Prostate Cancer Treatment

Overview

Prostate cancer is one of the most common cancers in men, and it behaves in very different ways from one man to the next. Some prostate cancers grow so slowly that they would never cause harm in a lifetime. Others are aggressive and need prompt treatment. The first appointments abroad are about finding out which kind you have, because that decides almost everything else.

The prostate is a small gland below the bladder that wraps around the urethra (the tube that carries urine out of the body). The nerves that control erections run along its sides, and the muscle that holds urine in sits just below it. This is why treatments for prostate cancer can affect bladder control and sexual function, and why a good consultation spends time on both.

The main options are active surveillance (careful monitoring), surgery to remove the prostate, radiation, and hormone therapy. Some men need a combination. The treating team recommends a plan; MediCurage arranges the practical side, from the visa letter and airport pickup to an interpreter for the consultations and a stay close to the hospital.

Who needs it

Most prostate cancers are found after a raised PSA (prostate specific antigen) blood test, or after a doctor feels a firm area during a rectal examination. Early prostate cancer often causes no symptoms.

Doctors put the cancer into a risk group using three things:

• The PSA level and how quickly it has been rising.
• The Gleason score and Grade Group, from the biopsy. The pathologist looks at how abnormal the cancer cells appear. Gleason scores for cancer run from 6 to 10, and the Grade Group simplifies this into 1 (least aggressive) to 5 (most aggressive).
• The stage, meaning whether the cancer is confined to the prostate, has grown through its outer layer, or has spread to lymph nodes or bones.

Broadly, low risk cancer is often suited to active surveillance. Intermediate and high risk cancer that has not spread is usually treated with surgery or radiation, often with hormone therapy alongside radiation. Cancer that has spread is treated mainly with hormone therapy and other drugs.

For a quote, hospitals generally ask for your PSA results (several readings if you have them), the MRI images and report, the biopsy report with the Grade Group, and any bone scan or PET scan. If your biopsy slides or blocks can be released, bring them, because many hospitals like their own pathologist to review them. On the quote form you can name a preferred country or ask hospitals in more than one country to quote.

How it is done

Tests and staging

If they were not done at home, the first week usually includes some of these:

• Repeat PSA and routine blood tests.
• Multiparametric MRI of the prostate, which shows suspicious areas and helps guide the biopsy.
• Biopsy, where thin needle samples are taken from the prostate, either through the skin between the scrotum and the back passage (transperineal) or through the rectum (transrectal). Results take several days.
• PSMA PET-CT, a scan using a tracer that sticks to a protein on prostate cancer cells. It can show small deposits in lymph nodes or bones that ordinary scans miss. Not every hospital offers it, and where it is not available a bone scan and CT are used instead. We check which hospitals in your chosen country can do it.

Active surveillance

For low risk cancer, you may be advised not to start treatment straight away. You have a PSA test every few months, a repeat MRI and sometimes a repeat biopsy, and treatment begins only if the cancer shows signs of change. Much of this monitoring can often continue with a urologist at home.

Radical prostatectomy

This operation removes the whole prostate and the seminal vesicles (two small glands behind it), and often nearby lymph nodes. Most centres now do it as keyhole surgery, very often robotic assisted, where the surgeon controls fine instruments through small cuts while seated at a console. Open surgery is still used in some cases. Where the cancer allows, the surgeon tries to spare the nerves for erections. You wake up with a urinary catheter, which usually stays in for one to two weeks while the join between the bladder and urethra heals.

Radiation

External beam radiation aims precise beams at the prostate from outside the body. Courses vary: about four weeks of weekday sessions is common, and stereotactic body radiotherapy (SBRT) delivers the dose in about five sessions. Brachytherapy places the radiation inside the prostate, either as tiny permanent seeds or through thin temporary tubes. It suits some men on its own and others as a boost to external radiation.

Hormone therapy

Prostate cancer usually needs testosterone to grow. Hormone therapy, also called androgen deprivation therapy, lowers testosterone, mostly by injections every one, three or six months, sometimes with tablets. It is often given for six months to three years alongside radiation, and it is the main treatment when cancer has spread. Common side effects are hot flushes, tiredness, weight gain, lower sex drive and thinning of the bones.

Recovery and how long you stay

After robotic or keyhole prostatectomy, most men spend one to three nights in hospital and walk on the first day. You then rest in nearby accommodation and return for the catheter to be removed. The surgeon also reviews the pathology report, which shows the final Grade Group and whether the edges of the removed tissue are clear. A realistic plan for surgery is two to three weeks in your destination.

Leaking urine is common when the catheter first comes out. For most men it improves steadily over weeks to months, and pelvic floor exercises speed this up, so bring pads for the flight home. Erections often take longer to return, sometimes a year or more, and depend on your function before surgery and whether the nerves were spared. Tablets, injections and other treatments can help during that time.

Radiation has no wound to heal, but it needs you nearby for the whole course. Allow about five to six weeks for a four week course including planning, or about two to three weeks for SBRT. Some hospitals use longer courses of seven to eight weeks. Tiredness, passing urine more often and looser bowels are common towards the end and usually settle in the weeks after. Before you fly home, your coordinator asks the team for a written summary and a PSA follow up plan your doctor at home can use.

Questions to ask your doctor

Ask the interpreter to stop the doctor whenever something is unclear, and write down the answers.

• What is my Grade Group, stage and risk group?
• Is active surveillance a reasonable option for me, and if not, why?
• Do I need a PSMA PET-CT or bone scan before deciding?
• Which treatments would you consider for my results, and how do their side effects compare?
• Will you try to spare the nerves for erections on one side or both?
• How long will the catheter stay in, and when can I fly?
• Will I need hormone therapy, and for how long?
• How often should my PSA be checked at home, and what level should prompt a call to you?

Many men find these subjects hard to raise in front of relatives. If you would rather speak to the doctor alone for part of the consultation, tell your coordinator beforehand and we will pass the request to the hospital.