How Do I Choose?

When you are first diagnosed with prostate cancer, you will be faced with making the decision as to what treatment will be best for your particular circumstances. Professor Stricker explains the various treatment options available to you and provides insights that will better inform your decision.

Transcript

SPEAKER_00 0:10

One of the most difficult decisions patients need to make is when they are confronted with the new diagnosis of prostate cancer and have to make a decision as to which treatment is ideal for their particular circumstances. Now there are many options now, and you need to understand the pros and cons of pretty well every option so that you can understand which way to go. And the options include various forms of surgery: open robotic, multi-port robotic, single port robotic, brachytherapy, both high dose rate and low dose rate brachytherapy, focal therapy, such as the nanonnife therapy, active surveillance, where you just monitor the cancer, various forms of radiotherapy, from stereotactic radiotherapy to MR linac radiotherapy, and there are even more coming on board at the moment, for example, tulsa, which is a minimally invasive new treatment for treating prostate cancer. So because there are so many options, it's important firstly you understand the pros and cons of each option, understand that not everybody's an expert at every option, and find the experts maybe to give you that information, and then finally understand the factors which may influence how you make a choice between the different options. So, what are the factors that help you determine which treatment to choose? I think the first factor is the actual cancer itself, the prostate cancer. So what's its grade, what's its extent, what's its position, and has it spread? All those factors are critical. For example, if you've got a low grade cancer, level one, or what we used to call gliesen six, active surveillance may be your best option. If you've got an intermediate grade, or level two or three, gliesen three plus four or four plus three, maybe even focal therapy may be an option if it's localized, or if it's spread around, maybe surgery or radiotherapy. If it's high grade, you may need to combine treatments such as surgery and radiotherapy or hormones and radiotherapy. So the cancer and the extent of the cancer are critical. The position of the cancer can also influence it. For example, if it's invading the seminal vesicle, this would push more towards a surgical option, whereas if it's invading the sphincter, that may push more towards radiotherapy. So the cancer is critical in deciding which treatment option that you have. So the next factor is the size of the prostate and whether you have urinary symptoms. Now, if you've got a big prostate with a lot of urinary symptoms, radiotherapy will make your symptoms worse, whereas surgery will get rid of those symptoms. So size of prostate and the urinary symptoms that occur because of that are key in making a decision as to which treatment you choose. For example, in some of the new treatments, such as tulsa, the size of the prostate has to be below a certain size, and there can't even be calcification in the prostate. The next important factor is you, the patient. How healthy are you? What's your life expectancy? As well as what are your priorities in life? For example, is sexual function a major priority? Is urinary incontinence a major fear? All those things need to be taken into consideration when choosing your treatment. For example, if your life expectancy is less than 10 years and you've only got a level 2 cancer, active surveillance may be your best option because you're going to die with the cancer rather than of it. If sexual function is your main priority, then you should pick the treatment with the lowest chance of sexual dysfunction as long as it still cures the cancer. For example, if your choice is between low-dose rate brachytherapy, external beam radiotherapy, and surgery, perhaps in that setting low-dose rate brachytherapy may be your best option. If you have a particular fear of incontinence, surgery is not your best option. If on the other hand you have a particular fear of radiotherapy, which some of my patients have, then radiotherapy shouldn't be your first choice. So all these personal aspects become critical in terms of choosing the right treatment for you. The other factor which is not quite as exact is specific conditions that you may suffer with. For example, if you have ulcerative colitis, that's one reason why you should never have radiotherapy because it can aggravate it. If you've had a bad fractured pelvis in the past, then you shouldn't have surgery because the likelihood of incontinence is much greater. If you've had previous radiotherapy, you can't have radiotherapy again. For example, if you had a bowel cancer and radiotherapy, then you shouldn't have radiotherapy for your prostate cancer. So sometimes certain medications make surgery or radiotherapy better options. For example, if you're on major blood thinners and you can't come off them, then it's best not to have radiotherapy because if you get bleeding complications after the radiotherapy, they'll be severely aggravated by that blood thinner. So you need to make your urologist aware of all the medications and your past history that are relevant to you, and because that can dictate which treatment is the ideal one. So just going back to some of the priorities that you might have. For example, if sexual function is a major priority and one of the options that you have is focal therapy, then focal therapy will have the lowest chance of causing erection problems. So if you've got a choice between focal therapy, surgery, and radiotherapy, that may push you in the direction of focal therapy if the cancer is suitable. Again, all these things are influenced by all the factors at the same time. Your life expectancy and your general well-being can also play into it. For example, if you've got a shorter life expectancy, then radiotherapy may be a better option. Whereas if you've got a very long life expectancy and you need all your options open to you in the future, then surgery may be better because you can always do radiotherapy for a recurrence after surgery, but you can't do surgery after a recurrence after radiotherapy. So it leaves your options open. So the younger you are, the more options you need left open for the rest of your life. Let me take you through some decisions that need to be made at times. If you, for example, have recently divorced and remarried and sexual function is an absolute priority, then a very tight nerve-sparing surgery or focal therapy or brachytherapy are better options than some of the other options which have higher chances of erection problems. Another way that could influence you is if you've got, for example, a level two cancer, Gleason 3 plus 4-7, and it's got a long natural history, and you've got a bit of time, it may be better to start off with active surveillance and then make a choice down the track when it's not quite as high a priority. Let me provide you with some ideal case scenarios. Ideal case for active surveillance, level one cancer, Gleason 6, where sexual function's a priority. It's pretty obvious that active surveillance is your ideal treatment. Ideal case for robotic nerve-sparing surgery, level two or three cancer, all contained, and you simply want it out and you want to close that chapter of your life and move on. Ideal case for radiotherapy, little bit older, over 70, a couple of comorbidities pertaining to your heart, maybe, but still need to treat the cancer, maybe level three or four, and at least then you've treated the cancer and you've taken that cancer out of the equation, even with only a 10 to 15 year life expectancy. Focal therapy with the nanoknife, ideal case scenario, a localized level two or three cancer in one area of the prostate where your priorities are to maximize quality of life, but knowing that you've always got a fallback position. Ideal case for low dose rate brachytherapy is a level two or three cancer, which is spread throughout the prostate, so it's not localized. The prostate's quite small, so the brachytherapy won't cause too much swelling, and you want to have the simplest treatment with a rapid recovery and the lowest chance of sexual side effects. Ideal for brachytherapy. Ideal case for MR linac radiotherapy is a patient who has a localized prostate cancer, level 2, 3, or maybe even four, who does not want surgery but still wants an equal cure rate to surgery, maybe with a slightly shorter life expectancy, and who wants to shorten the time of treatment from a standard radiotherapy program, which can take four to six weeks, down to one to two weeks. Ideal being aware that not every unit offers MR linac radiotherapy. You do need to understand that with the MR linac radiotherapy, sometimes hip replacements can make these impossible. Recently I've introduced single port robotic surgery at St. Vincent's, and this is another keyhole approach to removing the prostate. You still remove the prostate, but you do it through a smaller hole in a different area called the extraperitoneal area, so it's a quicker recovery. It's not for everybody, and for the more complex prostate cancers, multiport surgery is better. But if you've got a smaller prostate and if you've got previous operations which make going through the peritoneal cavity a little bit more dangerous, and the prostate's not too large, and the cancers not too extensive, this may be an ideal option with the added benefit of a quicker recovery. And then there's the newer treatments which don't have quite an established track record, such as Tulsa. This is shortly to be introduced at St. Vincent's by myself, and I see this as a treatment of intermediate risk prostate cancer, level two or three, in patients who are either unsuitable or who refuse surgery and radiotherapy. You need to be aware that you're trading certainty with a less invasive treatment. The difference between it and nanonyph therapy is that nanonnife's only appropriate if it's very localized, while Tulsa can treat the whole prostate. So they're both minimally invasive options, but obviously they don't have the track record of surgery or radiotherapy. So how do we then go about the process of making the right decision? Number one, give it time, don't rush it. Prostate cancer moves very slowly. Number two, trust your team. Number three, make sure that you've got the correct team. That may involve just a urologist, or it may involve a radiation oncologist, a medical oncologist as well, or even a nurse helping as well. As I said, give yourself time. The aim of this decision is to avoid regret. So be honest with yourself about what's important to you. Do a Venn diagram if you have to, and actually go through the process of seeing which treatment is likely to give you the best outcome with the least regret. So to do that, you need to know all your options, you need to understand all your factors, you need to understand yourself, and most importantly, you need to give it time. So if after all of that you're still unsure, get a second opinion. There's nothing wrong with getting a second opinion. I've been providing a second opinion service for over 20 years, and the gratitude of the patients is enormous. So don't hesitate to do that if you think you need more information.