Monday, 23 November 2015

Decoding your choice of care for prostate cancer

Decoding your choice of care for prostate cancer
Finding accurate information regarding prostate cancer can be difficult. Photo: Fotolia 

Prostate cancer is dubbed a silent killer as it has no symptoms in the very early stages of disease. Men will not know that they have prostate cancer unless they go for screening. By the time prostate cancer shows signs like urinary symptoms, pain in the hip or weight loss, it is usually too late.
Globally, prostate cancer is the second most frequently diagnosed cancer in men, and the fifth leading cause of death from cancer in men.
In Malaysia, it is the fourth most common cancer in Malaysian men.
Prostate cancer has been in the limelight across the globe and it has contributed to the establishment of the Movember movement, which is commemorated annually in November.
This is the month when men grow moustaches in an effort to raise awareness and spark important conversations about prostate cancer.
There are also prostate cancer support groups in Malaysia that offer support for prostate cancer patients and survivors.
Understanding prostate cancer
Most men are scared, worried, stressed, or even angry, when they are diagnosed with prostate cancer.
It is important to be aware that there are a lot of factors that influence outlook. This is because every cancer is different. There are many factors that control the growth of prostate cancer, which would affect the prognosis, such as the grade and stage of cancer, and how quickly it is growing.
Therefore, it is important that patients play an active part in understanding the disease and making choices on the course of care.
Once diagnosed with prostate cancer, patients need to undergo some tests to find out if the cancer cells have spread within the prostate gland or to other parts of the body.
In stage I, the cancer is found only in a small area within the prostate gland.
In stage II, the cancer has advanced by spreading to either a larger area in one or both lobes of the prostate, but has not yet spread out of the gland.
In stage III, the cancer has spread into the capsule that covers the prostate and may also have spread to the seminal vesicles.
In stage IV, the cancer has spread beyond the capsule or the seminal vesicles to nearby tissue or organs, such as the rectum, bladder, or pelvic wall, and/or distant sites such as lymph nodes or other organs, especially bones.
Cancer in stages I-III is considered localised disease, while that in stage IV is treated as advanced or metastatic disease.
Treatment for localised prostate cancer
Prostate cancer treatment is not “one size fits all” – what is best for one man may not be right for another.
It is important for patient and doctor to talk through and discuss the best treatment option based on individual circumstances.
In most situations, patients may need to consider several options before a decision is made.
For some men, an option may well be to not treat immediately, but to monitor the cancer closely and treat at a later time. Doctors call this active surveillance or watchful waiting.
Active surveillance is an option often recommended to patients diagnosed with early-stage, low-risk prostate cancer that grows slowly and is unlikely to spread or cause problems.
The reason for this is because many of these cancers may not actually cause any significant problems during life, such that many of these men actually die with the cancer, rather than of it. This may prevent unnecessary long-term side effects of treatment.
Men who choose active surveillance should undergo close monitoring of the disease so that treatment can be considered when it is confirmed that the cancer has started to show signs of further growth.
The monitoring involves regular clinic visits, PSA (prostate-specific antigen) tests, digital rectal examination, and sometimes, repeat prostate biopsies.
Watchful waiting is an option when the potential benefit from treatment is felt to be low, such that the risks of complications from treatment becomes less acceptable.
This may be so in situations when one’s life expectancy is predicted to be relatively short, such as in very elderly men or in men who are unwell with many other medical illnesses.
In this situation, doctors may advise to watch and wait until the cancer starts to spread before commencing any treatment.
Prostatectomy involves removal of the entire prostate gland, including the seminal vesicles and nearby lymph nodes. This is a very effective treatment to cure the cancer.
However, a surgery of this manner could include potential long-term side effects that may affect one’s quality of life, including urinary incontinence and impotence.
Hence, it is important for men to discuss with their doctor to find out whether this procedure is a suitable option for them.
Radiotherapy is a procedure that uses high-energy x-rays to kill cancer cells within the prostate without removing the gland. Radiation can be administered from outside the body (external beam) or inside the body via “radioactive pellets” placed in the prostate (brachytherapy).
Although radiotherapy achieves a cure as good as a prostatectomy without any surgery, it still has side effects due to exposure of nearby organs to some radiation during treatment. The possible side effects include tiredness, diarrhoea and urinary problems.
In the long term, it may cause impotence, and urinary and bowel problems like incontinence and bleeding. It is important to note that the risk of long-term complications with both prostatectomy and radiotherapy are low, apart from impotence, which can occur in 50 to 80 out of 100 men who undergo the treatment.
Technology improvements in radiotherapy have allowed for precise targeting of radiation, which can minimise the side effects further.
Treatment for advanced prostate cancer
Although most of these cancers are not curable, current available treatment is highly effective in controlling it, so that symptoms and quality of life can be improved, in addition to prolonging survival.
Hormonal therapy – it has been shown that prostate cancer grows and survives under the influence of testosterone.
The term “hormonal therapy” is a misnomer as it sounds as if we are giving hormones. In fact, this treatment aims to stop the production of testosterone or to block the action of the hormone. Another common term used to refer to this treatment is androgen deprivation therapy (ADT).
As prostate cancer cells rely on testosterone to grow and survive, cutting off the supply of hormones may cause cancer cells to die or grow slower. This can be achieved by either removal of the testes or giving specific hormone injections, which stop the testes from producing testosterone.
Some hormonal therapy can also block the action of testosterone so it is no longer able to stimulate cancer cells.
Radiotherapy may also be used to treat areas where the tumour has spread or metastasised, with the aim of relieving symptoms such as bone pain.
Immunotherapy is part of novel treatment approaches to stimulate a patient’s own immune system to help manage prostate cancer progression. Currently, the approved drugs in this area are very limited.
When the cancer has metastasised, or advanced beyond the prostate area and no longer responds to hormone therapy,chemotherapy may be used to kill the cancer cells. It has been proven to be effective in controlling the cancer and prolonging survival.
Although most men may not be keen on having chemotherapy due to the possible side effects, most of the side effects are usually very well tolerated by patients.
Side effects of chemotherapy may include hair loss, nausea and vomiting, diarrhoea, fatigue and an increased risk of infection. Most side effects generally stop when chemotherapy is stopped.
Supportive care (palliative care) involves providing care, both physical and psychosocial, to control the symptoms associated with the disease. Although the intention is not to cure, supportive care is very important to provide comfort and pain relief, which would improve patients’ quality of life.
It is very common for patients to have palliative care support as they undergo treatment described above for the cancer.
Looking forward
A diagnosis of any form of cancer can be very frightening, regardless of whether it’s early or late stage. It is crucial that patients play an active part in understanding the disease and making choices about their course of care.
When patients have good understanding of their disease and treatment options, they would be able to make better decisions on treatment.
Lastly, be reminded that dealing with cancer is like going on a journey. There may be light and darkness during different stages of the journey. As Kenji Miyazawa, a Japanese poet and author, puts it, “We must embrace pain and burn it as fuel for our journey.”

This article is courtesy of Drs Marniza Saad, Ong Teng Aik and Adlinda Alip of the Uro-Oncology Multidisciplinary Team at University Malaya Medical Centre in conjunction with the ‘Fight For Your Man Campaign’ by Janssen Malaysia. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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