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This is part 3 of a 5 part Information Guide. Introduction: Index


Having assembled all the data available about the diagnosis, the next step is to decide what treatment to choose - if indeed treatment is required.

It may sound like madness not to treat a disease diagnosed as cancer immediately. But not all cancers are equal and in many cases - probably the majority, prostate cancer is a slow growing or indolent disease which should be managed successfully as a chronic illness. Of course no one should ever ignore a potentially dangerous disease, but immediate action may not be essential. All treatments for prostate cancer have a risk of side effects (termed morbidity) which can, in many cases, significantly reduce the quality of life. It is important to ensure as far as possible that treatment is justified and that the most appropriate treatment is chosen.



When faced with this question, the traveler through this Strange Place will discover the greatest conundrum of the disease:


Relevant scientific data from randomized studies comparing the outcomes of various treatment options does not exist.

How can this be? This excerpt from a 1997 article in The New England Journal of Medicine, the prestigious American medical journal, sums up the position pretty clearly:

"... we have no firm guidelines for advising our patients about which therapeutic option is best. This means that education is more important than ever, but the art of multidisciplinary counselling is hampered by rivalries that seem more common among prostate cancer specialists than in other cancer specialties. This must change…. Close collaboration between surgeons, radiotherapists, and medical oncologists is mandatory for substantially improved control of prostate cancer."

There is no sign of any great change since that was written more than ten years ago. In contrast to virtually every other cancer, where oncologists are directly involved in the choice of appropriate treatment, prostate cancer is still mainly treated by urologists, most of whom are surgeons. They will usually recommend surgery. If a second opinion is sought from a radiologist, radiation therapy may well be recommended for the same diagnosis. Both can quote statistics to support their position - how can both be right? Until this is resolved, the newcomer to this Strange Place must make up his own mind what is best for him and choose a course of treatment balancing risks versus reward as defined by his values - these generally include both survival and quality of life considerations. Hopefully what follows will help him find his way through the uncertainty of this Desert of Doubt.


Before moving onto the treatment choices it is important to understand that there are no standard definitions for words like 'cured' or 'continent' or 'impotent' - all very important issues in the decision making process.

Much published information avoids stating definitions and outcomes directly and as a result, men misunderstand the odds when choosing treatment.

To make the decision that he will not regret, a man should understand his risk of morbidity (side effects) as well as his likelihood of a "cure" and how these terms are defined and measured.

When asked, a doctor may present percentage figures or other data regarding the likelihood of being 'cured', 'continent', and 'potent' following the course of treatment being recommended. It is essential to make sure that the terms used are understood. Most men expect 'cured' to mean that the tumour has been removed and that they will have no sign of the disease again: they do not expect to have regular PSA checks for the rest of their lives to ensure that the treatment has not failed. They expect 'continent' to mean that they will not leak and will be able to urinate without problems: they do not expect to have to use pads to remain dry or a penile clamp to stop leaking. And they expect 'potent' to mean that they will be able to achieve erections at will, whenever required: not to have to rely on medications such as Viagra or injections or mechanical devices. Yet studies have definitions of 'cured', 'continent', and 'potent' that differ markedly from these expectations and actual outcomes of treatment may be worse than they are said to be because of this. It is also important to understand that published information will usually show the results achieved by very skilled and experienced practitioners. Their results will almost certainly be better than someone who does not share these traits.

Men should be free to decide that they would rather live with the cancer than with the side effects of being treated for it. Men choosing treatment should not expect to be free of its side effects; men choosing Active Surveillance should expect eventual disease progression. These factors must be weighed against a man's expected longevity and pre-treatment situation - for example many men develop erectile problems as they age, so loss of this function might not be a big issue for them; a man with severe urinary problems from BPH (Benign Prostate Hyperplasia) might welcome the relief urinating freely again after surgery, and accept the possibility of bit of leakage. A young man diagnosed with aggressive disease is in a much different situation from that of an older man with low to moderate risk disease. If the probability of the tumour having spread beyond the gland is high, the odds of a 'cure' may be so low as to be a deciding factor not to have aggressive treatment. Family history should also be considered: sharing genes with someone gravely affected by prostate cancer may mean a genetic increase the risks of not being treated.

As long as the death rate from prostate cancer stays at about one in eight for those who have been diagnosed (regardless of stage and grade), the decision not to have immediate treatment should not be viewed as an illogical course.


Treatment options vary from country to country. The greatest variety available is in the United States of America where, it is said, there are at least fifteen, none of which are demonstrably better than each other. The main options and sub-sets are:

Surgery - This is the most common procedure, technically referred to as RP (Radical Prostatectomy). The main sub-sets are "open" and "keyhole" or laparoscopic procedures. Open surgery may be retropubic or perineal: keyhole surgery may be manual or robotic. Men with advanced prostate cancer may have their testicles removed surgically. This is called an Orchiectomy or an Orchidectomy, and although a surgical procedure it is really a form of hormone treatment.

Radiation Therapy - The most common form is EBRT (External Beam Radiation Therapy) with a number of sub-sets that refer to the method of delivering the radiation dose. Another form of radiation therapy - Brachytherapy - has radioactive 'seeds' introduced into the prostate gland on a permanent or temporary basis

Androgen Deprivation Therapy - This is referred to as ADT, but more commonly known as Hormone Treatment. There are many variations on this type of treatment, but essentially all involve using medication to suppress the hormonal mechanisms that help tumours to grow. Orchiectomy, surgical removal of the testicles, is an irreversible form of hormone treatment.

Active Surveillance - AS is often referred to as "Watchful Waiting". No conventional treatment is undertaken unless regular monitoring indicates disease progression. Men choosing AS often make changes to diet and lifestyle with the intention of boosting the immune system.

Cryotherapy - The prostate gland is frozen in this therapy usually referred to as Cryo. The treatment is evolving and now includes focal cryotherapy aimed at targeting a tumour (like a lumpectomy in breast cancer) and thus reducing the probability of side effects. It is still regarded as somewhat experimental.

High Intensity Focused Ultrasound- This procedure known as HIFU uses the heat generated by the ultrasound to focus on and destroy the tumour. Developed in China and used for some years in some European countries, Mexico and Canada, it is still regarded as experimental in the United States of America.

Chemotherapy - This treatment has not been used very much in dealing with prostate cancer except as a last resort if all else fails. New chemicals and protocols developed in the USA seem to be proving more effective than those in the past.


1. Be certain that immediate treatment is required. Some leading experts in the US say that the substantial majority of treatment procedures carried out for prostate cancer in the US are unnecessary - estimates vary between 25% and 80%.

2. The choice of treatment may be less important than the choice of who does the procedure.
The non-medical people in the prostate cancer community generally agree the experience of the person or team carrying out the chosen procedure is of utmost importance. The more experience, the less severe the side effects. This may seem obvious, but many men only find out the hard way. It may be embarrassing to ask a surgeon or radiologist to provide evidence of their skill, but bearing in mind the consequences, this question should never be avoided.

3. It is important to be as certain as possible that the disease is contained within the prostate capsule before making any final treatment decision.
This is where the Partin Tables and other similar nomograms are very useful. The information obtained by using the Partin Tables is no guarantee of the actual situation for any individual. It does however provide some indication of what treatment options might achieve the best result, and which might be ruled out because of the possible extent of disease.

There is need at this point for a short diversion to consider the tables before getting back to the discussion of treatment choices.

Diversion to consider the Partin Tables:

Allan W. Partin, M.D., Ph.D., and Patrick C. Walsh, M.D. at the James Brady Urological Institute in Boston, USA developed these tables which are based on the analysis of many biopsies. Their aim was to try to establish if there was any relationship between the various aspects of diagnosis and the likelihood of the disease having moved beyond the capsule. The tables are too complex to reproduce in this document, but essentially they look at the three main aspects of diagnosis - PSA (Prostate Specific Antigen), Gleason Score and Clinical Staging - and show, as a percentage, the statistical likelihood of the disease having escaped the capsule or being contained.

To take the example referred to above, where the man was diagnosed as PSA 7.2: GS 3+2=5: Stage T2bNXM0, and referring to the relevant section of the Partin Tables we would find the chances of:

o Organ-Confined Disease are Between 55% and 68% (median 62%)
o Established Capsular Penetration are Between 26% and 38% (median 32%)
o Seminal Vesicle Involvement are Between 3% and 8% (median 5%)
o Lymph Node Involvement are Between 0% and 2%(median 1%)

To give some idea of how one item might change these percentages, and how important the Gleason Score is, if the diagnosis was PSA 7.2: GS 4+4=8: Stage T2bNXM0, then the chances above would change to these:

o Organ-Confined Disease Between 17% and 33% (median 24%)
o Established Capsular Penetration Between 29% and 48% (median 38%)
o Seminal Vesicle Involvement Between 16% and 39% (median 27%)
o Lymph Node Involvement Between 3% and 20%(median 10%)

There is a lower probability of benefit from surgery or other local treatments, if there is a high probability of the disease having escaped from the organ.

Now, back to treatment choices:

SURGERY: This treatment is technically called RP (Radical Prostatectomy), and is often referred to as the "gold standard" treatment, implying it is the very best. It is the treatment most commonly prescribed for younger men or early stage prostate cancer. The traditional surgery was an "open" procedure but there is enormous and rapid growth in laparoscopic- 'keyhole' - surgery, especially the Da Vinci robotic procedure.

In open surgery, the prostate gland is reached either from the lower part of the front of the body - this is a retropubic procedure - or through the area between the anus and the scrotum - this is a perineal procedure. There are no studies that show either of these procedures to be superior to the other. In the past the operation involved a substantial loss of blood. There have been significant improvements in surgical techniques and it is now unusual for a transfusion to be required. Some surgeons recommend the drawing and storing of the patient's own blood ahead of the operation as a precautionary measure.

Retropubic Surgery

Perineal Surgery

Laparoscopic portholes
Laparoscopic surgery on the other hand requires five small ( five to 10 millimeters) incisions (or portholes), one just above or below the belly button and two each on both sides of the lower abdomen. Four arms are inserted into the portholes, three hold instruments, the fourth holds the camera - this is the laparoscope which enables the surgeon to get pictures of the prostate on a video monitor. Carbon dioxide is passed into the abdominal cavity through a small tube placed into the incision below the belly button. This gas lifts the abdominal wall to give the surgeon a better view of the abdominal cavity once the laparoscope is in place. The arms are used by the surgeon to remove the gland, through one of the portholes and are manipulated manually, except where the procedure is robotic assisted - a procedure usually referred to as the Da Vinci procedure. The surgeon sits at the console and looks through two eye holes at a 3-D image of the procedure, meanwhile maneuvering the arms with two foot pedals and two hand controllers. The Da Vinci System translates the surgeon's hand movements into more precise micro-movements of the instrument.

RP, whether open or laparoscopic is a major surgical procedure and will usually take 3 to 4 hours. Discharge from hospital was normally within 3 to 5 days for the 'open' procedures but is now likely to be 3 or less. Laparoscopic surgery, on the other hand, is far less traumatic and men are usually discharged from hospital in 24 hours. There is still a good deal of disagreement about the merits of the two procedures. Surgeons favouring open surgery say that they can feel the prostate and get a better idea of where the tumour might be and thus have more assurance of negative margins: doctors favouring laparoscopic surgery say that the better view obtained through the magnifying lens enables them to cut and stitch more accurately. As yet there are no long term studies to support either view. The incidence of initial morbidity are similar as are early failure rates. One thing has become clear - the learning curve for the laparoscopic procedure is a long one. One published study implies that it takes at least 250 procedures before the surgeon can be regarded as proficient.

In either case, a catheter will be in place, usually for some weeks. It normally takes about three months to regain control of the bladder function, although some men achieve this sooner. Recovery of erectile function will almost certainly take a good deal longer, many months and sometimes a year or more. Recovery of erectile function is dependent to a large extent on the ability of the surgeon to spare the erectile nerves, although this is not the only factor.

The main benefit of surgery is that it introduces an element of certainty. The prostate gland can be examined closely to establish the extent of the tumour, to verify the Gleason Score and to clarify the likelihood of the tumour being contained within the gland. If there has been no spread beyond the gland, then the removal of the prostate should, by definition, remove the tumour. For many men that is of utmost importance.

However, surgery may not be a good choice if the disease has metastasised - that is if the disease has spread to distant sites beyond the prostate. There is a view that, in such cases, the removal of the gland and the main tumour may accelerate the growth of the secondary, metastasised, tumours and make control of the disease much more difficult. Like many other aspects of prostate cancer, there is no consensus on this issue, which is the subject of some debate among physicians and researchers. Because it is so difficult to establish beyond doubt whether the disease has spread beyond the gland, there may be an element of risk in opting for surgery.

Success or "cure" is measured by taking PSA tests at intervals after the surgery. Ideally there should be no PSA measurement detectable with the normal PSA test. Ultra-sensitive PSA tests may show very low levels - well below 0.10 ng/ml. No formal studies have demonstrated the superiority of surgery over other forms of therapy, including Active Surveillance, in early stage cancer. There is a failure rate of about 30% - 35% over a period of 10 - 15 years for men undergoing surgery. Some failures have been reported at 20 years. In the event of recurrence or failure of the treatment, it is possible to use EBRT (External Beam Radiation Therapy) to treat recurrence thought to be confined to the prostate bed, or to use ADT (Androgen Deprivation Therapy) as a secondary treatment for recurrence where the disease has spread into other areas of the body.

The main side effects of surgery are erectile dysfunction (the difficulty or inability to have an erection) and bladder incontinence (the inability to control the bladder). The man also becomes infertile, since there is no ejaculate following the removal of the gland. Men intending to father children should bank sperm before surgery.

The first of these problems - erectile dysfunction (ED) - comes about because the nerves controlling erections are embedded near the surface of the prostate gland; one on each side of it. There has been a reduction in the reported rates of erectile dysfunction following the development of what is referred to as the "nerve-sparing" technique and the use of pharmaceutical drugs such as Cialis, Levitra or Viagra or one of the injectable materials - MUSE, Tri-Mix and the like. However, the position of the tumour may affect the ability of even the best surgeon to spare one or both of the nerves while removing all the cancer. The ED rate is still high - probably over 50%, especially for men over the age of 50. Studies quoted with better rates should be examined very carefully, especially for definitions of potency or erectile function. These studies usually involve excellent surgeons and may not reflect the general outcome of surgeries carried out by surgeons with less experience.

Total bladder incontinence is reported in a small number of men - about 5% - but many men experience some leakage, particularly during sexual arousal or when lifting, coughing, sneezing or laughing. Again it is important to look at definitions when considering studies showing levels of continence after treatment. It is not uncommon for the use of 'only' one or two pads a day to be regarded as fully continent in such studies. The outcomes of surgery carried out by urologists who do not have the experience of surgeons in a centre of excellence are usually worse.

Another issue to be aware of is stricture from scar tissue, which can also cause urinary problems. If the man has a history of poor scarring (some reports suggest that if any scar on his body is more than 10 mm (about 3/8") wide) then there is about an eightfold increase in urinary problems following RP (Radical Prostatectomy).

Penile shrinkage is also reported in a significant number of men, thought to be the result of maintaining the penis in the flaccid state during what can be many months of recovery of erectile function. It is thought this can be counteracted by stimulating erections with drugs or manual devices as soon as post-surgical healing has taken place.

A final issue, rarely discussed, is that of Peyronie's Disease or Peyronie's Syndrome. This condition is one where the erect penis acquires a 'bend' or deflection. The vast majority of Peyronie cases are very mild but others can cause severe problems. It seems unlikely that the condition is directly caused by a disease, or that it has any direct link with prostate cancer. A common cause is thought to arise from accidents during sexual activities, especially if the penis is not fully erect.

- most common form of Radiation Therapy is known as EBRT (External Beam Radiation Therapy). There are many other acronyms, such as RT (Radiation Therapy), IMRT (Intensity Modulated Radiation Therapy) and 3DRT. All refer to the procedure where photon radiation is directed at the site of the prostate gland from an external source. The variations usually refer to the different aiming techniques. A form of EBRT known as CyberKnife® delivers what are termed hypofractionated doses - fewer doses, very much larger than normal EBRT but, it is claimed, delivered more accurately and thus reducing the potential for collateral damage. A significantly different form of EBRT is PBT (Proton Beam Therapy). It is claimed that the proton beams can be directed more accurately than photon beams, again with less likelihood of collateral damage. PBT for prostate cancer is only done at a few sites, mostly in the US.

Another form of radiotherapy, is Brachytherapy or SI (Seed Implants). Radioactive "seeds" are implanted directly into the prostate gland, where they remain. There is a variation of this treatment known as HDR (High Dose Rate Brachytherapy) where seeds are inserted and then removed.

All radiation therapy is intended to destroy the cancer cells while leaving healthy tissue intact and is often the recommendation for older men for whom surgery presents a health risk. EBRT is also used where it is felt that the tumour has spread beyond the prostate gland and as a "salvage" treatment for failed surgery. EBRT used in conjunction with other treatments such as surgery or brachytherapy is known as adjuvant treatment. Radiation treatment is not recommended for men who have a high International Prostate Symptom Score (IPSS) prior to treatment. This signals severe urinary problems. Radiation therapies will often exacerbate these problems. The International Prostate Symptom Score (IPSS) is generated from what is termed a LUTS test (lower urinary tract symptoms).

EBRT takes place over a number of weeks - usually six or seven - with daily sessions of therapy, the exception being CyberKnife® which takes about five days. The effect of radiation is cumulative, so low doses given on a regular basis build up into high doses, lethal to the tumour cells. Most men tolerate the procedure very well, although as time goes by, they may feel fatigued and it may be desirable to rest in the afternoon. The feeling of fatigue will usually disappear after completion of the treatment.

Illustration of placement of seeds into prostate in brachytherapy procedure

Brachytherapy is usually considered as an alternative to surgery for men with a suitable diagnosis. SI is a relatively short procedure, taking two or three hours, after which the man can go home and carry on with his normal activities: HDR might need an overnight stay in hospital. There is sometimes a feeling of fatigue, as is the case with EBRT, but this usually recedes with time, as the dosage from the seeds reduces (they are only fully active for about six months). Brachytherapy is not a good option for a man who has previously had a TURP (Transurethral Resection of the Prostate).

Two aspects of SI could cause some concern. Firstly, the man is carrying radioactive seeds in his prostate and the question asked is whether those seeds can injure anyone close to the man - for example, grandchildren sitting on his lap. Studies have demonstrated this is not a risk. The second point concerns seeds migrating from the prostate to other parts of the body, notably the lungs. This happens when seeds work their way out of the prostate before the glandular tissue heals and locks them in place, or where they have not been securely placed. It is said this does not present any significant problem for the patient.

Success or "cure" for radiation treatments is measured by a gradual reduction in PSA level in the months after treatment is completed. The aim is to achieve a nadir, or low point, of 0.200 ng/ml and to maintain that level. Some authorities feel a nadir of under 1.00 ng/ml is an acceptable level. Some men experience what is referred to as a "bump" about 18 months after radiation when the PSA rises and then falls again. No formal studies have demonstrated the superiority of radiation therapy over other forms of therapy, including Active Surveillance. There is a failure rate of about 30% - 35% over a period of 10 - 15 years for men undergoing radiation therapy. A leading US institution claims better long-term freedom from disease using combined SI/EBRT therapy rather than EBRT alone. They term this treatment procedure as ProstRcision®.

In the event of recurrence or failure of radiation treatment, surgery is not a good option and is rarely successful because of the damage done to the tissue by the procedure. The usual option for further management is ADT (Androgen Deprivation Therapy) although Cryotherapy can also be used as a salvage treatment.

The side effects of radiation therapy are similar to surgery with the added complication of urinary urgency/frequency, difficulty in starting a urine stream and incontinence. Radiation can sometimes result in bowel incontinence as well as rectal bleeding. ("Incontinence" is the inability to control bladder or bowel). The reported incidence of bowel incontinence is fairly low for EBRT and even lower for SI and PBT. There is a reported improvement in radiation treatment side effects with modern techniques. Erectile dysfunction is reported to occur in a substantial number of cases, more so for EBRT than SI, but at about the same level as surgery. In contrast to surgery, where an immediate loss of function can be followed by a gradual recovery, erectile dysfunction associated with radiation therapy of any kind tends to occur well after treatment and to gradually grow worse over time.

ADT (ANDROGEN DEPRIVATION THERAPY) generally known as Hormone Treatment. There are many variations of this treatment, all with different acronyms. The theory behind this treatment is that growth of prostate cancer cells is fuelled by dihydrotesterone (DHT) a derivative of testosterone, the male hormone steroid, which is an androgen. A reduction in the production of androgen will therefore theoretically deprive these cells of nutrition and they will die. There are four methods by which the cells are deprived of androgen.

Ablation. The testes produce approximately 90% of the male body's testosterone with the balance being produced by the adrenal glands. Thus a simple way to reduce testosterone production is the surgical removal of the testes by way of an orchiectomy or orchidectomy (castration).

Additive. Testosterone production is attacked by dosing the man with oestrogen.

Inhibitive. This involves the use of chemicals to block signals from the brain to the production centres so that no testosterone is produced.

Competitive. The final method of treatment involves what are known as antiandrogens. These do not prevent the production of testosterone, but block the receptors on the prostate gland, preventing the androgen from being absorbed.

The last three treatments are sometimes used in unison, in which case the treatment is referred to as CHT (Combined Hormone Therapy) or ADT3. Treatment is administered in a variety of forms, from pills to monthly or quarterly injections.

ADT was at one time only used to manage late stage prostate cancer, where the tumour had spread beyond the capsule and therefore could not be treated by surgery or radiation and/or as a "salvage" therapy for failed surgery or radiation treatment. There is however a growing use of this therapy as a precursor to other treatments. This is known as neo-adjuvant therapy. Many practitioners are opposed to this practice because studies do not show any significant advantage for the inevitable side effects and there are several disadvantages. Some leading practitioners of both surgery and brachytherapy in the US will not treat men who have had this neo-adjuvant therapy.

The aim of ADT is to manage and control the disease, since it is extremely unlikely that this therapy will result in a permanent "cure". The degree of success achieved is measured by the reduction of the PSA to as low a level as possible and keeping it there. In many cases the PSA level can be undetectable and there are reports of men treated with this therapy achieving mortality rates very similar to those of men without the disease. Failure of this treatment occurs when the tumour becomes androgen independent (AI). This condition is often referred to as AIPC - Androgen-Independent Prostate Cancer, or Hormone Refractory Prostate Cancer (HRPC). This means the tumour has found a way of growing without the androgen associated with testosterone. Management of the disease at such a stage is very difficult although some success has been reported with new chemotherapy drugs.

There are numerous side effects associated with this form of treatment whether the treatment is being used as an adjuvant treatment for early stage tumours or as a palliative measure for advanced cancers. Some men have severe side effects, others have none: some appear early, some only after a long period of treatment. The ones reported most frequently by men undergoing any of the ADT methods are erectile dysfunction, loss of libido (no interest in sexual activity), hot flushes, osteoporosis (loss of bone), loss of muscle tone, weight gain and mood swings, with depression being widely reported.

Individual methods have other side effects such as the development of breasts, increased risk of thrombosis, and an initial rise in tumour activity, known as a "flare". This is usually of a temporary nature. Flare can be prevented by administering an anti-androgen one week prior to the first injection of the drug being used to inhibit testosterone production.

A list of potential side effects associated with ADT include:

Alcohol intolerance (with Casodex and Eulexin); Anaemia; Anxiety or depression; Arthritic symptoms; Appetite loss; Blood in urine; Breast swelling and tenderness (gynecomastia); Cholesterol and triglyceride increase; Constipation; Diarrhoea (eulexin); Disturbed sleep; Drowsiness; Dry mouth; Emotional instability (esp. Crying); Feet or lower legs, swelling of (peripheral oedema); Flatulence; Flu syndrome; Hair: decrease in pubic and axillary hair; facial hair grows more slowly; Headache; High blood pressure (hypertension); Hot flushes; Hyperglycaemia (high blood sugar ); Impotence (during the period of treatment and some months after); Indigestion; Itching; Insomnia; Liver problems; Memory loss; Methemoglobinemia (a crystallization in the blood); Nausea; Nocturia (need to urinate frequently at night); Nervous and twitchy legs; Osteoporosis; Pain: abdominal, back, chest, in right side; Pressure: feeling of extreme pressure in head; Prickling sensation on the skin; Shortness of breath; Testicular atrophy (shrinking) & soreness; Sweating; Weight gain (weight gain may continue for a while after treatment); Weight loss.


The following symptoms may reflect serious problems and if they occur, medical attention should be sought immediately:

Bluish lips, fingernails, or palms of hands; Dizziness (extreme) or fainting; Fatigue, weakness; Pain: bone, joints, pelvic; Numbness, coldness, or tingling of hands or feet; Infections; Rash; Urinary incontinence; Urinary tract infection; Vomiting; Weak and fast heartbeat; Yellow eyes or skin.

A recent development has been towards "pulse" therapy known as IHT (Intermittent Hormone Treatment) or IHB (Intermittent Hormone Blockade). Some studies indicate that stopping the ADT once the PSA count has been reduced and reintroducing the therapy if the PSA count rises again might produce some benefit. The duration of the side effects of ADT are reduced and it appears the possibility of the disease becoming androgen-independent may also be lessened. In some very rare cases, the PSA does not rise again after the ADT is stopped and the man can be considered to be in remission. Men on ADT welcome the treatment "holidays" as many of the side effects disappear or diminish as the effect of the drugs wears off. In some cases some of the side effects are permanent.

CRYOTHERAPY: This procedure uses probes to freeze the gland. The prostate tissue is destroyed by the very rapid thawing process which ruptures the cell membranes. The probes are placed through the perineal skin - between the scrotum and anus, like the tubes for brachytherapy. They are guided using transrectal ultrasound which is also used to monitor the freezing process in real time. It is unusual for fewer than three probes to be placed; additional probes may be placed to allow for adequate freezing of more extensive disease. Incontinence levels are kept low by warm liquid being circulated in the urethra during the procedure.

When this procedure was first used, the entire gland was destroyed, which led to a very high incidence of erectile dysfunction - almost 100% of men were impotent according to some studies. Later developments have seen the development of focused cryotherapy, which destroys only identified tumours and the healthy cells in the immediate vicinity of the tumour, leaving some or all of the erectile nerves untouched and resulting in levels of ED that are comparable with those resulting from other treatments. It can be difficult to pinpoint the position of small tumours. This usually involved a mapping biopsy using a large number of needles - as a rule of thumb the volume of the gland + 20 up to a potential maximum of 100 needles. This type of biopsy is usually undertaken under a general anaesthetic. .

One advantage this form of treatment has is that it can be repeated and it can be used in suitable cases as a salvage procedure for other failed treatments, notably radiation.

HIGH INTENSITY FOCUSED ULTRASOUND (HIFU): This procedure was developed in China and used for liver and pancreatic cancers, but was not used initially for prostate cancer. Subsequently several European countries, notable, France, Germany and Belgium started to treat men with prostate cancer. Basically the tumors are cooked to death quickly. The focused sound energy raises the temperature to around 140 degrees Fahrenheit (60 degrees Celsius), killing the cells in about one second. The ultrasound beam must travel through continuous tissue or fluid to the tumor site because the energy cannot be focused through gas or bone. By targeting tumour cells precisely, theoretically the tumor can be destroyed with minimum collateral damage. Like cryotherapy one of the immediate pre-treatment issues is how to identify the precise location of the cancerous cells.

HIFU is still regarded as experimental in a number of countries and has not been approved for prostate cancer by the FDA in the USA. Trials are being carried out there.

There have been alarming reports of bladder damage creating severe urinary problems. It is clear that experience with the equipment used for this therapy is even more important than in other therapies. An unskilled practitioner can do a deal of damage very quickly.

ACTIVE SURVEILLANCE: This option is still often referred to as WW (Watchful Waiting) although the terms have different meanings. In the past Watchful Waiting meant no action was undertaken unless the disease is seen to progress. Men choosing the Active Surveillance are monitored closely and will often use a variety of non-conventional or alternative treatments to manage the progression of the disease.

Dr. Jon Oppenheimer, a leading pathologist in the USA is on record as saying:

"For the vast majority of men with a recent diagnosis of prostate cancer the most important question is not what treatment is needed, but whether any treatment at all is required. Active surveillance is the logical choice for most men (and the families that love them) to make."

The rationale for this statement is that prostate cancer is what is termed an "indolent" disease in most cases, because it progresses so slowly it may never be a threat to life. The man choosing Active Surveillance over Watchful Waiting believes by taking a proactive stance he can harness his immune system to either halt the progress of the disease or possibly even cause it to regress.

Prime candidates for this option are those who have been diagnosed with an insignificant tumour or very low risk disease. There are various definitions of these terms, but broadly speaking they are similar to the one established by Johns Hopkins University School of Medicine in the US, where the definition of an insignificant tumour was established some years as one with the following characteristics:

Nonpalpable - the examining doctor would not feel anything when carrying out the DRE (Digital Rectal Examination)

Stage T1c - the tumour is discovered in the course of a biopsy following an elevated PSA test where there are no other symptoms

Free PSA - the percentage of free PSA should be 15% or greater

Gleason Score - less than 3+4=7 - or, as some practitioners have it, 7 or less

Size - less than three needle cores positive with none greater than 50% tumour. (In this definition it is assumed that a 12 needle biopsy is used)

The latest guidelines issued by National Comprehensive Cancer Network (NCCN®) following the codified changes to the Gleason grading system in January 2009 has this definition of very low risk disease:

Clinical Stage T1-T2a - the examining doctor felt nothing on DRE or felt something on one side of the gland only

Gleason Score 6 - the lowest score on the current range

PSA less than 10 ng/ml

Size - 3 positive needles or less with 50% or less positive material in each core

PSA density - less than 0.15 ng/ml/gm

Old studies have shown the majority of men with such a diagnosis will not have a life-threatening progression of the disease for many years. Current studies demonstrate that there is a negligible risk for suitable men in undertaking Active Surveillance.

The precise protocols for men choosing Active Surveillance vary, but broadly speaking they involve regular PSA tests (every man diagnosed with prostate cancer will continue to have these tests for the rest of his life to monitor him for any progression or return of the cancer) and other tests, notably biopsy procedures and DRE (Digital Rectal Examinations). Initially these may be done annually, but there is a view that once it has been established that the disease shows no sign of progression, the period between procedures may be extended. Other tests and scans, such as Color Doppler scans may be used to monitor significant changes in the tumour.

Because men choosing Active Surveillance have still have an untreated, entire gland they may therefore have to deal with issues such as BPH (Benign Prostate Hyperplasia) - the enlargement of the gland which causes urinary problems. BPH can be successfully managed with a variety of drugs or procedures such as a TURP (Trans Urethral Resection of the Prostate) - often referred to as a 'rotor rooter' operation .

The problem for any man considering Active Surveillance is the uncertainty of the diagnostic process, which is more art than science. It is not possible to identify, with absolute certainty, which tumours are indolent (the kitty cats) and which are aggressive (the tigers) or just where they fit in the range of diseases. There are good indicators: The ones listed above indicate disease that is most likely indolent; on the other hand PSA doubling times measure in months or weeks, high Gleason Scores - over 20 ng/ml, late stage disease - stages T3 and T4 all indicate a disease that requires early attention. Indolent disease can often be treated like a chronic illness.

For many men choosing this course, the essence of Active Surveillance is a belief in the mind/body continuum. The aim is to maintain the immune system in good condition to deal with the tumour. Since there are very few studies to guide men in this endeavour, and the medical professionals are often ill-informed on nutritional matters and similar issues, there is a tendency for each man to develop his own unique program. Most of the programs for which there is anecdotal support include the following elements:

Stress reduction: Stress is commonly regarded as one of the most universal causes of damage to the immune system. Stress reduction can be accomplished using activities such as meditation, visualisation or yoga.

Exercise: Moderate amounts of exercise are essential. Usually, subject to the fitness of the man, he is recommended to exercise at least three days a week at a level where the pulse rate is raised and sweat is formed.

Changes in diet: This subject is covered in a little more depth in the section titled Plains of Recovery, but essentially, the aim is to attain a vegetarian diet or better still a vegan diet. Red meat and dairy products are regarded as bad: fresh vegetables and fruit are regarded as good. Smoking should, of course, be stopped, as should consumption of alcohol, although small quantities of wine, especially red wine, are thought to be beneficial. Consumption of coffee, animal fats, fried foods and sugar should be kept to a minimum.

Weight loss: There is a clear connection between illness and obesity. Although following the steps above should lead to weight loss, this should also be incorporated as one of the aims of any successful program.

Successful Active Surveillance management should see a stabilising or even a reduction in PSA levels, and this is the primary measure of success. Because of the vagaries of PSA counts, this should not however be the only measure. There should also be an annual DRE (Digital Rectal Examination) and, some recommend, an annual or biennial biopsy. In considering this latter test, some thought should always be given to the potential for side effects from biopsy. A continuous rise in PSA or a positive DRE would be the trigger to contemplate further, conventional treatment. Many men - more than 20% in one study - who have chosen Active Surveillance have negative biopsy results on repeat biopsy. This does not necessarily mean that there are no longer cancer cells in the gland, because the biopsy process is literally 'hit and miss' but it does imply that there has been little or no significant growth in the tumour.

The side effects of a successful Active Surveillance program are all positive since the enhanced immune system will generally result in better health all round.

It is often difficult to deal with the uncertainty associated with Active Surveillance. This is often seen to be greater than the uncertainty of those who have had conventional treatment. However in three studies it has been found that essentially, if men are 'worriers' they have similar levels of concern whatever the path they choose. Those who are more phlegmatic accept the uncertainty more easily.

Anyone embarking on Active Surveillance will need determination to continue. The medical profession along with well-meaning friends and relatives, often create a good deal of pressure to 'do something'. This leads many men to abandon Active Surveillance and opt for conventional treatment even if there is no significant change in the diagnostic pointers.

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