prostate cancer treatment side effects
What are the side effects of prostate cancer treatment?
What are the side effects of surgery for prostate cancer?
Because the prostate is close to several vital structures, prostate cancer surgery can disrupt normal urinary, bowel, and sexual functioning.
. Urinary Incontinence
During a prostatectomy, the bladder is pulled downward and connected to the urethra at the point where the prostate once sat. If the sphincter at the base of the bladder is damaged during this process, some degree of urinary incontinence or leakage may occur. Nearly all men will have some form of leakage immediately after the surgery, but this will improve over time and with strengthening exercises. Most men regain urinary control within a year; approximately 1 in 10 men will have mild leakage requiring the use of 1 or more pads per day. Pelvic floor muscle training with a physical therapist can help. In the case where side effects are severe, an artificial urinary sphincter can be considered.
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. Sexual Function
Regardless of whether the nerves were spared during surgery, erectile dysfunction remains the most common side effect after treatment. This is because the nerves and blood vessels that control the physical aspect of an erection are incredibly delicate, and any trauma to the area can result in changes.
However, within one year after treatment, most men with intact nerves will see a substantial improvement. The skill of your surgeon or physician can have a significant impact on this outcome, so it’s important to select your team carefully. Likewise, men with baseline erectile dysfunction and/or other diseases or disorders that impair their ability to maintain an erection, such as diabetes or vascular problems, will have a more difficult time returning to pre-treatment function. It’s important to remember that your functionality after treatment can only be as good as it was before treatment. The best predictor of how you will be after treatment is how healthy you were going into treatment.
. Fertility
There are also definite fertility impacts from surgery.
. Bowel Function
It is very rare (less than 1%) for men to have altered bowel function after surgery. In rare cases of locally advanced prostate cancer where the cancer invades the rectum, surgery may result in rectal damage.
What are the side effects of radiation treatment for prostate cancer?
Short-term Complications
You may experience some temporary urinary symptoms, such as waking up in the night and needing to urinate, needing to urinate more often during the day, or urgency – needing to urinate right now, and not being able to hold it in for a long time. Tell your doctor; there are medications that can help reduce acute symptoms. You may also experience some rectal problems, including the need to have a bowel movement more often than usual, or loose stools. Diarrhea is rare, but if needed, there are medications that can help. Your doctor may also suggest that you try a low-fiber diet for a while.
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Long-term Complications
The risk of long-term problems after radiation therapy is very low, less than 5 percent. These may include proctitis (rectal inflammation), cystitis (bladder inflammation), urinary or rectal bleeding, narrowing of the rectum or urethra, chronic diarrhea or urinary frequency or urgency, or development of an ulcer in the rectum. All of these can be treated.
. Erectile Dysfunction
Similar to surgery, damage to blood vessels and nerves after radiation therapy can result in decreased erectile function over time. In general, radiation therapy has less of an impact on erectile function in the first 5 to 10 years after treatment compared with surgery, and approximately 70% of men who have baseline erectile function before treatment will keep erectile function after treatment. However, radiation therapy has a slower delay in erectile function decline than surgery; 15 years after treatment, the rates are similar to those who underwent surgery.
These rates do not appear to be affected in the long-term by the use of short-term (4 to 6 months) hormone therapy, but will be affected by the use of long-term (18 to 36 months) hormone therapy.
Newer techniques in radiation therapy, termed “vessel sparing” radiation therapy, have shown promising results for improving the preservation of erectile function, with close to 80% of men maintaining baseline function. Ask your radiation oncologist about vessel sparing radiation therapy.
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Other Complications
There are also fertility impacts from radiation therapy.
What are the side effects of hormone therapy treatment for prostate cancer?
Testosterone is the primary male hormone, and plays an important role in establishing and maintaining typical male characteristics, such as body hair growth, muscle mass, sexual desire, and erectile function, and contributes to a host of other normal physiologic processes in the body. The primary systemic treatment for prostate cancer, ADT, lowers testosterone and causes side effects related to reversing all of the normal functions of testosterone.
Although most men may experience only a few of these symptoms, the list of potential effects of testosterone loss is long: hot flashes, decreased sexual desire, loss of bone density and increased fracture risk (osteoporosis), erectile dysfunction, fatigue, increased risk of diabetes and heart attacks, weight gain, decreased muscle mass, anemia, and memory loss. “Bad” cholesterol levels rise, particularly LDL and total cholesterol, and muscle tends to get replaced by fat, especially around the abdomen.
Current research indicates a weak link between pro-longed ADT and increased risk of dementia; in a sub-sequent study, no increased risk was shown between ADT and Alzheimer’s. While substitute therapies for ADT are an active area of research for the Prostate Cancer Foundation, ADT is currently a part of the standard of care. While it’s important to be aware of the possible side effects, it should not affect your decision to receive life-extending care.
At this time, it is not possible to predict how severely any individual will be affected by lowering testosterone with hormone therapy, but work is being done to find ways to help predict who might be affected by which effects.
Changes in diet and exercise have been shown to relieve many of the side effects of ADT. Before beginning hormone therapy, every man should discuss the effects of testosterone loss with his doctor and nutritionist, so he can alter his lifestyle to accommodate or head off the changes.
Because hormone therapy is part of the treatment of prostate cancer for nearly half of all men with the disease, and is used to treat nearly every man with advanced prostate cancer, it is important to think about ways to prevent, reverse, or identify these effects so that men can live their best lives.
One important approach is considering lifestyle measures that can reduce some of these effects. Eating a heart-healthy diet low in red meat and high in vegetables and fiber, and maintaining physical activity through daily weight bearing exercise can reduce weight gain and maintain bone and muscle mass. Men should also discuss the increased risk of diabetes, heart disease, weight gain, and high cholesterol with their primary care physicians so that they can undergo screening and, if necessary, treatment for these other illnesses throughout the course of treatment for prostate cancer. When making these changes, it is important to talk with a doctor to ensure that you are planning lifestyle modifications that are safe for you. There are also some strategies that can decrease the hot flashes, including medications and acupuncture.
It is important to check bone mineral density around the time of starting hormonal therapy and every 1 or 2 years following, to assess the loss of bone density. There are medications that can be used to reduce the risk of fracture if early signs of bone loss are found.
What are the side effects of chemotherapy treatment for prostate cancer?
All chemotherapy drugs work in slightly different ways, making it challenging to predict side effects for individual patients. Dosages, drug combinations and drug responses will vary from patient to patient.
Chemotherapy drugs are powerful and can take a toll on the body. Reactions to drugs can vary widely from patient to patient, so it’s important to pay attention to any side effects that you experience, expected or otherwise.
The chemotherapy drug docetaxel is very well tolerated, and many men are surprised to find that disease-related symptoms (pain, fatigue, loss of energy) are improved after starting this therapy. However, docetaxel does have some side effects to be aware of. For example, between 5% and 10% of men will experience a fever with a low white blood cell count that will require medical attention and can be life threatening. The risk can be reduced through the use of white blood cell growth factors (Neulasta®); note that the use of this supportive medication is at the discretion of the physician who must weigh the benefits of Neulasta against its side effects. Despite use of Neulasta, there is still a risk of serious infection. About 50% of men will experience significant fatigue at some point in their therapy, usually for the first week of each cycle. About one-third of men will experience numbness or weakness in their toes or fingers that may interfere with function (neuropathy). This side effect is not always reversible, but in most cases resolves slowly over time. There are no treatments available to prevent neuropathy, but reducing the dose of docetaxel, delaying the next dose, or stopping treatment can slow neuropathy and potentially prevent it from progressing. It is important to talk with your doctor if you are developing neuropathy so that you can speak together about how to best handle further cycles of docetaxel.
Other side effects of docetaxel include low platelets which can result in bleeding (1%), anemia (5%), reduced heart function (10%), hair loss (65%), diarrhea (32%), nail changes (30%), loss of appetite (20%), shortness of breath (15%), and fluid retention (10% to 20%). Most of these are mild, reversible, and treatable, and should not be a reason to avoid chemotherapy if you need it.
Cabazitaxel, which affects blood counts, is almost always given with Neulasta to boost infection-fighting white blood cells because life-threatening infection due to a depressed immune system is the most serious side effect associated with this medication. A blood transfusion is sometimes necessary to treat anemia to combat the fatigue and shortness of breath related to low blood counts. Other possible side effects include: fatigue (37%), neuropathy (13%), shortness of breath (12%), headache (8%), hair loss (10%), abdominal pain (17%), diarrhea (6%), and low blood pressure
(5%). Fortunately, recent data suggests that the side effects of cabazitaxel may be reduced, and the drug equally effective, if it is given at a lower dose than was initially approved. Talk with your doctor about whether the reduced dose of cabazitaxel from the recently reported FIRSTANA trial may be a better option for you than the initially reported and FDA-approved dose.
Regardless of the type of chemotherapy you are receiving, you will be monitored very closely by doctors, nurses, and pharmacists to make sure that all side effects are being addressed. Many of these side effects, especially fever and inability to keep food/drink down, need to be addressed right away—don’t wait until your next appointment to tell your provider.
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What are the side effects of Immunotherapy treatment for prostate cancer?
The immune system has the remarkable ability to kills cells that can cause harm, such as infected cells or cancer cells. However, in most patients with progressing cancer, anti-cancer immune responses either never developed or have been turned off by the cancer. One way to fight cancer is to hack the immune system, retraining immune cells to respond to the malfunctioning cancer cells.
. Sipuleucel-T Immunotherapy
Sipuleucel-T (Provenge®) is a cell-based prostate cancer vaccine that has been approved by the FDA for men with metastatic prostate cancer that is resistant to hormone therapy. This treatment is meant for men with minimal or no pain, and is most commonly given before chemotherapy, although it appears to be effective in some men even after chemotherapy.
The treatment process involves filtering out your immune cells, stimulating them in a lab to fight prostate cancer, and then reinfusing those cells back into you intravenously (IV). This process is repeated every 2 weeks for a total of 3 treatments. The goal is to stimulate your own immune system to fight the cancer cells. This immunotherapy does not lower PSA, treat symptoms, or delay disease progression—however, it has been shown to prolong life. There are ongoing studies attempting to clarify exactly how this treatment works. Sipuleucel-T should only be considered in cases where the patient has a slow-growing tumor and does not need urgent cancer shrinkage (which can be achieved effectively with other agents).
This treatment can only be given in certain centers, and you should discuss with your doctor whether this treatment is appropriate for you.
The side effects of Sipuleucel-T are usually limited to the few days after infusion of the stimulated cells. You can sometimes experience a flu-like illness with fever, chills, nausea, and bone/muscle aches. This generally resolves within 3 days and can be treated with acetaminophen.
. Pembrolizumab
Pembrolizumab (Keytruda®) is a type of “immune checkpoint inhibitor,” which are a class of immunotherapies that block chemical signals that mask cancer cells and activate tumor-killing immune cells. Pembrolizumab was approved by the FDA in 2017 for the treatment of all solid tumors, including prostate cancer, that have mutations in mismatch repair genes (MMR) and/or exhibit microsatellite instability (MSI) in the tumor. Patients who qualify for this therapy must have progressed on prior treatment and have no satisfactory alternative treatment options. Hence, pembrolizumab would typically be considered after other available effective treatments (such as sipuleucel-T, abiraterone, enzalutamide, docetaxel, cabazitaxel, radium-223, etc.) have been used or ruled out.
Studies suggest that approximately 5%, and perhaps up to 10% of metastatic prostate cancer patients have evidence of MMR mutations and/or MSI in their tumors. Some of these mutations may be inherited, and may be associated with Lynch syndrome, a condition which predisposes individuals to higher risks of developing certain cancers such as colorectal cancer. At present, regardless of family history, MMR deficiency and MSI are determined by genetic tests performed on biopsies or tumor material from prostate surgery. Note that most tests for MSI are colon cancer-optimized and may not detect all prostate cancer patients who have MSI. Talk to your doctor about more comprehensive MSI tests which may be available.
Pembrolizumab is delivered intravenously once every 3 weeks. The most common side effects are fatigue, cough, shortness of breath, nausea, constipation, itching, rash, and decreased appetite. Because it works by modifying the immune system, there are rare but serious side effects related to overactive immune responses which are typically treated by stopping the drug and, in some cases, starting steroid medications to suppress the immune reactions.
What are the side effects of Targeted drug therapy for prostate cancer?
Because the treatments are designed to target cancer cells and spare damage to healthy cells, targeted therapy drugs may cause fewer side effects than conventional treatments such as chemotherapy.
Targeted therapy side effects may include:
. Rashes or dry or flaking skin
. Cracked or inflamed fingernails or cuticles
. Diarrhea or digestive problems
. Impaired blood clotting or wound healing
. High blood pressure
. Fatigue
Targeted therapy drugs are powerful and may cause side effects in caregivers and family members who come in contact with them. If you’re taking a targeted therapy at home, be aware of special handling, storage and disposal requirements.