(1) Follow-up observation and treatment

        After the prostate biopsy, if it is judged that immediate treatment is not necessary and life will not be affected, follow-up observation and treatment can be used to avoid overtreatment. Perform rectal examination and PSA examination every 3 to 6 months, conduct prostate biopsy about 1 to 3 years, and start treatment plan if the disease progresses. Most of the patients will experience a decrease in their quality of life due to surgery and other treatments. In order to prevent this from happening, follow-up observation treatment has become very popular and has been valued.

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        The state suitable for follow-up observation and treatment is that the PSA value is below 10ng/ml, the disease stage is below T2, and the Gleason score is below 6, which should be comprehensively judged with other indicators. During the follow-up observation treatment, the PSA test was carried out at 3 to 6 months to confirm the increase. If the doubling time of the PSA value is more than two years, follow-up observation and treatment should be continued.

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      (2) Focal therapy

        Focal therapy is between follow-up observation therapy and surgery. During treatment, normal tissue should be preserved as much as possible, and bodily functions should be maintained. This treatment is chosen when the cancer cells are only in the prostate. Focal therapy includes a variety of treatments (hyperknife, cryotherapy, intra-tissue radiation therapy, etc.), and it is difficult to evaluate after treatment, and it is impossible to confirm whether it is completely cured at this stage. The most important thing is to discuss and decide on the treatment method with the attending physician.

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      (3) Surgery (surgical treatment)

        The operation is to remove the prostate and seminal vesicle, and remove all the prostate connected to the bladder and urethra. Lymphatic debridement surgery is also sometimes performed. The main reason for recommending surgery is that cancer cells are in the prostate, and it will be performed when it is judged that there is a possibility of survival of more than 10 years. However, surgery may also be performed when cancer cells break through the capsule and spread. Surgical methods include laparotomy, laparoscopic surgery, and Da Vinci robotic arm.

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• Laparotomy: Laparotomy is performed under general anesthesia and a straight incision is made from the lower abdomen.

• Laparoscopic surgery: Laparoscopic surgery is a surgery in which several small holes are opened in the abdomen, carbon dioxide is used to inflate the abdomen, and special cameras and medical instruments are used. Compared with laparotomy, the amount of bleeding is less and the wound is smaller, less burden on the body, and the recovery of complications is faster.

• Da Vinci robot surgery: The Da Vinci robot arm is a surgical robot arm equipped with precision cameras and medical instruments through remote operation after opening several small holes in the lower abdomen. Not only can it suppress the slight vibration of the doctor's hand during the operation, and the operation can be performed through the enlarged screen. The effect is the same as laparotomy, the wound is smaller than laparotomy, and the recovery speed of complications is faster than laparoscopic surgery.

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Postoperative complications:

      _cc781905-5cde-319 4-bb3b-136bad5cf58d_The main complications after surgery are urinary incontinence and sexual dysfunction .

• Urinary incontinence: Surgery can damage the muscles that regulate the mechanism of urination, making the urethra less constrictive and causing urinary incontinence when coughing. In order to prevent this phenomenon from happening, the nerve and urethral sphincter should not be damaged as much as possible during the operation, but it is not currently possible to perform the operation without damaging the above-mentioned parts at all. After surgery, most of the urinary incontinence will last for several months, and it will return to a state that does not affect daily life in about half a year. But it can't be completely cured yet.

• Sexual dysfunction: Erectile dysfunction will almost certainly occur after surgery. The recovery of erectile dysfunction depends on the degree of nerve preservation, age and preoperative erectile function. It is generally difficult to fully return to a normal state. But in the case of nerve preservation, erectile dysfunction can be treated with drugs after surgery.

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      (4) Radiation therapy

        Radiation therapy uses high-energy X-rays and electron beams to irradiate cancer cells to shrink them. There are external radiation therapy and internal tissue radiation therapy. There are many methods, which are characterized by the duration of treatment and the occurrence of side effects, but there is no data that can be directly compared, so it is currently impossible to say which treatment is the best. Overseas studies have shown that it is recommended to use internal tissue irradiation therapy and external irradiation therapy at the same time, but there are also clinical trials showing that the effectiveness of external irradiation therapy alone is better, but there are more side effects relative to the improvement in effectiveness. The decision on which treatment to use needs to be made after discussion with the attending physician.

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• External Beam Therapy: Radiation delivered to the prostate through the outside of the body. The range of treatment is determined by the computer, and the irradiation is only targeted to the prostate as much as possible to reduce the possibility of radiation exposure to surrounding organs. It also uses its evolved intensity-modulated radiation therapy (IMRT). Generally speaking, it needs to be done once a day and five times a week for 7-8 weeks. There is also a method of using localized radiation therapy to focus irradiation on the target, and most of them are short-term treatments (about five treatments).

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In addition, heavy ion and proton beams are used. When using X-ray therapy, the maximum dose is applied to the surface of the body, but when heavy ion and proton rays are used, the dose can be adjusted to irradiate the deep part of the body (cancer site). It's just that the facilities available for treatment are limited.

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The main side effects of external radiation exposure can be divided into acute side effects and side effects that develop over time. Common acute side effects are frequent urination and pain when urinating/defecating. After a period of time, the side effects include bleeding during defecation and hematuria. The treatment time for side effects may take years, but the frequency will become less and less frequent, and the more serious side effects are less likely to occur.

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• Intra-tissue irradiation therapy: Internal irradiation performed by putting a sealed small granular container with radioactive substances into the prostate. Because the radiation source is very close to the cancer tissue, it is less likely to deviate from the position and maintain high-energy radiation therapy. However, this treatment cannot be used in patients who have undergone partial resection due to enlarged prostate. In addition, when the prostate is too large, part of it will be covered by the pubic bone, which may not be possible. Before treatment, endocrine therapy may be required to reduce the size of the prostate before internal radiation therapy.

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There are mainly two types of intra-tissue radiation therapy: permanent placement in the body (using low-dose radiation) and short-term placement in the body (high-dose radiation). In the method of permanent insertion into the body, anesthesia is first performed, the position is confirmed using ultrasound, and radioactive substances are injected into the human body from the perineum (between the scrotum and anus) using specialized medical equipment. Although the operation was completed within half a day, at least one day of observation was required after the operation. Its effect can last for about half a year and does not need to be taken out. There will be residual radiation in the body, but it will not affect the people around.

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In the short-term intracorporeal method, a tubular needle is inserted into the prostate, and radiation is introduced through the needle for irradiation. The treatment period varies depending on the facility, but most of the treatment is divided into several sessions, and you need to keep your body in a stable state during the treatment.

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In terms of side effects, most of the side effects of external radiation therapy are related to defecation, while those of internal tissue radiation therapy are related to the side effects of urination. After treatment, within 3 months, there will be gradually dysuria and frequent urination. After about a year, side effects related to urination will gradually decrease. Urinary incontinence occurs only in rare cases. Regarding the maintenance of sexual function, although it is also related to age, external radiation therapy will be easier to maintain than internal radiation therapy, but the amount of semen will decrease.

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      (5) Drug treatment

• Endocrine therapy (hormonal therapy): Prostate cancer is stimulated by the androgen (male hormone) secreted by the testis and adrenal glands, resulting in the development of the disease. Endocrine therapy is the use of drugs that inhibit the secretion of male hormones to slow down the progression of the disease. Endocrine therapy is used when surgery and radiation therapy are difficult, before and after radiation therapy, or when cancer cells have metastasized to other organs.

 

1. Problems of endocrine therapy: The problem with endocrine therapy is that continuous long-term treatment will weaken the effect and relapse again. Although endocrine therapy is effective for prostate cancer, it cannot achieve a radical cure. In case of recurrence, estrogen and adrenal cortex hormone are used, but long-term treatment also weakens the effect.

 

2. Treatment of castration-resistant prostate cancer: When the recurrence is diagnosed, the effect of endocrine therapy is weakened, which is called castration-resistant prostate cancer. Xtandi (androgen receptor inhibitor) and Zytiga (androgen synthesis inhibitor) are generally used. There are also treatments that use a combination of chemotherapy and adrenocortical hormones.

 

3. Side effects of endocrine therapy: The side effects of endocrine therapy include hot flashes, sexual dysfunction, breast-related side effects, impact on bones, and fatigue. Sexual dysfunction is erectile dysfunction and decreased libido. Due to the decline of male hormones due to treatment, the state of female hormones (men also have female hormones) is more, resulting in breast enlargement and nipple pain symptoms. The effect on the bones is a decrease in bone density, leading to an increased risk of fractures. Most patients will gradually get used to the effects of side effects, but when the side effects are severe, drug changes or treatment will be terminated.

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• Chemotherapy: Chemotherapy is carried out through injection, drip and oral way, so as to achieve the effect of destroying or shrinking cancer cells. Generally, it is performed on patients with metastases and endocrine therapy ineffective.

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      (6) Drug treatment

         Palliative care treatment is to alleviate the mental and physical pain caused by cancer from the time of cancer diagnosis, and to maintain the patient's quality of life. It is not only carried out when the disease progresses, it is adjusted according to the patient's physical and mental condition. Since only the patient himself knows about the pain, the patient must actively ask the attending physician.

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3. Rehabilitation

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      (1) Precautions for daily life

      _cc781905-5cde-319 4-bb3b-136bad5cf58d_ Precautions for daily life vary depending on symptoms and treatment status . Please make a decision after discussing with your attending physician according to your own situation.

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• Daily life during follow-up observation: Basically, there are no special restrictions on daily life. Maintain good living habits as much as possible, such as: no smoking, no alcohol, healthy diet, exercise and maintain an appropriate weight, and prevent infection symptoms.

 

• Daily life after surgery: Basically, there are no special restrictions on diet and exercise, but the side effects caused by surgery mainly include urinary incontinence and sexual dysfunction. Disposable diapers can be used for urinary incontinence. To prevent diaper rash, please change diapers regularly and keep your body tidy.

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• Daily life after radiation therapy: Basically, there are no special restrictions on diet and exercise, but there may be reactions of fatigue and loss of appetite, please adjust according to your own condition. Because some patients have worsening urination symptoms after drinking alcohol, please decide whether to prohibit alcohol according to your own situation. The part irradiated by radiation will cause inflammation symptoms, frequent urination, pain during defecation, bleeding and hematuria during defecation. Side effects may last for months to years. If the symptoms of side effects are more serious, please discuss with the attending physician.

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• Daily life after drug treatment: Basically, there are no special restrictions on diet and exercise, but there will be various side effects such as fatigue and loss of appetite. If the symptoms of side effects are more serious, please discuss with the attending physician.

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• Sexual life and childbearing: Sexual behavior should be avoided during treatment. There are many reasons for the impact on sexual life and fertility due to treatment, and there are corresponding methods. If you want to maintain fertility, please discuss it with the attending physician before treatment.

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      (2) Follow-up observation

      _cc781905-5cde-319 4-bb3b-136bad5cf58d_ The period of follow-up observation will vary according to the stage of the disease, mainly After treatment, checkups are required every three months for two years, and every six months for the next two years, and then once a year, and PSA and imaging tests are performed according to the physical condition. If you have symptoms, please discuss them with your physician as soon as possible.

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For prostate cancer-related drug information, you can refer to the medical assistant blog

https://www.medicalsupporter.org/medicalblog/tag/prostate