Treatment Options for Prostate Cancer and What I Chose

Editor’s note: In our lifetime, one in eight men will be confronted with the challenges presented by prostate cancer. This is the second story in a series of six articles where Jackson Rainer will discuss the implications of prostate cancer diagnosis, treatment and the impact on quality of life. 

I have prostate cancer, staged as an "intermediate unfavorable risk" with high Gleason scores. The Gleason score is a number assigned to prostate cancer cells, based on their likeliness to spread.  The score of the two main cell types in a tumor predicts its aggressiveness. Through the diagnostic process, providers continued to tell me what a lucky man I was to have the cancer diagnosed while the tumor was still localized to the prostate's fibrous capsule.

Biopsies revealed the tumor to be aggressive, translated in my colloquial understanding and non-medical mind that the cancer was building enough steam to launch a somatic field trip, using my lymph system as a roadmap and my bones as its interstate freeway. Luck was held in the finding of the tumor's containment to the gland, while it was still at the gate and before it left the station, providing different treatment options.

One thing is certain about prostate cancer: It is complicated. I learned there is no obvious choice when it comes to decisions as I was tasked to weigh options leading a chosen course of treatment that I could live with, based on thinking over multiple factors, including the stage of the cancer, age, lifestyle and risk of side effects, such as urinary incontinence and erectile dysfunction.

Credit: Illustration by John Gilman for Next Avenue

The urologist served as my initial and primary guide. In a consultative appointment, I was seated in his office, clothed, with my notebook and pen (quite different from a clinical examination where I was disrobed, poked and prodded in unfamiliar and unpleasant ways). While invited to bring a companion and to record the conversation, I preferred to be alone with the physician and to take notes on the findings for myself.  

Choices for treatment of prostate cancer include:

• Radical prostatectomy (surgically removing the prostate gland)
• Radiation, including external beam, implanted pellets, or proton
• Focal therapy (leaving most of the gland intact)
• Hormonal therapy (which suppresses testosterone, the primary fuel for prostate cancer)

I learned that each of these treatments has pluses and minuses. Despite years of research and efforts to improve results, complication rates are stubbornly high, especially true in the case of sexual complexities. 

Men often report difficulty achieving erections for several years after radical prostatectomy, even when surgeons try to avoid damaging the nerves and blood vessels in the prostate that control erectile functioning. 

Sexual complication rates tend to be lower with radiation than they are with surgery, but radiation is associated with higher rates of long-term urinary incontinence and irritation, and impotence rates tend to rise over time. While significant focus of the conversation was on sexual impact, and I was interested in hearing about expected erotic hydraulics related to treatment effects, I was more focused toward issues of longevity and broader quality of life factors.

The urologist said, "If you choose the surgical option, I'll be your primary physician." Like most men, I shuddered at the risks of a radical prostatectomy, especially the specter of permanent impotence, which used to occur in nearly all cases. 

"No, no, no," the physician said. "Using the Da Vinci protocol, I operate robotically." With my liberal arts and humanities background, I know Da Vinci primarily as a Renaissance artist. I learned his moniker now is ascribed to a machine invented as a contemporary means of major surgery for prostate cancer. Manipulating robotic arms to perform a laparoscopic prostatectomy, the surgeon sits away from the operating table and uses tiny cameras attached to surgical instruments to locate and remove the diseased prostate gland. 

During this surgery, called nerve-sparing, the physician frees the two bundles of nerves that lie on either side of the prostate gland controlling erections. This robotic version of the surgery tends to reduce the likelihood of other serious side effects, such as prolonged urinary incontinence. When the procedure is successful, it takes a year or more for tiny nerve fibers to heal and knit together for a sufficient restoration of continence and sexual function. 

According to medical research reported by Harvard Medical School in 2024, nerve-sparing and traditional surgery have no difference in long-term (10-year) survival rates.

"You have other options," said the urologist. "With your cancer, you have the choice to pursue a combination of hormone therapy and radiation treatments. Let me refer you on to the providers who can be instructive."

I had new teachers – a fine interventional radiologist and oncologist. They outlined a comprehensive and complex set of options that I quickly learned. Despite the adage that prostate cancer is a slow grower, both physicians made it clear that, for me, time was of the essence.

Androgens are the family of male sex hormones, including testosterone, that function as fuel for growth in normal development. For some men, including me, they can also drive the progression of prostate cancer. Known by its acronym ADT, androgen deprivation therapy uses drugs to lower hormones and slow the cancer's growth.

Radiation treatments are delivered by aiming an external beam of radiation at a tumor or by surgically implanting small radioactive pellets in the prostate glad (an approach called brachytherapy). 

I was offered the option of proton beam therapy. In this course of treatment, radiation is released in a very narrow band, theoretically minimizing damage to surrounding tissue. This type of treatment continues to be under active research to determine if proton therapy offers a significant difference from Intensity-Modulated radiation therapy (IMRT), which increases radiation to the prostate while reducing radiation to normal tissues. IMRT is currently the most common form of radiation therapy in the United States.

I was challenged to decide among my options for surgery, ADT, radiation or a combination of approaches. For all men, this is a complicated decision informed by many different variables including age, personal preferences, and the presence or absence of other accompanying health problems. Attitudes toward incontinence, erectile dysfunction and the potential need for additional therapy are figural factors that come into play.

Providers told me that the ideal course of non-surgical treatment would include receiving proton beam therapy plus ADT and would include enrollment in a clinical trial so that the risks and benefits of the therapy would be identified in a well-designed study.

I have a cohort of friends that are smart, collegial and companionable. Several in my loving circle of those I call "my peeps" include professionals working as ministers, entrepreneurs, pharmacists and engineers; several are physicians. I took diagnostic findings and recommendations to them for consideration.   

One friend, a physician specializing in genetics research, facilitated access to an interventional radiologist practicing in another regional health care system. It was his suggestion that "…You do the radiation and ADT. Be ready to stay miserable for about six months, then get on with a healthy life."

My engineer friend opened doors with one of the surgical pioneers of Da Vinci surgery. His advice?  "Your diagnostic findings are on the fence for comparable options. If you go the surgical route, once you get over it, you'll never have to worry about it again."

All in my coterie offered thoughtful personal and professional opinions. As an extroverted social ager, their attention and willingness to talk through and weigh options was encouraged and welcoming. I am in a monogamous romantic relationship. My "main squeeze" listened and lovingly said, "Make the choice that you can live with and we'll figure it out."

Ultimately all agreed as I chose the option of combined ADT and radiation therapy. It is now known as a standard option for those whose cancer is considered high-risk when the tumor has not extended beyond the prostate. Research supported that six months of hormonal therapy slowed cancer progression among men with my diagnostic profile and the radiation effectively rids the gland of cancer.

I settled in for the long haul and prepared for the lifestyle steps needed to meet the challenges of treatment.

Jackson Rainer is a board certified clinical psychologist living and working in Atlanta, Georgia and Tryon, North Carolina.  He may be contacted  by [email protected].
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