The success of prostate cancer treatment depends on the early detection and radical removal of the last remaining cancer cells. With prostate cancer this was difficult to achieve prior to the invention of the PSA test, as there was no way to diagnose stage A prostate cancer. With the PSA test it is now possible to detect cancer of the prostate earlier and with the introduction of the selective radical prostatectomy excellent cure rates of 15 and 20 year survival rates are achieved, which for practical purposes can be considered a cure.
Prostate cancer therapy (type of therapy for different stage)
A : selective radical prostatectomy
B : selective radical prostatectomy
C : external beam radiotherapy and bicalutamid (should be replaced by bio-identical progesterone)
D : external beam radiotherapy, bicalutamid ± chemotherapy (see more below)
Here are the most common treatment methods to deal with prostate cancer.
1. Radical prostatectomy
In the past with a radical prostatectomy the nerves supplying impulses to the penis for erection were severed.
However, now with the help of new technology and the use of an operating microscope the urologist is able to do a selective radical prostatectomy, which will preserve penis erection after the surgical procedure is done in most cases. However, the urologist can only do what is technically possible and unfortunately there will be some cases where cancer tissue has overgrown the nerve supply and it has to be removed. In such a case in the interest of the man’s survival, the nerve may have to be severed as the cancer is removed. Overall the statistics show that about 85% of stage A and B prostate cancer patients can have a successful selective radical prostatectomy, in other words only 15% lose their potency. There are now several forms of this surgery:
a) radical retropubic prostatectomy
b) radical perineal prostatectomy
c) laparoscopic radical prostatectomy
d) robotic prostatectomy. This latest method combines all others and has the lowest complication rate. Watch this mini video, which shows the principal of it.
2. Radiation therapy including brachytherapy
For stage A and B cancer of the prostate radiotherapy used to be the “gold standard”. In an elderly man who may soon die of a stroke or a heart attack this might still be the treatment of choice as a selective radical prostatectomy is a certain surgical risk. The long-term survival curves are almost identical for the 5-year and 10-year points. However, the 15- and 20-year survival curves show clearly a survival advantage for the surgical approach.
However, for stage C and D where the cancer has broken through the tough prostate capsule surgery gives no survival advantage versus the radiotherapy approach. Therefore only external radiotherapy is available as an option to marginally improve survival.
Brachytherapy is a modification of local radiotherapy where radioactive beads are implanted into the prostate gland and surrounding region. This will damage the cancer cells, but unfortunately can also damage the healthy tissue in the region. There may be very special cases where technically brachytherapy is better suited than conventional external beam radiotherapy.
With cryotherapy (like liquid nitrogen) the cancer is treated and removed in combination with a transrectal ultrasonography (TRUS). Here is a link about cryotherapy. The problem with this method is that it is difficult to know when and whether the last cancer cell was successfully eradicated. Careful follow-up exams with PSA blood tests and imaging methods need to be done every 6 or 12 months to look for recurrences.
This is used for cases where regional or distant metastases of prostate cancer are present.
Here is a link regarding chemotherapy treatment of prostate cancer.
5. High Intensity Focused Ultrasound (HIFU)
Here the prostate cancer is removed with a high frequency ultrasonic shock wave, similar to how kidney stones can be removed. Here is a link that explains HIFU in detail. The advantage is the simplicity of the procedure in the hands of a urologist familiar with the treatment. However, the danger is that some of the prostate cancer could stay behind, which would not be the case with a selective radical prostatectomy.
In 2014 the FDA decided not to approve this method at this time. More information about this, see this blog.
6. Active surveillance (also known as “watchful waiting”)
With this method, which is only advisable in the very early stages, the doctor is following the patient very closely and uses different tests and imaging methods to see whether the patient’s prostate cancer progresses or stays about the same. Often this method is used in older, higher risk patients where an invasive surgical procedure may not be in the best interest of the patient. The down side is that the cancer may run away while observing and could change from a grade B tumor (still local) into a stage C tumor with a much poorer prognosis.
7. Hormonal therapy
In breast cancer many cancer types have estrogen receptors and the estrogen blocking agent tamoxifen is used to block cancer growth. Hormone manipulation was thought to be also effective in the treatment of prostate cancer as the cancer cells often have testosterone receptors on their surface and the hope was that cancer growth could be slowed down by removing testosterone or blocking testosterone receptors. The interesting thing is that newer studies in 1999 and beyond (see Ref. 12 for details) have shown that prostate cells and prostate cancer cells have also estrogen and progesterone receptors on the cell surface. This changed the whole foundation of the traditional belief system and many physicians and cancer centres completely ignore this fact to the detriment of the prostate cancer patient.
In the past it was thought that growth of prostate cancer would be significantly reduced when testosterone was removed from the system. There is a whole industry built around suppressing testosterone in the man who has prostate cancer when the modern evidence states that testosterone is necessary for the functioning of all cells in the male and that prostate cancer growth is not suppressed by testosterone removal (Ref.13).
In the past this was achieved by castration (=bilateral orchiectomy = removal of both testicles) as explained in the beginning of the prostate cancer chapter where the findings of the surgeon Dr. Huggins from Chicago were cited. His publication was in 1941. With the introduction of an analogue to the hypothalamic hormone called “luteinizing hormone-releasing hormone” this surgery, which many men were afraid of, was no longer necessary as it is as effective as a bilateral orchiectomy. However, there are still traces of testosterone in the system from the adrenal gland metabolism. As Ref. 6 points out this can be treated with antiandrogenic medication such as bicalutamide (brand name: Casodex). In a stage C patient the hormone manipulation in that manner will lead to a survival advantage of 2 years when the treatment is compared to a control group treated with radiotherapy alone. I do not agree to this regimen and all hormone manipulations that attempt to remove testosterone, because of the new findings that it is actually the female hormone, estradiol, that causes the genetic mutations and ultimately prostate cancer (due to the dysbalance of estrogen/testosterone and the lack of progesterone). In breast cancer it was proven that estradiol is the culprit that causes breast cancer. The theory that testosterone would be responsible for the development of prostate cancer could not be proven. Dr. Lee (Ref. 12) explains that it is estradiol again that causes prostate cancer in the man (see below). For this reason I think that it is malpractice to use the testosterone suppressing agents as described and as still practiced in many cancer clinics.
The latest about hormone modifications (doing it bio-identically)
Newer insights into the causation of prostate cancer found that prostate cancer often develops in men who have an excess of fatty tissue (abdominal fat). Due to the presence of aromatase in the fatty tissue, which is an enzyme that converts male hormones into estrogens, there is an excess level of estradiol (the main female hormone) that affects tissues of the body. As these men are typically older than 50 years, these men typically have no discernible progesterone level (or an extremely low level), which would normally be present in younger men. Estradiol and progesterone levels in younger men are much lower than in females, but progesterone is relatively higher than estradiol to prevent cancer from developing. Also the testosterone/estradiol (T/E ) ratio is 20 or higher in healthy men (Ref.12). Overweight or obese men have unopposed estrogen (estradiol) in their system with a T/E ratio of less than 20, which is carcinogenic and causes prostate cancer or other cancers. Anti-aging physicians are trained to look for this subtle hormone dysbalance that can be determined accurately with saliva hormone tests. Dr. Platt states in Ref. 11 that men above the age of 50 often have higher estradiol levels than menopausal women. If there is a low progesterone level, progesterone cream can be administered and saliva hormone tests can be repeated after 2 to 3 months so that the hormone ratio of progesterone to estradiol will be increased. This way prostate cancer cells that carry estrogen receptors on their surface will be kept at bay (prevention or significant suppression of metastases). At the same time excess body weight needs to be reduced by exercise and attention directed to reduced calorie intake. As already mentioned (Ref. 12), Dr. John Lee pointed out that the premise of wanting to remove testosterone from prostate cancer patients was wrong. It is unopposed estradiol, an estrogen, which is the cause of prostate cancer. Men with prostate cancer are deficient in testosterone and progesterone when saliva hormone tests are done. Hormone deficiencies are treated by replacing what is missing with bio-identical hormones. Seek a second opinion from an anti-aging physician, before you allow conventional medicine to ruin your sex life and push you into permanent testosterone hormone deficiency. Also, understand that only compounded bio-identical hormones that are applied as creams are acceptable treatment. Artificial hormones are dangerous drugs that partially inhibit hormone receptors and cause malfunctions in the body such as heart attacks, strokes, arthritis and cancer. Insist on bio-identical hormones that are custom-made in compounding pharmacies.
More info about prostate cancer treatment:
American Cancer Society: http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?dt=36
Prostate cancer treatment Guide: http://www.prostate-cancer.com/news/prostate-cancer-news.cfm
An overview of the various treatments for prostate cancer is given here (thanks to www.everydayhealth.com for this link).
Radiotherapy review from the Princess Margaret Cancer Centre in Toronto, Ont/Canada: http://www.radiationatpmh.com/body.php?id=102&skeywords=prostate cancer
The following references were used apart from my own clinical experience:
1. Cancer: Principles &Practice of Oncology, 4th edition, by V.T. De Vita,Jr.,et. al J.B. LippincottCo.,Philadelphia, 1993.Vol.1: Chapter on Prostate cancer.
2. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999.Chapter 233, p.1918-1919.
3. Cancer: Principles&Practice of Oncology. 5th edition, volume 1. Edited by Vincent T.DeVita, Jr. et al. Lippincott-Raven Publ., Philadelphia,PA, 1997. Chapter on prostate cancer.
4. A Waghray et al. Cancer Res 2001 May 15;61(10):4283-4286.
5. BM Fisch et al. Urology 2001 May;57(5):955-959.
6. CC Parker et al. BJU Int 2001 May;87(7):629-637.
7. B Aschhoff Drugs Exp Clin Res 2000;26(5-6):249-252.
8. Conn’s Current Therapy 2004, 56th ed.,
9. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright 2004 Mosby, Inc
10. Suzanne Somers: “Breakthrough” Eight Steps to Wellness– Life-altering Secrets from Today’s Cutting-edge Doctors”, Crown Publishers, 2008
11. Michael E. Platt: “The Miracle of Bio-identical Hormones” © 2007, Clancy Lane Publishing, Rancho Mirage, California, USA ; pages 111-113.
12. John R. Lee: “Hormone Balance for Men – What your Doctor May Not Tell You About Prostate Health and Natural Hormone Supplementation”, © 2003 by Hormones Etc.
13. Abraham Morgentaler, MD “Testosterone for Life – Recharge your vitality, sex drive, muscle mass and overall health”, McGraw-Hill, 2008