Watchful Waiting is sometimes used to describe a less intensive type of follow-up that may mean fewer tests. It relies more on changes in the man’s symptoms, to decide if treatment is needed. It may also be offered to men who are unable to tolerate other therapies like surgery or radiation because of serious health conditions or may be very advanced in age that would make treatment difficult.

Advantages

• The side effects of treatment are avoided whilst on active surveillance or watchful waiting.

Disadvantages

• There is a chance that the cancer may change and grow in between doctor follow-up visits. If it does, this may limit which treatment you may take and if your cancer can be cured.
• Some men may worry about their cancer growing.
• Partners and family members may worry about their loved one and find it hard to understand why they are not having treatment.

External Beam Radiotherapy is delivered using a machine (usually a linear accelerator) that emits high energy X-Rays, gamma rays and other sources to destroy the cancer cells and shrink tumours. The treatment is given in short daily sessions over a long period of time. Normally once a day, five days a week over a four to eight-week period, to minimize damage to normal tissue.

Advantages

• If your cancer is localised or locally advanced, radiotherapy will aim to get rid of the cancer completely.
• Many men can carry on with many of their normal activities while having treatment, including going to work and driving.
• Radiotherapy can be an option even if you are not fit or well enough for surgery.
• Radiotherapy is painless (but you might find the treatment position slightly uncomfortable).
• The treatment itself only lasts around 10 minutes, including the time it takes to get you into position. But you’ll probably need to be at the hospital for up to an hour each day to prepare for your treatment. Overnight stay at the hospital is not a requirement.

Disadvantages

• You will need to go to hospital for treatment five days a week for 6 to 8 few weeks. This might be difficult if you have to travel far.
• Your bowel may need to be empty during each treatment session. You may be given medicine to help empty your bowel each day. This can take a while to work, and some men may find this inconvenient.
• Radiotherapy can cause side effects such as bowel, urinary and erection problems, as well as tiredness and fatigue. But there are usually treatments and ways to help manage these.
• It may be some time before you know whether the treatment has worked.

Hormonal therapy (HT), also called androgen suppression therapy, involves any treatment that can lower the body’s androgen levels of the male sex hormones Testosterone, (produced by the testes) or dihydrotestosterone (DHT), produced by the adrenal glands. Androgens stimulate prostate cancer cells to grow. HT lowers androgen levels by stopping the body from making testosterone or stopping it from reaching the prostate cancer cells. This makes the prostate cancer shrink or grow more slowly over time. HT alone does not cure prostate cancer but the treatment will aim to control or delay symptoms in recurrent or advanced prostate cancer.

Advantages

• It can be used in combination with other treatments like LDR Brachytherapy and external beam radiation therapy to achieve a more effective outcome.
• It can help to reduce some of the symptoms of advanced prostate cancer, such as urinary symptoms and bone pain.

Disadvantages

Possible side effects of hormone therapy may include:

• Reduced or absent sexual desire
• Erectile dysfunction (inability to have an erection)
• Shrinkage of testicles and penis
• Hot flashes, which may get better or go away with time
• Breast tenderness and growth of breast tissue (gynecomastia)
• Osteoporosis (bone thinning), which can lead to broken bones
• Anaemia (low red blood cell counts)
• Decreased mental sharpness
• Loss of muscle mass
• Weight gain
• Fatigue
• Increased cholesterol levels
• Depression

For some men diagnosed with early stage prostate cancer with no symptoms, where the cancer is expected to grow very slowly and is confined to the prostate, immediate treatment may not be necessary. Instead your doctor may recommend “Active Surveillance.” This means your doctor will monitor the progression of the cancer by performing regular follow-up Digital Rectal Examinations (DRE) and PSA tests. If your tests show that the cancer is growing, treatment will be offered with the intention to cure the disease

Radical prostatectomy is a common treatment for early stage localised prostate cancer. It is a major surgical procedure in which the surgeon removes the prostate gland along with some surrounding tissue and a few lymph nodes. It is performed through an open incision into the lower abdomen or by using laparoscopic techniques.

Both types of surgeries may be done as nerve-sparing, to minimize damaging the nerves running alongside the prostate which control the ability to get an erection. Non-nerve sparing surgery removes the entire prostate, the surrounding tissue and its nerves.

Advantages

• If the cancer is completely contained inside the prostate, surgery will remove all of the cancer.
• The prostate is looked at under a microscope to give a clearer picture of how aggressive your cancer is, whether it has spread outside your prostate and if you need further treatment.
• Your health professionals can get a good idea of whether your cancer was completely removed during surgery. Your PSA level should drop so low that it’s not possible to detect it (less than 0.1 ng/ml) at six to eight weeks after surgery.
• If there are signs that your cancer has come back or wasn’t all removed, you may be able to have further treatment.
• Some men find it reassuring to know that their prostate has been physically removed, although you will still need to have follow-up tests to make sure no cancer cells have spread outside the prostate.

Disadvantages

• Bleeding during or soon after the operation and possibly needing a blood transfusion
• Injury to nearby tissue, including the bowel, blood vessels, nerves and pelvic floor muscles. This may lead to urinary incontinence and erectile dysfunction (inability to have an erection).
• Blood clots in the lower leg that could travel to the lung (less than two out of every 100 men)
• Infection (about one to five out of every 100 men)
• Scarring where the surgeon makes the cuts in your abdomen
• You will be required to stay in hospital for a few days – usually between one and five days depending on the type of surgery you have.
• The surgeon may not be able to remove all of the cancer if it has spread outside the prostate, and further treatment may be necessary.

Things that can affect how your surgery goes, your risk of side effects, and whether or not you will need more treatment include:

• Whether your cancer has spread
• How aggressive your cancer behaves?
• Your general health
• Your surgeon’s experience and skill.

High dose-rate brachytherapy (HDR) involves inserting thin needles into the prostate gland. These needles are attached to tubes called catheters and a source of radiation is delivered into the prostate for a few minutes to destroy cancer cells. After treatment, the needles and catheters are removed, so no radioactive material is left in the body.

HDR brachytherapy is most suitable for men whose cancer has not spread outside the prostate gland and for those who have a medium or high risk of cancer cells spreading outside the prostate or coming back after treatment. HDR brachytherapy is often used in conjunction with other treatments such as hormone (androgen deprivation) therapy and external beam radiation therapy (ERBT). It is less commonly given alone.

There is currently, no health care institution offering this treatment for prostate cancer in Trinidad and Tobago.

Advantages

• HDR brachytherapy delivers a high dose of radiation directly into the prostate. This means healthy tissue nearby only gets a small dose of radiation and is less likely to be damaged and cause side effects.
• Recovery is quick, which means you can usually return to your normal activities within a week.
• If your cancer comes back, you may be able to have further treatment.

Disadvantages

• It can cause side effects such as urinary, bowel and erectile dysfunction.
• You will need a general anaesthetic.
• A short hospital stay is required. More than one radiation treatment may be necessary over 1-2 days. You may need to stay in the same position between treatments, with the tubes still in your prostate. Some men find this uncomfortable.

LDR brachytherapy involves the implantation of tiny, permanent radioactive pellets (seeds) into the prostate. These seeds emit concentrated amounts of radiation aimed at destroying the cancer cells. The radiation is limited to the prostate and a few millimetres around it effectively wiping out the cancer cells without causing long-term harm to healthy tissues surrounding the prostate. This form of treatment is more commonly offered for early stage localised prostate cancer but can also be offered with external beam radiation therapy as a boost for men who have a higher risk of cancer growing outside the prostate. LDR Prostate Brachytherapy can be accessed locally through Trinidad & Tobago Prostate Brachytherapy (TTPB) Ltd.

Patient selection criteria for LDR Prostate Brachytherapy

LDR brachytherapy is generally a treatment for men who meet the following criteria:

• Localised cancer confined to the prostate gland
• Gleason Score equal to or less than 7
• Initial PSA level lower than 10ng/ml

Advantages and disadvantages of LDR Brachytherapy

Advantages

• Clinical data shows excellent cure rates similar to that of external beam radiation and radical prostatectomy.
• Lesser risk of long term effects to healthy tissues (rectum, bladder and urethra)
• Better preservation of erectile function.
• Patient arrives at the hospital in the morning. The procedure takes approximately one hour, then leaves the hospital in the afternoon.
• It is a one-time, minimally invasive procedure that is better tolerated than surgery or external beam radiation.
• Recovery times are short and patients can return to their normal routine within a day or two.
• Combined with either External Beam Radiotherapy (ERBT) or Hormone Therapy (HT) this has been shown to give good results for more advanced cancers.

Disadvantages

• Mild prostate swelling develops after the implant procedure along with irritation of the urethra and bladder neck. These symptoms combined with the slow release of radioactivity may cause urinary tract side effects. Some patients experience moderate urinary urgency, frequency and a weak urinary stream for several weeks. These symptoms will however gradually ease up and eventually disappear as the radiation levels decrease. Doctors may often use medications to reduce these side effects. Most patients respond well to alpha-blocker medications and nonsteroidal anti-inflammatories.
• Although the seeds remain radioactive for almost a year, the energy and activity of the seeds is so low that there is negligible risk of exposure to others and only simple precautions are necessary for the first 2-3 months.