After receiving your diagnosis, the next step is to decide on a treatment plan. Though many therapies are approved for various types and stages of prostate cancer, your path will be uniquely yours. It should include input from your doctor, health care team, the loved ones you choose to involve and, most importantly, you.
To determine the treatments that are appropriate for you, your doctor will consider several factors, including the stage and grade of disease and whether it has metastasized (spread), your age, and results of risk assessments, predictive tests and molecular testing. Next, you will discuss your goals of treatment. Is it to cure the prostate cancer or manage it?
Lastly, it is key to weigh the potential side effects that accompany each type of treatment. Share your expectations for your quality of life. Be open and honest about the side effects you are most concerned about, and find out if and how they can be managed. Some can temporarily or permanently affect sexual function, fertility and bladder and bowel control. Learn as much as possible before you begin treatment so you are not surprised later. It is crucial that you are comfortable with your decision.
Types of Treatment
Active surveillance delays active treatment while closely monitoring the course of the cancer. This may be an option for men who have complicating illnesses that make therapy risky. The physician may recommend an MRI every 12 to 18 months and a biopsy every 2 to 3 years.
Watchful waiting is similar to active surveillance, but the goals are to minimize any symptoms or serious medical consequences from the cancer. It requires less frequent visits to the doctor and fewer imaging studies, such as MRIs or PSMA PETs. Biopsies are only done “for cause” if treatment becomes necessary to avoid serious symptoms from the cancer. Watchful waiting is often recommended for much older men, particularly those with other serious medical issues.
Surgery is a common option that may be used alone or with another therapy based on the size and location of the tumor.
The standard surgery is a radical prostatectomy, which removes the entire prostate, surrounding tissues and the seminal vesicles. Ask your doctor if a nerve-sparing approach, in which the surgeon attempts to preserve the prostate nerves that control erection capability, is an option for you. This approach may increase the chances of maintaining sexual function.
An open radical prostatectomy can be performed in different ways:
- A radical retropubic prostatectomy, the most common method, involves making a large incision in the lower abdomen.
- A radical perineal prostatectomy requires an incision in the area between the anus and scrotum.
A closed or minimally invasive radical prostatectomy is another approach:
- A robotic-assisted radical prostatectomy is the most common minimally invasive option. The surgeon performs the procedure by controlling robotic arms that operate surgical tools through a few small abdominal incisions.
- A laparoscopic radical prostatectomy allows the surgeon to operate through a few small incisions while guided by a laparoscope, a thin lighted instrument with a tiny camera attached that provides views of the surgical field through a telescopic lens.
A pelvic lymph node dissection may be performed along with prostatectomy to remove lymph nodes.
An orchiectomy, not a part of a standard radical prostatectomy, surgically removes both testicles. It is a form of hormone therapy used to reduce testosterone levels.
Transurethral resection of the prostate (TURP) is a procedure that removes tissue from the prostate to relieve symptoms caused by a tumor, such as urinary symptoms. TURP is not designed to cure the cancer, but only to relieve obstruction to voiding.
Radiation therapy may be given as a form of treatment to cure the cancer or simply to prevent or relieve symptoms. Several forms of radiation therapy are available and used depending on the grade and stage of the prostate cancer.
External-beam radiation therapy (EBRT) involves a large machine that aims radiation at the prostate and surrounding tissues (see Figure 1). Types of EBRT include the following:
- Stereotactic body radiation therapy (SBRT) uses high-energy radiation beams to treat cancer in five or fewer treatments.
- Proton beam radiation therapy uses streams of protons to kill tumor cells.
- Three-dimensional conformal radiation therapy (3D-CRT) combines computed tomography (CT) images and computer software to aim beams that match the shape of the tumor.
- Intensity-modulated radiation therapy (IMRT) uses small beams of different strengths to match the shape of the tumor in the prostate and surrounding tissue.
- Image-guided radiation therapy (IGRT) uses a computer to create a picture of the tumor that helps guide the radiation beams to ensure they target the same spot every time. It can be used with the other types of radiation.
Brachytherapy, also called internal radiation therapy, involves placing tiny radioactive “seeds” or needles directly into the prostate. Radiation may be delivered at a “high dose rate” (over several hours) with needles implanted and removed a short time later or as a “low dose rate” with small radioactive “seeds” that are permanently implanted. Combined with EBRT, it can also be used as a “boost” to treat intermediate or high-risk cancers.
Alpha emitter radiation therapy uses radiopharmaceuticals, which are drugs that give off targeted radiation, to suppress cancer in the bones and reduce pain.
The following types of systemic therapy affect the whole body (see Figure 2). They may be used alone or with another treatment.
Hormone therapy adds, blocks or removes hormones. Androgens are male hormones, and prostate cancer cells need them to grow. The main male androgen is testosterone. A type of hormone therapy called androgen-deprivation therapy (ADT) slows tumor growth by preventing the body from producing androgens or by blocking the effect the androgens have on the tumor. Several types of ADT are available.
Luteinizing hormone-releasing hormone (LHRH) agonists and LHRH antagonists both prevent the testicles from making testosterone, resulting in medical castration. These drugs suppress the body’s production of certain hormones, which is what ultimately stimulates the testicles to produce androgens.
Antiandrogens block the protein receptors for testosterone and other androgens, thus blocking the stimulation that androgens exert in cells. Used primarily with medical castration as initial treatment, they are sometimes combined with an LHRH agonist or surgical castration in a treatment strategy known as a combined androgen blockade or total androgen blockade.
Androgen synthesis blockers block enzymes important in converting certain hormones into testosterone in the fat tissue, adrenal glands and even cancer cells.
An orchiectomy surgically removes both testicles to reduce testosterone levels.
Chemotherapy uses drugs to kill rapidly multiplying cells throughout the body. To treat prostate cancer, it may be given intravenously (IV) through a small tube inserted into a vein or port, or taken orally as a pill. It is typically delivered in cycles, with treatment periods followed by rest periods to give your body time to recover.
A specific strategy may consist of a single chemotherapy drug, a combination given at the same time or drugs given one after another. Chemotherapy may be used alone or with other forms of treatment.
Recent evidence suggests that chemotherapy as well as androgen-deprivation therapy (ADT) and androgen synthesis blockers may be combined with surgery or radiation therapy as treatment for prostate cancer that seems localized in the prostate but has features that indicate a high likelihood of spread.
Targeted therapy uses drugs or other materials to target specific substances, such as biomarkers, genes, proteins or other factors. Your doctor will likely order tests to identify any substances present in the tumor that may respond to this type of therapy. A blood sample may be used for finding an inherited mutation or for tumor DNA floating in the bloodstream. Genomic tests may be performed on new or previously collected biopsy tissue to determine the mutations within the tumor.
Using the test results, your doctor will determine the most effective treatment possible. Some targeted therapy drugs are oral medications given in pill form, and others may be given intravenously by a needle inserted into a vein. They may be given alone or in combination with other drug therapies.
Immunotherapy harnesses the potential of the body’s own immune system to recognize and destroy cancer cells. By training the immune system to respond to cancer, this strategy has the potential for a response that can extend beyond the end of treatment. Immunotherapy in the form of a vaccine may be used. A man’s white blood cells are collected, modified in a lab to recognize prostate cancer cells and then injected back into his body to find and destroy the cancer.
Bone-modifying (strengthening) therapy uses drugs to help relieve bone pain and may reduce the risk of bone problems. They may be recommended when cancer metastasizes (spreads) to the bone or if a man is receiving androgen-deprivation therapy (ADT) for a year or more, as ADT itself increases the risk of osteoporosis. Your doctor may order a bone scan at diagnosis as well as during treatment to monitor bone health (see Figure 3).
Thermal ablation uses extreme cold or heat to treat cancer cells:
- Cryoablation or cryotherapy kills cancer cells by freezing them with a probe super-cooled with liquid nitrogen or a similar substance. This may be an option when surgery or irradiation are not advisable, or for recurrent prostate cancer.
- Radiofrequency ablation (RFA) places needles in the area of the prostate tumor. High-frequency electric waves generate heat at the tips of the needles, which destroys the tumor.
- Another option involves the use of high-energy sound waves that create heat to kill cancer cells. This is known as high-intensity focused ultrasound (HIFU).
Clinical trials are medical research studies that may offer access to leading-edge prostate cancer treatments not yet widely available. Sometimes clinical trials may be a first-line treatment option, which is the first treatment given. Clinical trials for treating and managing different stages of prostate cancer are underway. Ask your doctor if you should consider this valuable option first or at any other time during your treatment.
Explaining PSA Persistence and Recurrence
The recurrence of prostate cancer can be detected in different ways. The goal of treatment is for the PSA level to fall close to zero. The very first indication that recurrence has happened is a measurable and increasing PSA blood level. If the PSA does not fall to or near zero, it is called PSA persistence. When the PSA level falls close to zero but subsequently rises, it is referred to as recurrence. Recurrence or persistence of PSA will usually prompt your doctor to repeat other tests, such as a bone scan, CT or MRI. The management of recurrent or persistent PSA will depend on other types of therapy you have received and whether evidence of spread of the cancer to other organs is detected. Each of these conditions is treated uniquely. Your doctor will discuss treatment options with you.
COMMON DRUG THERAPIES FOR PROSTATE CANCER
These therapies may be used alone or in combination.
|mitoxantrone hydrochloride (Novantrone)|
Androgen Synthesis Blocker
GnRH Receptor Antagonists
|lutetium Lu 177 vipivotide tetraxetan (Pluvicto)|
|radium Ra 223 dichloride (Xofigo)|
|Some Possible Combinations|
|abiraterone acetate (Zytiga) with prednisone|
|bicalutamide (Casodex) with a luteinizing hormone-releasing hormone (LHRH) analog|
|cabazitaxel (Jevtana) with prednisone|
|darolutamide (Nubeqa) with docetaxel|
|docetaxel (Docefrez, Taxotere) with prednisone|
|flutamide (Eulexin) with a luteinizing hormone-releasing hormone (LHRH) analog|
|goserelin acetate implant (Zoladex) with flutamide (Eulexin)|
|mitoxantrone hydrochloride (Novantrone) with corticosteroids|
|nilutamide (Nilandron) with surgical castration|
As of 8/8/22
What is castration-resistant prostate cancer (CRPC)?
Prostate cancer growth is often driven by male sex hormones (androgens), which include testosterone. Because of this, a common treatment option for prostate cancer is to use hormone therapy (also referred to as androgen-deprivation therapy) to lower the levels of androgens in a man’s body.
Treatments can include surgically removing the testicles or prescribing drugs that stop the testicles from making androgens or block how they affect the body. However, prostate cancer sometimes continues to grow even when the amount of testosterone in the body is reduced to very low levels by medical or surgical treatment. This is known as castration-resistant prostate cancer (CRPC).
CRPC can be detected at early or advanced stage or when the cancer has spread. Non-metastatic CRPC (nmCRPC) means the cancer is not detectable in other parts of the body by any method typically used, such as a CT, MRI, bone scan or physical exam. Metastatic CRPC (mCRPC) means that spread beyond the prostate has been detected despite prior treatment including drugs or other treatments used to lower androgen levels in the blood.
It is not uncommon for men with metastatic prostate cancer to develop castration-resistant disease. If this happens, the treatment strategy must change.Although hormone therapy is often continued to keep the androgen levels low, several other treatment options may be considered as well.Although hormone therapy is often continued to keep the androgen levels low, several other treatment options may be considered as well.
- Targeted therapy . A type of targeted therapy known as a PARP inhibitor helps to kill cancer cells by preventing the body from repairing damaged DNA in cells.
- Immunotherapy . Available as a vaccine using the patient’s own blood cells or a drug infusion, immunotherapy stimulates the body’s immune response.
- Radiopharmaceuticals . A radioactive substance given by injection may be an option for treating cancer cells that have metastasized (spread) to the bone.
Before deciding on a treatment, it is important to talk with your doctor about your overall goals of treatment. Managing your symptoms while still enjoying a certain quality of life may become your priority, and each treatment option has potential risks and benefits. Talk openly and honestly with your doctor about your feelings and concerns so you know what to expect.
Questions to Ask Your Doctor
- How soon should I begin treatment?
- What type of prostate cancer do I have?
- What are the goals of my treatment?
- Should I consider a clinical trial?
- What potential side effects are associated with each type of treatment?
- How can I manage the side effects of treatment?
- How will we know if my treatment is working?