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Weighing Treatment Options

The method selected to treat prostate cancer depends largely on the prostate cancer stage (localized, locally advanced, or metastatic) and other factors. Localized prostate cancer is a cancer that is contained within the prostate gland. Locally advanced prostate cancer is a cancer that has spread beyond the prostate to surrounding tissue and may also have spread to lymph nodes located within the pelvis. Metastatic prostate cancer is a cancer that has spread beyond the prostate and pelvic lymph nodes into other distant parts of the body, such as any bone or organ.

It is important to consider the benefits and potential side effects for each treatment option. These factors should be discussed thoroughly between a patient and his doctor. Certain treatments are chosen more frequently than others for each stage of prostate cancer. Decisions about prostate cancer treatment can be complex. In making these decisions, a number of important factors may be considered, including

• The stage and grade of the patient's cancer
  For more information on grading and staging, click here.
• The patient's age, general health, and life expectancy
• The patient's feelings about the individual treatments, potential side effects, and the quality of his life

Treatments for Localized or Locally Advanced Prostate Cancer

In general, treatments intended to cure prostate cancer are pursued when the cancer has not yet spread (metastasized) and is still localized, or locally advanced, at the time of initial diagnosis. These treatments with curative intent aim to remove and eliminate all prostate cancer tissue from the body. Treatments intended to cure localized prostate cancer include prostatectomy, transurethral resection of the prostate, external beam radiation therapy, brachytherapy, and cryotherapy. Localized prostate cancer may also be treated with watchful waiting. Treatments intended to cure locally advanced prostate cancer may include combinations of some of the options mentioned above, and under certain circumstances, hormonal therapy.

Prostatectomy
Prostatectomy is the surgical removal of the prostate, and is performed by a urologist (urologic surgeon). A radical prostatectomy is an operation to remove the entire prostate gland, seminal vesicles, and some of the tissue around it. This type of surgery may help prevent further spread of the cancer.

If the tumor is small and has not spread outside of the prostate, then surgery may optimally treat the disease. However, complete surgical removal of the prostate is not usually recommended when the cancer has spread to the lymph nodes or other sites.

Radiation Therapy
Radiation therapy uses high-energy rays to kill prostate cancer cells, shrink tumors, and prevent cancer cells from dividing and spreading. It is difficult to direct these rays only at the cancer cells. As a result, both cancer cells and healthy cells nearby may be damaged. Radiation therapy is not given all at once; it is usually given in small doses spread out over time. This potentially allows the healthy cells to recover and survive, while the cancer cells eventually die.

There are two ways in which the high-energy rays can be delivered. Radiation therapy involves either external beam radiation, or a type of internal radiation called brachytherapy. The first method, external beam radiation, uses machines that aim special radiation beams at the prostate to destroy cancer cells. A machine delivers the radiation in brief sessions, usually one session each weekday for several weeks. Many patients compare the treatments to having an X-ray. The procedure itself is painless and lasts for just a few minutes. In the second method, brachytherapy (sometimes called interstitial radiation therapy or "radioactive seeds"), the radiation comes from tiny radioactive seeds inserted directly into the prostate. Specialized equipment is used to view the tumor so the surgeon can place the seeds correctly. The seeds are inserted into the tumor during a minor surgical procedure under anesthesia. Brachytherapy is usually performed as an outpatient procedure. The seeds are too small to be felt by a patient and do not cause any discomfort. Brachytherapy usually is not an option for treatment of prostate cancer that has spread beyond the prostate gland.

Cryotherapy
Cryotherapy, also called cryosurgery, is a procedure where the tumor is frozen, allowed to thaw, and then frozen again. In cryotherapy, a probe is inserted into the prostate where it will freeze the tumor and the surrounding tissues. Cryotherapy kills the cancer cells as well as some surrounding healthy cells.

Watchful Waiting
For some patients with prostate cancer, the recommended treatment may simply be to "watch and wait." Watchful waiting is the decision not to treat localized prostate cancer with surgery, radiation, or any other treatments. The doctor monitors the patient's prostate cancer by checking PSA levels and looking for signs and symptoms of cancer growth. If the PSA levels start to go up, or the signs and symptoms of cancer growth become more obvious, treatment may be started.

Watchful waiting may be chosen by a patient and his physician if a patient falls into one or more of the following categories:

• Men in their late 70s or 80s with limited long-term life expectancy (ie, <10 years)
• Men in their 60s and early 70s with other potentially life-threatening health problems
• Men with cancers that are small, slow-growing, and confined to the prostate (stage T1a)
• Men with no symptoms
• Men with low PSA levels (<4 ng/mL)

Treatments for Metastatic (Advanced) Prostate Cancer

Treatment with prostatectomy or radiotherapy may fail in some patients with prostate cancer, as indicated by a recurrence of the cancer in the months or years following treatment. The cancer may return in a distant site such as bone or organs and is known as metastatic prostate cancer. Treatments for metastatic prostate cancer, even at the time of initial diagnosis, do not eliminate the prostate cancer completely. Currently, metastatic prostate cancer is usually treated with hormonal therapy, which is frequently effective for a certain period of time, but not curative. At this time, chemotherapy is generally used at the later stages of metastatic prostate cancer.

Hormonal Therapy
The primary strategy of hormonal therapy is to decrease the production of testosterone by the testes or block the actions that testosterone has on the prostate cells. Hormonal therapy cannot cure prostate cancer. Instead, it slows the cancer's growth and reduces the size of the tumors. The types of hormonal therapy that may be used in prostate cancer are orchiectomy and hormonal drug therapy.

Orchiectomy
Orchiectomy or surgical castration is the surgical removal of the testes, which produce about 95% of the body's testosterone. Since the testes are the major source of testosterone in the body, this procedure is a form of hormonal therapy. Surgical castration is generally reserved for patients with hormonal-responsive advanced metastatic prostate cancer who do not choose hormonal drug therapy.

Hormonal Drug Therapy
There are drugs that prevent the production or block the action of testosterone and other male hormones. Three classes of drugs most commonly used as hormonal therapy in prostate cancer include

• LHRH analogs (luteinizing hormone-releasing hormone analogs) or medical castration—a class of drugs that prevent testosterone production by the testes
• LHRH antagonists—another class of drugs that prevent testosterone production by the testes (yet work differently than LHRH analogs)
• Antiandrogens (also called nonsteroidal antiandrogens)—a class of drugs that block the action of testosterone at the prostate

Another type of hormonal therapy involves using two hormone therapies to block testosterone action and pairs an antiandrogen with an LHRH analog or orchiectomy. This combination therapy is called combined androgen blockade (CAB), total androgen blockade (TAB) or maximal androgen blockade (MAB). LHRH analogs or orchiectomy prevent testosterone production from the testes; however, neither suppresses the production of androgens that are secreted by the adrenal glands. Therefore, there is still a small amount of androgen present in the body after LHRH analog administration or orchiectomy. Antiandrogens may be added to block the actions of the remaining androgens.

Hormonal therapy is most commonly used to treat locally advanced or advanced metastatic prostate cancer. In locally advanced prostate cancer, hormonal therapy may be used in combination with radiation therapy.

Radiation Therapy
Radiation therapy may be used for pain relief in prostate cancer that has spread to the bones or that is no longer responding to hormonal therapy.

Chemotherapy
Chemotherapy drugs are usually administrated by a medical oncologist in an outpatient setting. These drugs circulate throughout the body in the bloodstream and may kill any rapidly growing cells, including healthy ones. Chemotherapy drugs are carefully controlled in both dosage and frequency so that cancer cells are destroyed while minimizing the risk to healthy cells. Chemotherapy is generally reserved for patients with advanced stage prostate cancer that no longer responds to hormonal therapy.

Investigational Therapy (Clinical Trials)
For some patients, investigation therapy may be an appropriate option.

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