How Prostate Cancer Is Treated
The treatment options for prostate cancer can vary based on many factors, including the aggressiveness of the tumor, the stage of the disease, personal preferences, and more. Curative options may include surgery or radiation therapy. With less aggressive tumors, watchful waiting (active surveillance) with treatment begun only if the cancer progresses may be an option. There are also a number of different therapies that can be used to control the growth of these cancers, including hormone therapies, chemotherapy, and newer treatments such as immunotherapy. In addition, many alternative treatments are being evaluated in clinical trials.
Understanding Your Options
Many prostate cancers are non-aggressive, and if, left alone, would not pose a problem over the long term. With these tumors, observing the tumor (active surveillance) and treating the tumor only if it shows signs of progressing may be an option.
With early prostate cancers that show signs of being aggressive, and in people who are able to tolerate treatments such as surgery, the aim of therapy is usually a cure. Surgery and radiation are considered standard treatment options, though alternatives—such as proton therapy, cryoablation, and high intensity focused ultrasound—are being evaluated.1
With more advanced prostate cancers (including metastatic tumors), or in those who are unable to tolerate curative treatments, the aim is usually to control the growth of the cancer for as long as possible. Systemic treatments may include hormonal therapies, chemotherapy, immunotherapy, or a clinical trial. Keep in mind that, unlike many cancers, advanced prostate cancer can often be controlled for a long period of time with these treatments (often decades).2
Knowing whether your cancer is low-grade, intermittent-grade, or high-grade is critical in making the best choices about treatment.
Many men are more likely to die with prostate cancer than from prostate cancer, and in many cases, the goal is to treat the disease while preserving the best quality of life.3
Active surveillance is often referred to as though some use these terms to describe slightly different approaches.4
With active surveillance, a man chooses not to have his cancer actively treated at the current time. PSA levels are checked at specific intervals (for example, every six months), with a digital rectal exam performed yearly, and second and third biopsies done six to 12 months and two to five years after beginning surveillance. (The timing can vary depending on characteristics of the cancer.) If at any time the cancer appears to progress, active treatment is then started.
Active surveillance is most often used with early-stage, slow-growing tumors, for which the side effects of treatment (such as erectile dysfunction and incontinence) outweigh the potential benefits of treatment.
It is used most often with Gleason 6 tumors, but may also be used for men with tumors that have higher Gleason scores who may decide the side effects of treatment outweigh benefits for personal reasons, or due to other health conditions.
It’s extremely important to note that active surveillance is viewed as a standard treatment method by many of the cancer organizations. It’s thought that around a third of men who are “treated” with active surveillance will require active treatment at some point in the future, but waiting to see if a person falls in that category does not carry the risk of the disease suddenly metastasizing and causing death.
When a physician makes a distinction between this and watchful waiting, he or she is typically using the latter term to refer to a similar approach with no or less frequent testing. This may be an option for treatment for those who are expected to live less than five years, for example. In this case, follow-up tests are not usually done unless symptoms develop, and if this occurs, treatment may be initiated at that time. There are a number of other reasons why this option may be chosen as well.
Surgery can help cure prostate cancer if it hasn’t spread beyond the prostate gland. Radiation can also be curative. Other surgical procedures may be used for other reasons, such as symptom control.
In a traditional prostatectomy, an incision is made midline in the abdomen, between the belly button (umbilicus) and pubic bone. A surgeon uses this access point to manually remove the prostate gland as well as surrounding tissues, such as the seminal vesicles. In a radical retropubic prostatectomy, pelvic lymph nodes may be removed as well.5
Surgeons can also achieve this treatment goal with what’s known as a robotic prostatectomy. Instruments are inserted into several small incisions in the lower abdomen, which are moved by a robot controlled by a surgeon rather than the surgeon’s hands themselves.
This is less invasive than the manual procedure, gives the surgeon better visibility, and may have several other advantages, including less of a risk of blood loss, shorter recovery time, and faster removal of the catheter (one is required for either procedure).
Robotic prostatectomy is a highly specialized procedure, and there is a steep learning curve in learning the technique. For those who choose this option, you must find a surgeon specially trained to perform the procedure and has a significant level of experience in doing so.
The risk of sexual side effects as well as incontinence is similar among the above options.5
After the surgery is performed, the prostate tissue is sent to a pathologist to determine if all of the tumor was removed. With prostate cancer, this can be challenging. The rectum and bladder lie within millimeters of the prostate gland and cannot be removed with surgery. This means that sometimes a surgeon will cut through a tumor rather than around the tumor, leaving prostate cancer cells behind.
When cancer cells are left behind (when surgical margins are positive) the risk of the cancer recurring is around 50 percent. Further treatment will depend upon the aggressiveness of the tumor but may include careful monitoring, radiation treatment to the prostate fossa, hormonal therapy, and/or chemotherapy.
Transurethral Resection of the Prostate (TURP)
In this procedure, a resectoscope is inserted in the urethra, and an electrically activated wire loop is used to burn away prostate tissue.
A TURP is not done as a curative treatment for prostate cancer. It is sometimes recommended as a palliative procedure (to help symptoms but not cure the disease) for cases. It may also be done to treat BPH (benign prostatic hyperplasia) with symptoms that persist despite treatment.5
An orchiectomy is the surgical removal of both of the testicles. Since the testicles produce of the testosterone in the body, this procedure greatly reduces the amount of the testosterone in the body. (Just as normal prostate cells are driven by testosterone, the hormone acts as the fuel that drives the growth of prostate cancer cells.)
After a prostatectomy (either manual or robotic) men will have a in place. The catheter will usually be left in place for at least 24 hours but may need to remain in place for up to two weeks while swelling and inflammation resolves. During the first few days, it’s normal to pass some blood or small clots. Your surgeon will instruct you in following discharge, which can reduce your risk of infection or other complications.
In general, men can return to their normal activities within four weeks of surgery but may be able to do so in as little as a week following outpatient procedures.
As with any surgical procedure, there is a risk of side effects and complications following a prostatectomy. Possible complications, which may be temporary, include the following. Most men do not experience all of these:
- Difficulty urinating
- Urinary incontinence, though there are a number of hat can help this
- Erectile dysfunction
- (ejaculation into the bladder rather than out of the penis)
- Surgical injury to structures surrounding the prostate
- an uncommon but potentially serious complication of TURP surgery that results from a serious drop in serum sodium due to flushing of fluids during the procedure
- With a radical prostatectomy, roughly 20 percent of men will note a change in size or girth of the penis of 15 percent or more
Radiation to damage and kill cancer cells and may be used as the primary treatment for prostate cancer as an alternative to surgery (curative therapy); after surgery as an adjuvant therapy to treat any remaining cancer cells that remain; or as a palliative treatment to improve symptoms, but not to cure the cancer.6 Radiation can be very helpful to treat areas of bone metastases due to the disease.
Radiation therapy may be given externally or internally, and oftentimes the two methods are used together.
External Beam Radiation Therapy
In this procedure, you are positioned on an exam table and radiation is delivered through the outside of the body and focused on the prostate gland and surrounding tissue. A gel called spaceOAR may be placed between the rectum and prostate to reduce the risk of rectal burns, but techniques for delivering radiation have improved remarkably in recent years and cause much less damage to surrounding normal tissues than in the past.6
Brachytherapy (Radioactive Seed Placement)
Internal radiation therapy, also known as brachytherapy, radioactive seed placement, or simply “seed implant,” may be used as the primary treatment for prostate cancer in the early stages, or in combination with external radiation therapy when there’s an increased risk of cancer spreading beyond the prostate. In this procedure, small seeds or pellets of radiation are implanted in a tumor. Radioactive seeds may be either temporary or permanent.
Traditional brachytherapy is used mostly for low-grade or slow-growing tumors. For men with low to intermediate risk prostate cancer, low-dose brachytherapy may be used alone as the primary treatment for prostate cancer according to of the American Society of Clinical Oncology and Cancer Care Ontario.
High-dose brachytherapy (HDR) is often used for more advanced tumors. In HDR, a catheter is placed into the prostate between the scrotum and anus, and a needle containing the rice-sized radioactive seeds is then placed inside the catheter and kept in place for five to fifteen minutes. Generally one to four treatments are given over two days.6
When used as a curative therapy, radioactive seed implantation results in higher cure rates than standard beam radiation. In combination, these treatments appear to lower the risk of relapse at nine years post-treatment by 20 percent, relative to men who have external beam radiation alone. It’s thought that for men with intermediate- or high-risk prostate cancer who choose external beam radiation therapy, either a low-dose or high-dose brachytherapy boost should be offered.7
Brachytherapy is not as effective in men who have an enlarged prostate gland.
Side effects of both forms of radiation may include painful urination, frequency, and urgency; incontinence; loose stools; bleeding or pain when passing stools. These symptoms are usually mild to moderate and improve over time. Erectile dysfunction may occur but is more often seen in older men with this pre-existing issue. When it occurs in others, it tends to resolve quickly and completely after treatment.
With external radiation, redness, a rash, and blisters may form on the skin overlying the prostate.
When radioactive seeds are left in place in brachytherapy, cautions are needed as others who are nearby may be affected by the radiation. Men are usually instructed to stay away from pregnant women or small children,6 sometimes for a significant period of time. It’s also important to note that the radiation may be strong enough to be picked up at airport screening.
Other Local Therapies
In addition to surgery and radiation therapy, there are a few other local treatments that may be used with a curative intent.
Proton Beam Therapy
is similar to conventional radiation therapy in that it uses high energy to destroy cancer cells. However, the rays—which are composed of accelerated protons, or positive particles—pass through tissue directly to a tumor and stop, as opposed to continuing on past the prostate gland where they can damage normal tissue (as is the case with regular radiation).
Proton therapy appears to about as effective as traditional radiation but is thought to cause less damage to normal, healthy cells.
Proton therapy is relatively new compared with some other treatments, and its role as primary therapy (monotherapy) for prostate cancer is promising but still unclear.6
Cryosurgery or cryoablation is a technique in which argon and helium are used to freeze the prostate. It is used in the operating room while men are under anesthesia.
Used less than other treatments, cryotherapy can only be used on tumors that are contained within the prostate gland and only present in one location. It may also be used after failed radiation treatment.8
The positive benefits may include a more rapid recovery and shorter hospital stay than surgery (prostatectomy), although the technique carries a greater risk of erectile dysfunction.
High-Intensity Focused Ultrasound (HIFU)
High-intensity focused ultrasound (HIFU) uses ultrasound to generate heat and kill cancer cells. It’s thought that HIFU may be less effective than other common treatments, but surgery or radiation therapy may be subsequently used if it is not successful.
Medications can be used to reduce the amount of testosterone present in the body (just like orchiectomy) or interfere with the ability of testosterone to act on prostate cancer cells.
Hormone therapy (androgen deprivation therapy) does not cure prostate cancer but is a mainstay for controlling its growth—sometimes for an extended period of time.
Hormone therapy can be used for men who would otherwise not tolerate other treatments. It can also be used before radiation, to reduce the size of a prostate cancer and make it easier to treat (neoadjuvant therapy), or after, to help “clean up” any remaining cancer cells to reduce the risk of recurrence or relapse (adjuvant therapy). Finally, it can be used for men who have prostate cancers that have recurred after primary treatment or who have cancers that have metastasized (spread) to other regions of the body.9
Luteinizing releasing hormone (LH-RH) analogues or agonists block the signal that tells the testicles to make testosterone, reducing overall production. These drugs are a medical version of an orchiectomy, and the treatment is sometimes referred to as medical castration.9 In contrast to orchiectomy, however, treatment is reversible.
Drugs in this category include:
- Lupron (leuprolide)
- Zoladex (gosrelin)
- Trelstar (triptorelin)
- Vantas (histrelin)
When LH-RH agonists are first used, they often cause an increase in testosterone levels. To counteract this effect, and anti-androgen medication is often used during the first weeks of treatment.
LH-RH antagonists also reduce the production of testosterone by the testicles but do so more rapidly than LH-RH agonists.
Drugs in this category include:
- Firmagon (degarelix)
Unlike LH-RH agonists and antagonists, CYP17 inhibitors interfere with the production of testosterone by the adrenal glands (small endocrine glands that sit atop the kidneys). They do so by blocking the enzyme CYP17, which is needed in the reaction that produces androgens.
There is one drug in this category that is approved for use in the United States.9
- Zytiga (abiraterone)
There are others (such as orteronel, galeterone, VT-464) that are in clinical trials and more in development. Ketoconazole, an antifungal with CYP17 inhibitory properties, is sometimes used off-label for prostate cancer.
is used along with the medications discussed above to block the production of all testosterone in the body and is used primarily in advanced/high-risk and metastatic prostate cancer. Side effects are usually mild and include problems with potassium levels in the blood. It is sometimes given along with prednisone to reduce these problems, but corticosteroids like prednisone. The medication also enhances the effect of some cholesterol-lowering medications.
Some anti-androgen medications bind to the androgen receptor on prostate cancer cells so that testosterone cannot, preventing cell division and growth.
- Eulexin (flutamide)
- Casodex (bicalutamide)
- Nilandron (nilutamide)
Others block the signal from the receptor to the nucleus of the cell, achieving the same result.
While not often used by themselves in the United States, these include:
- Xtandi (enzalutamide)
- Earleada (apalutamide)
Benign Prostatic Hypertrophy (BPH) Medications
The medications Avodart (dutasteride) and Proscar (finasteride) block dihydrotestosterone.
Avodart or Proscar may be used in prostate cancer:
- For men with Gleason 6 tumors to suppress tumors or cause them to regress
- Along with Lupron or Casodex to make these drugs work better
- To help maintain men on active surveillance and reduce the risk they will need surgery or radiation
When used for men who do not have prostate cancer, these drugs appear to reduce the risk of developing the disease, though there is an increased incidence of high-grade cases in those who do end up diagnosed.
Side Effects and Considerations
Most of the side effects related to hormone therapy are secondary to the reduction of testosterone in the body. It’s important to note that one’s physical appearance does not change due to these treatments, nor does the voice change. Side effects may include:
- Hot flashes
- Erectile dysfunction
- Decreased sex drive
- Breast enlargement (gynecomastia)
- Weight gain
- Reduced muscle strength
- Reduced bone density (osteopenia and osteoporosis)
To reduce these side effects, hormone therapy may sometimes be used intermittently, with breaks from the drug to improve quality of life.
Since testosterone “feeds” prostate cancer, some people have wondered whether men with prostate cancer can take testosterone; replacement hormone can help low sex drive, erection issues, fatigue, and more. Many people would quickly say “no,” but there are some situations in which this is possible:
- With low-grade or benign tumors (the types that would never spread such as Gleason 6 tumors)
- For men who have had surgery or radiation therapy and are felt to be cured, after a waiting period of two to five years
- For men who have relapsed after surgery or radiation who are receiving intermittent Lupron, though experts’ opinions are divided
- For men with prostate cancer who have very severe weakness or muscle loss; the risks of not treating with testosterone may outweigh the risk of the cancer growing.
Chemotherapy drugs work by killing rapidly dividing cells such as cancer cells, although normal cells can also be affected. Chemotherapy may both extend life and reduce symptoms for men living with prostate cancer. That said, it cannot cure the disease.
Chemotherapy drugs used for prostate cancer include:
- usually the first-choice chemotherapy drug
- Jevtana (cabazitaxel), an enhanced form of chemotherapy that can be used in men who become resistant to Taxotere
- Novantrone (mitoxantrone)
- Emcyt (estramustine)
Chemotherapy is usually used for prostate cancers that have spread beyond the prostate gland and are no longer responding to the hormonal therapy drugs, but this is changing.10
A published in The New England Journal of Medicine found that men who had hormone-sensitive tumors and were treated with Taxotere and Lupron survived much longer than men who were treated with Lupron alone. Due to these findings, chemotherapy is now recommended earlier, prior to the development of hormonal resistance for men with significant metastatic disease.
Some of the common side effects of chemotherapy include:
- Hair loss
- This can include a low white blood cell count (chemotherapy-induced neutropenia), a low red blood cell count (chemotherapy-induced anemia), and a low platelet count (thrombocytopenia).
- Numbness, tingling, and pain in the hands and feet are common, especially with drugs such as Taxotere and Jevtana. While most of the side effects of chemotherapy resolve shortly after treatments are completed, peripheral neuropathy may persist.
- Nausea and vomiting: Medications can now control these symptoms so that many men experience little or no nausea.
Biological therapy, also called uses your body’s immune system to fight cancer cells. One type, called has been developed to treat advanced, recurrent prostate cancer.11
Provenge is a therapeutic cancer vaccine that is approved for men with prostate cancer that have developed resistance to hormone therapies and have either no symptoms or only mild symptoms of the disease. Like vaccines that stimulate the body to fight off bacteria or viruses, Provenge stimulates a man’s body to fight off cancer cells.
Provenge consists of autologous (coming from the patient himself) peripheral blood mononuclear cells, including antigen presenting cells (APCs), that have been activated during a defined culture period with a specific stimulating product.
Provenge is thought to work through APCs to stimulate T-cell immune response targeted against prostatic acid phosphatase (PAP), an antigen that is highly expressed in most prostate cancer cells, as this treatment can induce the recruitment of CD4 and CD8 T cells to the tumor microenvironment.12
With this therapy, a man’s blood is first withdrawn (in a procedure called plasmapheresis that is similar to dialysis) and his T regulatory cells are isolated. The Tregs are then exposed to prostatic acid phosphatase, a molecule found on the surface of prostate cells, training the Tregs to recognize these cancer cells as invaders. The cells are injected back into the man to do their job.
Monitoring progress can be challenging for men with Provenge, as PSA levels and the size and extent of tumors does not change. Yet, this can extend survival by several months with minimal side effects.11 It has more benefit when the medication is started sooner, as the effect is cumulative over time.
Combining radiation therapy with immunotherapy appears to make the treatment work better via a process called the abscopal effect. The dying cells from radiation help the immune cells identify tumor-specific molecules so they can hunt them down in other areas of the body.