Endorectal coil MRI, in which a coil is inserted into the rectum near the prostate to pick up the MRI signal, has been used to guide biopsies in men with persistently elevated PSA and negative results following transrectal ultrasound–guided biopsies. Complications of transrectal ultrasound–guided biopsies include hematospermia, hematuria (for as long as three days), fever, and rectal bleeding. A small percentage of men develop urinary retention or require hospitalization—usually for urosepsis.39,40 Antibiotic prophylaxis with ciprofloxacin to minimize the risk for infection is considered standard care.41
Patients may be concerned by the possibility that cancer cells will spread during the transrectal biopsy. While there have been isolated reports of tumors recurring in the needle biopsy tract, the incidence is low and this risk should not prevent an indicated biopsy.42
TREATMENT
For patients with disease confined to the prostate gland, treatment options include radical prostatectomy (RP), radiation therapy (RT, external beam and/or brachytherapy), and active surveillance. When disease extends through the prostatic capsule into the seminal vesicles or into regional lymph nodes, definitive local therapy may be combined with adjuvant RT and/or androgen deprivation therapy.43
When choosing treatment for an individual patient, the clinician should consider several factors, including the extent of disease, the patient’s age, and the presence or absence of significant comorbidity. In untreated patients, prostate cancer–related mortality occurs 10 to 20 years after diagnosis.5,44,45
The patient’s chance of being cured following definitive therapy is high if the tumors are confined to the prostate gland.46 The chances of cure decrease when the tumor has spread beyond the prostate capsule, invaded the seminal vesicles, or metastasized to regional lymph nodes.
The overall survival of men with early-stage prostate cancer is prolonged. Ten-year survival rates after RP or RT are high (averaging between 60% and 90%).5,47 Because of the risk for late relapse and mortality, biochemical relapse (as detected by a rise in serum PSA) is monitored. The patient’s likelihood of remaining disease-free, as evidenced by an undetectable serum PSA level (“biochemical progression–free survival”5), is inversely related to the presence of extraprostatic extension, seminal vesicle extension, evidence of tumor spread to the lymph nodes, or evidence of positive margins at surgery.46 Men in the Scandinavian Prostate Cancer Group-4 Randomized Trial (SPCG-4)46 who underwent RP were evaluated 12 years after surgery; those with extracapsular tumor growth had 14 times the risk for prostate cancer death than those without it.
Increasing numbers of selected low-risk patients are being placed on active surveillance for the management of prostate cancer—a protocol that includes repeat prostatic biopsies and routine follow-up visits.48 The PSA should be reassessed two to three times annually, with annual biopsies to determine whether the cancer has become more aggressive.5,16 Patients with cancer that is becoming more aggressive should convert to primary treatment.5
Difficulties with this option include psychological distress, poor compliance with scheduled appointments and repeat biopsies, and the risk for missing the therapeutic window in which the cancer can be cured.5,16 No results are yet available from randomized clinical trials comparing active surveillance with immediate definitive treatment; two large trials are under way.49,50
Radical Prostatectomy
RP is the definitive treatment for localized prostatic cancer.5,16 The potential for cure in men who undergo RP is highest when the cancer is confined to the prostate gland (clinical stage, T1-T2). RP is also an appropriate option for some men with locally advanced prostate cancer. Additionally, RP is used as a potentially curative salvage procedure to treat carefully selected men with a local recurrence after RT for localized prostate cancer.
The SPCG-4,46 which included predominately men whose cancer was not detected by PSA, was the first randomized trial to show that RP decreased the risk for prostate cancer mortality as well as the risk for metastases.2,46 Results were analyzed at 8.2 years’ and 10.8 years’ follow-up. Almost all men in the RP group who died of prostate cancer initially had tumor growth outside the prostate capsule. No men who underwent RP and had specimen Gleason scores of 2 to 6 died of prostate cancer. Rates of local recurrence and/or progression were lower in the RP group than in the “watchful waiting” group (whose members used hormonal and other palliative treatments).46 Subgroup analysis by age showed that men younger than 65 received the greatest benefit from prostatectomy.46,51
Surgical options include open retropubic RP, laparoscopic RP, and perineal RP. Da Vinci (robotic) RP is the method most commonly used in the US to achieve surgical removal of the prostate.16 The procedure is associated with reduced blood loss, compared with other methods, and the 10x magnified vision allows for nerve-sparing techniques, improving postoperative sexual function.16,52