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.

One or more of these therapies may be recommended. Some treatments can temporarily or permanently affect sexual function, fertility and bladder and/or bowel control. Ask about all potential short- and long-term side effects of each option. 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 frequently recommended to treat early-stage cancers and may also be considered in some cases for locally advanced disease (Stage III). The standard surgery is a radical prostatectomy, which removes the entire prostate, surrounding tissues and the seminal vesicles.

A nerve-sparing approach, in which the surgeon attempts to preserve the prostate nerves that control erection capability, is sometimes possible. 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 (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.

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.

Radiofrequency Ablation

Radiofrequency ablation (RFA) involves placing needles in the area of the prostate tumor. High frequency electric waves generate heat at the tip of the needle, which destroys the tumor.

Radiation Therapy

Radiation therapy may treat early-stage disease or manage late-stage symptoms.

  • External-beam radiation therapy (EBRT) is most commonly used and involves a large machine that aims radiation at the prostate and surrounding tissues. Hypofractionated radiation therapy delivers higher doses of radiation in far fewer sessions, which can be more convenient for patients. Proton beam irradiation employs particles (protons) generated by a cyclotron; these high-energy particles can be finely focused to destroy the cancer.
  • Brachytherapy, also called internal radiation therapy, involves placing tiny radioactive “seeds” or needles directly into the prostate. With brachytherapy, 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. Brachytherapy is typically used for early-stage (Stage I or II), often slow-growing tumors. Combined with external beam radiation, it can also be used as a “boost” to treat intermediate or high-risk cancers.

Figure 2

Radiopharmaceutical

Radiopharmaceuticals are drugs that give off targeted radiation to suppress cancer in the bones and reduce pain.

Hormone therapy

Hormone therapy is also referred to as androgen-deprivation therapy (ADT). Androgens are male hormones, and prostate cancer cells need them in order to grow. 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 hormones (LS and FSH), 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. Antiandrogens are also used to treat castration-resistant prostate cancer (CRPC), which is cancer that has progressed despite testicular suppression.
  • Androgen synthesis blockers block an enzyme important in converting certain hormones into testosterone in the fat tissue, adrenal glands and even cancer cells.
  • Surgical castration (removing both testicles) reduces testosterone levels. The procedure has not been shown to be more effective than LHRH agonists.

Prostate cancer that doesn’t respond to ADT or that returns following treatment with ADT is called CRPC. If the cancer hasn’t spread, it is called non-metastatic CRPC.

Chemotherapy

Chemotherapy may be an option when hormone therapy stops working. Recent evidence suggests that chemotherapy as well as ADT and androgen synthesis blockers also improve survival in men for whom initial treatment for localized prostate cancer (surgery or irradiation) indicates a high risk of subsequent spread/recurrence.

 

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. A therapeutic vaccine for prostate cancer is the first FDA-approved immunotherapy for metastatic castration-resistant prostate cancer. Unlike traditional vaccines, which boost the immune system to prevent disease, this type 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.

Targeted Therapy

Targeted therapy uses drugs or other substances to identify and attack specific types of cancer cells. Unlike chemotherapy, which attacks healthy cells as well as cancer cells, targeted therapy is designed to affect only cancer cells. Some targeted therapy drugs are oral medications given in pill form; others are given by IV. Some may be given in combination with other drug therapies.

Drugs For Bone Metastases

Drugs for bone metastases, also called bone-modifying (strengthening) drugs, may be recommended when cancer metastasizes to the bone. These help prevent the loss of calcium, which can lead to osteoporosis and increased risk of bone fractures.

For more on bone health, click here.

 

Commonly Used Medications 

Chemotherapy
cabazitaxel (Jevtana)
docetaxel (Docefrez,Taxotere)
mitoxantrone hydrochloride (Novantrone)
Hormone Therapy
Androgen Synthesis Blocker
  • abiraterone acetate (Zytiga)

Antiandrogens
   First Generation

  • bicalutamide (Casodex)
  • flutamide (Eulexin)
  • nilutamide (Nilandron)
   Second Generation
  • apalutamide (Erleada)
  • darolutamide (Nubeqa)
  • enzalutamide (Xtandi)
LHRH agonists
  • goserelin acetate (Zoladex)
  • histrelin acetate (Vantas)
  • leuprolide acetate (Eligard, Lupron, Lupron Depot)
  • triptorelin pamoate (Trelstar)
LHRH antagonist
  • degarelix (Firmagon)
Immunotherapy
sipuleucel-T (Provenge)
Radiopharmaceutical
radium Ra 223 dichloride (Xofigo)
Targeted Therapy
olaparib (Lynparza)
rucaparib (Rubraca)
Some Possible Combinations
abiraterone acetate (Zytiga) with prednisone
bicalutamide (Casodex) with a luteinizing hormone-releasing hormone (LHRH) analog
cabazitaxel (Jevtana) with prednisone
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 5/7/20

Additional Resources

 

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