Casodex

Learn how to help your patient explore his treatment options.

Your patient has questions. Having undergone external beam radiation therapy as primary treatment for prostate cancer, he's just learned that his cancer has returned and wants to know what his options are now. In this article, I'll explain what to tell him about his cancer recurrence and which type of treatment-if any-he might consider next.

PSA tells a story

Many factors come into play when a man is considering treatment options for prostate cancer. His cancer status, age, medical condition, and quality of life concems all affect his choices. And the results of a single blood test may be a key consideration.

The prostate secretes a protein known as prostatespecific antigen (PSA). Along with digital rectal examination of the prostate, monitoring blood PSA levels is important to gauge whether a man has prostate cancer and whether cancer treatment has been successful. (To learn more about testing, see What PSA Levels Signify.) The rate at which PSA levels rise is key.

In someone with a history of prostate cancer, a rapidly rising PSA level generally signals recurrence and the need for additional treatment. The patient's options will depend largely on the location and stage of the cancer, so finding the tumor is critical. Typically, cancer confines itself at first to the prostate gland and surrounding tissue, known collectively as the prostate bed.

A rising PSA level after a man has had radiation therapy doesn't always signal the need for additional therapy For example, in an older patient whose PSA levels are increasing slowly, the physician may recommend watchful waiting. Although cancer cells may still be present, the cancer probably won't cause health problems for the rest of the man's lifetime.

If the physician feels that watchful waiting isn't the best approach for your patient, he'll consider many factors before recommending a course of action: the patients age, the stage and grade of his tumor, his general health (including coexistent diseases), previous treatments, and how he feels about the risks and benefits of certain options. The treatment choices include brachytherapy, cryosurgery, surgery, and hormone therapy.

Brachytherapy plants radioactive seeds

Brachytherapy is a process by which the physician, guided by fluoroscopy and ultrasound, implants small radioactive "seeds" in the prostate. Men who receive brachytherapy, particularly when its combined with external beam radiation, generally have good outcomes.

Brachytherapy is appropriate for a man with positive biopsies at multiple sites, perineural invasion, or cancer penetrating the capsule (covering) of the prostate. Minimally invasive, the procedure takes about an hour. Recent advances in computer and ultrasound technology have dramatically minimized unwanted effects, such as impotence and urinary incontinence. (For discharge teaching about the various types of therapy, see What to Expect AfterTreatment.)

Cryosurgery makes a chilling cut

Used since 1990 to manage prostate cancer, cryosurgery destroys tissue by exposing it to very low temperatures. The physician uses ultrasound guidance to implant needle-like transperineal probes into the prostate to circulate liquid nitrogen and freeze the cancerous areas. At the same time, a urethral warmer preserves the area of the prostate that surrounds the urethra.

Cryosurgery is an option for a man whose cancer recurrence is confined to the prostate after external beam radiotherapy or radioactive seed implantation. Although long-term results on this technique aren't available, studies have shown that it significantly reduces PSA levels in many men.

Less invasive and less expensive than prostatectomy, cryosurgery causes less pain and bleeding and fewer other complications. The physician makes a small incision to insert the cryoprobe and freeze the tissue. Typically, the patient stays in the hospital the night after the procedure.

The downside of cryosurgery is that it causes impotence in most men. Urinary incontinence is an occasional unwanted response, and a few patients develop a fistula between the rectum and prostatic urethra.

Surgery cuts to the quick

If your patient's recurrent cancer is limited to his prostate, surgery may be an option. However, prostatectomy after radiation therapy is frequently unsuccessful and carries the risk of major complications, such as damage to the bowel or bladder. Other conditions such as heart disease, obesity, or advanced diabetes increase his risks.

The postoperative risks to a patient who's had prostatectomy include excessive bleeding, hypotension, and infection.

Hormones inhibit cell growth

Malignant prostate cells frequently use the male hormone testosterone as "fertilizer" to promote their growth, so hormone therapy may block its effects. Hormone therapy is a simple option because the patient takes oral doses at home or gets injections every 1 to 4 months. Whether continuous or intermittent therapy is more effective is still under study.

Hormone injections used to treat prostate cancer include luteinizing hormone-releasing hormone agonists (such as Lupron, Precis, or Zoladex) to block testosterone production by the testes. Oral doses of antiandrogens (such as Casodex, Eulexin, or Nilandron) block testosterone's effect on the cancer cells, but these drugs aren't totally effective in a man whose testes are functioning, so they're rarely given alone.

The female hormone estrogen suppresses testosterone production and is sometimes used as early therapy or when other hormones aren't effective. High doses, however, can increase the risk of blood clots and cardiovascular problems, so estrogen use is losing favor.

Practitioners differ on when to begin hormone therapy for prostate cancer. Some delay therapy to postpone unwanted long-term effects, including paralysis, broken bones, and kidney failure. The physician may recommend waiting until cancer recurs or the patient develops symptoms such as bone pain. Hormone therapy eventually fails because the cancer cells become resistant to the hormone.

Help your patient cope with uncertainty

To help your patient make wise treatment decisions about prostate cancer, welcome his questions and see that he gets the information and emotional support he needs. Make sure he and his family understand the information they get. Repeat your advice or give them printed literature to help them retain information. Share success stories, help them through their uncertainty, and firmly project positive views of your own. Along with your teaching, one of the greatest gifts you can give them is hope.

SELECTED REFERENCES

Bakker, J., et al.: "Biopsychosocial Aspects of Prostate Cancer," Psychosomatics. 41(2):85-94, March-April 2000.

delaTaille, A., et al.: "Salvage Cryosurgery for Recurrent Prostate Cancer after Radiation Therapy: The Columbia Experience," Urology. 55(1):79-84, January 2000.

Myers, C.: "The Treatment of Recurrent Prostate Cancer," Cancer Communication. 15(4):1-16, October 1999.

Pisters, L.: "The Efficacy and Complications of Salvage Cryotherapy of the Prostate," Journal of Urology. 157(3):921-925, March 1997.

Talcott, J.: "Patient-reported Symptoms after Primary Therapy for Early Prostate Cancer: Results of a Prospective Cohort Study," Journal of Clinical Oncology. 16(1):275-283, January 1998.

Tefilli, M., et al.: "Quality of Life in Patients Undergoing Salvage Procedures for Locally Recurrent Prostate Cancer," Journal of Surgical Oncology. 69(3):156-161, 1998.

Rene Jackson is a staff nurse in the medical imaging department special procedures, at Charlotte Regional Medical Center in Punta Gorda, Fla.

Copyright Springhouse Corporation Apr 2002
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