fa Proton Therapy for Prostate Cancer in India - Apollo Proton Cancer Centre

"More than 2 million cases are diagnosed each year worldwide. It is second only to lung cancer as a cause of cancer deaths among men."

Diagnosis

 

If you have prostate cancer, it’s important to get an accurate diagnosis as soon as possible. This helps increase the odds of successful treatment and recovery.


One or more of the following tests may be used to find out if you have cancer and if it has spread. These tests also may be used for followup.

Digital rectal exam (DR.E)

The simplest screening test for prostate cancer is the digital rectal exam (DR.E). The health care provider gently inserts a gloved forefinger into the rectum to feel the prostate gland for enlargement or other abnormalities, such as a lump.


The DR.E is not a definitive cancer test, but regular exams will help detect changes in the prostate over time and also if lumps are present. These changes might signal cancer or pre-cancerous conditions or even plain simple enlargement.


Although this test usually is not as reliable as the PSA blood test, a DR.E may be able to find cancer in a man with a normal PSA level. A DR.E also may be used to tell if prostate cancer has spread or returned after treatment.

Prostate-specific antigen (PSA) test

Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. It is found mostly in semen, but a small amount only is in the blood as well. When cancer cells invade normal prostate cells, PSA starts leaking into the blood and can be used as a tumor marker.


A blood test measures the amount of PSA circulating in the blood. This level is used to assess prostate cancer risk. A PSA of 4 nanograms per milliliter or lower is considered normal. A higher PSA level usually means a higher chance of having prostate cancer.


PSA tests have limitations. Prostate tissue and prostate cancer both produce PSA. Sometimes prostate cancer does not produce much PSA. In other cases, high PSA levels can be caused by factors other than cancer. These include:


  • Enlarged prostate, also called benign prostatic hyperplasia (BPH), which is found often in older men
  • Age: PSA levels normally go up slowly as men's age
  • Prostate infection or inflammation, which also is called prostatitis
  • PSA may rise briefly after ejaculation, then return to normal levels

Certain conditions may make PSA levels low, even when a man has prostate cancer. These include:


  • Some drugs used to treat BPH or other conditions
  • Certain herbal medicines or supplements
  • Obesity

Despite its limitations, PSA testing has helped detect prostate cancer in countless men. In 1984, before PSA testing was available, the chance of finding early prostate cancer was about 50%. In 1993, after PSA testing became widely used, that figure jumped to more than 90%. Men with very low PSA levels may need to be tested every two years. If PSA is higher, the doctor may recommend more frequent testing.


There are other modifications of the PSA testing which can be used to clarify whether the patient is suffering from CaP.


PSA tests can also be used in men who have been diagnosed with prostate cancer. For instance, they may:


  • Help doctors plan treatment or further testing
  • Determine if cancer has metastasized (spread beyond the prostate)
  • Find out if treatment is working or cancer has returned
  • Aid in active surveillance (also called watchful waiting) by showing if cancer is growing
Imaging exams

Radiological imaging can help identify the area of the prostate that should be biopsied. They can also determine how far cancer has spread beyond the prostate. Images of the prostate are typically taken with a probe inserted through the rectum.


TRUS – transrectal ultrasound


MP-MRI prostate – this is currently turning out to be a game-changer – a very good sensitivity and specificity in picking up a cancerous lesion in the prostate – only if a correct protocol was applied. Prostate MRI does not use radiation. It provides images that are clearer and more detailed than other imaging methods.


A multi-parametric magnetic resonance imaging (mpMRI) scan is a special type of scan that creates more detailed pictures of your prostate than a standard MRI scan. It does this by combining four different types of images. These images give your doctor information about whether or not there is any cancer inside your prostate.


During the mpMRI scan, you will be injected with a Gadolinium-based contrast agent which is an essential part of this type of imaging. It allows for a clearer picture of the prostate. The gadolinium (a metal ion) in these dynamic contrast agents has been chemically adapted to make it safe to use as part of a mpMRI scan. Part of the quality control for mpMRI involves using the lowest possible effective dose of the contrast agent. There is not yet any clinical evidence that gadolinium causes any harm when used as a contrast agent for mpMRI, however, we will continue to monitor the situation carefully. The contrast agent will not be administered if it's clinically contraindicated, for example, when dealing with kidney problems.


In 2017, the results of a new study called PROMIS were published. The study involved hundreds of men and examined whether mpMRI before biopsy can provide a more accurate diagnosis for men with suspected prostate cancer and can rule some men out of unnecessary biopsy. The study has shown that mpMRI:


§ is significantly better at identifying clinically significant prostate cancer compared to TRUS biopsy


§ reduces the number of men having biopsies unnecessarily by a quarter (27%) because the scan will only pick up cancers which could cause men to harm and need further tests


§ helps improve the accuracy when taking biopsy samples, targeting directly any suspicious areas seen on the MRI


§ PET – PSMA:

Currently growing in popularity for the last few years – it is done for both diagnosis and follow-up of patients.

Biopsy

In a biopsy, a small amount of suspected cancer tissue is removed and examined under a microscope. This is the only way to tell for sure if you have prostate cancer.


Biopsies for prostate cancer are usually outpatient procedures done in a doctor’s office or other facilities. A local anaesthetic like dentists use, often lidocaine is injected into the area close to the prostate to make the procedure more comfortable.


In most cases, a small trans rectal ultrasound (TRUS) probe with an imaging device is inserted into the rectum. The doctor can then view the prostate on a video screen. Using this image as a guide, the physician injects a thin needle through the wall of the rectum into the prostate. At least 13 samples are taken to make sure we don’t miss cancer.


Based on the patient’s situation, we also conduct biopsies where the needle is inserted through the perineum instead of the rectum. Cognitive Fusion biopsies, which use special software to target abnormalities found in an MRI, are also an option.


Transperineal biopsy is appropriate for all patients, but may specifically benefit patients with the following conditions:


  • History of infection after a previous trans rectal biopsy
  • History of prostatitis
  • Inflammatory bowel disease
  • Rectal bleeding complications after the previous biopsy
  • Previous negative trans rectal biopsy with suspicion of anterior prostate tumor

"Research so far suggests that the transperineal approach is non-inferior in terms of diagnostic yield when compared to transrectal biopsy, although some studies do show a slightly higher detection rate with the transperineal approach,"

Treatment

 

The patient undergoes a staging process and a CMT discussion and decided on individualized/personalized treatment. Patients in each risk group often get the same general recommendations for treatment.

Low-risk prostate cancer treatment

Many low-risk prostate cancers can go years or even decades without causing any serious health problems. Because of this, doctors often recommend active surveillance for these patients. During active surveillance, a patient is closely monitored for changes to his cancer.


In some cases, low-risk prostate cancer patients do choose to have treatment. A younger patient, for example, may select treatment instead of potentially decades of surveillance. Patients with low-risk disease may also choose treatment if they have a certain genetic condition or a large amount of cancer tissue.

Intermediate-risk prostate cancer treatment

Men with intermediate-risk prostate cancer should be treated in most cases. Treatment options typically are surgery to remove the prostate or radiation therapy. The patient may also get hormone therapy along with radiation therapy.

High-risk prostate cancer treatment

Low- and intermediate-risk prostate cancers are usually considered curable. Some high-risk prostate cancers can be cured. In other cases, it is not curable and will require multimodal treatment.


High-risk prostate cancer is usually treated with a combination of therapies. Standard options include surgery, radiation therapy, hormone therapy with or without chemotherapy.


Doctors will recommend the combination based on each patient’s


  • Specific cancer subtype
  • Stage of the disease
  • Age
  • Other factors
Metastatic prostate cancer treatment

If a patient’s prostate cancer has spread beyond the prostate and the surrounding area, he is given hormone therapy and possibly early chemotherapy. While cancer responds to hormone therapy, it is called castrate sensitive disease. Over time, the disease may become less responsive to hormone therapy and start growing again. This is called castrate-resistant disease. Patients with castrate-resistant disease can be treated with several additional therapies. Many are eligible for clinical trials with newer drugs or drug combinations, including immunotherapy.

Radiation therapy

When is Radiation therapy advised in prostate cancer?


Radiation therapy for prostate cancer is one of the most common treatment treatments offered for Prostate Cancer. It has a potential role in almost every stage of prostate cancer-from early stage to an advanced stage.


  • Radiation therapy can be offered in the early stages of prostate cancer as a single curative modality. Large randomized clinical trials have shown that the long term results of radiation therapy are equivalent to surgery in this early-stage prostate cancer. Radiation therapy has been shown to yield a nearly 95% survival rate in this stage.
  • Radiation therapy can be offered in high-risk or locally advanced cancers along with hormone therapy also called androgen deprivation therapy. In this stage also, radiation and androgen deprivation therapy can yield a long-term survival of 80-90%.
  • Radiation therapy can be given as a postoperative treatment after radical prostatectomy either due to residual disease after surgery or due to an increase in serum prostate-specific antigen after surgery. If done at the appropriate time, the likelihood of long-term cure in this subset is also around 80%.
  • Radiation therapy can be offered as a curative treatment along with hormone therapy as well as newer drugs in advanced or metastatic prostate cancer if the metastases are limited to a few sites or a few lymph nodes. This stage of the disease is called oligometastatic disease as the metastatic burden is limited.
  • Radiation therapy can be offered as a palliative treatment for the palliation of bone pain, bleeding, etc in advanced or metastatic prostate cancer.

Radiation therapy is a non-invasive form of treatment that has shown to yield equivalent results to invasive surgery. The choice of treatment depends on patient symptoms, preference and logistics.


What is the duration of treatment?


Duration of prostate cancer treatment varies, ranging from 7-8 weeks for conventional treatment, to 4 weeks with hypofractionated treatment. Most treatments worldwide have been reduced to 4-5 weeks in patients with intact prostate. Large scale randomized trials have shown that shorter schedules are as efficacious as prolonged schedules and result in similar toxicities thereby improving patient convenience.


Postoperative radiation therapy is usually given for about 6-7 weeks. Also, treatment is exclusive of simulation and planning, which usually takes about a week before the start of treatment.


What are the types of Radiation in prostate cancer?


There are two types of radiation treatment for prostate cancers, which are External beam radiotherapy which includes 3-dimensional conformal radiation therapy, Intensity-modulated radiation therapy, volumetric modulated arc therapy, and Proton beam therapy. All these treatments are delivered with image guidance and hence also referred to as image-guided radiation therapy or IGRT. IGRT in most modern centres involves daily CT imaging.


The other option is brachytherapy, which can be done either via interstitial needle implantation under sedation, which includes placement of needles with template guidance thereby delivering uniform doses to the prostate cancer, and seed implants, which are permanent implants, which are inserted under image guidance and left in the body, which delivers low dose radiation to a prolonged period, thereby treating the malignancy.


Brachytherapy is usually considered for low/intermediate-risk prostate cancers, where the target is mainly the prostatic lesion, whereas external beam radiotherapy is noninvasive and can treat both prostates as well as the involved nodes. Sometimes, a combination of external beam radiotherapy and brachytherapy are also considered based on the clinical decision for high risk localized or locally advanced prostate cancers.


SBRT for prostate cancer


Traditionally, prostate cancers are treated over 7-8 weeks with conventional fractionation. Modern hypofractionation schedules incorporate schedules of treatment for 4-5 weeks. However, Stereotactic body radiotherapy (SBRT) or Stereotactic ablative radiotherapy (SABR) for prostate cancer is a radiation technique where the entire treatment is condensed over five sittings of radiation. It delivers a high dose per fraction, which takes into advantage the radiobiology of prostate cancers. This advantage translates to delivering biologically higher doses of radiation in a shorter period of time without increasing the likelihood of toxicities or side-effects associated with treatment.


In early localized prostate cancers (low and intermediate-risk prostate cancers), SBRT is now considered standard with equivalent cancer control outcomes and limited toxicities. Its role is emerging even in patients with locally advanced and node-positive prostate cancers. The cancer outcomes of SBRT remains the same as that of conventional external beam radiotherapy/brachytherapy or surgery. The biggest advantage is patient convenience which can be completed over a week.


Methods to deliver SBRT


  • Linear accelerator-based SBRT
  • Dedicate radiosurgery equipment such as Cyberknife
  • Proton beam therapy

Radiation for metastatic Prostate Cancer


Radiation therapy can be considered as a curative treatment for metastatic prostate cancers when the metastatic disease burden is limited, i.e, oligometastatic, which means spread of the disease to limited sites or nodes. It can also be considered as a palliative treatment, for control of bone pain, or bleeding, or control of lower urinary tract symptoms, which focus mainly on quality of life for these patients.


Radiation therapy for Prostate cancer - Procedure


Planning typically includes:


Radiation simulation. A few days before your radiation simulation appointment, several marker seeds will be inserted into your prostate by a radiologist. These markers help to locate your prostate more precisely during each radiation treatment session. During the simulation, you must lie down still throughout the procedure. Your radiation therapy team will help you find a comfortable position during treatment. Customized immobilization devices are used to help you hold still in the right position. Your radiation therapy team will make marks on your body to be used during your radiation therapy sessions.


Planning scans. Your radiation therapy team performs computerized tomography (CT) scans to determine the exact area of your body to be treated. After the planning process, your radiation therapy team decides what dose you will receive based on your stage of cancer, your general health and the goals for your treatment.


During a treatment session:


  • You lie down in the position determined during your radiation simulation session.
  • You might be positioned with customized immobilization devices to hold you in the same position for each therapy session.
  • The proton gantry may rotate around your body to deliver radiation beams from different directions.
  • You lie still and breathe normally during the treatment.
  • Your radiation therapy team stays nearby in a room with video and audio connections so that you can talk to each other.
  • You will not feel any pain. Speak up, if you feel uncomfortable.

What can one expect during the treatment?


Generally, side effects do not appear until the second or third week of treatment. As proton therapy is a local treatment, only the areas of the body where it is directed will experience side effects. Most patients will experience some or all of the following:


  • Increase in the frequency of urination
  • Urinary urgency
  • Weak urinary stream
  • Difficulty starting urination
  • Burning or tingling with urination
  • Occasional diarrhea
  • Softer and smaller volume bowel movements
  • Increased frequency of bowel movements
  • Worsening of hemorrhoids or rectal irritation with occasional scant blood and fatigue

Depending on the severity of these side effects, you may be prescribed medications such as anti-diarrheal medication (Immodium or Lomotil) or medication to decrease the frequency of urination (Flomax or Urispas) for symptom relief. Most of these symptoms are short-term and go away after the proton therapy ends. The time for full recovery depends on the patient and the type and severity of urinary or bowel symptoms, and whether the patient had any symptoms before treatment.


As part of your treatment planning, you will be asked to fill out questionnaires to help evaluate your bladder, rectal and sexual function. It is important to discuss the nature and severity of your particular symptoms with your doctor, since this may influence your treatment course. Patients typically continue with their normal daily activities during treatment.


Many questions may arise during radiation therapy treatment. Your doctors will be available to answer questions throughout your treatment.


What are the side effects? What can I do about side effects?


Fatigue — Fatigue may occur later in radiation therapy treatment. Consider taking a nap during the day. If working, consider decreasing work hours or taking leave, if possible. However, try to maintain a level of physical activity and a well-rounded diet. Nutritionists are available to assist if desired. Contact your doctor if fatigue becomes severe. It is typically more in patients who are also receiving concurrent androgen deprivation or hormone therapy.


Diarrhea, flatulence or painful defecation — These symptoms usually occur after the second or third week of treatment. Symptoms will resolve after the treatment ends. During proton therapy, dietary modification usually helps reduce the frequency and severity of diarrhea. Try to avoid or reduce fried foods, greasy foods and highly spiced foods. Reduce foods with insoluble fiber, such as lettuce and cauliflower, and increase low-fiber and soluble-fiber foods, such as bananas, mashed potatoes, applesauce, white rice, canned or cooked fruits and vegetables.


Maintain your intakes of lean proteins, such as pulses, turkey, chicken and fish, and increase your fluid intake to avoid dehydration. Using moist toilet paper, baby wipes or sitz baths may help relieve rectal irritation. Your doctor may recommend anti-diarrheal medications. Contact your doctor if you see blood in your stool, if diarrhea worsens or if you become light-headed or dizzy.


Frequent urination, burning with urination and difficulty urinating — These are the most common complaints. Occasionally the urinary stream will weaken. Generally, these symptoms are managed with medications to help the bladder function better or eliminate burning. Rarely, your doctor may order a urine test. Symptoms will resolve after the end of treatment. Contact your doctor if you see blood in your urine or if you are unable to urinate.


Skin irritation — This is uncommon, but if it occurs, do not rub or scratch the area. Avoid clothing that rubs and avoid alcohol-containing lotions or colognes. Your doctor can recommend a skincare regimen and topical creams or lotions to relieve the symptoms. Contact your doctor if you develop a rash all over your body.


What other special details should I be aware of?


Before you go home, you will be given detailed written instructions about the following issues:


Radiation safety — There is no remaining radiation in your body once your treatment is complete and it is completely safe to be around other people.


Sexual function — A small percentage of men experience a decline in erectile function after radiation therapy. The likelihood of impaired potency is influenced by age, which is the primary risk factor, the use and duration of hormone therapy, smoking and medical conditions, such as hypertension and diabetes, as well as the medications used for their treatment.


The effects of short-term hormone therapy (four to six months) appear to be largely reversible. Similar levels of sexual function are reported at four years by patients who received hormone therapy and patients who did not receive hormone therapy. Most men who are not taking nitrate-containing medications can use any one of the oral medications on the market that improve erectile quality with excellent success. Patients may experience a prolongation of the time to orgasm. Some experience a change like their ejaculates, such as thicker and less fluid, a decrease in the quantity or an absence of ejaculate after radiation treatment. Patients on long-term hormone therapy may have more pronounced sexual dysfunction and you must discuss with your doctor.


Sperm production — Sperm are produced in germinal cells in the testicles. During prostate radiation, low levels of "scatter radiation" that originate inside the patient's body can reach the testicles and decrease sperm production. The dose of radiation that reaches the testicles usually leads to a temporary reduction (months to years) in the sperm count. However, it is possible to have a permanent reduction in sperm count or sterility. If you are considering fathering additional children, you may wish to seek medical advice regarding your fertility and need to bank sperm.


Testosterone production — Testosterone is secreted by the Leydig cells in the testicles. Generally, the doses of internal scatter radiation that reaches the testicles are not high enough to impair Leydig cell function.


Rectal Bleeding — About 2-3% of the patient may have inflammation of the rectum which may result in bleeding. The best way to avoid this side-effect is to avoid constipation. If it is severe and prolonged, you may need an endoscopic intervention or per rectal medications. Please contact your doctor in case that happens.


How often will I need to see my doctor for a follow-up?


Following Proton therapy, you will have an initial appointment to make sure that treatment-related side effects are diminishing or have gone away.


The frequency of follow-up appointments will be based on the risk of cancer recurrence. In general, serial PSA blood tests will start around the third month after treatment completion. Testing typically occurs every three to four months during the first two to three years after treatment completion and then every six months thereafter. Changes to this schedule may be made during the process of follow-up evaluation.


How will I know if the treatment is working?


Serial PSA blood tests will be used to monitor your progress after definitive treatment of your prostate cancer. Following proton therapy, your PSA will fall but will not reach its lowest value, or nadir, immediately after treatment. Though infrequent, it may take up to two to three years for the PSA to reach its nadir.


This does not mean that PSA testing should be abandoned at this time. It remains an important monitoring tool and serial testing at regular intervals is critical to its effective use. Your doctor will evaluate additional data in conjunction with the PSA to monitor your treatment outcome.


Will I need additional treatment?


Usually, no additional treatment is needed after radiation therapy. The need for additional treatment is determined by the PSA, Gleason score and stage of the prostate cancer and having your daily treatments as scheduled, particularly for external beam radiation therapy (EBRT). Regular post-treatment PSA evaluation plays an important role in monitoring and evaluating the need, if any, for additional treatment in the future.


If cancer recurs, options for treatment will, in part, depend upon the initial treatment. Additional or alternative forms of radiation therapy, prostatectomy, cryotherapy, hormone therapy or any of several treatments under evaluation in clinical trials may be recommended. Your team of doctors, including a radiation oncologist, urologist and medical oncologist, will discuss treatment options and recommendations with you.


Proton therapy for Prostate Cancer


Proton Therapy. A New Era in Cancer Care


Proton therapy is a type of non-invasive radiation therapy that is an incredibly precise cancer treatment that uses a beam of protons moving at very high speeds to destroy the DNA of cancer cells, killing them and preventing them from multiplying. Proton therapy is a revolutionary modality to treat certain patients with prostate cancer. For more than one-half of a century, the idea of using energized protons to treat cancer has been evolving in the laboratories of physicists and medical scientists around the world. Advancements in imaging, along with the development of improved treatment delivery technology and sophisticated computers in recent years, made it possible for Proton Beam Therapy to be available in the established medical centers now. Prostate cancer is the most common indication for proton therapy worldwide.


The Power of Proton Therapy over Conventional Radiation


Conventional radiation therapy uses photons to treat tumours. Photons radiate not only tumour cells but also everything in their path, including healthy cells and structures around and behind the tumour.


Proton therapy uses high energy protons to treat tumors instead of x-rays. In contrast to conventional radiation, Protons can be made to stop in the tumor where they deposit their entire energy enabling complete tumor destruction. Because protons deposit nearly their entire energy in the tumor, there is no radiation beyond the tumor. This characteristic results in no or very minimal damage to surrounding healthy cells making them safer compared to conventional radiation.


How does Proton Therapy work?


Proton therapy uses pencil beam scanning to deliver radiation and match each tumour’s exact shape and size in three dimensions. This allows a single layer of a tumor to be treated at a time, in effect painting the tumor with radiation layer-by-layer and slice-by-slice until the entire area has been treated.


How are protons produced?


Protons are produced in a machine called the cyclotron. They are then released, from a gantry, in a sharp beam (approximately 3 mm in size); the latter may vary depending on various factors. The energy of the proton beam varies with the depth of tissue/ tumour that has to be treated. Each energy form treats a layer of tissue as a series of spots. The position of the gantry is changed to access the tumour from various directions for accurate delivery of the proton beam, without compromising the safety of adjacent normal tissue.


What are the benefits of Proton Therapy?


Because it involves significantly less radiation exposure to normal tissues, proton therapy lowers the risk of side effects and secondary, radiation-induced cancers. Proton therapy, alone or in combination with other treatments, may be a great choice for many specific types of cancers and benign conditions. Additionally, proton therapy can treat recurrent cancers and also children with cancer. It is also an important treatment option for cancers that cannot be completely removed by surgery. This advanced technology:


  • Gives better protection to surrounding healthy tissues
  • Lowers the risk of radiation-induced secondary cancers
  • Results in fewer side effects and better quality of life

Why should you choose Proton Therapy for Prostate Cancer?


Proton therapy is one of the most effective forms of treatment for prostate cancer. Proton therapy may be used as the only treatment or can be combined with hormonal therapy or after other treatments, such as surgery, to manage cancer that has recurred or is at high risk of recurrence.


Proton therapy has an excellent record of success, providing long-term disease control and survival rates equivalent to other treatments, including surgery. Several research studies published in leading scientific journals have reported very low genitor-urinary, gastrointestinal and sexual function related toxicities with proton therapy. Several patients prefer proton therapy due to its non-invasive nature and minimal, or no adverse effect on their quality of life.


As per our experience at APCC, proton therapy ensures the least possible doses to the urinary bladder and rectum. The below picture represents a dose comparison between proton therapy and IMRT. Better sparing of the dose to healthy normal urinary bladder as well as the rectum is obvious with proton therapy.







Bladder dose comparison between IMRT and Proton therapy: Lesser the dose to bladder, lesser is the urinary toxicity related to urinary bladder irradiation.




Rectal Dose Comparison between IMRT and Proton therapy: Lesser the dose to the healthy rectum, lesser is the rectal toxicity.


How do you prepare for Proton Therapy?


Before you undergo proton therapy for prostate cancer, your care management team guides you through a planning process to ensure that radiation reaches the precise spot in your body where it's needed. Accurate planning is essential for the use of all radiation therapy, but especially so for Proton therapy. The goal is to precisely deliver radiation to cancer while minimizing damage to surrounding healthy tissue.


What can I expect during proton therapy?


Undergoing proton therapy is similar to having a routine X-ray. Proton therapy cannot be seen, smelled, or felt.


In Proton therapy, the patient is treated on an outpatient basis and the therapy will be administered five days a week over about four to eight weeks. Each treatment session usually lasts less than an hour, most of which is the preparation time. The actual radiation treatment takes only a few minutes.


How should I expect to feel after proton therapy?


After completing proton therapy, urinary and bowel side effects may persist for two to six weeks, but they will improve over time. You may need to continue some medications.


Other minor problems may include dry itchy skin, a sensation of heaviness in the perineum, anal and rectal irritation, and a flare-up of hemorrhoids. However, patients are usually well enough to continue with normal daily activities.


Large series of patients treated with proton therapy published a few years ago showed excellent sexual function in patients in younger than 60 years.

Prostate cancer surgery

Surgery for prostate cancer is known as a radical prostatectomy. This is usually done with the help of a robot – called a robot assisted radical prostatectomy. During this procedure, the surgeon removes the entire prostate. Lymph nodes near the prostate may also be removed to look in biopsy for evidence that the disease has spread.


These surgeries result in smaller incisions, less blood loss, less pain and shorter hospital stays.


Surgery for prostate cancer usually requires an overnight hospital stay. Patients must have a catheter for about one week after the procedure. They typically can return to work after two weeks. There are no restrictions on activity after four weeks.

Hormonal therapy

Hormonal therapy (Androgen Deprivation therapy)


The majority of prostate cancers when they begin are hormone-sensitive, which means male hormones (androgens) such as testosterone fuel the growth of cancer. About one-third of prostate cancer patients require hormone therapy. This treatment reduces the tumor size or makes it grow more slowly but does not cure the disease.


There are two main types of hormone therapy for prostate cancer patients:


  • Antiandrogens: Antiandrogens block testosterone and other androgens from interacting with the cancer cell. They are taken by mouth every day. Antiandrogens are used most often in combination with androgen synthesis inhibitors.
  • Androgen synthesis inhibitors: These drugs reduce levels of testosterone and other androgens produced by the body. A principle type of androgen synthesis inhibitor is LHRH agonists. These work by over-stimulating the pituitary gland to produce luteinizing hormone-releasing hormone (LHRH). This causes an initial surge of testosterone, followed by lower testosterone production by the testicles. Androgen synthesis inhibitors are delivered by injections, which last from one to six months, or by small pellets implanted under the skin.

Hormonal therapy is most often used for late-stage, high-grade tumours with a Gleason score of 8 or higher or in patients with cancer that has spread outside the prostate.


Hormone therapy may be used to treat prostate cancer if:


  • Surgery or radiation is not possible
  • Cancer has metastasized (spread) or recurred (come back after treatment)
  • Cancer is at high risk of returning after radiation
  • Shrinking cancer before surgery or radiation increases the chance for successful treatment

Side effects of hormone therapies for prostate cancer may include:


  • Impotence, inability to get or maintain an erection
  • Loss of libido (sex drive)
  • Hot flashes
  • Growth of breast tissue and tenderness of breasts
  • Loss of muscle mass, weakness
  • Decreased bone mass (osteoporosis)
  • Shrunken testicles
  • Depression
  • Loss of alertness and higher cognitive functions
  • Anemia (low red blood cell count)
  • Weight gain
  • Fatigue
  • Higher cholesterol levels
  • Increased risk of heart attacks, diabetes and high blood pressure (hypertension)

If you are treated with hormone therapy and have side effects, be sure to mention them to your doctors. Many of these side effects can be treated successfully.


Second Generation Anti-Androgens


In patients who have developed Castration-Resistant Prostate Cancer, the conventional hormonal agents don’t work. Second generation Antiandrogens include Abiraterone acetate which acts by inhibiting Androgen biosynthesis and Enzalutamide, which is a potent androgen receptor blocker and also inhibits nuclear translocation of androgen. They have shown improved disease control and improved survival in such patients. Recently, they also are used in upfront metastatic carcinoma prostate (hormone-sensitive prostate cancers) as they result in longer biochemical control and radiologic disease control than androgen deprivation therapy with surgical or medical orchidectomy. The adverse effects are similar to the first generation antiandrogens.

Chemotherapy

Chemotherapy drugs are designed to kill fast-growing cells, including cancer cells. For Castrate Resistant Prostate Cancer patients, the option of chemotherapy is given if they have a high disease burden and are physically fit to receive chemotherapy. Especially in younger patients with biological aggressive disease (high grade, high disease burden), they are preferred. Docetaxel is the preferred drug and is either given 2 weekly or 3 weekly along with oral prednisolone. The side effects include a decrease in blood counts, peripheral edema, hair loss, etc. With optimum supportive care, the incidence of adverse effects have decreased and often patient are able to tolerate them well.

Winning Over Cancer

Chances are slim when it comes to Proton therapy. Dr. Srinivas Chilukuri, Senior Consultant, Radiation Oncologist, speaks about the safe, most effective and least impactful treatment that maintains sexual function even after treatment.

FOR APPOINTMENT

Dr. Srinivas Chilukuri, Senior Consultant, Radiation Oncologist, speaks about the care, dedication and expertize that goes into treating a child with cancer. He said that APCC is well equipped to detect cancer very early and has expert oncoloigsts for the treatment, he further added that all the facilites to treat cancer are available under one roof.

FOR APPOINTMENT

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