Running Head: TREATMENTS FOR PROSTATE CANCER
Treatments for Prostate Cancer
Megan Oliver
East Tennessee State
University
Research in Allied Health 4060
April 24, 2008
Abstract
Treatments for Prostate Cancer
By
Megan Oliver
Prostate cancer is a disease that affects most
elderly men. Researchers and physicians have continually searched for a treatment that will take away this cancer. Over the
centuries many different treatments have been made available for treatment. With the many treatment options available it is
hard to know which one is the most preferred and most offered. What are physicians’ perceptions regarding the efficacy
of prostate cancer treatment options? This research is intended to do just that.
CHAPTER 1
INTRODUCTION
Prostate cancer is a very common disease that
affects many elderly men, mostly age 65 or older. “Prostate cancer is the abnormal growth of cells in a man’s
prostate gland” (Gallagher, 2006). Prostate cancer is more common in men
that are older than 65. Research has shown that most men do not die from prostate cancer (Gallagher, 2006). This raises questions
such as whether or not prostate cancer should be treated and if so which treatment will be more effective. What are physicians’
perceptions regarding the efficacy of prostate cancer treatment options?
Physicians
have many opinions on the treatments of prostate cancer. Some physicians have adopted the wait
and see, also known as watchful waiting, treatment. This treatment is becoming more popular because most men that have
prostate cancer do not die from the disease. Prostate cancer grows very slowly so some men may never need treatment for their
cancer. Older men who have small, slow growing tumors are the best for this type of treatment. Prostate cancer is of concern
due to all the new findings that men with prostate cancer can live just as long and have a better quality of life if they
do not treat their cancer. They can live with out all of the side affects of the treatments and not die from the prostate
cancer. It is still of concern if this treatment is the best way to go when it comes to treating cancer. The topic of prostate
cancer treatment is of theoretical interest in the sense that it is not known if the wait
and see approach is a valid treatment option for prostate cancer. There have been studies done showing the significance
of this option and the benefits that it has on living a normal life with prostate cancer. “The American Cancer Society
(ACS) estimates that during 2007 about 218,890 new cases of prostate cancer will be diagnosed in the United States. About 1 man in 6 will be diagnosed with prostate cancer in his lifetime,
but only 1 man in 34 will die from it” (da Vinci, 2006).
Purpose of the Study
The purpose of this study is to determine physician’s
opinions on the various types of treatments offered for prostate cancer, focusing particularly on the watchful waiting treatment. This research was conducted to differentiate the effectiveness of other treatment
options for prostate cancer compared to the effectiveness of the watchful waiting treatment. There are many treatment options
available for men with prostate cancer and this study is designed to investigate physicians’ opinions as to which treatment
option is the most effective. This study is intended to determine the preferred treatment methods that physicians are using
for the treatment of prostate cancer.
Significance of the Study
Many important benefits will come from this study on prostate cancer treatments. Men
will be more aware of the different treatments offered for their disease and what physicians really think about these treatments
and their effectiveness. Physicians will be informed about what other physicians think about the treatment options and whether
they prefer one treatment option over another. There have been many studies done on the treatments of prostate cancer, however
this study is geared towards what the physicians think about the treatments and how well they are working.
Research Questions
A single research question quides this study.
Do physicians believe the wait and see treatment a viable treatment optotion compared
to others?
Assumptions
It is assumed that the physicians that are interviewed
answer the questions to the best of their ability and as honestly as possible. It is assumed that a man that is diagnosed
with prostate cancer would want some kind of treatment option and to know which one is supposed to be more effective.
Limitations
Since the only way to collect the data in this
research is to use interviews of physicians it is impossible to know if the physicians are telling the truth and answering
the questions to the best of their knowledge and ability. Since my research is limited to the Tri-Cities area of Tennessee it is impossible to make generalizations about the perceptions
of physicians at large on the treatments of prostate cancer. Another limitation is that the variable chosen for study (physicians’
perceptions) are only opinions on the matter; no experimental design will be used to see which treatment is actually more
effective. These perceptions are a larger piece of the prostate cancer treatment process.
CHAPTER2
REVIEW OF LITERATURE
Prostate cancer has become one of the most common
cancers found in males in the Western world (Mason, 2003). Every year in this country, more than 317,000 men are found to
have cancer of the prostate gland (Bostwick, 1999). The prostate is a gland, just below the bladder that is found in men.
Its function is not perfectly understood, but it seems to be entirely linked to the reproduction process. Cancer of the prostate
feels very hard, and occasionally a small nodule can be felt on the prostate (Mason, 2003). Prostate cancer begins when something
triggers an abnormal growth of cells in the prostate gland (Bostwick, 1999). The process that is used in defining the extent
of a cancer is called staging. The most widely used system to classify the spread
of prostate cancer is the TNM staging system. TNM stands for tumour, nodes, and metastases (Mason p.11 2003). Men may have a tumor in their prostate for many years before they even know it is there. Prostate cancer
is so slow growing that many men die with prostate cancer not because of prostate cancer. Prostate cancer poses tough choices. Depending patient’s tests results, they
will have to choose whether to wait and see what happens, to undergo an operation, to have radiation treatments, or to do
something else entirely (Bostwick, 1999).
Treatments
of curative intent are performed for prostate cancer that has not yet spread and is still localized at the time of the initial
diagnosis. Treatments of curative intent aim to remove and eliminate all prostate cancer tissues and cells from the body.
Treatments of curative intent for localized prostate cancer include radical prostatectomy, certain forms of external beam
radiation therapy, brachytherapy, and cryotherapy. A treatment that can help reduce the severity of advanced prostate cancer
is called palliative treatment (How, 2008).
Marks (2003) stated that, radiation therapy is a well-established technique of killing
cancer cells with one of two different types of radiation that are used to treat prostate cancer today. The most accepted
is called external-beam therapy, also known as teleradiotherapy. It is considered the gold standard of radiation therapies.
Beams of high-energy radiation are focused from outside the body onto the target area. The patient will have what is called
a simulation, where special x-rays are taken to help determine the dose and focus the radiation. Shortly thereafter the patient
will start their treatment based on a set schedule, usually at the same time every day, until completed. The full course of
external-beam therapy takes about six and one-half to seven weeks, Monday through Friday. Because of the radiation technique
and the nature of cancer-cell growth, the time it takes to complete the radiation cannot be shortened. Radiation takes ten
to fifteen minutes each day. The main goal of radiation treatment is to control cancer growth and prevent the spread of cancer.
There continues to be debate as to whether radiation kills the cancer cells or simply stuns them. Radiation offers good treatment
for the right candidate without the standard risks that go along with surgery and anesthesia. There is no risk of surgical
bleeding, no hospitalization, usually no pain, any heart attacks, strokes or blood clots (Marks, 2003). The doctor uses computers
to help aim the radiation beams with precision, and focus as much radiation as possible on the prostate gland and as little
as possible on the surrounding area (Lange, 2003).
Brachytherapy is another cancer treatment that
uses ionizing radiation to destroy the cancer cells. The radioactive material is placed directly into a malignant tumor or
very close to it. Brachytherapy means short therapy in Greek. The radiation kills
the tumor by destroying the deoxyribonucleic acid (DNA) within the cancer cell. When the cancer cell attempts to divide itself,
it is unable to because the DNA is no longer intact and because of this the cell dies. Doctors have used brachytherapy to
treat prostate cancer as early as the 1900s. There are two common types of prostate brachytherapy that are used; permanent
low dose rate (LDR) and temporary high dose rate (HDR). LDR brachytherapy treatment uses radioactive materials in the form of seeds,
which are about the size and shape of a grain of rice, are deposited in the prostate and left in place. HDR brachytherapy
treatment involves placing radioactive materials in the prostate for a specified period of time and then removing them from
the prostate. Prostate brachytherapy can be performed using a permanent implant or a temporary one, but never both (Gurel,
2005).
A radical prostatectomy is another treatment
option for those who want to go the surgical route. “A radical prostatectomy offers a better chance for long-term survival
and a longer time without return of the cancer than do the more conservative treatment options such as radiation hormone treatment
or watchful waiting” (Marks, 2003). Garnick (1996) stated that “Radical
prostatectomy is a surgical procedure in which the prostate gland, seminal vesicles, and closely associated tissue that surrounds
the prostate gland are removed. The radical prostatectomy has historically been the treatment option most commonly chosen
by patients with localized prostate cancer. This includes all stage A and B disease and certain patients with stage C disease.
However, because the operation resulted in impotence in almost all the patients who underwent it, radical prostatectomies
lost a great deal of popularity among both patients and surgeons in the late 1970s and 1980s” (Garnick, 1996). There are three types of radical prostatectomy procedures to choose from. The first
is a radical retropubic prostatectomy. “Radical retropubic prostatectomy is the most common method of surgery for prostate
cancer. Retropubic means ‘behind the pubic bone.’ In a radical retropubic prostatectomy, surgeons reach the prostate
through the front of the abdomen. The surgeon removes the prostate, the seminal vesicles, and if necessary the, nearby lymph
nodes. Radical perineal prostatectomy is the oldest surgical approach for treating prostate cancer. It is now less common
than radical retropubic prostatectomy. Radical perineal prostatectomy involves the removal of the prostate through an incision
in the perineum. The prostate is removed through this incision. During the procedure, which usually lasts from one and one
half to four hours, the patient is on his back with his knees pulled towards his chest so the surgeon can access the perineum.
Laparoscopic radical prostatectomy (LRP) is a combination of well-established prostatectomy techniques. LRP integrates a variety
of new technologies, including robots. Using a robot rather than a human assistant allows for a less crowed operating table
and allows the operative team a steady view of the prostate area. In this technique, several small incisions are made in the
abdomen, through which specially designed instruments are inserted to view and remove the prostate. One of the incisions made
is then extended slightly to allow the surgeon to remove the prostate (Crawford, 2005).
Another way to kill prostate cancer is to freeze
the prostate, almost like turning it into a ball of ice. Doctors have used a similar approach to kill warts, dipping a swab
into a tank of cooled liquid nitrogen, then dabbing the swab onto the wart, then it eventually dies and falls off. Prostate
tissue dies the same way and is absorbed and then eliminated by the body. The procedure involves inserting five to seven thin
metal rods; each rod is six inches long, through the perineum and into the prostate gland. An ultrasound probe placed in the
rectum helps positions the rods. When the rod tips are in place, liquid nitrogen is released into the rods, where it circulates
and lowers the temperature to about -374 F. As the tissue freezes, the formation and expansion of ice crystals within the
cancerous cells cause them to rupture and die. A catheter is placed inside the urethra and filled with a warming solution
to keep the urethra from freezing with the prostate gland. The whole procedure takes about two hours long, with the majority
of the time used to carefully position the rods (Mayo, 2000). Cryotherapy is not as invasive as radical prostatectomy. Precise
methods are used to destroy the cancer cells so healthy tissue is preserved (Kavanagh, 2005).
Many of the prostate cancers feed off androgens.
When a man has prostate cancer, the circulation of male sex hormones throughout the body and around the cancer makes the cancer
grow faster. The most common way to treat advanced prostate cancer is to cut off the supply of the hormones to the cancer.
About seventy five percent of men with advanced prostate cancer have chosen this form of treatment. Hormone therapy uses drugs
to do one of two things, or sometimes both: stop the body from producing most, not all, male sex hormones, and block remaining
hormones from getting into cancer cells (Mayo, 2000). “The goal of hormonal therapy is to make prostate cancers shrink
or grow more slowly, but hormone therapy alone will not usually completely free the body of cancer” (Amling, 2005).
Hormone therapy has been so effective at shrinking tumors that it is being used in some early-stage cancers in combination
with surgery and radiation. The hormones shrink the large tumors so that the surgery and radiation can destroy them more easily.
After surgery or radiation the hormones can help kill stray cells that are left behind at the tumor site (Mayo, 2000). There
are three main types of hormonal therapy. Luteinizing hormone-releasing hormone (LHRH) agonists are medications that cause
the testicles to stop making testosterone. The LHRH agonists work by stopping the pituitary gland from releasing luteinizing
hormone, which is the main hormone that causes the testicles to produce testosterone. LHRH agonists are given by injection
into a muscle or underneath the skin. Antiandrogens are just the opposite of LHRH. Antiandrogens stop prostate cancer cells
from using testosterone that has already been produced by the testicle and the adrenal gland. Antiandrogens, that are taken
daily in pill form, include drugs such as bicalutaide (Casodex), flutamide (Eulexin), and nilutamide (Nilandron). Antiandrogen
therapy may be used as part of a combined hormonal therapy or alone. Orchiectomy involves removing the testicles from the
scrotum. Some men mistakenly think that in an orchiectomy the surgeon removes the testicles and the sac of skin covering them.
An orchiectomy only removes the testicles from the scrotum. Orchiectomy is the oldest treatment for prostate cancer (Bostwick,
2005)
Watchful waiting may be recommended if the cancer
is not causing any symptoms, is expected to grow slowly, and is small and contained in one area of the prostate. Many men
choose watchful waiting because they feel the side affects of aggressive treatment outweigh the benefits. Choosing not to
have active treatment does not mean there will be no medical care or follow-up care. While the cancer will not be treated
with radiation or surgery, the condition will be carefully observed and monitored (Attigere, 2005). Marks (2003) stated that,
“This is ideal for elderly men or men with significant health risks who have cancer that is believed not to be significant”
(Marks, 2003). The reason why watchful waiting may be sensible is some patients are, first, not all cancers will progress
during the patient’s lifetime to cause the patient trouble. Another factor is that all the treatments have side-effects
(Mason, 2003). Some patients will use watchful waiting until they can decide which type of active treatment is going to be
best for them. There are many treatments available for prostate cancer and deciding which one is the right one can be a difficult
process.
The qualitative research method used in this
research study is unstructured interviewing as a research design. I will use a defined set of interview questions to ask each
physician about their opinions on the different treatments for prostate cancer. In my study I hope to understand the physician’s
opinion on the different types of treatment methods offered for prostate cancer and which treatment would be more effective.
I want to understand the physician’s viewpoint on why one treatment is better than another and why they have come to
that conclusion. The goal is to analyze the data from several physicians and reconstruct it in a way that would be useful
to other doctors, patients, and students. I hope that other physicians and patients can gain an understanding of the different
types of treatments for prostate cancer and why some treatments are better than others. I want the information to be useful
to patients when trying to decide which treatment would be best for them, and to students when studying about this disease.
Physicians can learn about the views of other physicians and where they stand on the treatments and why.
The theory would be that more of the physicians
will lean towards the watchful waiting treatment for prostate cancer as long as the cancer is not extremely advanced. It is
one of the newest forms of treatment and allows the patient to live a normal life without all the harsh side affects of the
other treatment options. Choosing the watchful waiting does not mean that you can not choose to start a treatment later on.
I think that the majority of the physicians will think that this treatment plan is the best option for patients that have
slow-growing cancer and little to no symptoms.
The
participant selection was chosen using a unique-case selection. The physicians are selected on the criteria that they are
doctors that deal with prostate cancer and are local in the Tri-Cities. I did not have access to interviews with physicians
out of the local area at this time. They are not just any physicians they are ones that specialize in the field of prostate
cancer and the treatment that are used for the cancer. The physicians are unique in their field and that is the criteria used
to select them from other physicians. The research would also include a convenience
sample because only local physicians where used in this study. The data will not include the physicians’ opinions from
all over the country. The physicians that were the most convenient and available were the ones chosen. There was no formal
way that the physicians were chosen. Most of them were physicians that family members have known or recommended. There was
no random sampling involved in deciding what physicians to interview.
The data collection method that was used in this
research project was done by the process of interviewing. The structured interview was used, allowing each physician to answer
the same set of questions. This was done so that I could easily compare the opinions of one physician to the next and there
was not an excess of data from using the unstructured interview. If the questions needed to be reworded in a form that made
more since I tried to accommodate to the physician. I, the researcher, was the
instrument that was used in this research case. If the interview was done face-to-face I recorded the interview with a hand-held
recorder if the physician allowed, eliminating the possibility of over looking some crucial information. Some of the interviews
are done face-to-face and some were done by telephone. The dated was collected by interviewing each physician about their
opinions on the different types of treatments offered for prostate cancer. The physicians were asked about there positions
in the facility were they were located and about their experience in dealing with prostate cancer. They were asked which option
they thought would be the most effective for the treatment of prostate cancer and why. The questions were open-ended and allowed
the interviewee to answer in a many words as they pleased. This allowed for the differentiation in opinions to be seen. The
information can be complicated and by allowing each physician to elaborate on their answer you get a better idea of what their
true opinion is. Each physician was asked the same set of questions, but was
allowed to answer in any style or manner they wished. The age range included physicians above age 25. A larger sample would
be preferable for this study but do to time only a select few could be selected.
The method used for data analysis in this research
study is Pattan’s (1980) and Lincoln and Guba’s (1985) patterns, categories, and descriptive units. I organized
the data making sure that all the interviews are accounted for. I read through all of the transcripts making notes in the
margin. Each interview was put into a category based on what type of treatment the physician thought was best.
DISCUSSION
According to the literature I collected my beginning
assumptions were correct. Overall the physicians had become more accepting of the wait
and see treatment option. This gives the patient the chance to live a normal life style. This does not mean that later
on they can choose to adopt some form of treatment, which is why most prefer this over others. There are many treatment options
and not all prefer the wait and see option simply because there are a large variety
of other options that are also available. The majority of these opinions are just that, opinions. The sample needs to be larger
to get an actual range as to which treatment is really the most preferred. Only the patient can decide which treatment is
really going to be better in treating their disease.
CONCLUSION
Considering the wide variety of treatments offered
for the treatment of prostate cancer, and the variety of professional opinions, one would not be able to say that just one
kind of treatment is the best. While the opinions of the physicians are very valuable, only the patients’ point of view
can decide which treatment option looks the best to them. One physician expressed absolute confidence in the wait and see treatment, while another expressed that the other treatment options that are almost guaranteed to
get rid of the cancer. With the facts that were collected I feel that the study is some what inconclusive. The sample of physicians
was not large enough to draw definite conclusions towards the treatment that is most preferred by physicians. With more studies
that involve a greater number of participants, I think that we can learn what treatment physicians really preferred and recommend
to their patients.
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