If you have just been diagnosed with prostate cancer by your urologist or Nurse Specialist, you may be wondering what to do next. First of all, do not panic. There are more than 40,000 cases of prostate cancer diagnosed in the UK every year and very good support networks, so you are not alone. Generally, depending on the grade (aggressiveness) and stage (extent) of the cancer and your physical fitness there will be more than one treatment option that you can choose from, and generally there is no urgency in you making your choice. You will be told if this is not the case for you and if you must seek urgent treatment. It’s important that whatever treatment option you choose that you feel, having weighed up the advantages and disadvantages of each, that what you have chosen is right for you.
You should take your time to do detailed research on available treatments and don’t dismiss any option out of hand unless you have a good reason for doing so. Don’t be put off by the fact that to get the best treatment you might have to travel to a hospital that’s some distance from home – your best chance of cure is with your first treatment so it is vital that you stack the odds as heavily in your favour as possible. Once you know what you want to do, ask your GP to refer you to a specialist urologist. Most GPs are happy to refer you to whoever you want to see, as long as they know that you have a good reason for seeing them. For example, if you choose to undergo surgery you should want to select a skilled surgeon who has excellent results, has many years of experience and is a high-volume surgeon (someone who performs more than 100 operations a year).
Although there might be several treatment options available to you, they are unlikely to be equal in terms of you enjoying a successful result. For instance, younger patients and those with more aggressive and/or bulky tumours are usually better served by surgery because of the greater certainty it gives, together with the back-up options of radiotherapy and hormonal therapy if needed in the future. Although younger patients worry the most about the potential side-effects of surgery (such as incontinence and impotence), they are actually much less likely to experience these than older patients, especially in the hands of a high-volume surgeon.
Unfit patients or elderly patients might choose radiotherapy instead. Active surveillance (where the cancer is not treated but monitored due to it being slow-growing and contained within the prostate) is the default option for low-risk tumours, but this option also carries a small risk of missing the time ‘window’ of being able to cure the cancer. Some treatments, such as focal therapy, high-intensity focused ultrasound (HIFU) and cryotherapy are regarded as experimental because we don’t have enough evidence of their safety and/or effectiveness, and these treatments should only be used in the context of a clinical trial.
Once your GP has referred you to a specialist in the treatment of your choice, you will meet with them to discuss your test results during a consultation. Consultations will generally take 15 – 30 minutes and will usually start by you being asked about your past medical history (any operations and serious illnesses), what drugs you take regularly, if you smoke (give up now – smoking increases the risk of heart and lung disease, as well as a number of cancers) and what you do or did for a living. All these lifestyle factors can influence the specialist’s understanding of your health, and what treatment they recommend.
The questions will then become focused on your prostate. The specialist will need to know if:
- you have any urinary symptoms;
- your erections are normal or if you need to take tablets such as Viagra for them;
- there is any family history of prostate cancer.
The specialist will then go through your test results: your biopsy report, the results of any scans (such as MRI, CT, CT PET, bone) and other test results. You may then have a rectal examination. They will then ask you if you know what treatment you want, and offer their professional opinion on its suitability (or otherwise) for you. If you’re not sure, they will discuss the options available to you, and explain the advantages and disadvantages of each, together with an estimate of the time you will need to wait for each. Don’t feel rushed into making a decision – it’s quite common to go home to think over the options for a few days before finally deciding.
As a quick summary, I have put together this overview table which summarises the various treatment options for prostate cancer and shows how suitable they are for each situation.
|Appropriateness for low-risk cancer*||Appropriateness for high-risk cancer^||Need for general anaesthetic||Addresses urinary symptoms||Results influenced by skill of the specialist?||Certainty of success after the treatment||Are other options available if the treatment is unsuccessful?|
|External beam radiotherapy (EBRT)||✔✔||✔✔||✔||✔||✔✔||✔✔||✔✔|
|EBRT + BT||✔||✔✔✔||✔✔✔||✔||✔✔✔||✔✔||✔✔|
|Surgery (radical prostatectomy)||✔||✔✔✔||✔✔✔||✔✔✔||✔✔✔||✔✔✔||✔✔✔|
|HIFU or cryotherapy||✔||✔||✔✔✔||✔✔||✔✔✔||✔||✔✔✔|
|Hormonal therapy (HT)||✔||✔||✔||✔✔||✔||✔||✔✔✔|
*Low-risk cancer is defined as a PSA score between 0 and 9.9, Gleason 6, cancer stage T1-2a.
^High-risk cancer is defined as a PSA score greater than 10, Gleason 8-10, cancer stage 2c-4.
✔ = no
✔✔ = perhaps
✔✔✔ = strong yes