Prostate\Prostate Cancer Treatment Options

Fortunately, various treatment options are available nowadays.

The appropriate treatment should be carefully selected considering the stage of the disease, current medical conditions, and the patients and the physicians concern.

The main treatment options are:

• 1. Radical prostatectomy: Complete surgical removal of the prostate, which the gland is completely removed. This is normally performed through an incision in the lower abdomen. By tradition the most common treatment for early stage cancer.
• 2. Radiation therapy: The cancer cells are exposed to high doses of radiation. This therapy takes advantage of the effect that cancer cells are much more susceptible to radiation than normal tissue. The radiation can be delivered externally (external beam radiation) or internally (brachytherapy).
• 2.1. Seed implantation: Permanent brachytherapy : Small radioactive sources with a length of 4.5 mm are permanently placed inside the prostate . The treatment takes advantage of the fact that cancer cells are more susceptible to radiation than normal tissue. Each seed emits a certain radiation dose to its surrounding tissue. By placing the seeds all over the prostate in well defined distances the organ is covered with exactly the required doses to destroy the cancerous cells. The tissue and organs surrounding the prostate are nearly not affected by the radiation as it is applied directly within the prostate.
• 2.2. External beam: Focused radiation is applied from outside the body : This treatment option is delivered using a so-called linear accelerator that emits a high energy X-ray beam. The beam is targeted using various configurations at the prostate cancer. The treatment is delivered once a day (5 days/week) for approximately six to seven weeks. This treatment at daily intervals, also known as fractionation, allows to minimize the damage to the normal tissue that the beam has passed through.
• 2.3. High dose rate (afterloading therapy): Highly radioactive sources are temporarily inserted into the prostate. Tubes are surgically inserted into the tumour and a radioactive iridium wire is deposited temporarily into the tubes. Due to the high dose rate this treatment has to be split into various sessions. This modality is mainly used as a boost treatment after external beam radiation or radical prostatectomy.
• 3. Hormone treatment: Hormonal therapy is a treatment option for cancer which has already spread beyond the prostate region, or has recurred following initial treatment by surgery or radiotherapy. It is also sometimes used for short periods in combination with radiotherapy. Male hormones (also called androgens)are important for prostate growth - Indeed the normal development of the prostate to its adult form is very dependent on testosterone, the principal male hormone released from the testicles. Prostate cancer cells that have left the prostate and are growing in other areas of the body (metastases) are also stimulated to grow by male hormones. Consequently one relatively common treatment for prostate cancer which has spread outside the prostate region is to lower the levels of male hormones in the body and thereby stop the growth of cancer cells. This happens irrespective of whether the cells are in the prostate or in other areas of the body. Indeed, prostate cancer cells typically respond to the withdrawal of male hormones by dying. Unfortunately, not all prostate cancer cells die, and with time, often several years later, the cancer returns. Nevertheless, good cancer control and a symptom-free lifestyle can be achieved for many years by men on hormone therapy.
• 4. Watchful waiting: No treatment is applied, but the cancer is closely watched at regular intervals.
• 5. Cryotherapy: In cryotherapy the prostate is frozen solid. Ultrasound guidance controls the extent of the freeze. The procedure is done under anesthesia and requires at least an overnight stay in the hospital. This technology has improved in recent years but is still associated with a very high incidence of impotence and urinary incontinence. In addition, fistulae (or holes) between the prostate and rectum can occur, especially in patients who have had unsuccessful EBRT. There are also a large number of patients who undergo cryotherapy after unsuccessful EBRT who experience pelvic and/or rectal pain.
• 6. HIFU: Transrectal High Intensity Focused Ultrasound : Ablatherm is a medical device piloted by a computer designed to treat localized prostate cancer using high intensity focused ultrasound (HIFU). Under a spinal or epidural anesthetic an ultrasound probe is inserted in the rectum to map the exact outline of the prostate gland. Using this map, high intensity ultrasound waves are delivered through the rectal wall precisely focused on the prostate. This focusing produces intense heat and causes the destruction of the tissue inside the targeted zone without damaging surrounding tissues. The treatment generally takes 1 to 3 hours.

What is HIFU?

Ablatherm® HIFU is a procedure where the temperature inside the prostate is raised to 85° Celsius using a focused ultrasound beam.

A probe is placed into the rectum after spinal or epidural anesthesia has been administered. This probe emits a beam of high intensity focused ultrasound. At the point where the ultrasound is focused (focal point) the sudden and intense absorption of the ultrasound beam quickly raises the temperature which destroys targeted cells. The area destroyed by each beam is very small and precise.

By repeating the process and moving the focal point it is possible to destroy the prostate tissue. The treatment takes from 1 to 3 hours depending upon the size of the prostate and is usually performed on an outpatient basis.

Ablatherm® HIFU is an appropriate treatment option for essentially any male who has prostate cancer which can be cured by any other means. The stages of cancer of the prostate are:

• 1. T-1 Prostate cancer: This is a cancer which has no signs or symptoms and is totally unsuspected. The prostate feels normal to the physician on rectal exam. The cancer is detected either by an elevated Prostatic Specific Antigen (PSA) blood test and subsequent biopsies or by examination of tissue removed during treatment of an enlarged prostate. This tumor can be cured by surgery, radiation, and Ablatherm® HIFU.
• 2. T-2 Prostate cancer: This is a tumor which is suspected on rectal exam. One or both lobes of the prostate have areas of firmness and biopsies reveal the cancer. The PSA is also usually elevated. This tumor can be cured by surgery, radiation, and Ablatherm® HIFU.
• 3. T-3 Prostate cancer: This is a tumor that has spread outside the prostate capsule and may have reached the seminal vesicles. This tumor is not curable by surgery, radiation, or HIFU.
• 4. T-4 Prostate cancer: This tumor may have spread to the rectum or bladder or to distant organs or bone. This tumor is not curable by surgery, radiation, or HIFU.

Patients with both T-1 and T-2 prostate cancer will have an imaging scan, such as an MRI or CT, to try to detect cancerous extension outside the prostate or to other organs (lymph nodes, liver, etc.). A Bone Scan is used to rule out spread to bone. These tests will show no spread of tumor outside the prostate in T-1 or T-2 cancer.

Patients with T-1 and T-2 prostate cancer who have had external beam radiation therapy (EBRT) and recurrent cancer, but no spread outside the prostate, can be treated for cure by Ablatherm® HIFU. The sooner a patient is treated after the diagnosis of failed EBRT the better the chance he has for cure by Ablatherm® HIFU.

Patients with T-1 and T-2 prostate cancer who have had a radical prostatectomy and recurrent cancer but no spread outside the prostate can be treated for cure by Ablatherm® HIFU. In fact, Ablatherm® HIFU remains one of the only therapy options for these patients.

It is important to know that the ability to detect microscopic spread of the tumor beyond the walls of the prostate is limited by today's technology. It is estimated that approximately 30% of patients diagnosed as having T-2 prostate cancer actually have a spread of cancer cells outside the prostate wall (T-3) and are therefore not curable. This is particularly true if the PSA is equal to or greater than 10 or the Gleason score is greater than 7.

What Do the Clinical Studies Show?

Ablatherm® HIFU has been extensively used in Europe. Over 90% of patients undergoing Ablatherm® HIFU therapy will not require further treatment for their prostate cancer. In those developing a recurrence, they remain candidates for surgery, radiation or hormone therapy.

Is Ablatherm® HIFU a Proven Therapy?

In 1989, three prestigious European research groups united in their efforts and initiated a project to develop an efficient and non-surgical treatment for localized prostate cancer. After ten years of development Ablatherm® HIFU was approved for treatment in Europe. At present, Ablatherm® HIFU is being used throughout Europe, Russia and other Asian countries. To date, thousands of patients have been treated successfully in many European centers and throughout the world.

What are the Benefits of Ablatherm® HIFU?

The treatment of localized prostate cancer with High Intensity Focused Ultrasound has many advantages:

• Patient does not undergo any radiation exposure.
• Usually no hospital stay is required.
• Treatment is performed under spinal or epidural anesthesia.
• Treatment can be repeated if necessary.
• Other therapeutic alternatives can be considered in case of incomplete results. Ablatherm® HIFU can be used for the treatment of local recurrences (i.e. after external beam radiotherapy).