Management of complications of prostate cancer treatment

Abstract

Prostate cancer is the most commonly diagnosed noncutaneous cancer in men in the United States. Treatment of men with prostate cancer commonly involves surgical, radiation, or hormone therapy. Most men with prostate cancer live for many years after diagnosis and may never suffer morbidity or mortality attributable to prostate cancer. The short-term and long-term adverse consequences of therapy are, therefore, of great importance. Adverse effects of radical prostatectomy include immediate postoperative complications and long-term urinary and sexual complications. External beam or interstitial radiation therapy in men with localized prostate cancer may lead to urinary, gastrointestinal, and sexual complications. Improvements in surgical and radiation techniques have reduced the incidence of many of these complications. Hormone treatment typically consists of androgen deprivation therapy, and consequences of such therapy may include vasomotor flushing, anemia, and bone density loss. Numerous clinical trials have studied the role of bone antiresorptive therapy for prevention of bone density loss and fractures. Other long-term consequences of androgen deprivation therapy may include adverse body composition changes and increased risk of insulin resistance, diabetes, and cardiovascular disease. Ongoing and planned clinical trials will continue to address strategies to prevent treatment-related side effects and improve quality of life for men with prostate cancer.

FIGURE 1

Sample Treatment Plan for External Beam Radiation Therapy to the Prostate. (A) Coronal, (B) sagittal, and (C) axial computed tomographic images of a representative plan for low-risk prostate cancer. Isodose lines depict radiation doses at various distances from the target tissue. Full dose is contained within the pink isodose line. Shading of organs of interest is as follows: prostate (red), bladder (yellow), anterior rectum (light blue), and posterior rectum (green). The close proximity of bladder and anterior rectum to the prostate leads to significant radiation doses to portions of these structures.

FIGURE 2

Acute and Late Radiation Therapy Side Effects. (A) Acute inflammation and mucosal loss can occur in both the bladder and rectum (as pictured). Desquamation begins 2 to 3 weeks into treatment and may continue several weeks after treatment is complete. (B) Mucosal thickening and telangectasias in the anterior rectal wall following radiation therapy. These findings can be seen months to years after treatment in both the bladder and the rectum. (C) Secondary rectal cancer visualized on colonoscopy. Patients are at a slightly increased risk of rectal or bladder cancer >10 years after treatment.

FIGURE 3

Serious Complications of Brachytherapy. (A) Superficial urethral necrosis visualized on cystoscopy. Patients who undergo a transurethral resection of the prostate before treatment or to relieve treatment-induced retention are at increased risk. (B) Rectal fistula seen on colonoscopy. Combination external beam radiation therapy and interstitial brachytherapy; inflammatory bowel disease and severe vascular disease increase the risk of this rare complication.