It consists of the application of the treatment adapted according to age of the patient, life expectancy, associate illnesses, Gleason, level of PSA, TNM, symptoms, side effects of the therapeutic ones and election informed on the part of the proper patient.

It is necessary to depart from the base of which, in general, the prostate cancer is an illness of long evolution, almost chronic.

For it, it is necessary to take in consideration many factors. Except exceptions, the decision of the treatment in prostate cancer is not an urgent question. Nothing of that one so typical of "avenges Monday on that we will operate".

First of all, it is necessary to insure itself that has all the information and that has understood all his content.

The age is a factor of big importance, since, in persons of advanced age, the aggressive treatments are not convenient and better the least aggressive, with special attention to fighting the possible symptoms.

Even more that the proper chronological age, to think the life expectancy that depends on the age, but, also, of the general state of health and of the presence or not of other associate illnesses (diabetes, hypertension, cardiopatía, respiratory insufficiency, etc).

The Gleason grade allows to know the aggressiveness of the tumor, they being more conservatives in the treatments when the Gleason is low.

The level of the PSA is an approximate indicative of the quantity of active cells of the cancer of prostate.
The TNM is fundamental to value the need or not of an immediate treatment or of the deferred one.

The treatments, especially surgery and hormonoterapia, can alter severely the quality of life of the fond person for the illness. Powerlessness and incontinence of urine, feminización, etc, there are topics it sufficiently important as so that the doctors explain them in detail and his incidence as the treatment that should be chosen.

Finally, with all the available information it is convenient often to request the second opinion, to contrast pareceres. And, if it needs, a third opinion.

The basic treatments which we have in cancer of prostate located in the gland are a (prostatectomía) surgery and radiotherapy. The hormonoterapia is indicated in the cases recidivantes (the illness repeats after the curative initial attempt) and in the metastásicos. Also sometimes it is used before the radiotherapy, to diminish the tumor mass and to facilitate the irradiation.

There will be patients who, when they consider the information about his illness that the doctor has given them, will want to choose his future bearing more in mind the following priorities:

a) Treatment: Any men will not want to run the risk of losing control on the urine or of remaining impotent, to have a cancer dominated potentially (not always) mortally, enclosed without treatment.
b) Incontinence of urine and/or sexual powerlessness they are of the biggest risk factors at the time of deciding on the treatment, bearing in mind that they affect seriously the quality of life of the person.
c) Quality of life: Many men do not resist the idea of having a cancer in the prostate and he prefers that they are extirpated while others do not want to risk suffering from urinal incontinence and/or sexual powerlessness and choose not surgical treatment.

TO WAIT AND TO SEE

It is the situation in which, after the diagnosis of cancer of prostate, it is decided to abstain from treating the patient and going on to his observation, to see as the events develop.

Or that, observation means....?

To choose not to treat the prostate cancer.

But this is not done in other cancers: is not it true?

Practically never. The prostate cancer, for his slightly aggressive growth, allows the observation without treatment to be a legitimate election in certain circumstances.

In which?

When it is more probable that you die for other causes before his cancer could start growing and cause problems or to kill him.

To establish this, there are considered to be many factors: age (all that more age more possibilities that a cancer of slow growth does not go so far as to develop); individual life expectancy (it depends on the chronological age, of course, but also on the general state of health of the person and of the associate illnesses that it has; to minor life expectancy, less possibilities that the prostate cancer could be lethal).

Taking in consideration exclusively age and life expectancy, the best candidates for the observation are, men of more than 75 years, with limited life expectancy; or, men between 60 and 75 years, with associate illnesses that threaten his existence.

But it is necessary to value very much factors of the proper cancer: patients with T initials, of T1a to T2b, low Gleason - the tumors with low Gleason develop more slowly than those with tall Gleason and low PSA, which they predict a tumor growth so slow that it is possible that the active treatment does not improve the life expectancy of the patient. The patients constitute the exception with symptoms, an expectation of life of more than 20 years, a major Gleason of 6 and one PSAcreciente (in these cases local treatment is preferred with radiotherapy or prostatectomía).

It is necessary to value this series of factors and, in many cases, the patient will be able to choose not to talk each other.

On the other hand, it is known that there are many persons with cancer of prostate who at least go so far as to know it during his lives (one knows for autopsies in dead aged persons for traffic accidents; in the autopsy there them is often cancer of prostate that was never evident).

If I choose "to wait and to see": what do I have to do?

In fact "to wait and to see" demands the periodic medical control, to detect symptoms, problems or increases of the PSA that were leading to the conclusion that the cancer is growing too quickly.

Therefore, during the observation period the PSA must be practised regularly (every four or six months). With his determination, the doctor will value the possible symptoms and, if he considers it to be precise, he will practise a rectal tact.

And if the cancer begins growing?

If it does it slowly, it is possible to wait a little more the PSA continuing.

If it makes it rapid (for example, the PSA increases very much and/or the doctor appreciates increase of the tumor in the prostate with urinal symptoms), there can begin the treatment (by it sometimes it is named "waiting and "to see", "deferred treatment").

A good norm for constara the importance of the increase of the PSA is, from that a significant increase is detected, to repeat it monthly two or three times. he is growth suspects when it increases clearly month after month.

Are the treatments now different that if it had chosen to talk each other from the beginning?

Probably, not and the possibilities of treatment will be the initials, according to the TNM.


Although it is demonstrated that the tumor is growing: can I continue in observation since it has been said that the prostate cancer grows very slowly?

If, it is possible sometimes. The possibilities of dying for this cancer are low, although they would be increasing with the step of the years.

PROSTATECTOMÍA

The radical prostatectomía consists of the eradication of the whole gland prostática.para the treatment of the cancer of prostate

It is used, with curative attempt when the cancer is located in the prostate.

It is realized or with general anesthesia completely asleep (patient) or with anesthesia epidural (in that the low part of the body is anesthetized).

There are two prostatectomía forms:

*Prostatectomía retropúbica, most used. Low abdominal incision is practised. He allows to explore the lymphatic ganglions. If they are affected, the prostate is not extirpated and there are considered to be other treatments; if they are not affected, the prostate is extirpated.

A form of the prostatectomía retropúbica is that in that one tries to avoid the section of the nerves placed on both sides of the prostate. since these nerves are fundamental for the erection, to leave them diminishes (although not always) the powerlessness risk, recovering, in the favorable cases, the erection at the age of 12 or 18 months of the prostatectomía.

*Prostatectomía perineal, in that the eradication of the prostate is done across an incision between year and scrotum. It does not allow to extirpate the ganglions. To do it, it is necessary to proceed also to a small incision in the abdomen or to use a laparoscopio.

It does not also facilitate the preservation of the nerves that intervene in the erection.

On the other hand, the prostectomía perineal is less traumatic for the organism, she allows a more rapid recovery of the patient and with less pains.

Does Cúal prefer the urologists?

They usually prefer the prostatectomía retropúbica, for the described advantages.

How long does a prostatectomía last?

The intervention lasts between 2 and 4 hours, since the prostate is placed very deeply and the hemorrhage risk is big.

Is the prostatectomía dangerous for my life?

The consequences of the prostatectomía have been minimized. The blood transfusions are not usually very necessary and the mortality is lower than 0.05 % in the hospitals with enough experience and technology.

The stay in the hospital usually ranges between 3 and 6 days, with a recovery period in the domicile between 4 and 8 weeks.

It facilitates very much the recovery tackling physical exercise, of which the most appropriate is to walk, increasing progressively the distances. If in a given moment, one is tired, sweating excessively and nauseatingly, the fact is that exercise has been demanded too much and must be moderated, increasing again gradually.

It is advisable to distribute the walks in approximately 4 to 6 times a day.

Even the entire recovery must avoid the bicycle, to avoid any type of pressure on the perineal area, area where urinal bladder and urethra have got connected. When this sport is allowed again, it is necessary to do it step by step. It is recommended the saddle not to be hard and narrow, but soft and wide.

It is not convenient to raise things weighed up to the recovery. Neither to lead a car up to at least three weeks after the surgery. And although one goes of passenger, it is necessary to avoid long trips for some weeks.

The persons who were practising before the intervention other physical exercises (golf, tennis, skittles, swimming, etc), must consult the doctor to be advised on the progressive practice of the same ones.

To facilitate the one that the patient could urinate with facility, a catheter is placed across the penis that comes up to the bladder of the urine. One supports approximately two or three weeks.

For the corporal hygiene, there is no limitation to the corporal showers, being preferable that the bathtub, which forces to positions that can be counter-productive.

There are no restrictions in the diet, you can eat for what you long to him, although the best thing the Mediterranean Diet is always. But, bearing in mind that during a certain time it can experience, after the surgery, a certain tendency to the constipation, it is convenient to eat abundant fibre (cereals, fruits, vegetables, etc) and to drink a lot of water and liquids.

If the constipation is important, to consult the doctor.

The surgical scars usually recover in approximately six weeks, but the entire process can last up to 1 year.

I would like to know the possible complications of the prostatectomía.

There are the following ones:

The principal ones are a sexual powerlessness and incontinence. But we will refer first to two more immediate possible consequences, hemorrhage and tightening of the neck of the urinal bladder.

a) Hemorrhage. It takes place because the structures of about the prostate are rich in multiple and thick blood glasses (arteries and veins). In the eradication of the gland some glass can be cut, but it is slightly frequent.

b) Tightening of the neck of the urinal bladder. Due to a scar produced in the neck of the bladder. It can endure urinal problems. It can be observed in one of every 20-30 prostatectomías.

It usually solve with a few metallic dilators or, if he persists, the scar is extirpated surgically.

c) Sexual powerlessness. It is necessary to distinguish between powerlessness (incapability to have and to support an erection that serves for the sexual relation) and erectile malfunction (aptitude to have an erection that could not be adapted for the sexual relation. For example, because I did not last the sufficient time).

It owes to the surgical damage caused in the eradication of the prostate. after the prostatectomía and, up to past one year of the same one, the patients have some problem of erection. Finally, and depending on the age (how much younger minor problem), between 65 % and 90 % of produced will remain impotent. But what aggravates the problem is that the patient preserves the líbido. And this dissociation is perceived by the patients as a significativaagravación d ela situation that they endure.

The form of prostatectomía who tries to avoid the section of the nerves of the erection, in patients with small tumors, 50 % to which before the intervention they were powerful sexually, they recover the erection. But the quality of the same ones is not usually just as before the intervention. But said 50 % of patients, recovers his sexual potency between the 2 and 24 months of the operation.

For the treatment of the powerlessness it is necessary to come to specialists in the matter.

d) Urinal incontinence. It is the loss or involuntary leakage of urine or incapability to control the urinal current.

There are three basic forms of urinal incontinence:

*Por stress. The urine escapes on having done efforts, like coughing, to sneeze, to laugh or to do exercise. It is the most frequent after prostatectomía.

*Por rebosamiento. It owes, in general, to blockade or tightening of the exit of the bladder, for tightening of his neck or exit. that can be caused by the surgery, for the formation of a textile cicatricial.
* Of urgency (irresistible need to urinate). It happens when the bladder becomes very sensitive to the dilation or stretching of the bladder when it is filling with urine.


The urinal incontinence takes place because the surgery can affect the called sphincter of the urinal bladder, or muscular valve that supports the urine inside the urinal bladder. Or the essential nerves are damaged for the functioning of the sphincter.


In general, the incontinence after the surgery recovers between several weeks until some months after the surgery. A year, most of patients control his urinal bladder.

But it can be supported permanently in 35 % of taken control by cancer of prostate (in light form, like incontinence of stress). But between 2 and 15 %, they take severer incontinence as a stress, which can be a perm.

A way of preparing the incontinence and of fighting it is practising the Kegel exercises.

This exercise is already recommended to begin it before the prostatectomía and to continue it later, up to the recovery of the incontinence.

It consists of reinforcing the musculature of the pelvis, doing an exercise similar to the one that normally we can carry out when we are urinating and stop voluntarily the jet of the urine. Or, pressing closely the buttocks, as if we wanted to retain something between both.

It is recommended to carry these exercises out before the prostatectomía and after the intervention when the catheter inserted in the penis moves back.

It is adapted to realize 5 minutes every hour, during the day hours. The best exercise is of pressing the musculature of the pelvis hard but without releasing suddenly it, but supporting it a little and repeating during 5 minutes.

But it is solved, it is necessary to consult with specialists.

The prostatectomía robotics or surgical system of Vinci, is a form of less invasive (aggressive) prostatectomía than the traditional one. it is less aggressive because it is realized across five small incisions, with what, as soon as the process was overcome, the scars are minimal and minor than with surgical open sea proceeding. And the recovery time is shorter.

The urologist, during the intervention, sees the prostate praised in a console that mejorasu visualization, destrezay precision. There are used cameras of high resolution and instruments of microscopic surgery. A computer coordinates the achievement of the micro-movements, guiding exactly the arms robóticos, directed by the urologist during the intervention.

His followers and producers say that the intervention robotics is very effective and is necessary and that it allows to support the sexual potency and avoid the problems of urinal incontinence. But it is difficult to be resulted very much in percentages on powerlessness and incontienecia with this skill. Neither are studies randomizados (comparative) between the prostatectomía robotics and the traditional one.

It is so an interesting advance but that must be quantified objectively since his cost is very superior to that of the traditional prostatectomía.

CRIOTERAPIA

Of what does the crioterapia consist?

It is the freezing of the prostate to try to treat a cancer in this gland. this skill also is known by the name of criocirugía.

The target is of killing the cancerous cells.

It offers the advantages of his simplicity, facility and rapidity with which it is practised as well as his low cost.

Nevertheless, it is even considered to be an experimental treatment, because there are no long-term studies that show his real efficacy. Therefore, it is not known if it is so effective as the surgery or the radiotherapy.

How is it practised?

It is done under anesthesia of the person.

Under control by means of ultrasound scan transrectal, there are placed in the prostate a few special probes by which there is done circular liquid nitrogen, which freezes the textile of the prostate.

To prevent the urethra from freezing, a warm liquid becomes circular for the same one during the crioterapia.

What secondary problems can it cause?

There are temporary declarations produced by the annoyance of the urethra or of the bladder of the urine.

They consist basically of burn sensation on having urinated, frequent urine, often without previous notice, hematuria - to urinate blood - pain on having urinated, similar inconveniences on having defecated and distension of the penis and/or of the scrotum.

Few persons present more serious problems, like scars in the urethra and/or more serious difficulties on having urinated (that can need the laying of a catheter).

A severer complication is the formation of a fistula, by means of the communication between urethra and rectum.

Powerlessness and incontinence of urine?

The powerlessness is a serious complication of the crioterapia, which affects 75-80 % of persons.

On the other hand, the urine incontinence is very rare.

In short?

It is an interesting treatment but that cannot take as the first election, since his long-term efficacy is not proved científicamente. An indication to be considered is his use in cases of relapse (reappearance of the illness) after the radiotherapy. When irradiation has been applied on the prostate by prostate cancer, it is not possible to apply surgery. the radiotherapy believe adhesions between the textiles that prevent the surgical dissection. this is one of the reasons that the urologists use to convince the patients so that they choose the prostatectomía since, they say to them "if him the illness reappears and there is elejido radiotherapy as the first treatment then it will not be possible to produce". Well, nowadays there are alternatives in case of relapse, the said crioterapia and also the HIFU (see further down).

HIFU (ultrasónidos focused of high intensity), is the least aggressive available option nowadays in the treatment of the located cancer of prostate or in the relapses of the illness, in the cases in which the radiotherapy fails. To see braquiterapia is realized without punctures, without seeds (), without irradiation. And it has the enormous advantage of which it is possible to repeat when it needs. The hospitalization is very brief.

There is used a beam of convergent ultrasónidos of high intensity, generated by a tranductor of big potency, to produce heat. HIFU necrosa (destroys) the prostate textile, without affecting the textiles of around.

Yes, in case of the HIFU they are, thanks to essays long and realized with thousands of patients. In 87 % the biopsies after HIFU were negative, preserving the erection 47 % of patients and without incontinence severe.

RADIOTHERAPY

It is a curative skill in cases located (with equal effectiveness that the prostatectomía) to destroy tumors in the one that there use beams (similar to the RX) or particles (electrons or protons), of high energy.

The tumor is surrounded with normal cells, which the irradiation also can destroy, which is convenient to avoid in the possible thing.

The difference between normal and cancerous cells, as for radiotherapy, is that the first ones have a big aptitude to repair or to correct the damage that causes them the irradiation.

On the other hand, the cancerous cells have minor repair capacity great.

This way it is possible to destroy much more the tumor than the normal cells. Although some of these die for the effect of the irradiation, the organism can replace them by the development of new normal cells.

Of all the ways is the radiotherapy applied?

Basically, there are two forms of radiotherapy that are applied to the treatment of the cancer of prostate, external radiotherapy and internal radiotherapy or braquiterapia.

The external radiotherapy comes from a machine (bomb of cobalt, linear gas pedal, etc), placed out of the patient. the irradiation goes to the area where the tumor is, in this case, the prostate.

The radiotherapy interns or braquiterapia or interstitial radiotherapy is that in that radioactive materials are placed in the prostate, in the shape of small "pellets" or "seeds". For weeks or months they express neither radioactivity not harmful to the patient nor his family.

Can he explain to me more on the external radiotherapy?

The specialist who applies this treatment knows each other like radioterapeuta or like oncologist radioterapeuta. The radiotherapy is a local treatment (for T1 and T2), equivalent to the surgery, although also it is useful, the radiotherapy, in the treatment of located but widespread cancers (T3, T4), which the surgery cannot tackle for his excessive extension.

Also it is indicated in the persons who, for other motives, should not want or could not surrender to surgery.

How is it applied?

First of all, it is realized what we know as a simulation. By means of a few special X-rays, the treatment is simulated, to determine the dose and the exact area to treat. It does not represent any inconvenience for the patient.

As soon as the simulation was realized the authentic treatment begins.

They have said to me that it is a very long treatment. Is it true?

The whole treatment comes to last between 6 and 7 weeks. It is applied five days a week, generally from Monday until Friday. The rest of two days is done to facilitate the recovery of the normal cells of the surroundings of the tumor.

How long does a meeting last?

About 10 minute. The dose of standard irradiation is to 70 Gy.

Does it have advantages the radiotherapy with regard to the prostatectomía?

First of all, there is avoided anesthesia and hospitalization and the side effects of the surgery.

There is hemorrhage risk not neither of pain, nor cardiac problems or of embolisms for blood clots.

Then: what are the possible side effects of the radiotherapy?

The weariness is very frequent, towards the end of the treatment. Also, about 15 % of patients develops cystitis (annoyance on having urinated) and/or rectitis (inconveniences on having defecated, pain, urgent need to defecate).

Are these inconveniences permanent?

In most of persons, they disappear on having finished the radiotherapy, maximum in approximately two or three months later.

In a few patients, they can prolong and need treatment.

Does the radiotherapy produce urine incontinence?

Only in 5 % of patients.

Powerlessness?

The radiotherapy can cause powerlessness, if it damages the blood glasses and nerves necessary for the erection.

For it, between the third one and half of men treated with radiotherapy will experience some grade of decrease of the erection. Of presenting before itself, it does not do it immediately, but it takes like minimum 1 or more years in being evident.

Is the radiotherapy curative?

Just as the prostatectomía. The efficacy is similar.

After the radiotherapy: when will I be able to work again?

Except those persons who have fatigue (which recovery after the treatment can last a few weeks), the others can continue with his physical activity (for example, deport) during and after the treatment.

Can he explain more on the internal radiotherapy?

The radiotherapy interns or braquiterapia it uses a few small masses, of the approximate size of a grain of rice, prepared to be radioactive.

By means of thin needles they are introduced in the prostate, being planned the treatment so that the radioactivity affects to the whole tumor.

How do the needles get with the seeds in the prostate?

The needles interfere across the skin of the periné (under the scrotum and opposite the year.

His biggest advantage with regard to the external radiotherapy is the short duration of the treatment, one day.

What radioactive elements are used?

At first radioactive 125 was using more iodine. At present, there prefers in general the palladium 109, which is more powerful and seems to assure more the death of the cells of the tumor.

The braquiterapia: is it so effective as a radiotherapy or prostatectomía?

It is possible, but long studies need, to demonstrate it. up to the date we have long-term studies in patients treated with radiotherapy or surgery.

The side effects that the braquiterapia produces: are they like those of the radiotherapy?

Yes, the same ones and in the same proportion.

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HORMONOTERAPIA

His target is to diminish the levels of masculine hormones, the principal one of which it is the testosterone.

The prostate cancer is sensitive to the effect of the testosterone, which produces his development and growth.

On having eliminated the testosterone, in most of patients the cancer stops developing.

In what situations are the hormones indicated?

In five,

1. Most used it is when the illness finds widespread (metástasis). The illness can stop in long periods of time, although he does not go so far as to recover.

2. Also it is indicated in patients whose illness has repeated locally, after having being treated successfully, and there are no possibilities of a new local treatment

3. Before surgery or radiotherapy, to diminish the size of the tumor and to facilitate his eradication or his irradiation. it is a question of the call hormonoterapia neoadyuvante.

4. In some cases, it is applied after the local treatment, to improve the results of surgery or radiotherapy.

5. In persons of advanced age, when the treatment is necessary because it is a question of a progressive illness, but the local treatments are contra-indicated 8especialmente surgery, for his biggest risks).

The hormonoterapia: is it applied by surgery or by medicines?

The most frequent thing is with medicines. But precisely the hormonoterapia started by being surgical, for the practice of the orquiectomía or eradication of the testicles.

The orquiectomía is part of the call hormonoterapia ablativa.

But: why are they extirpated or they were extirpating the testicles?

Because the testicles produce 95 % of the testosterone. There are still urologists who are partial to the orquiectomía in the hormonal treatment of the cancer of prostate, but it is necessary to bear in mind his enormous psychological impact, with deterioration of the car image and of the proper esteem. It is very effective, since it diminishes suddenly the biggest source of production of testosterone. But the hormonal medicines have placed it in a secondary place of the hormonal treatment.

Nowadays, the orquiectomía: does it have still any indication?

It keeps on having a place in the patients cardiópatas (cardiac problems) that, with prostate cancer, need hormonal treatment. In these cases the hormonal treatment is not recommended with medicines because they can aggravate the cardiopatía.

Another advantage of the orquiectomía is that the testosterone levels fall down almost to zero between 3 and 12 hours of realized the intervention. Men with bony pain for metástasis can see as his pain disappears in a few days.

On the other hand, the orquiectomía does not produce these effects by what this situation is indicated.

What can he say to me about the hormonal medicines?

They are part of what it calls hormonoterapia additive, because there are added a few medicines that are going to change the hormonal state of the person. Most of these medicines are directed to produce a castration of chemical type, annulling the sources of production of androgen (principally, testosterone).

He has said that 95 % of androgen takes place in the testicle. And 5 % remainder?.

In the adrenal glands (named this way for one is placed on every kidney). This androgen is eliminated neither by the castration nor for the hormonal treatments that cause the chemical castration. They need, if they want to be eliminated, a special treatment with medicines that are called antiandrogenic.

Explain to me the medicines that are used in hormonoterapia additive.

First of all, the DES or dietilestilbestrol, that is like an estrogen (feminine hormone).

Is it used at present?.

Practically, no. Years ago it was the only hormonal treatment. But it was seen that enough was increasing the risk of enduring heart attacks, cerebral hemorrhage and mortal clots of blood.

It is a big disadvantage, because it is a very cheap medicine and that takes easily (a pill a day).

But he has had to give in.

So: what medicines are used at present?

Called similar of the liberating hormone of the hormone luteinizante (LHRH). Basically there are copies of natural hormones produced in our organism and that stimulate the testosterone production.

Most used there are the acetate of leuprolide and the acetate of goserelina. They diminish the levels of testosterone of a way as effective as the castration. They produce so a chemical castration.

How are they applied?

In deep intramuscular injection or in injection under the (subcutaneous) skin of the abdomen, one a month (in the form Depot) or also he gets ready now of another form Depot, which applies itself once every three months.

How do they act?

Once they have been administered, provoke a stimulation of the production of testosterone for fifteen days. The body interprets this increase like which it has produced testosterone in excess, therefore it stops the production of the stimulant hormone of the production of testosterone.

Our organism is "cheated" in certain way by the similar one of the hormone.

Is not the testosterone increase dangerous for 15 days?.

In effect, it is not suitable. To resist it, before initiating the treatment with a similar one of the LHRH they are indicated 15 days with an antiandrogenic one, to neutralize the testosterone increase.

Can it clarify this to me?

First, leave to me that I explained to him what is an antiandrogenic one. We have already said that a small androgen proportion is made of the adrenal glands.

To block his action, there were synthesized a few medicines, called antiandrogenic, which action consists of blocking, at level of the prostate, the action of the androgen.

This way two indications are born for the antiandrogenic ones:

*En the treatment of the cancer of prostate, associated with a similar one of the LHRH, inside the strategy that is named an entire hormonal blockade, which we will define later.

*Para to prepare the testosterone increase the fifteen first days of the application of a similar one of the LHRH.

What are the antiandrogenic most secondhand?

They are flutamida and bicalutamida.

How and all that they take?

They present before themselves in the shape of tablets for administration for the mouth. The flutamida is prescribed three times a day while the bicalutamida, once every 24 hours.

Of what does the entire hormonal blockade consist?

Some authors believe that the best hormonal treatment is based on the association or combination of a similar one of the LHRH with an antiandrogenic one or entire hormonal blockade. This way there would be controlled 100 % of the production of androgen.

There is a lot of polemic if really the elimination of 5 % of androgen produced by the adrenal ones increases the benefits as for avoiding defeats of the treatment, when only the similar one is used, or if the entire blockade would increase the survival of the patients.

There is no definitive information, therefore any doctors prefer the entire hormonal blockade and others apply only the similar one.

Is there any group of patients in whom it has already been demonstrated that the entire hormonal blockade is better that the alone similar one?

Yes, it is the group formed by patients with cancer of prostate, with few illness (metástasis) in the bones and with minimal symptoms.

The hormonal treatment: does the survival of the patients increase with metástasis?.

It has not been demonstrated. What if it does is to improve the quality of life of the patients and it diminishes the complications risk.

A patient with metástasis for cancer prostate: how long does the hormonal treatment have to take?

In Medicine there are always tendencies and polemics.

For a few doctors, the majority, the hormonal treatment has always to take. it is the called continuous hormonal treatment. They believe that this way they control better the illness.

Others, on the other hand, prefer the called intermittent hormonal treatment.

It consists of initiating the hormonal treatment and of following it until the PSA and the symptoms should have diminished at his minimal level and then they should become stable. Then the treatment stops and it is not resumed until it increases, in two or three monthly analyses, the PSA again. This way treatment is happening or not, according to the evolution of the patient.

The intermittent treatment studied in animals of experimentation, has showed that it can be better that the continuous one and that does not cause problems.

The intermittent treatment is cheaper than the continuous one and it has another additional advantage, which is that of leaving rest periods to the patient in whom he is eliminated by the unpleasant symptoms produced by the hormones.

Some studies in human beings show favorable results with the intermittent treatment.

What are the poisonous or secondary effects of these medicines?

The orquiectomía already explained like form of hormonal treatment, causes, in more than 90 % of men, decrease of the sexual desire (libido) or absence of the same one and powerlessness. Sometimes, suffocations. These are mitigated usually in the course of time.

The similar ones of the LHRH are similar to those of the orquiectomía. Perhaps the most frequent effect is the presentation of suffocations (10 to 15 % of men). There are like heat waves and sudoración, that come and go away and return. In general, they do usually diminish with the time.

These medicines also can produce sensibility in the breasts and, sometimes, increase of his size (ginecomastia). In slightly frequent cases, the precise painful sensibility low doses of radiotherapy or surgery to solve the problem.

To watch the tendency to the weight increase with these medicines.

As for the antiandrogenic ones, the most pronounced effect is the diarrhea, especially with flutamida. If they are supported, it is necessary to lower the dose of the antiandrogenic one, to suspend it or to replace it. also morning sickness and weariness can take place.

The continued use of these medicines can harm to the liver, by what, periodically, control panel must be realized by means of analysis to value as it works.

Also there is decalcification danger (osteoporosis), therefore there are convenient supplements of calcium, vitamin D and to sunbathe.

If the cancer with metástasis becomes resistant to the hormonal treatment exhibited so far: does he get ready of other medicines also of hormonal type?

A medicine used in cases of resistance to the hormonal therapy is the estramustine. In fact it is a medicine that placed on horseback between hormonoterapia and chemotherapy.

In effect, estramustine it combines a feminine hormone, an estrogen, with a medicine quimioterápico, the nitrogenous mustard.

The estramustine is used alone or associate to other quimioterápicos (mitoxantrona, etoposido, vinblastina, paclitaxel).


CHEMOTHERAPY

It is another option for patients resistant to all kinds of hormonal treatment.

Two types of medicines are used:

*citotóxicos, that interfere with the development of the cancerous cell and produce his death.

*citostáticos, that promote the cellular aging and make the cellular multiplication difficult. They do not kill cells straight, but they cause little by little his disappearance, on having stopped reproducing.

Most of the used ones belong to the first group.

Most of citotóxicos affect the cells that are multiplying at the moment when the medicine is administered. For it, and even if they affect more to the cancerous cells, they present unwanted side effects. They owe to the normal cells affectation in division and multiplication; basically those of blood, digestive pipe and skin.

Also, up to the present. the chemotherapy has not produced good results.

The medicines citotóxicos more used are, taxotere, etoposido, vinblastina, paclitaxel and mitoxantrona, apart from estramustine, already commented in the paragraph dedicated to resistance to the hormonal therapy.

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INDICATIONS OF THE TREATMENT AS TNM AND OTHER FACTORS

The treatment is individualized according to the personal characteristics (age, the general health the state, life expectancy), of the tumor (Gleason) and of his extension (TNM).

Let's consider these situations.

T1. It is necessary to consider separately T1a of T1b, T1c, T2aA and T2b:

T1a. it is necessary to raise three fundamental aspects, life expectancy, level of PSA after the resection of the tumor and index of Gleason.

SITUATION A. *Si the life expectancy is major than 20 years (for example, men 40-year-old young people 0 50 years),

*y/o the PSA keeps on being major than 1 ng/ml and,

*el major Gleason of 6,

TO CONSIDER TREATMENT WITH RADIOTHERAPY OR RADICAL PROSTATECTOMÍA, without discarding completely the deferred treatment.

SITUATION B. *Esperanza of life 20-year-old minor,

*PSA minor of 1ng/ml after the eradication of the tumor,

*Gleason of 6 or less,

NOT TREATMENT UNTIL THE HAGUE SYMPTOMS (deferred treatment).

T1b, T1c, T2a and T2c. They have the following possibilities:

1. Gleason between 2 and 4,

Hopefully of life 10-year-old minor,

NOT TREATMENT UNTIL SYMPTOMS OR RADIOTHERAPY APPEAR.

Hopefully of life between 10 and 20 years,

NOT TREATMENT UNTIL THERE IS SYMPTOMS OR RADIOTHERAPY OR RADICAL PROSTATECTOMÍA.

Hopefully of life of more than 20 years,

RADIOTHERAPY OR RADICAL PROSTATECTOMÍA.

2. Gleason 5 or 6,

Hopefully of life 10-year-old minor,

NOT TREATMENT UNTIL SYMPTOMS OR RADIOTHERAPY APPEAR.

Hopefully of major life of 10 years,

RADIOTHERAPY OR RADICAL PROSTATECTOMÍA.

3. Gleason 7 to 10,

Hopefully of life 5-year-old minor,

NOT TREATMENT UNTIL SYMPTOMS OR RADIOTHERAPY APPEAR.

Hopefully of major life of 5 years,

RADIOTHERAPY OR RADICAL PROSTATECTOMÍA.

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T3a. It depends on the extension of the tumor to one or to two lobes you (depart) from the prostate:

If the tumor spreads beyond the prostate, but only in a side,

RADIOTHERAPY OR HORMONAL TREATMENT OR BOTH (the prostatectomía can be indicated if the Gleason is 6 or less and there is no excessive extension of the tumor).

If the tumor spreads beyond the prostate, but in both parts,

RADIOTHERAPY OR HORMONAL TREATMENT OR BOTH.

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T3b and T4NOMO:

RADIOTHERAPY OR HORMONAL TREATMENT OR BOTH

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Affectation of ganglions (N1, N2, N3),

The HORMONAL TREATMENT can be chosen, with or without radiotherapy, or NO TREATMENT UNTIL SYMPTOMS APPEAR

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Metástasis,

HORMONAL TREATMENT.