PROSTATE CANCER

( By JASCAP )

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Treatment for early prostate cancer

Overview of Treatments

The treatment options for early prostate cancer include active surveillance (active monitoring), surgery (removal of the prostate gland) and radiotherapy (external beam or brachytherapy).

Sometimes, hormonal therapy may be given before and/or after surgery or radiotherapy.

Choosing treatment

Deciding on the best treatment is not always straightforward and a number of factors have to be taken into account. The most important of these are:

  • your general health
  • the grade of the prostate cancer
  • the size of the cancer
  • your PSA level
  • the likely side effects of treatment
  • your views about the possible side effects of treatment and how much you are willing to risk side effects for the possible benefits in controlling the cancer
  • whether you have had treatment before
  • your age.

The possible treatments for your situation are likely to be discussed by a group of doctors working together. This is known as a multidisciplinary team and includes a surgeon (urologist) and doctors who are specialists in radiotherapy, hormonal therapy and chemotherapy treatments (clinical oncologists).

The team may also include specialist nurses, social workers, and physiotherapists. It is common to see a surgeon, an oncologist and a specialist nurse to help you to make the decision.

Treatment choices

If the cancer is likely to develop very slowly you may be offered active surveillance. Men who have a moderate to high-grade cancer are more likely to be offered surgical removal of the prostate gland (radical prostatectomy) or radiotherapy to the prostate. These treatments aim to get rid of all of the cancer cells and cure the cancer.

For some men these treatments will cure the cancer, but for other men some of the cancer cells may be left after the treatment. In some men the treatment may seem to get rid of all the cancer cells for a period of time, but the cancer may come back in the future.

In men with early prostate cancer, surgical removal of the prostate (prostatectomy) or radiotherapy to the prostate seem to be equally effective at treating the cancer. The radiotherapy can be given from an external machine or directly into the prostate gland as brachytherapy.

Hormone therapy may be used for some men as well as prostatectomy or radiotherapy. Cryotherapy (also known as cryosurgery) or high intensity focussed ultrasound (HIFU) treatment may be offered to some men.

You may be offered a choice of treatment. Each of the treatments has different benefits and side effects.

Treatment or not?

You may be advised not to have treatment immediately but to be monitored. This is known as active surveillance.

Blood tests and biopsies can now find cancer at a very early stage, but it is not possible to tell whether the cancer is going to grow enough to cause any symptoms. Many prostate cancers grow extremely slowly and a small, early-stage prostate cancer may never cause any problems within a man's lifetime.

The treatments for prostate cancer can cause side effects such as erection problems or incontinence, which for some men may be worse than the effects of the cancer. Your doctors may advise waiting to see whether the cancer is the sort that can cause problems, rather than giving treatment straight away.

Second opinion

Some people find it helpful to have another medical opinion to help them to decide about their treatment. Doctors can refer you to another specialist for a second opinion if you feel that this would be helpful.

Consent to treatment

Before you have any treatment, your doctor will explain its aims of to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

  • the type and extent of the treatment you are advised to have
  • the advantages and disadvantages of the treatment
  • any other treatments that may be available
  • any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

You may feel that the hospital staff are too busy to answer your questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can't make a decision when it is first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you do not have it. It is essential to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes.

You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages of treatments for early prostate cancer

Your doctor will explain the benefits and possible disadvantages and side effects of the treatments to you. You can then decide which is best for your particular situation. The benefits and disadvantages of the treatments for early prostate cancer are outlined in the following pages. Before you have any treatment it is important that you are fully aware of them.

It is not possible for doctors to predict accurately who is going to be affected by the side effects of each treatment. So, you need to be given full information about the risks beforehand and have plenty of opportunity to discuss them. Remember, there are often choices to be made about which treatment you should have, or even whether to have treatment. You can take as large or small a part in those choices as you wish.

Active surveillance

Most early-stage prostate cancers may be very slow-growing and may never cause any symptoms. For this reason, some men and their specialists decide to wait and see whether the cancer is getting bigger (progressing) before starting any treatment. The active surveillance approach involves regular check-ups with PSA tests, rectal examination of the prostate and possibly repeat biopsies.

Benefits: Many men who choose active surveillance will avoid the complications of surgery, radiotherapy, or hormonal therapy.

Risks: Some men find it difficult just to wait and see if their cancer progresses before starting any therapy. Some men will need surgery, radiotherapy or hormonal therapy if their cancer shows signs of developing.

Radical prostatectomy

A major surgical operation to remove the whole prostate gland.

Benefits: Removing the whole prostate gland may stop an early cancer from spreading and may result in a cure. Radical prostatectomy appears to prolong life for some men with more fast growing cancer, but for men with small, slow-growing cancers the benefits are unclear, and probably only apply to younger men. In two out of five men, the cancer cells are not fully removed, and therefore the operation may not result in a cure.

Risks: One in 200 men over 65, and one in 1000 men under 65, may die from problems caused by surgery. For every 100 men who have a radical prostatectomy up to 20 will develop slight leaking of urine; around 5 will have incontinence of urine; and about 70 will have problems getting an erection.

External beam radiotherapy

High-energy rays are used to destroy cancer cells.

Benefits: Radiotherapy may lead to a cure in early prostate cancer, but as with prostatectomy, the benefits in small, slow-growing cancers are uncertain. A complete course takes up to seven weeks. Giving hormone therapy before and during the radiotherapy may improve the results.

Risks: For every 100 men who have external beam radiotherapy: up to 30 will develop occasional bleeding from the rectum (back passage); about 10 may have bleeding, a change in bowel habit and some discomfort; and up to 70 will develop erection problems (though this depends on age). Rarely, some men may have leakage of urine or incontinence of urine.

Brachytherapy

A new type of radiotherapy, which uses radioactive 'seeds' inserted into the prostate.

Benefits: Same as for external beam therapy. A simpler procedure than external beam radiotherapy, as it usually only involves one planning session and one treatment session (under general anaesthetic) during a stay in hospital of one or two days.

Risks: Side effects to the bladder, such as inflammation (cystitis) may be more severe than external beam radiotherapy, but bowel problems (diarrhoea) and impotence are expected to be less common. Scar tissue may cause gradual narrowing of the urethra which may need to be treated.

Hormonal therapy

Lowers the levels of testosterone in the body, by removing the testes or using tablets or injections. Hormonal therapy may be used on its own or given with radiotherapy treatment.

Benefits: Can slow or stop the growth of cancer cells for many years. Does not involve surgery or radiation so there is little risk of bowel or bladder problems.

Risks: It will not get rid of all the cancer cells if it is the only treatment given and can cause a range of side effects that include breast swelling and hot flushes, impotence and lowered sex drive.

Active surveillance for early (localised) prostate cancer

Active surveillance means that your doctors will keep a close eye on you to see if the cancer is growing significantly. You will usually have blood tests every 1-3 months to monitor your PSA levels and frequent digital rectal examinations, and will be asked if you have developed any new symptoms. You may also have prostate biopsies every few years.

If these regular tests show that the cancer is starting to grow your doctors will then recommend treatment intended to cure the cancer, such as surgery or radiotherapy. If your cancer is not growing or developing, it is safe to continue with active surveillance.

Surgery for early prostate cancer

Surgery to remove the prostate gland may be a treatment option for you. This operation is known as a radical prostatectomy.

Before any operation, make sure that you have discussed it fully with your doctor. It is important that you understand what it involves, including the chances of success, the likely side effects, and whether there are other treatment options that may be more appropriate to your particular circumstances. Your doctor may suggest that you have hormonal therapy before or after your surgery.

Radical prostatectomy

A radical prostatectomy is carried out by specialist surgeons. The whole prostate gland is surgically removed either through a cut made in the abdomen or through a cut made between the scrotum and the back passage. This aims to get rid of all of the cancer cells. This operation is done only when the cancer is thought not to have spread beyond the prostate and usually in men under 70.

The operation often causes impotence - the inability to have and maintain an erection. It can also cause problems with control of passing urine (urinary incontinence). Sometimes it is possible to do a special type of operation, called a nerve-sparing prostatectomy, which reduces the risk of erection problems.

As doctors cannot predict which men will be affected by these side effects it is important that you are fully aware of these risks beforehand. Your doctor will discuss the operation, its possible side effects and other possible treatment options with you.

Although prostatectomy can get rid of the cancer cells completely for many men, in about 1 in 3 men (33%) the cancer cells may come back in the area of the prostate a while after the operation. If this happens, external radiotherapy may be given to the prostate area. The treatment is given over a larger area, which can cause more side effects.

Laparoscopic prostatectomy

With a laparoscopic prostatectomy your surgeon doesn't need to make a large opening but can take out your prostate gland using only 4 or 5 small cuts (about 1cm each) in your tummy area (abdomen). The surgeon uses specially designed instruments that can be put through these small cuts. This type of surgery is also known as keyhole surgery.

After making the small cuts the surgeon uses carbon dioxide gas to fill (inflate) the abdomen. A tiny video camera gives a magnified view of the prostate gland onto a video screen. The prostate gland is then cut away from surrounding tissues and removed through one of the cuts in the abdomen.

Sometimes, laparoscopic prostatectomy can be carried out using a machine (robotic assisted laparoscopic prostatectomy). Instead of the surgeon and assistant moving the camera and instruments, they are attached to robotic arms. The robotic arms can move very delicately, steadily and precisely. The machine used in robotic laparoscopic prostatectomy is called a da Vinci® machine - so this type of surgery is sometimes called the da Vinci prostatectomy. Only a few surgeons in the UK are trained in these techniques and there are only a few robot- assisted systems such as da Vinci®, so this treatment is not yet widely available. Your specialist will be able to tell you if it might be appropriate for you and whether it may be available to you.

Most studies have shown that laparoscopic surgery and robotic-assisted laporoscopic surgery are as successful at treating prostate cancer as open surgery. Your surgeon can discuss with you the potential risks and benefits. These types of surgery are only carried out by surgeons with specialised training and experience in the techniques involved.

After your operation

After prostatectomy you will have a drip (intravenous infusion) into a vein in your arm and a tube (catheter) to drain urine from the bladder. If the operation is done through the abdomen you will also have an abdominal wound. You may have a small tube in the wound to drain any excess fluid that is produced. After your operation you may have some pain or discomfort which may continue for a few weeks, particularly when you walk. Regular painkillers should help to ease this, so let the staff on the ward know if you are still in pain.

You will probably be ready to go home from a week to ten days after your operation. Your catheter will probably stay in for 1-3 weeks to allow the urethra to heal. Arrangements can be made for a district nurse to visit you at home, and if you have any problems you should contact your doctor as soon as possible.

Side effects of radical prostatectomy

Surgery to the prostate can cause problems in getting an erection (sexual impotence) and in controlling the bladder (incontinence). Erection problems are caused by a reduction in the blood flow to the penis due to damage to the arteries or nerves. Often the need to remove all of the cancer cells makes it impossible to avoid nerve damage. In men aged under 60 who have had nerve-sparing prostatectomy, the risk of erection problems after total prostatectomy may be 1 in 2 (50%) or higher. The risk increases to about 4 in 5 (80%) or more in men over the age of 70 and may be higher if nerve-sparing techniques are not used. Our section on side effects discuss ways of coping with erection problems.

Problems with controlling the bladder as a result of radical prostatectomy are less common. Most men have some incontinence when the catheter is first removed, but this usually improves with time. About one year after the operation up to 20% of men will leak an occasional drop of urine. Some men may need to wear an incontinence pad, but it is very rare to be completely incontinent and need to have a permanent catheter. Another less common effect of surgery is scarring of the bladder which can make it difficult to pass urine. This is fairly easily treated with minor surgery (known as a bladder neck dilation).

Some men may find that they have diarrhea or constipation for a few months after prostatectomy.

Care after an operation

If you think that you might have any difficulties coping at home after your surgery, let your nurse or social worker know when you are admitted to hospital so that help can be arranged.

As well as being able to offer practical advice, many social workers are also trained counsellors who can offer valuable support to you and your family, both in hospital and at home. If you would like to talk to a social worker, ask your nurse or doctor to arrange it for you.

Before you leave hospital you will be given an appointment to attend an outpatient clinic for your post-operative check-up. This is a good time to discuss any problems you may have.

Radiotherapy for early prostate cancer

Radiotherapy treats cancer by using high-energy x-rays to destroy the cancer cells, while doing as little harm as possible to normal cells. Radiotherapy for cancer of the prostate is usually given from an external machine (external beam radiotherapy), but for some men with early prostate cancer it can be given by inserting small radioactive seeds into the tumour (brachytherapy). External radiotherapy and brachytherapy both appear to be equally effective in curing prostate cancer. Your doctor may suggest that you have hormonal therapy before or after your radiotherapy.

When radiotherapy is used

In early prostate cancer, the radiotherapy is given to the prostate gland. The aim is to destroy the cancer cells, while doing as little harm as possible to normal tissues in the surrounding area such as the bladder or back passage (rectum). This is known as radical radiotherapy.

External radiotherapy

Radiotherapy is given in the hospital radiotherapy department, usually as daily sessions from Monday to Friday, with a rest at the weekend. For early prostate cancer, the course of treatment may continue from 4-7 weeks.

Planning radiotherapy

Planning is a very important part of radiotherapy and may take one or two visits. The treatment has to be carefully planned to make sure that it is as effective as possible. You will be asked to have a CT scan or lie under a machine called a simulator, which takes x-rays of the area to be treated. The treatment is planned by a cancer specialist (clinical oncologist).

Marks are usually drawn on your skin to help the radiographer (who gives you your treatment) to position you accurately and to show where the rays will be directed. These marks must stay in place throughout your treatment, and permanent marks (like tiny tattoos) may be used. These are tiny, and will only be done with your permission. You may feel a little uncomfortable while it is being done.

Treatment sessions

At the beginning of each session of radiotherapy, the radiographer will position you carefully on the couch, and make sure you are comfortable. During your treatment you will be left alone in the room but you will be able to talk to the radiographer who will be watching you. Radiotherapy is not painful but you have to lie still for a few minutes while the treatment is being given.

Conformal radiotherapy and IMRT

Conformal radiotherapy (CRT) or intensity modulated radiotherapy (IMRT) are usually used.

In conformal radiotherapy, a special attachment to the radiotherapy machine carefully shapes the radiation beams to match the shape of the prostate gland. Shaping the radiotherapy beams reduces the radiation received by the healthy cells in nearby organs such as the bladder and rectum. This reduces the side effects of radiotherapy treatment and may allow higher doses to be given, which could be more effective.

IMRT is a newer, more complex type of conformal radiotherapy and allows the radiotherapist to vary the dose of radiation given to different parts of the tumour and surrounding tissue. It is not yet known whether IMRT is better than conformal radiotherapy.

Short-term side effects

Radiotherapy to the prostate can make it more difficult to have an erection. There are various treatments which can help.

Radiotherapy to the prostate area may irritate the rectum, and cause discomfort and diarrhoea. It may cause soreness around the anus. Your doctor can prescribe medicines to reduce this and you may be advised to change your diet.

The radiotherapy may also cause cystitis, which can make you want to pass urine more often or cause a burning feeling when you pass urine. Your doctor can prescribe medicines to reduce this. These effects usually disappear gradually a few weeks after the treatment has ended. Rarely, if you have difficulty in passing urine, it may be necessary to have a urinary catheter put in.

Radiotherapy can also cause general side effects such as tiredness, which are mild for some men and more troublesome for others. The radiographer will be able to advise you what to expect. Try to balance rest with regular, gentle exercise, especially if you have to travel a long way for treatment each day.

The radiotherapy may make some of your pubic hair fall out. When you have finished the course of treatment, the hair will grow back. However, the hair may be thinner or finer than it was before.

Most side effects of radiotherapy gradually disappear once the treatment has ended. However, others may continue for some months and some may even be permanent. If you have any problems during your treatment, talk to the radiotherapy staff as they will be able to help you.

Radiotherapy does not make you radioactive and it is perfectly safe for you to be with other people, including children, throughout your treatment.

Our general information section on radiotherapy gives more details about this treatment and its side effects.

Although radiotherapy can get rid of the cancer cells completely for many men, in about 1 in 3 men (33%) the cancer cells may come back in the area of the prostate at some time after the treatment. In this situation, surgery can very occasionally be done to remove the prostate gland. This type of surgery is known as salvage surgery.

Possible long-term side effects

Radiotherapy to the prostate area can sometimes lead to long-term problems.

Radiotherapy for prostate cancer can cause an inability to have an erection (impotence) in about 3-5 in 10 (30-50%) of the men who have this treatment; this may develop over a period of 2-5 years.

This side effect of treatment can be very difficult to deal with and can affect your sex life and your relationship with your partner. You may find it helpful to read our section on sexuality. Many organisations offer counselling for sexual or relationship problems.

In a number of men, the bowel or bladder may be permanently affected by the radiotherapy. The blood vessels in the bowel and bladder can become more fragile and this can make blood appear in the urine or when you pass bowel motions. This can take many months or years to occur. If you notice any bleeding, it is important to let your doctor know so that tests can be carried out and appropriate treatment given. Occasionally bowel movements may be more urgent after radiotherapy and, rarely, there may be some difficulty in controlling the bowels.

Often, radiotherapy can help to improve problems with passing urine, but for some men radiotherapy can lead to leakage of urine due to damage to the nerves that control the bladder muscles (urinary incontinence). This is unlikely unless you have had a TURP or prostatectomy as well. If this happens it is important to discuss it with your doctor, who can arrange for you to see a specialist continence nurse. You may also find it helpful to contact the Continence Foundation.

If radiotherapy has been given to the lymph glands in the pelvic area as well as to the prostate, it can cause some swelling of the legs, known as lymphodema.

We have a booklet about the long-term side effects of pelvic radiotherapy.

Brachytherapy

This type of radiotherapy is available in some hospitals in the UK. It is also sometimes called internal radiotherapy, implant therapy or seed implantation. It can be carried out under a general anaesthetic or a spinal anaesthetic (epidural). Small radioactive metal „seeds' are inserted into the tumour so that radiation is released slowly over a period of time. The seeds are not removed but the radiation gradually fades away over about six months. There is no risk of it affecting other people.

Before the seeds are put into the prostate, a study of the prostate gland will be done (known as a volume study). This is to confirm the exact size and position of the prostate gland. For 24 hours before the volume study you will need to follow a special diet to make sure that your bowel is empty. You will also be given an enema to empty your bowel, so that the ultrasound picture is as clear as possible. The volume study is done in the operating theatre and you will need to have an anaesthetic for a short time.

A trans-rectal ultrasound is used to take pictures of the prostate. These provide a three- dimensional model which is then used to decide the number of seeds needed for treatment, and exactly where they should be put.

The implant procedure takes about one hour. An ultrasound probe is inserted into the rectum to show the prostate. Around 80-100 radioactive seeds are then inserted through the skin between the prostate and the anus, and guided into the prostate gland. As the procedure may cause some swelling of the prostate, which can lead to blockage of the urethra, a catheter is sometimes inserted into the bladder to drain urine. This may be removed after a couple of hours or left in place overnight.

Antibiotics are given after the implant, to prevent infection. Most men go home the day after the implant, but some leave hospital as soon as they have recovered from the anaesthetic and are able to pass urine normally. After the implant it is best to avoid heavy lifting or strenuous physical activity for two or three days.

All the radioactivity is absorbed within the prostate and so it is completely safe for you to be with other people. However, women who are (or could be) pregnant and children should not stay very close to you for long periods of time. You should not let children sit on your lap, but can hold or cuddle them for a few minutes each day and it is safe for them to be in the same room.

The seeds stay permanently embedded in the prostate gland, but there is a tiny chance of a single seed being passed in the semen during sexual activity. So it is advisable to use a condom for the first few weeks after the implant. During this time the semen may be coloured black or brown - this is normal and is due to bleeding that may have occurred during the procedure. Condoms should be disposed of in the dustbin and should be double-wrapped.

Side effects of brachytherapy

Brachytherapy causes similar side effects to external beam radiotherapy. It is also common to feel mild soreness, and to have some bruising and discoloration between the legs for a few days after the procedure. Your doctor can prescribe painkillers to relieve this.

You may also notice some blood in the urine. This is quite normal but if it becomes severe or there are large clots present you should let your doctor know immediately. It is important to drink plenty of water to help prevent blood clots and flush the bladder.

As with external radiotherapy, erection problems develop in 3-5 in 10 (30–50%) of men some years after the treatment.

Brachytherapy may be less likely to affect the bowel than external beam radiotherapy, although the risk of urinary problems (such as narrowing of the urethra) is higher. Up to one in seven men may not be able to pass urine immediately after the procedure and may need to have a catheter inserted for a while. Some men may develop narrowing of the urethra some time later, which may cause problems with passing urine.

The risk of leakage of urine is about 1 in 100 (1%). Some men find that they have pain or discomfort on passing urine, need to pass urine more often or have a weaker urine stream. This is usually due to the radiation from the seeds in the prostate and improves over 3-12 months as the seeds lose some of their radioactivity. Drinking plenty of fluids and avoiding caffeine may help to reduce these effects.

Hormonal therapy for early prostate cancer

Hormonal therapy may be given in addition to surgery or radiotherapy - this is known as adjuvant therapy . The aim is to reduce the chance of the cancer coming back.

Hormones control the growth and activity of normal cells. In order to grow, prostate cancer depends on the hormone testosterone produced by the testicles. Hormonal therapies reduce the amount of testosterone in the body. They can be given as injections or tablets.

Injections

Some drugs 'switch off' the production of male hormones from the testicles by reducing the levels of a hormone produced by the pituitary gland. These drugs are called pituitary down- regulators or gonadotrophin releasing hormone analogues (GnRH analogues) . They include goserelin (Zoladex®), leuprorelin (Prostap®) and triptorelin (Decapeptyl®).

They are usually given as a pellet injected under the skin of the abdomen (goserelin), or as a liquid injected under the skin or into a muscle (leuprorelin or triptorelin). Injections are given either monthly or every three months.

Tablets

Other hormonal therapy drugs work by attaching themselves to proteins (receptors) on the surface of the cancer cells. This blocks the testosterone from going into the cancer cells. The drugs are called anti-androgens and are often given as tablets. Commonly used anti- androgens are flutamide (Chimax®, Drogenil®),bicalutamide (Casodex®) and cyproterone acetate (Cyprostat®).

Anti-androgen tablets are also usually given for two weeks before the first injection of a pituitary down-regulator. This prevents tumour flare, which is where symptoms get worse after the first dose of treatment.

Research trials are being carried out to find out:

  • whether it is better to start the hormonal therapy before or after the surgery or radiotherapy
  • how long to give the treatment for (it can range from two months to two years).

Side effects

Unfortunately most hormonal therapies usually cause erection difficulties and loss of sexual desire for as long as the treatment is given. If the treatment is stopped, the problem may disappear. Some types of anti-androgens are less likely to cause impotence than others.

In about half the men who have hormonal therapies the side effects that cause them the greatest problem are hot flushes and sweating. Flushes stop if the treatment is stopped. In the meantime some medicines can help. We can send you information about this.

Hormonal treatment can also make you put on weight and feel constantly tired, both physically and mentally. Some drugs (most commonly flutamide and bicalutamide) may also cause breast swelling and tenderness. Some hormonal therapy, particularly GnRH therapy, may increase your risk of developing diabetes or heart disease.

However the benefits of hormonal treatment generally outweigh the possible risks. You can discuss the possible side effects with your doctor before you start treatment. Being warned about possible side effects can make them easier to cope with.

We have sections about individual hormonal therapies , with more information about how the drugs work and tips on coping with possible side effects.

Newer treatments for early prostate cancer

The following treatments are sometimes used for early stage prostate cancer; however they are not widely available. If you think that one of the treatments may be suitable for you it is best to discuss this with your cancer specialist. They can advise whether the treatment could be helpful in your particular case.

Cryotherapy

Cryotherapy is available as a treatment for early prostate cancer in some hospitals in the UK. It may be as effective as the other standard treatments for prostate cancer.

Cryotherapy is carried out under general or spinal anaesthetic. A number of metal probes are put through the skin and into the affected area of the prostate gland. The probes contain liquid nitrogen, which freezes and destroys the cancer cells. Local anaesthetic is used to numb the treatment area, but even so the treatment can cause pain. Painkillers may be necessary for a few days after the treatment. Men who have had cryotherapy treatment can have radiotherapy or surgery if their cancer comes back.

After the cryotherapy procedure, a tube (catheter) is inserted into the bladder through the skin of the abdomen to drain urine. The catheter is left in place for 1-2 weeks.

The possible side effects include erection problems in approximately 8 out of 10 men (80%), and urine leakage (incontinence) in less than 1 in 10 men (10%). However, the long-term side effects are not yet known. It is only suitable for very small prostate cancers and cannot be used for cancers near the outer edge of the prostate.

High intensity focused ultrasound (HIFU) treatment

High Intensity focused ultrasound (HIFU) is sometimes used as a treatment for early prostate cancer. This treatment may be as effective as surgery or radiotherapy for early prostate cancer.

HIFU treatment is given under a general or spinal anaesthetic. A probe is inserted into the back passage (rectum). The probe produces a high-energy beam of ultrasound. This heats the affected area of the prostate gland, destroying the cancer. The probe is surrounded by a cooling balloon to protect the normal prostate tissue from damage.

The side effects can include urine infections, leakage of urine, erection difficulties and, rarely, damage to the bowel wall, which may need to be repaired by surgery. The long-term side effects of this treatment are not yet known.

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