Prostate Cancer

Treatment options

You and your doctor will consider several different factors in deciding which treatment option is best for you. The stage and grade of your cancer and your PSA level are often the most important factors, but your age and overall health are also important. Ask your doctor which factors he or she is considering in developing your treatment plan. Each treatment type has risks and benefits; learning about these can help you decide which treatment is best for you. Your doctor may recommend options besides the ones listed here.

Considering your options

In many men with prostate cancer, the cancer is diagnosed while it is still at an early stage. Men with early-stage prostate cancer often have several treatment options. Many prostate cancers grow slowly, and you may not have any symptoms from yours. If that is the case, you may decide not to be treated right away. Some men prefer to avoid possible side effects for as long as possible and choose to forgo treatment until it is necessary. Other men are more concerned about removing or destroying the cancer as soon as possible. You should discuss your priorities with your medical team, who can help you decide which treatment plan best supports your priorities.

Getting a second opinion about your diagnosis and treatment can be valuable. Consider talking to a medical oncologist (a doctor who treats cancer with medication), a urologist (a surgeon who treats problems of the urinary tract and male reproductive system) and a radiation oncologist (a doctor who treats cancer with radiation therapy). These specialists may have different ideas about treating your cancer.

Your medical team may include the types of doctors discussed previously as well as others, so effective communication with each one will help everyone work together to manage your therapy. Current treatment options for prostate cancer include active surveillance or watchful waiting, high-intensity focused ultrasound, surgery, cryosurgery, radiation therapy, hormone therapy, chemotherapy and immunotherapy.

Side effects of treatments will vary. You can find more information about common side effects here. This guide also contains articles devoted to treatment options for erectile dysfunction, incontinence and bone health.

Active surveillance and watchful waiting

Because prostate cancer often grows slowly and causes no symptoms, some men with prostate cancer may never need treatment for it. Instead, their doctors may decide to use watchful waiting or active surveillance.

Some doctors use the terms “watchful waiting” and “active surveillance” to mean the same thing. For other doctors, they mean something slightly different. If your doctor recommends this approach, ask him or her to explain exactly what he or she means.

Active surveillance means monitoring the cancer closely with regular prostate-specific antigen (PSA) tests and digital rectal exams (DREs) to see whether the cancer is growing. Prostate biopsies may also be done. If your test results change, your doctor will reevaluate your condition and consider treating the cancer.

Watchful waiting is follow-up with fewer tests. It relies more on changes in the patient’s symptoms to decide whether treatment is necessary. Both active surveillance and watchful waiting are used when treating the cancer may cause more discomfort than the disease itself. They are both options for small tumors within the prostate that have a low Gleason score, which means they are expected to grow slowly and cause no symptoms, as well as for elderly men who have other illnesses.

 

Glossary terms – Words to know

Androgen: Any male sex hormone. The major androgen is testosterone.

Biopsy: Removal of tissue to be tested for cancer cells.

Catheter: A small tube used to deliver fluids to (or remove them from) the body.

First-line therapy: The initial (first) therapy used in a person’s cancer treatment.

Gleason score: A range from 2 to 10 that grades prostate cancer tissue based on how it looks under a microscope. A low Gleason score means the cancer tissue is similar to normal prostate tissue and the tumor is less likely to spread; a high Gleason score means the cancer tissue is very different from normal and the tumor is more likely to spread.

Prostate-specific antigen (PSA):A protein made by the prostate gland and found in the blood. It may be found in abnormally high levels in men who have prostate cancer or other conditions.

Prostatectomy: Surgical removal of all or part of the prostate gland.  

 

High-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) is a new form of treatment for early-stage prostate cancer. It destroys cancer cells with heat from highly focused ultrasound beams. HIFU has been used in Europe for about a decade as well as in China, Hong Kong and Japan. It was approved by the Food and Drug Administration (FDA) for use in the United States in October 2015.

Surgery

Surgery is often used to treat prostate cancer that has not spread outside the prostate gland. The most common type of surgery for prostate cancer is radical prostatectomy. For radical prostatectomy, the surgeon removes the entire prostate gland and some of the nearby tissues, including the seminal vesicles. A few different techniques are used to perform radical prostatectomy.

Radical open prostatectomy

In an open approach, the surgeon operates through one incision (see Figure 1). The incision can be either in your lower abdomen (from the belly button to the pubic bone) or in the skin between the anus and the scrotum (the perineum). If the incision is in your lower abdomen, the procedure is called a radical retropubic prostatectomy. If it is in your perineum, the procedure is called a radical perineal prostatectomy.

There are a few differences between the retropubic and perineal approaches. During a radical retropubic prostatectomy, the surgeon may also remove lymph nodes, which are examined for cancer cells. Lymph nodes cannot be removed during a radical perineal prostatectomy. Because of this, the perineal approach is used less often than the retropubic approach. Perineal procedures are also more likely to cause problems with erections than retropubic ones. After either technique for open prostatectomy, a catheter will be inserted through the penis and into the bladder to help drain urine while you heal. It typically remains in place for one to two weeks. You can expect to stay in the hospital for a few days after either approach to an open radical prostatectomy.

Minimally invasive (closed) surgical techniques

Laparoscopic radical prostatectomy

Laparoscopic radical prostatectomy involves removal of the same tissue as in an open prostatectomy, but with the use of small incisions in the abdomen through which the surgeon inserts special instruments and visualizes the surgical field with a telescope-like device called a laparoscope.

Robotic-assisted laparoscopic radical prostatectomy

This surgery uses a robotic system. During robotic-assisted laparoscopic surgery (RALRP), the surgeon controls robotic arms to complete the operation through a few small incisions in the patient’s abdomen (see Figure 1). Benefits of RALRP include less blood loss and less time in the hospital than with open radical prostatectomy.

Figure 1

Cryosurgery

Cryosurgery (also called cryotherapy) is the use of extreme cold from liquid nitrogen or argon gas to destroy cancer tissue. It can be used to treat early-stage prostate cancer that is contained within the prostate gland. It can treat only limited areas, so it is not used for prostate cancer that has spread beyond the gland or distant part of the body.

In cryosurgery, the doctor uses transrectal ultrasound (TRUS) to guide several needles into the prostate. The cold gas then goes through the needles, creating ice that destroys the prostate. To prevent the urethra from freezing, warm salt water is circulated through a catheter inserted in the urethra. The catheter will remain there for a few weeks after surgery to help drain the bladder. Cryosurgery is less invasive than radical prostatectomy, but it usually results in erectile dysfunction and its long-term effectiveness is not clear. Because of this, cryosurgery is rarely used as the primary treatment option but may be used for recurrent cancer.

Radiation therapy

Radiation therapy uses high-energy rays or particles to kill cancer cells and shrink tumors. It is used to treat all stages of prostate cancer. It can be used as the first treatment for low-grade cancer that has not spread beyond the gland or in combination with hormone therapy as first treatment for high-grade cancers and those that have spread into nearby tissues. Radiation therapy may also be used if cancer remains or recurs after surgery. In advanced cancers, radiation therapy can reduce the size of the tumor and provide pain relief. Two main types of radiation therapy are used to treat prostate cancer: external-beam radiation therapy (EBRT) and brachytherapy (also called internal radiation).

  • In EBRT, beams of radiation are aimed at the prostate gland from a machine outside the body. EBRT is used to try to cure early-stage cancers or to relieve symptoms associated with late-stage cancers. With a standard treatment plan, you will be treated five days a week for seven to nine weeks. EBRT is painless. EBRT can be given in a few different ways, including three-dimensional conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT) and proton beam radiation therapy. These methods use different techniques to do the same thing: direct radiation beams to the cancer.
  • Brachytherapy is also called internal radiation therapy because it involves the placement of small radioactive pellets, or “seeds,” directly into the prostate (see Figure 2). Each seed is about the size of a grain of rice. Brachytherapy is used to treat early-stage, slow-growing prostate cancers and can be either permanent or temporary. In permanent brachytherapy, seeds with lower doses of radiation are placed in the prostate and remain there for weeks or months while the radioactive material works. The seeds are left in place after the treatment has been completed. Permanent brachytherapy is also called low-dose rate (LDR) brachytherapy. In temporary, or high-dose rate (HDR), brachytherapy, seeds with higher doses of radiation are used for a short time (several days) and then are removed. Brachytherapy is often combined with EBRT.

Figure 2

Hormone therapy

Hormone therapy is also called androgen-deprivation therapy (ADT) or androgen-suppression therapy. It is most often used to treat Stage III or IV prostate cancer. Prostate cancer needs male hormones called androgens to grow. The primary androgens are testosterone and dihydrotestosterone (DHT). Most androgens are made in the testicles. The goal of hormone therapy is to stop cancer from growing by reducing androgen levels in the body or preventing androgens from stimulating the cancer cells.

The types of ADT drugs available include luteinizing hormone-releasing hormone (LHRH) agonists and LHRH antagonists, which prevent the testicles from making testosterone. Given as an injection, both result in “medical castration.” Surgical castration (surgical removal of the testicles) also reduces the testosterone level but has not been shown to be more effective than treatment with an LHRH agonist or antagonist. ADT is used:

  • if the prostate cancer has spread to other parts of the body (bones and/or lymph nodes are the most likely places)
  • or in conjunction with either EBRT, brachytherapy or surgery if your physician determines that the risk that your cancer might spread is high.

Several types of hormone therapy are used to treat prostate cancer (see Table 1). Some decrease the amount of androgens in the body, and others stop androgens from working.

Surgical castration

The simplest way to reduce androgen levels in the body is orchiectomy (surgical castration). With this approach, a surgeon removes the testicles, which produce most of the body’s androgens. Once the testicles are removed, most prostate cancers stop growing. Because this method is permanent and emotionally difficult for many men to consider, it is not as common as other hormone therapies.

Drugs that decrease production of androgens

Drugs can decrease the amount of androgens produced in the testicles just as well as surgical castration. Because of that, treatment with these drugs may be referred to as chemical castration or medical castration. Luteinizing hormone-releasing hormone (LHRH) analogs are one kind of drug that can lower the amount of testosterone made by the testicles. Depending on the drug, LHRH analogs are injected or implanted under the skin and given between once a month and once a year. LHRH analogs are also called LHRH agonists or gnRH agonists.

When you first start taking LHRH analogs, your testosterone levels go up briefly before falling to a much lower level. This sudden increase and rapid decrease is called flare. Flare can cause bone pain in men who have prostate cancer that has metastasized to the bones. FDA-approved LHRH analogs include goserelin (Zoladex), histrelin (Vantas), leuprolide (Eligard, Lupron) and triptorelin (Trelstar).

LHRH antagonists are another kind of drug that decreases testosterone levels. They work like LHRH agonists, but they work faster and do not cause flare. Degarelix (Firmagon) is an LHRH antagonist. Abiraterone (Zytiga) is an androgen synthesis inhibitor, which also reduces the amount of androgens the body produces.

Anti-androgens

Anti-androgens are drugs that stop androgens from working. If another hormone therapy stops working, anti-androgens are often added to the initial hormone therapy. Anti-androgens are given as pills that are taken daily and include bicalutamide (Casodex), flutamide (Eulexin) and nilutamide (Nilandron). Enzalutamide (XTANDI) is a newer kind of anti-androgen.

Over time, ADT will become less effective, allowing the cancer to grow. When this happens, the cancer is called “hormone-refractory” or “castration-resistant.” Treatments for castration-resistant prostate cancer are available (see Table 2). Talk to your doctor about the best choice for you.

Table 1. Hormone therapy drugs for prostate cancer

Type of treatment Drug Form
LHRH (luteinizing hormone-releasing hormone) analogs
goserelin (Zoladex)
histrelin (Vantas)
leuprolide (Eligard, Lupron)
triptorelin (Trelstar)
Injection (goserelin, leuprolide, triptorelin) or implant (histrelin)
LHRH antagonist
degarelix (Firmagon)
Injection
Androgen synthesis inhibitor abiraterone (Zytiga) Oral, taken with prednisone
Anti-androgens
bicalutamide (Casodex)
enzalutamide (XTANDI)
flutamide (Eulexin)
nilutamide (Nilandron)
Oral
 

Table 2. Treatment options for castration-resistant advanced prostate cancer

Treatment Most common side effects
abiraterone (Zytiga) Weakness, joint swelling or pain, diarrhea, hot flushes
cabazitaxel (Jevtana) Low red bood cell count (anemia), low blood platelet count, fever, fatigue, nausea
docetaxel (Taxotere) Nausea, diarrhea, vomiting, neuropathy, hair loss
enzalutamide (XTANDI) Fatigue, back pain, decreased appetite, constipation, joint pain, diarrhea
radium Ra 223 dichloride (Xofigo) Nausea, diarrhea, vomiting, peripheral edema
sipuleucel-T (PROVENGE) Chills, back pain, joint ache, fatigue, fever, nausea

Chemotherapy

Chemotherapy is the use of strong anticancer drugs to kill or shrink the cancer. Chemotherapy drugs enter the bloodstream and circulate through the body, which makes them useful for treating cancers that have spread. Chemotherapy may be used when the cancer has spread beyond the prostate gland and is not responding to hormone therapy. This treatment is given in cycles, and a typical cycle is a few weeks long. Chemotherapy is usually given intravenously (through a vein), but some chemotherapy drugs are available as pills.

The primary recommended chemotherapy drug for prostate cancer is docetaxel (Taxotere) combined with prednisone, a corticosteroidgiven every three weeks. The length of treatment is based on its effectiveness and how well side effects can be managed. Cabazitaxel (Jevtana) may be used as second-line therapy. Other chemotherapy options include carboplatin (Paraplatin), doxorubicin (Adriamycin), estramustine (Emcyt), etoposide (Etopophos), mitoxantrone (Novantrone), paclitaxel (Taxol) and vinorelbine (Navelbine).

Radiopharmaceuticals, the third type of radiation for prostate cancer, are drugs that contain a radioactive substance. For prostate cancer, a radiopharmaceutical can be used only for cancers that are resistant to medical or surgical treatments to lower the testosterone level and that have spread to the bone (but not to other parts of the body). The approved agent is radium Ra 223 dichloride (Xofigo). It is given as an intravenous injection. Two other radiopharmaceuticals can help relieve pain caused by bone metastases, but only radium Ra 223 dichloride has been shown to help men who have prostate cancer that has spread only to their bones live longer.

 

Specialty pharmacies

As more oral anti-cancer drugs have become available, patients and their pharmacists have taken on a more active role in treatment. Some anti-cancer drugs are available only through limited distribution to certain pharmacies, called specialty pharmacies. In addition to dispensing the drugs accordingly, these specialty pharmacies must be able to provide clinical support and patient education, including information and counseling on the proper administration, intended benefit and potential adverse effects of each drug. A specialty pharmacy may also have a pharmacist or nurse make regular follow-up calls to patients to help guide them through their comprehensive cancer care. This involvement allows more effective monitoring of a patient’s disease progression, medication adherence and quality of life. It also allows medical personnel to respond appropriately to specific complications from a medication.

Specialty pharmacies are crucial to the success of many anticancer regimens because they help optimize care for people with cancer. Your doctor will let you know if your prescription requires a specialty pharmacy and will work with you to get the prescription filled.

 

Immunotherapy

Immunotherapy is a type of cancer treatment that works by stimulating the patient’s own immune system to find and fight cancer. Sipuleucel-T (PROVENGE) is a therapeutic vaccine for prostate cancer and is the first FDA-approved immunotherapy for metastatic castration-resistant prostate cancer. Unlike traditional vaccines, which boost the immune system to prevent disease, sipuleucel-T boosts the immune system to identify and attack prostate cancer cells. The vaccine is made specifically for each patient. A patient’s own white blood cells (part of the immune system) are collected in a sample of blood drawn from a vein. The white blood cells are modified in a lab to recognize prostate cancer cells and are then injected back into the patient’s body. The modified white blood cells find and destroy the cancer — and help other white blood cells attack the cancer too.

Other types of immunotherapy are being studied in clinical trials, which are research studies that involve people. Many of these types of immunotherapy show promise in treating prostate cancer. Talk to your health care team about participating in any available clinical trials you are eligible for. For more on clinical trials, click here. For more about immunotherapy, click here.

Drugs for bone metastases

Men with castration-resistant prostate cancer and bone metastases may also be treated with drugs to prevent or delay fractures (breaks) or other bone problems. Denosumab (XGEVA) and zoledronic acid (Zometa) both have similar effectiveness in reducing fractures, but denosumab has been shown to delay the first fracture by a few additional months. The theory underlying the use of these agents is to prevent the loss of bone mineral (calcium), a process that can progress to osteoporosis and as a resultant increase the risk of bone fractures.

The three radiopharmaceuticals, samarium SM 153 lexidronam, radium Ra 223 dichloride and strontium-89 chloride, may also be used to suppress prostate cancer in the bones and reduce pain. Talk to your doctor about which drug may be best for you. Your doctor will probably order periodic bone scans or other imaging studies to monitor bone metastases. For more on bone health, click here.

Additional Resources

 

Previous Next

 



Register Now! Sign Up For Our Free E-Newletter!

Read Inspiring Cancer Survivor Stories

Order Your Guides Here