Less Invasive Treatment Options for Prostate Cancer

To speak about the less invasive treatment options available for prostate cancer, we need to talk about how we got to this point.

By the time a man has been diagnosed with prostate cancer, he has likely undergone numerous tests, including but not limited to a digital rectal exam (DRE), multiple prostate-specific antigen (PSA) tests and at least one biopsy.

As we learned in the previous installment, the biopsy helps determine what's next because lab analysis of the cells harvested during a prostate biopsy gives your urologist a great deal of information. It helps them understand the details and type of cancer you have and helps shape the contours of the best path moving forward.

"If [the biopsy] shows cancer, there are basically different grade groups of prostate cancer," said Petar Bajic, M.D., a urologist specializing in men's health with the Cleveland Clinic. "One is the least aggressive, five is the most aggressive. Depending on that, and depending on the PSA and other factors, the guy would discuss with his urologist what the options might be for each individual case."

The grades of cancer are part of a system for understanding cancer known as Gleason scores, a tiered schematic developed in the 1960s by a pathologist who studied the patterns healthy cells take as they mutate into cancer cells. Grade 1 refers to basically normal cells, while grade 5 represents cells so mutated they hardly look like human cells at all.

The types of treatments discussed here are typically only offered to individuals with lower-risk types of prostate cancer.

For men with low-grade, non aggressive prostate cancer, the best treatment option may be none at all—or at least nothing invasive. Not right away, anyhow.

Prostate cancer is a slow-growing type of cancer that can take years or even a decade to develop. What's more, cancers rarely, if ever, progress from one grade to another in Gleason scores. If you're diagnosed with low-risk cancer, it's improbable to jump to a higher risk level.

These days, it's understood that even with an elevated PSA level and a biopsy showing cancer, if it's a nonaggressive type, your best choice moving forward may be simply watching out for any changes.

"Active surveillance means keeping a close eye on things, which is not the same as doing nothing," Bajic said. "It means we're following the PSA closely, sometimes using MRIs, sometimes repeating biopsies, all to make sure that things are not getting any worse. If a man doesn't want to have treatment, it's recommended that he undergo active surveillance, actively keeping a close eye."

It's important to emphasize that active surveillance isn't the same as a "watchful waiting" approach to prostate cancer. Watchful waiting, an approach now largely sidelined, more or less amounted to waiting for prostate cancer symptoms to develop; active surveillance, on the other hand, entails an ongoing series of periodic tests over time and keeping a close eye on the man's overall health.

Among the breakthrough medical advances regarding prostate cancer is our ability to get a much clearer picture of what's going on with the prostate gland and the implications for treatment.

It wasn't all that long ago that an elevated PSA level meant you were likely to be counseled to strongly consider an immediate prostatectomy, or the surgical removal of all or part of the prostate. These days, the either/or nature of prostate removal surgery has taken on previously unheard of layers, levels and nuances, because of improved testing and a generally more cautious approach. But it's also due to improved precision in how doctors can view and analyze prostate tumors before they raise a scalpel.

"MRIs [magnetic resonance imaging] allow us to identify if there are multiple lesions, the size of the lesions, and the location and relational anatomy of the lesions," said Aditya Bagrodia, M.D., a urologic oncologist at the University of California San Diego Health. "We're able for the first time to say what the likelihood is of other tumors being in there, and whether we feel fairly confident that we have not just an imaging understanding of the prostate, but accurate histopathology/biopsy information of the prostate."

The importance of being able to draw an accurate picture of the landscape of the prostate, including precise locations of tumors, cannot be overstated. For many men, it may mean the difference between losing the whole prostate versus losing only the tumor and keeping as much of the rest as possible.

"So once we develop an accurate roadmap of the prostate, one of the natural following questions is, much like we've gone from radical mastectomy to mastectomy to lumpectomy in breasts, 'Is it safe to do this in the prostate, as well?'" Bagrodia said.

That supposition leads us to the next category of potential prostate cancer treatment: focal therapy and ablation.

Ablation in terms of cancer treatment means destroying tumor tissue by a variety of tightly focused methods. It usually entails cutting off the blood supply to the cells to prevent future growth. Here are a few of the main methods used today:

Cryotherapy

During cryotherapy, under anesthesia, probes are inserted into the prostate in locations where tumors are believed to be. The needles then deliver tiny amounts of liquid nitrogen or argon gas, which creates ice crystals around the probe's tip, thus freezing the cancerous cells and killing them as well as their blood supply.

High-intensity focused ultrasound (HIFU)

During high-intensity focused ultrasound, you are anesthetized. An ultrasound device the size of a finger is inserted into the rectum and positioned near the prostate gland, which is just on the other side of the front of the rectum wall. An imaging device in the probe then creates a precise map of the prostate, which the urologist uses to deliver the tightly focused ultrasound waves to destroy the tumors.

Transurethral ultrasound ablation (TULSA)

A promising new procedure, transurethral ultrasound ablation, isn't available everywhere but it's gaining steam. TULSA involves performing the ultrasound procedure inside an MRI, allowing the urologist to even more precisely target the diseased tissue. During the procedure, the device constantly monitors the real-time temperature difference between the tumor material and surrounding tissue, taking a reading every six seconds and adjusting on the fly to minimize the damage done to healthy prostate tissue.

"The reality is there's probably no one [technique] that's meaningfully better than any other one right now," Bagrodia said. "It's that whatever's being done is being done in an appropriate way, with an appropriately selected patient, by somebody who's got familiarity and expertise with the technology that they use."

While these approaches are still, if not in their infancy, maybe in their tween years, there is much reason to be happy about focal prostate treatments.

Guys need to be aware that not every type of prostate cancer is suitable for focal therapy, regardless of which ablative technique is preferred.

"[Focal therapy] is only appropriate in certain situations, because the worry is that even if there's an area of the prostate that doesn't have cancer, it may be predisposed to developing cancer later on because of whatever the biological reason is the cancer formed in the first place," Bajic said. "Focal therapy is an area of a lot of investigation right now, trying to determine who are the optimal candidates for this."

Understanding the specifics of your particular type of prostate cancer is crucial for your urologist to begin sketching out a plan to treat it.

It's also vital for you. You need to understand all of the various options available, because your participation in the process of building a treatment plan is essential.

Your particular goals and desires are going to play a huge part in guiding your medical team down the path that will yield the most agreeable outcome for you. While it's true that not every treatment type is appropriate for every type of prostate cancer, you can educate yourself on the specifics of your cancer type and learn more about how it might be treated, and go over the options with your urologist.

The main takeaway should be to understand there are always choices, there is always hope and you are never facing your cancer alone. You are part of a team, and they are with you all the way, with the goal of creating the best outcome for you.