Prostate Cancer Diagnosis and Staging: Practice Essentials, Overview, Relevant Anatomy

Treatment Side Effects, Quality Of Life Factors In Prostate Cancer

It's crucial for patients with prostate cancer to know that all treatments come with side effects, which may affect their quality of life.

Dr. Tyler M. Seibert spoke to patients with prostate cancer to discuss quality of life factors, such as sexual functioning during treatment.

Treatment options for patients with localized prostate cancer depend on how aggressive the cancer is, which opens conversations about quality of life.

At the CURE® Educated Patient® Prostate Cancer Summit, Dr. Tyler M. Seibert spoke to patients with prostate cancer about quality-of-life factors, such as sexual functioning, as they pertain to treatment options.

Glossary

Localized prostate cancer: cancer only in the prostate; has not spread.

Prostatectomy: a surgical procedure to partially or fully remove the prostate.

Urinary incontinence: involuntary leakage of urine.

Seibert is an associate professor in the Division of Radiation Oncology at the University of California San Diego.

"When I was trained to treat prostate cancer, we said a lot of things that turned out to be somewhat inaccurate, and it was because we didn't really have the data to answer the right questions," Seibert explained. "So we used to say, for example, that sexual function was much worse after radiation. I'm not saying that there's no impact, but what we were looking at was really large studies."

However, he emphasized that focusing on this kind of data wasn't necessarily accurate for patients in the real world. Seibert noted that there were some problems with this approach. For example, surgery would be the go-to treatment option for men who were younger, had lower-risk prostate cancer and did not smoke. Men who had heart disease and were at risk for surgery tended to receive radiation, Seibert explained.

Treatment Approaches for Patients With Prostate Cancer

A common treatment option for patients with localized prostate cancer is active surveillance, said Seibert. This treatment approach is when doctors closely monitor the prostate cancer without providing treatments during this time, according to the Mayo Clinic.

"The first question is, is active surveillance safe? If there's one thing I want everybody to understand is that it is very safe for the right patients," he explained. "But it must be active, so you can't just ignore the cancer and go away. You have to be monitored because most of these patients eventually need treatment, but they had years of no treatment."

READ MORE: Next-Generation Imaging a 'Gold Standard' in Metastatic Prostate Cancer

Other treatment approaches, including prostatectomy and radiation therapy, may also be considered. Both approaches are "highly effective" at "getting rid of the prostate cancer," Seibert clarified.

"They're equivalent — it doesn't really matter [which approach is used]," he explained. "I know this is a stressful decision, but you can't really go too wrong because they're both going to be effective."

Nonetheless, some patients with higher-risk prostate cancer may require both surgery and then radiation, Seibert said, but "it's important to assess that risk." He emphasized that patients who may require this should talk to their doctors about their chance of needing radiation because the "side effects are worse if you need both."

When considering the side effects associated with prostate cancer treatment, it's important to note that some treatments may cause fewer side effects. However, "no therapy has no side effects," Seibert explained.

Of note, Seibert described some of the common side effects that affect quality of life after surgery, radiation or both for patients with prostate cancer. These included urinary incontinence, waking up at night to urinate more than twice and changes in sexual functioning.

Urinary incontinence is a side effect that may occur after surgery or radiation, but more patients with prostate cancer who undergo surgery may need to wear a pad than those who underwent radiation, Seibert said.

Waking up at night to urinate two or more times is a side effect more patients may experience after undergoing radiation versus surgery in the long term. In a study published in The New England Journal of Medicine, patients with prostate cancer were more likely to experience this side effect during the first year since receiving treatment. At around six months, the side effect peaked, but became better after one year, the study showed.

Changes in sexual functioning were another common side effect experienced by patients who underwent prostate cancer treatment. Seibert noted that sexual functioning is better one year after treatment versus after six years in patients who received radiation versus surgery.

"I [want to] remind you that 12 years out, a lot of these patients are in their 80s. Even [patients who received] active monitoring eventually got treatment," Seibert said. "But they're declining in terms of sexual function over time."

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Side Effects Of Treatment

Well, when you talk about complications of prostate cancer, prostate cancer in and of itself does not have complications. When disease is progressed or when it's advanced, you can suffer some of the side effects of advanced disease, like blood in the urine or difficulty with urination or pain from chronic or aggressive disease. But complications of prostate cancer are typically associated with the treatment that is potentially offered.

So the two treatments that are available for prostate cancer are radiation and surgery. Surgery, the common or the more classic complications that gentlemen come to us and discuss with are incontinence or erectile dysfunction and impotence. Nowadays, with newer technology, newer surgical techniques-- robotics is a perfect example of that-- we are able to maintain both potency and urinary control post-operatively. So we're very happy with that.

In regards to radiation therapy, what we've found is that men may not suffer the side effects immediately. But the effects of radiation therapy, we found, are somewhat more delayed.","publisher":"WebMD Video"} ]]>

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RAJ LAUNGANI

Well, when you talk about complications of prostate cancer, prostate cancer in and of itself does not have complications. When disease is progressed or when it's advanced, you can suffer some of the side effects of advanced disease, like blood in the urine or difficulty with urination or pain from chronic or aggressive disease. But complications of prostate cancer are typically associated with the treatment that is potentially offered.

So the two treatments that are available for prostate cancer are radiation and surgery. Surgery, the common or the more classic complications that gentlemen come to us and discuss with are incontinence or erectile dysfunction and impotence. Nowadays, with newer technology, newer surgical techniques-- robotics is a perfect example of that-- we are able to maintain both potency and urinary control post-operatively. So we're very happy with that.

In regards to radiation therapy, what we've found is that men may not suffer the side effects immediately. But the effects of radiation therapy, we found, are somewhat more delayed.

Focal Therapy May Reduce Side Effects, Improve Quality Of Life In Prostate Cancer

With approaches like high intensity focused ultrasound, patients with prostate cancer may experience lower rates of urinary incontinence and erectile dysfunction, an expert said.

Focal therapy, a targeted treatment for prostate cancer, may reduce side effects and improve quality of life compared to traditional treatments.

Limited treatment to a specific area with focal therapy is an "emerging area for treatment for prostate cancer," with the potential to reduce side effects and have a major impact on quality of life in patients with prostate cancer, an expert said. 

At the recent CURE® Educated Patient® Prostate Cancer Summit, Dr. Kara L. Watts, associate professor of urology at Montefiore Einstein in the Bronx, New York, discussed how focal therapy — particularly high-intensity focused ultrasound (HIFU) — can be used in the treatment of prostate cancer.

In particular, HIFU is a newer treatment option in this space for patients with prostate cancer, which involves the targeted delivery of ablative energy to a portion of the prostate with cancer. With this approach, care teams intend on causing cell death while minimizing harm by not treating the entire prostate, Watts explained.

"Rather than the traditional radiation to the entire prostate or radical prostatectomy to remove the entire prostate, focal therapy is really aimed at finding the prostate cancer with imaging, treating just that area, but not treating the rest of the prostate that doesn't have cancer, or has cancer that doesn't need to be treated right now."

Reasoning Behind Focal Therapy

Focal therapy is considered organ-preserving therapy and is an approach often used for other cancer types, but Watts said the use of focal therapy in prostate cancer has lagged for a while. She attributed this lag to the ability to find and localize prostate cancer and because prostate cancer can spread in different parts of the prostate.

"Now that we have really, really great technology with MRI and using guided biopsies to identify the cancers where they are, the world of focal therapy has really become a promising and a growing option for a lot of men," Watts added.

The main goal of focal therapy is to preserve quality of life, as it aims to minimize side effects associated with whole-gland treatment like radiation or radical prostatectomy. The most common side effects associated with these two treatment options include difficulty with erections and urinary incontinence.

Watts discussed some real-world findings during her presentation regarding the prevalence of side effects after whole gland radiation or radical prostatectomy. For example, a study published in the journal JAMA Surgery in 2021 found that after radical prostatectomy, 74% of patients reported that they were able to control their urine one year after the procedure, meaning that 26% of patients were having difficulty with urine control.

"This is a real concern for people and a real outcome that patients consider," Watts said.

Regarding erectile dysfunction, in a study published in the journal JAMA in 2020, researchers found that its occurrence ranged between 30% and 70% in patients with prostate cancer who underwent whole-gland treatment with radiation or surgery.

Patient regret of their treatment decision may also play a factor in prostate cancer. Watts noted that there are several published papers that assess patient-reported regret after undergoing radiation or radical prostatectomy for their treatment.

"What you find is with focal therapy, the goal really is striking a balance between controlling cancer in a way that is effective, but also preserving function and quality of life," Watts added.

She explained that there are several options related to focal therapy modalities, including cryotherapy, which she said was essentially killing cancer cells by freezing. Irreversible electroporation, or IRE, is a needle-based therapy where needles are placed around the area that needs to be ablated through the perineum, and the needles deliver an electric current through a controlled setting to promote cell death.

High-Intensity Focused Ultrasound

With HIFU, Watts explained that this is a different application of ultrasound than what it is traditionally used for to see organs like the kidney, bladder or spleen, among others.

"It's an ultrasound probe that gets inserted into the bottom, similar to how we see the prostate during a biopsy, although this is a different type of probe," Watts said. "And the way that I describe this to patients is … you have a magnifying glass with a leaf. If you take a magnifying glass and you hold it over a leaf on a sunny day. And it's very far away and not focused, nothing happens. But if you hold that magnifying glass the right angle and distance away from the leaf, it will burn a hole, because it is focusing, in a beam, those rays of sunlight into a very precise, pinpoint spot on the leaf to cause it to burn."

Through this approach, which was approved by the Food and Drug Administration in 2015, the focused beams of ultrasound energy can heat the affected area to burn in a very controlled manner within the prostate.

The treatment involves an ultrasound probe to see the prostate, Watts explained, for which patients would receive an enema before the procedure so nothing impedes the ultrasound's ability to deliver energy to the prostate. Patients are put under general anesthesia for this procedure, which is typically performed in a hospital operating room or ambulatory surgery center and takes approximately two to three hours. Patients are able to return home the same day, so HIFU does not require an overnight hospital admission.

After the procedure, patients often go home with a catheter for a few days, which depends on how much tissue is treated during the procedure.

"[The catheter is] usually in place for about three to five days to allow some swelling from the procedure to settle down," Watts said. "It's very often just minimal or mild symptoms post-procedure."

A week after the procedure, patients may undergo an MRI to see whether the affected area was treated completely. Patients are then monitored by repeating PSA and getting another MRI within the first year after the procedure.

"The timing may depend on who's doing the treatment," Watts explained. "And most people doing this treatment will also do a follow-up biopsy, usually at about six or 12 months, to confirm that the area has been completely treated and there isn't anything else developing."

When Can HIFU Be a Treatment Option

Watts said that HIFU is often a treatment option for patients with localized prostate cancer without metastasis (no disease spread).

"It's typically best for a low volume of prostate cancer," Watts added. "So, if you have a really large tumor, this is probably not the best option for that. It is given in both initial or primary treatment, so sort of as your first treatment. And it can also be given for certain cases of recurrence after radiation treatment. So men who have had a recurrence of prostate cancer in the prostate after prior radiation, you can potentially be treated with HIFU."

The most common disease type treated with HIFU in the U.S. Is intermediate-risk prostate cancer, Watts said.

Even with its advantages, HIFU does have some potential risks for side effects, Watts said. The risk for urinary incontinence is approximately 1%, and nearly 15% of patients reported erectile dysfunction after the procedure. There is also a low risk for the development of urethral strictures or fistulas. Watts also noted the potential need for retreatment, which is "the most important [risk] that I really counsel men on." She noted that this can occur in 20% to 40% of patients in five years.

"What that can mean is, you could have a recurrence in the area that's treated, or you could have a new cancer develop in another part of the prostate," Watts said. "One of the benefits of focal therapy, especially with HIFU, is typically, all options still remain open to you, should that be needed. But this is one of the reasons it's very important to continue to be monitored after, really, any form of focal therapy for prostate cancer."

Several studies have analyzed outcomes after focal therapy in patients with prostate cancer. In one study comparing radical prostatectomy with focal therapy, Watts said that the rate of failure-free survival — or needing to progress onto additional treatment — was similar in both groups at up to seven years. Findings from another study demonstrated that at five years after treatment, approximately 83% of men with intermediate-risk disease did not need to progress onto additional treatment.

Watts urged patients to discuss this treatment option with their care teams, although it may not be suitable for every patient.

"This is not an option for every patient," she said. "It's something to discuss with the urologist to find out if you may be a candidate, and that's the most important feature of this talk."

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