Cancer have to ruin you sex life

THE good news is there have been significant advances over the past decade in treatment for men with advanced prostate cancer, says Professor Roger Kirby, who is one of the world’s leading prostate surgeons, trustee of Prostate Cancer UK and secretary of The Urology Foundation.’

Meanwhile other advances, such as the use of MRI scans rather than ultrasound (the standard tool), are set to make a huge difference in diagnosis.

Taking a biopsy is literally a bit of a stab in the dark. The specialist inserts a needle into the prostate gland between eight and 18 times to collect samples. Most private hospitals and some NHS cancer units now offer MRI before a first biopsy to map out the prostate and guide the biopsy needle.

The wide range of treatments means it can be bewildering for men diagnosed with this disease.

Here, with the help of Professor Kirby, Dr Tom Stuttaford, who campaigns to raise awareness of prostate cancer, and Professor Chris Eden, consultant urologist at the Royal Surrey County Hospital, we look at the latest options.

FOR CANCER THAT’S IN THE PROSTATE

Active surveillance

WHAT IS IT? This is where a slow-growing cancer is not treated straight away but is monitored. It is offered to men whose cancer has not spread beyond t he prostate and is low risk.

Men will be tested regularly to check that the cancer isn’t growing, with PSA tests, a prostate biopsy a year after diagnosis and scans.

‘Active surveillance can avoid side-effects caused by more radical treatments such as removing the prostate,’ says Ali Rooke, senior nurse specialist at Prostate Cancer UK. In the UK, two in five men with lowrisk prostate cancer that hasn’t spread are on active surveillance.

Studies show that there’s no difference in death rates between those on active surveillance and those who have surgery.

‘It’s becoming the default option for men with early prostate cancer who have a Gleason score of six or less and which has not spread,’ says Professor Eden. The Gleason score measures the aggressiveness of the cancer (above six is aggressive). CONS: Patients may feel anxious their cancer is not being treated and surveillance may miss cancers that suddenly become more aggressive.

Radical prostatectomy

WHAT IS IT? The entire prostate gland is removed, either by open surgery or keyhole. Keyhole means less scarring and faster post-op recovery.

‘As long as a surgeon is experienced, keyhole surgery does now seem to be the better option and open surgery is done less frequently,’ says Professor Eden. Later this year, all surgeons must reveal their prostate surgery results (such as complication rates). CONS: Side- effects include incontinence and difficulty getting and maintaining an erection, although there doesn’t seem to be any difference in rates between men who undergo open surgery and those who have keyhole procedures.

Robotic radical prostatectomy

WHAT IS IT? The surgeon guides a robot to remove the prostate using keyhole methods. This is said to be more accurate and helps spare the nerves which control continence and erectile function. CONS: This type of surgery is only available at a handful of NHS and private clinics. Surgeons need to be specially trained. According to Cancer Research UK, there’s no evidence yet that this is any better than standard keyhole surgery. ‘A skilful surgeon will achieve similar results whether they use a robot or not,’ says Professor Eden.

Radiotherapy

WHAT IS IT? Radiotherapy is routinely offered to men who have prostate cancer, whether it’s localised, has spread to the lymph nodes or elsewhere around the body. External beam radiotherapy is standard, with beams directed at the whole prostate from outside the body. IMRT is an advanced form of high precision radiotherapy, where 3D imaging and computerised dose calculations determine the intensity and direction of the beams. Studies show that, with IMRT, higher and more effective radiation

doses can safely be delivered to tumours with fewer side-effects than conventional radiotherapy. CONS: Not all hospitals offer IMRT.

Brachytherapy

WHAT IS IT? Brachytherapy is where radioactive pellets are placed in or near the tumour. Around 30 per cent of men who need radiation therapy have low-dose brachytherapy.

‘This causes less collateral damage than the standard radiotherapy,’ says Professor Eden.

Men are radioactive after the treatment so should limit contact with their grandchildren or pregnant women for the first month or two.

Less common is high-dose brachytherapy, where tiny hollow tubes are placed i nto the prostate under general anaesthetic, into which wires are inserted. A computer-controlled dose of radiation is delivered through the wires. It l eaves no residual radiation in the body. It is not widely available on the NHS. CONS: It’s not suitable for men who have enlarged prostates or moderate to severe urinary symptoms. The procedure can cause inflammation, making the bladder neck narrow. ‘This may require surgery, as well as having a catheter passed into the narrowed area several times a week to keep it open,’ says Professor Eden.

High Intensity Focused Ultrasound (HIFU)

WHAT IS IT? Experimental treatment that destroys cancer cells using ultrasound ener energy (high-frequency sound waves).

‘ There i s gro growing i nterest in treating only the part of the prostate affected by canc cancer,’ says Professor Kirby. The ultrasoundultras is focused on the prostate via a probe inserted into the rectum.

Nearby healthy tissue is protected with a balloon filled with cooling water that’s plac placed in the rectum.

CONS: The jury i is still out whether HIFU is effective long-term. ‘There are no long-term follow-up data,’ says Professor Eden.E A clinical trial is under way at University College Hospital, Londo London, The Hampshire Hospital in BasingstokeBas and The Churchill HospitalHospit in Oxford.

CrythotherapyCrythother

WHAT IS IT? A tre treatment to destroy cancer cells by freezingfr them using argon gas. Sp Special probes are inserted through the perineum into the prostate and the gas pumped in.

It is thought it may be as effective as surgery or radiotherapy,rad and that it could help retainreta a man’s potency.

CONS: It’s not wi widely available and going privately c can cost thousands of pounds. It mightmi not destroy all the cancer so a m man may need regular treatment andan the cancer could return. ‘Cryother ‘Cryotherapy is very similar to HIFU in terms of the way it works and results,’ say says Professor Eden. ‘Long-term result results are still unknown.’

FOR CANCER THAT HAS SPREAD

Combination therapy

WHAT IS IT? For men with locally advanced prostate cancer, which has spread beyond the prostate, surgeons may opt to remove the prostate and surrounding lymph nodes (small organs that help remove waste from the tissues and which may spread cancer), curing up to 80 per cent with surgery alone.

For the rest, hormonal therapy (see below), which causes testosterone levels to fall, and sometimes radiotherapy is used.

‘There’s growing evidence that the role of lymph nodes in the spread of prostate cancer is hugely important,’ says Professor Eden.

‘Just like with breast cancer 15 years, surgeons are recognising that lymph node removal can be lifesaving. There is much more emphasis now on operating on men with locally advanced disease.’

CONS: It may not get all the cancer and should be used in conjunction with other therapies.

CyberKnife

WHAT IS IT? A precise form of radiation therapy which continuously monitors the precise position of the prostate and adjusts accordingly.

The prostate can move unpredictably as air passes through the rectum and as the bladder empties and fills, even when a man is under general anaesthetic.

CyberKnife is used mostly to treat men with early-stage prostate cancer confined to the prostate or in combination with another therapy, such as conventional radiation, for

patients where the disease has spread beyond the prostate. CONS: On the NHS, it is available only to men taking part in clinical trials, but it is available privately.

Hormone therapy

WHAT IS IT? This therapy is offered to all men with cancer that has spread and can be used in conjunction with other treatments. It works by starving the cancer cells of testosterone, which they need to survive, causing the tumour to shrink.

Medical hormone therapy can be given by injections or with daily pills (both are equally effective). CONS: It will not cure cancer but can keep i t at bay for years. however, men can develop female distribution of hair, fat and some breast development, as well as becoming impotent. It can also cause memory problems.

ADVANCED CANCER

Chemotherapy

WHAT IS IT? ‘Chemotherapy is an effective fall-back option for men whose prostate cancer no longer responds to hormone therapy,’ explains Professor eden. It’s not a first- line treatment as other options are more effective and have less unpleasant side-effects. CONS: Patients can experience the typical side- effects of chemo, including nausea and hair loss.

Hormone therapy

WHAT IS IT? Until recently, men were routinely offered orchidectomy, or surgical removal of the testicles when they had advanced prostate cancer, to stop testosterone production. Today, orchidectomies are rarely performed. ‘ Instead, we use medical hormone therapy, which has the same effect,’ explains Professor eden.

These include new drugs abiraterone and enzalutamide. The latter is eight times more effective than the more commonly used bicalutamide, says Professor Kirby. ‘It now has a licence to be used before chemotherapy.’ CONS: nice has approved the use of Abiraterone only if chemotherapy has been unsuccessful.

Internal radioactive therapy

WHAT IS IT? Radioactive material is passed through the entire body via an injection. This is used to reduce pain and symptoms linked to secondary tumours in the bone. There are two types, strontium 89 and isotope Radium 223 (Xofigo). CONS: Strontium 89 can destroy bone marrow, so is a one- off treatment. Radium 223 is less likely to damage bone marrow but is very expensive. It is available through the Cancer Drug Fund in england on a case-by-case basis.

TURP

WHAT IS IT? This is performed to improve urine flow in patients with an enlarged prostate, but if a cancer tumour is growing enough to cause problems with urination, your doctor may recommend this (see previous page).

Contact Prostate Cancer UK specialist nurses on 0800 074 8383/ www.prostatecanceruk.org