The outlook for men diagnosed with prostate cancer has never been brighter. Doctors now have a variety of ways to treat prostate cancer, including surgery, radiation, and drugs that slow the growth of cancer cells. Both the safety and effectiveness of prostate cancer treatments has been steadily improving.
That’s good news, of course. But with so many different approaches to prostate cancer treatment, each with its own benefits and risks, weighing your options and choosing the most appropriate treatment can be complicated. The right treatment for each man depends on their stage of cancer and how aggressively the cancer cells are growing. For example, a man with early prostate cancer that is slow growing may opt for watchful waiting. Another man with early prostate cancer that is growing aggressively might choose surgery plus radiation, or another combination of therapies.
Here are the basics you need to know about the leading treatments for prostate cancer.
Watchful Waiting: Active Surveillance of Prostate Cancer
Thanks to screening and early detection, many prostate cancers are first detected long before they pose a threat. Indeed, many of the cancers detected by PSA tests and biopsies prove to be very early cancers or so slow-growing that they never pose a life-threatening danger.
Because of early diagnosis, the best approach for a growing number of men is to monitor the cancer for signs that it is getting worse. Called active surveillance or “watchful waiting,” this strategy allows men with early-stage or very slow growing prostate cancer to avoid treatment and its side effects -- or actively monitor the disease and to take action if the cancer grows or spreads.
Experts say this approach could be appropriate for 40% of all men diagnosed with the disease in the U.S.
“Active surveillance is a choice to consider if your cancer is a less aggressive type, occurs only in a small part of the prostate gland, and has not spread outside the gland,” says Peter Carroll, MD, MPH, professor and chair of urology at the University of California, San Francisco. Other good candidates for active surveillance are men who are older or in poor health, when the risks of surgery or radiation may outweigh the benefits.
Active surveillance doesn’t mean doing nothing, Carroll says. Men are regularly monitored with PSA tests, digital rectal exams, imaging, and follow-up biopsies to make sure the cancer hasn’t progressed. The use of ultrasound, CT, bone scans, or MRI might also be used to watch for disease growth and the need for treatment.
In some cases, men who choose active surveillance may eventually need treatment. Others may not.
The risk, of course, is that by waiting you might miss the window of best opportunity for treating the cancer. “Still, by carefully monitoring the cancer and a patient’s condition, we think that risk is very small,” says Carroll, who is directing a large study of men who have opted for active surveillance.
Types of Radiation Treatment for Prostate Cancer
Radiation therapy has been used to treat prostate cancer for many years. Recent advances allow doctors to target prostate cancer cells more precisely and with a higher dose of radiation, lowering the risk of unwanted side effects while at the same time improving effectiveness.
External beam radiation treatment targets prostate cancer with high-energy X-rays delivered from outside the body. It is one of the main treatment options for prostate cancer confined to a small area. External beam radiation treatment typically consists of treatments five days a week over a period of eight weeks. Each treatment takes about 15 to 25 minutes. Because there is no pain, anesthesia is not required. Side effects can include sexual problems, fatigue, loss of appetite, and urinary or rectal urgency and bleeding.
Radioactive seed implants deliver radiation via tiny radioactive metal pellets or "seeds" that are implanted into the prostate gland, where they release low-doses of radiation over a period of several months. Toward the end of the year the pellets lose their radioactivity . The procedure, called brachytherapy, is done under general anesthesia and typically takes an hour or two. Between 40 and 150 seeds are usually implanted, each about the size of a grain of rice. Implants pose less risk of damage to surrounding tissues in the rectum than external beam radiation, but they may have a higher risk of impairing urinary function than external beam radiation. Side effects can also include sexual problems.
Proton therapy is a type of external radiation that uses positively-charged particles to treat the cancer. This type of radiation therapy may allow your doctor to reach tissues deeper within the body.
Surgery for Prostate Cancer
Many different approaches are used, each with its own risks and benefits. As with any surgery, the outcome depends in large measure on the expertise of the surgeon. It’s crucial to find a surgeon with extensive experience in performing the type of surgery you choose.
Open radical retropubic prostatectomy involves removing the prostate through a cut made in the lower abdomen. This technique allows surgeons to remove not only the prostate but also any nearby lymph nodes that have become cancerous. Nerve-sparing techniques are now widely used to preserve urinary control and sexual function. The operation typically requires two or three days in the hospital. Most men need a urinary catheter in place for one two weeks after the surgery. For cancers confined to the prostate, radical prostatectomy remains the most effective way to remove cancer.
Radical perineal prostatectomy involves removing the prostate through a cut made in the perineum, the area between the anus and scrotum. This approach typically causes less bleeding, but surgeons are unable to remove nearby lymph nodes, making it useful only when the cancer is confined to the prostate.
Robot-assisted radical prostatectomy is performed through five or six tiny “keyhole” cuts in the lower abdomen. Manipulating robot-like fingers that pass through these cuts, surgeons can remove the diseased prostate with minimal disturbance to healthy surrounding tissue. The technique also allows surgeons to remove cancerous lymph nodes. The principle advantage of this robot-assisted prostatectomy is a shorter hospital stay and faster recovery time from surgery.
Laparoscopic prostatectomy involves your surgeon making four or five very small cuts -- about a half inch each -- in the abdomen. The surgeon inserts tiny cameras and surgical tools through the cuts to remove the cancerous tissue.
Nerve-sparing surgery is performed by cutting prostate tissue carefully away from the nerve bundles without damaging them. This surgical technique was developed to potentially prevent erection difficulties that may occur after prostate surgery.
High-intensity focused ultrasound involves delivering high energy to the affected area using ultrasound waves. Cancer cells heat up and are destroyed.
Cryosurgery for Prostate Cancer
Cryotherapy kills prostate cancer by freezing prostate tissue. But so far, the technique has not been widely adopted because of a high risk of damage to the rectum or urethra from freezing. Loss of sexual function is also much more likely after cryosurgery than after other treatments.
In cryotherapy, surgeons pass liquid nitrogen or argon gas through narrow rods inserted into the prostate. Cryosurgery can be performed in two to three hours, and patients are often able to leave the hospital the same day.
Hormone Therapy for Prostate Cancer
Male sex hormones, mostly testosterone, provide the fuel that drives prostate cancer growth. The goal of hormone therapy is to deprive prostate cancer cells of that fuel. Hormone therapy is used to treat advanced prostate cancer, but it can also be used to shrink larger tumors, making other treatments easier. Hormone therapy does not kill cancer cells but can significantly shrink tumors and slow any further growth. Side effects include loss of sex drive, impotence, nausea, diarrhea, and fatigue. Hormone therapy takes three forms:
ADT or androgen deprivation therapy. These medications are injected into the buttocks either once a month, once every three to four months, or once a year, depending on the specific drug. If these treatments are used instead of surgery, these drugs must be administered regularly for life.
Anti-androgens prevent prostate cancer cells from using testosterone. They are given in pill form. This type of therapy is not given by itself. It is used in combination with surgery or other hormonal therapies.
Orchiectomy involves the removal of the testicles, which reduces testosterone production by about 90%. (About 10% of testosterone is produced by the adrenal glands.) This approach is sometimes chosen by older men who do not want the inconvenience or expense of taking medications. Silicone implants are placed within the testicular sac to preserve a natural look.
Combination Therapy for Advanced Prostate Cancer
To treat aggressive cancers that have spread beyond the prostate gland, doctors may recommend various types of therapies.
ADT and anti-androgens are often prescribed together, for example, to block the maximum amount of testosterone from reaching prostate cancer cells. Hormone therapies are also increasingly used in combination with radiation therapy or surgery. Doctors sometimes prescribe hormones to shrink the prostate cancer before delivering radiation.
There’s growing evidence that combination therapy improves survival time for men with aggressive cancers. In 2009, researchers at the Mount Sinai Medical Center in New York reported results from a study of combined radioactive seed implants, external beam radiation, and hormonal therapy. The 181 men in the study, with a median age of 69, all had Gleason scores of 8 or higher, indicating very aggressive tumors. Even in this high-risk group, prostate cancer survival rates after eight years were 87% with combined therapy.
Provenge (sipuleucel-T) is a "vaccine" for advanced prostate cancer. It doesn't cure prostate cancer but helps prolong survival. Provenge isn't your everyday vaccine. It's an immune therapy created by taking immune cells from a patient, genetically engineering them to fight prostate cancer, and then putting them back into the patient. It's approved only for treatment of patients with few or no prostate cancer symptoms whose cancer has spread outside the prostate gland and is no longer responding to hormone therapy. The most common side effect is chills, which occurs in more than half of the men that receive Provenge. Some other common side effects include fatigue, fever, back pain, and nausea.
One drug, Xofigo, is approved for use in men who have advanced prostate cancer that has spread only to the bones. Candidates should have also received therapy designed to lower testosterone. Xofigo, given by injection once a month, works by binding to minerals within bones to deliver radiation directly to bone tumors. A study of 809 men showed that those taking Xofigo lived an average of 3 months longer than those taking a placebo.
Another treatment for cancer that has spread and doesn't respond to hormone therapy is the medicine Zytiga. The drug is taken with the steroid prednisone and may help prolong survival. Common side effects include high blood pressure, fatigue, joint swelling or pain, diarrhea, and fluid retention.