Type Of Therapies
There are 2 main types of radiotherapy – external and internal. They can be used to treat any stage of prostate cancer. In early stage prostate cancer, radiotherapy can be used either in place of surgery or after surgery to destroy any remaining cancer cells. Radiotherapy may also be recommended in advanced stage prostate cancer to help with pain relief.
External radiotherapy. This means a sophisticated machine is used to deliver the radiation and a computer is used to pinpoint the radiation to target the prostate. Treatment is usually given 5 times a week over a number of weeks. Each radiotherapy session only lasts a few minutes.
Brachytherapy. This form of treatment involves inserting either dozens of radioactive seeds into the prostate using needles or several tubes into the prostate which are loaded with radioactive material.
There are two types of brachytherapy. Low Dose Rate (LDR), which is the insertion of radioactive seeds via a day/overnight procedure, and HDR (High Dose Rate), which means tubes are temporarily placed in the body, and loaded with radioactive therapy for up to five treatment sessions. HDR is not conducted in South Africa as yet.
The seeds give off radiation for a few weeks or months and then remain in the prostate permanently once the radiation wears off. The seeds can be implanted as an outpatient procedure, meaning you will not need to stay in hospital and you will probably be able to resume normal activities within a few days. You may be concerned about how the radioactive material in your body could affect you or those around you. Although the majority of the radiation seeds only emit radioactivity within 2.5cm of the seed it’s worth taking note of the following precautions:
- You should limit prolonged close contact (less than 2 metres) with pregnant women, those who may be pregnant, or children, for 2 months after the seeds have been implanted
- If you have seeds implanted you must avoid allowing children to sit on your lap for prolonged periods, for 2 months after the seeds have been implanted
- You’ll be given a lead container in which to place any seeds you might pass in your urine. You should pick these up with a spoon or a pair of tweezers, place them in the lead box and return them to your radiation oncologist who dispose of them safely.
- You should avoid sexual intercourse for 2 weeks after the seeds have been implanted as you may pass a seed when you have an orgasm
- You should wear a condom when you have sex for 2 months after the seeds have been implanted
The tubes are loaded with radioactive material during a treatment session that lasts a few minutes and then the radioactive material is removed. This process can be repeated up to 5 times and you’ll have to stay in hospital for about 1 to 2 days. The tubes will be removed before you leave the hospital.
You may experience side-effects such as diarrhoea, rectal pain, urinating more often and a burning pain when you empty your bladder. These side-effects should go away gradually
Hormone Suppression Therapy
Prostate cancer cells rely on testosterone to help them grow. Therefore, hormone or anti-androgen therapy is used to stop your body from producing testosterone in the hope that cancer cells will die or grow more slowly.
Hormone therapy can be used in a number of scenarios:
- For advanced prostate cancer, to shrink or slow the growth of tumours
- For early-stage prostate cancer to shrink tumours before radiotherapy and to ensure radiotherapy is a success
- After surgery or radiotherapy to slow the growth of any cancer cells left behind
If you are to have hormone therapy to treat your prostate cancer the following options may be available to you:
- Luteinising hormone-releasing hormone (LH-RH) agonists. These drugs prevent the testicles from making testosterone. Examples include: leuprolide, goserelin. These types of drugs are usually given by an injection into a muscle or under the skin.
- Anti-androgens. This group of drugs blocks the action of male hormones on cancer cells. Examples include: bicalutamide and flutamide. You’ll probably be given an anti-androgen along with an LH-RH agonist or before starting on an LH-RH agonist. Anti-androgens are available in tablet form.
- Abiraterone acetate. This drug is taken by mouth and works by reducing levels of testosterone in the body. It’s been shown to reduce the size of prostate cancer tumours, which helps improve quality of life in patients suffering from CRPC. Clinical trials have also shown that abiraterone can improve survival times in CRPC that’s progressed after treatment with LH-RH agonists, anti-androgens and/or docetaxel chemotherapy.
- The testicles may be surgically removed as they are the main source of testosterone in the body.
- Other drugs may be given to prevent the adrenal gland from making testosterone. Examples include: ketoconazole and aminoglutethimide.
Side-effects associated with hormonal therapies include: erectile dysfunction, hot flushes, weakened bones, reduced sex drive and weight gain.
Chemotherapy is reserved for patients with stage IV prostate cancer. The effectiveness of this treatment method depends on specific medical circumstances of men affected by prostate cancer.
The greatest benefit of chemotherapy has been noted in patients with newly diagnosed prostate cancer with extensive metastatic spread. The addition of docetaxel chemotherapy to androgen-deprivation hormone therapy extended survival for men with newly diagnosed metastatic hormone-sensitive prostate cancer by more than 13 months.
Other chemotherapeutics like carbazitaxel prolonged survival of patients with castrate/hormone resistant prostate cancer who failed earlier lines of therapy. Mitoxantrone hasn’t demonstrated a survival improvement but remains a palliative therapeutic option when other methods of therapy failed or are not available.
Chemotherapy is a very effective method of cancer treatment that’s helped save millions of lives, but it does cause side effects. The medicines used in chemotherapy can’t distinguish between fast-growing cancer cells and other types of fast-growing cells, such as blood cells, skin cells and the cells inside the stomach.
This means most chemotherapy medications have an effect on the body’s cells and tissues causing problems including:
- Fatige and weakness
- Feeling and being sick
- Hair loss
Some chemotherapy side effects are mild and treatable, while others can cause serious complications if not recognised immediately and corrected. Frequently, people only have minimal side effects, but for some people, a course of chemotherapy can be unpleasant and upsetting.
Living with and adapting to the side effects of chemotherapy can be challenging. However, it’s important to realise that most, if not all, side effects will disappear once the treatment is complete. There’s no risk of the side effects of chemotherapy being passed to other people, including children and pregnant women, if they’re in close contact with someone having chemotherapy.
You’ll be monitored regularly to check for side-effects and to check on your general health. It’s possible for some of your side-effects e.g. nausea or diarrhea, to be managed with other medications.
New treatment options are becoming available that can be used in men whose cancer has failed to be managed by radiotherapy, surgery and hormonal therapy. This type of advanced stage prostate cancer is known as castration-resistant prostate cancer and, until now, there have been very few available treatment options for use at this stage.
Discussed below are some of the newer treatments available, however, you’ll need to discuss with your doctor which options are available in South Africa, or the country in which you are being treated.
Radium 223. This is a radiopharmaceutical agent that binds with minerals in the bone to deliver radiation directly to bone tumours, thereby limiting the damage to the surrounding normal tissues. The U.S. Food and Drug Administration (FDA) approved the drug in May 2013. Radium 223 significantly improves overall survival in men with metastatic, hormone-refractory prostate cancer that’s spread to bones (but no other organs), according to the results of a study published in the New England Journal of Medicine.
Cabazitaxel. This is a chemotherapy drug that’s currently being studied in many clinical trials. This describes the testing process of a new drug before it reaches the market and becomes widely available. It’s been approved in the U.S.A for the treatment of CRPC that has not responded to other treatments including other chemotherapy with docetaxel, and is approved for use in South Africa.
Enzalutamide. This works by more effectively blocking the action of male hormones on cancer cells than other anti-androgens. Clinical trials have shown that Enzalutamine can improve survival in CRPC that’s progressed after treatment with LH-RH agonists, anti-androgens and/or chemotherapy with docetaxel. This product is soon to be registered for use in South Africa.
Sipuleucel-T. This is a vaccine that stimulates the patient’s defenses to respond against the cancer. It’s the first of this type of treatment to be approved in the U.S.A but is not yet available in South Africa.
In addition to these therapies approved in the U.S.A and that are available, or should become available in South Africa in the future, other therapies are under investigation which offer more promise in the treatment of prostate cancer.
Questions to ask your Doctor
Questions to ask your doctor:
- What radiation options are available to me?
- When can I start treatment and how long will it last?
- How often will I need to have treatments?
- How will I feel when I receive the radiotherapy? Will I need to stay overnight in hospital? Can I drive myself to and from the hospital or outpatient clinic?
- How should I take care of myself during treatment?
- How will you check if the treatment is working?
- Will I have side-effects directly after the radiotherapy?
- Will there be long-lasting side-effects from the radiotherapy?
Questions to ask your doctor:
- What hormone therapy options are available to me? Is there a particular option that is better for me?
- How often will I need to have treatment, what will it involve and how long will it last?
- Will I need to stay in hospital or will I be treated as an out-patient?
- How will I feel during treatment?
- How will we know if the treatment is working? How often will I need to come for check-ups?
- What are the chances of me having side-effects and what are the long- and short-term side-effects?