt you. A study called Pivot is under way to determine whether the strategy is as effective as surgery.
- A surgical prostatectomy to remove the prostate can sometimes be done with nerve-sparing techniques that, in a good surgeon's hands, may allow men to have erections again after some time has passed.
- A robot-assisted prostatectomy known as da Vinci surgery is a popular new option. The robot can use smaller instruments than human fingers can and has finer wrist control for extra precision.
- With external beam radiation therapy, a machine blasts the cancer with X-ray beams — or, in five U.S. hospitals — with precision proton beams. Advanced X-ray techniques called IMRT, 3-D conformal radiation therapy and Calypso can help spare healthy tissue.
- With internal beam therapy, also called brachytherapy, radioactive seeds are implanted inside the prostate itself to kill cancer cells.
- Tumor-freezing cryosurgery is approved in the U.S. HIFU, which kills tumors with heat, is approved in Europe and Canada but not here. In the U.S., it's available in some clinical trials, including one at Thomas Jefferson University.
- A variety of hormone therapies taken either as shots or pills are available for more advanced prostate cancer. Radiation and chemotherapy may also come into play.
If you've just been diagnosed, a call to the American Cancer Society toll-free helpline is a good way to begin sorting things out. The number is 800-227-2345.
On the horizon
- Closer attention to "mismatches." A new study has found that men often choose "mismatched" treatments that make exisiting health problems worse. Brachytherapy may be a bad match for men with urinary trouble. External radiation may be a bad match for men with bowel problems.
- Hopes for prevention. In one study, the medicine finasteride reduced the risk of prostate cancer by 25 percent. Another study is under way to determine if selenium and vitamin E supplements can help prevent it. Vaccines also show promise, Lee says. "After you're done having your kids, you'd have your prostate cancer prevention shot."
- Incoming medical tourism. A 220-ton particle accelerator that's now being installed by Penn Medicine is likely to draw out-of-towners for prostate cancer treatment. In Loma Linda, Calif., where proton-beam therapy has already begun, some men plan golf outings around their appointments. Philly's cancer "cyclotron" should be accepting patients late next year.
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