How Is Prostate Cancer Treated?

Prostate cancer begins when cells in the prostate gland change (mutate) and grow out of control, forming a lump or mass called a tumor. Treatment options for prostate cancer depend on the type and stage of the cancer, your age and overall health, and personal preferences.

For slow-growing prostate cancers, a treatment approach called active surveillance may be recommended. This means that treatment will only begin if the cancer progresses. Standard treatments include surgery, radiation therapy, hormone therapy, and chemotherapy. Newer approaches, like cryotherapy and immunotherapy, may be an option for certain types of tumors. 

A multidisciplinary group of healthcare providers called a cancer care team will recommend a treatment plan. The goal of treatment is to either cure the cancer or manage symptoms and prolong your life, depending on the stage of the disease. This team may include a urologist (a doctor who specializes in conditions affecting the urinary tract), a radiation oncologist (a doctor who specializes in treating cancer with radiation therapy), a medical oncologist (a doctor who specializes in cancer), nurses, and other healthcare providers. 

Active Surveillance

Active surveillance is an approach that involves holding off on treatment until there are signs the disease has progressed. Prostate cancer is often slow-growing and, for some people, the side effects may outweigh the benefits of treatment. Prostate cancer is considered to be low-risk when the tumor is small and confined to the prostate, does not cause symptoms, and when prostate-specific antigen (PSA) blood tests indicate PSA levels below 10. 

With active surveillance, the tumor will be closely monitored and treatment will only begin if it grows. If you choose this option, your cancer care team will want to see you for frequent check-ups, which may include: 

• A PSA blood test and digital rectal examination (DRE) every 6 months 
• Prostate biopsy every 1 to 3 years
• Imaging tests (e.g., transrectal ultrasound) every 1 to 3 years 

Watchful waiting is a term that is often used interchangeably with active surveillance, but the two are different. Watchful waiting is often recommended for older adults or people with life-threatening illnesses who may not benefit from prostate cancer treatments. With this approach, follow-up tests to monitor the tumor usually aren’t done. Instead, treatments to manage symptoms may be recommended. 

Surgery 

Surgery is a common treatment approach for prostate cancers that are limited to the prostate gland. This involves usually involves the removal of the prostate gland and sometimes the seminal vesicles (the glands that produce the fluids that eventually turn into semen) and pelvic lymph nodes (part of the body’s immune system that filters lymphatic fluid).

The type of surgery your healthcare provider recommends will depend on the stage of the disease and your overall health.

As with any surgical procedure, prostate surgeries have risks and side effects. Not everyone experiences these complications, and many are temporary:

• Difficulty urinating 
• Urinary incontinence (loss of bladder control)
• Erectile dysfunction 
• Changes in orgasm (orgasm is still possible, but ejaculation will not occur)
• Loss of fertility 
• Change in penis length 

Radical (Open) Prostatectomy

A radical prostatectomy is used when cancer is thought to only be in the prostate gland. It involves the surgeon making an incision in your abdomen from the belly button to the pubic bone. You will be placed under anesthesia so you are not awake and won’t feel pain during the procedure. Once the incision is made, the surgeon will remove the prostate gland and seminal vesicles. Lymph nodes in the pelvis may also be removed.

Laparoscopic or Robotic Prostatectomy 

A laparoscopic or robotic prostatectomy are minimally-invasive procedures that typically have a shorter recovery time. For a laparoscopic procedure, the surgeon makes several small incisions in the abdomen and inserts special long instruments—one of which has a small camera on the end so the surgeon can see inside your body—to remove the prostate. 

Robotic prostatectomy involves the use of robotic instruments to remove the prostate. The surgeon uses a control panel to direct the robotic instruments to perform the surgery and remove the prostate gland. 

Transurethral Resection of the Prostate (TURP)

A TURP procedure is sometimes recommended to relieve symptoms of prostate cancer, not to cure the disease. In this procedure, a surgeon inserts a resectoscope (narrow tube) into the urethra to cut and remove the prostate, or burn away prostate tissue.

Radiation Therapy 

Radiation therapy uses high-energy X-rays to kill cancer cells or prevent them from growing. This may be recommended as a standalone treatment or used in combination with hormone therapy. Different types of radiation therapy for prostate cancer include external-beam radiation therapy and brachytherapy (internal radiation therapy).

Both external and internal radiation therapy can cause side effects. These tend to be mild or moderate and usually resolve once treatment is complete:

• Bowel problems (rectal pain, bleeding, diarrhea) 
• Urinary problems (frequent urination, pain when urinating) 
• Erection problems
• Fatigue 

External-beam radiation therapy

External-beam radiation therapy uses a machine outside of the body to focus a beam of X-rays (radiation) on the prostate gland. This type of radiation is often used for early-stage prostate cancer to try to cure the disease or to relieve pain if cancer has spread to the bones. Radiation treatments are given five days a week for several weeks. Each treatment takes a few minutes, but the time it takes to get you set up for the treatment usually takes longer.

Brachytherapy

Brachytherapy is a form of internal radiation therapy that involves placing radioactive seeds directly into the prostate. These seeds give off radiation where they are inserted to kill off cancer cells. Low-dose radioactive seeds work up to a year after insertion and are left in the prostate permanently. High-dose seeds are left in the body for about 30 minutes and may need to be repeated 1 to 4 times.

Other Focal Therapies 

Focal therapies are minimally-invasive treatment options for low to medium-risk prostate cancers. These may be used in place of surgery and radiation to try to cure prostate cancer. 

Cryotherapy 

Cryotherapy uses very cold temperatures to freeze and kill cancer cells. For this procedure, the doctor uses transrectal ultrasound (TRUS) to guide and insert probes (needles) through the skin between the scrotum and rectum to reach the prostate. Cold gasses are sent through the probes to freeze and destroy the tumor and prostate tissues. 

Side effects of cryotherapy can include blood in the urine, pain in the rectum and bladder, frequent urination, and urinary incontinence. Most side effects are temporary, but the freezing process may damage nerves near the prostate that control sexual function and lead to erectile dysfunction.

High-Intensity Focused Ultrasound

High-intensity focused ultrasound (HIFU) uses ultrasound waves to generate heat and destroy cancer cells. HIFU may be less effective than standard treatments; however, some people may opt for this treatment before trying radiation therapy or surgery because HIFU is minimally invasive and does not damage healthy areas of the prostate.

Hormone Therapy 

Prostate cancer cells use testosterone and other sex hormones in order to grow. Hormone therapy, or androgen deprivation therapy (ADT), is used to block or lower the amount of sex hormones, essentially starving prostate cancer cells of the fuel they need to survive.

Hormone therapy may be administered surgically, orally, or through injection. Different types of hormone therapies for prostate cancer include:

• Orichiectomy: This is surgical castration that involves removal of the testicles, where most sex hormones are made. Most prostate cancers stop growing or shrink after the procedure. The effects are permanent and cannot be reversed.
• LHRH agonists: Luteinizing hormone-releasing hormone (LHRH) agonists are drugs that reduce the amount of testosterone produced by the testicles. These drugs are small implants that are injected or placed under the skin once a month or once every 6 months. 
• LHRH antagonists: Luteinizing hormone-releasing hormone antagonists work similarly to LHRH agonists. These drugs lower testosterone levels rapidly and may be given as a monthly injection or taken orally once a day.

Side effects of hormone therapy include a low sex drive, erectile dysfunction, shrinkage of the penis and testicles, hot flashes, weight gain, fatigue, and loss of muscle mass. These effects are usually short-term and stop once therapy is completed. The long-term risks of hormone therapy include bone loss, heart disease, and diabetes.

Chemotherapy 

Chemotherapy (chemo) uses drugs to destroy cancer cells in the body. Chemo is recommended if prostate cancer has spread to other areas of the body. It is not a curative treatment for prostate cancer, but it may stop cancer cells from growing and spreading and help people live longer. Chemotherapy drugs used to treat prostate cancer include: 

• Taxotere (docetaxel)
• Jevtana (cabazitaxel)
• Novantrone (mitoxantrone)
• Emcyt (estramustine)

Chemo is usually administered via intravenous (IV) infusion, though some drugs are taken orally. Chemotherapy regimens usually involve repeating cycles that include a period of treatment followed by a period of rest.

Side effects of chemo drugs vary depending on the person, the drug(s) used, and the length of treatment. Fatigue, mouth sores, nausea and vomiting, diarrhea, and bruising or bleeding more easily are common side effects. Most go away once treatment is completed, but some may linger for months or even years. Your doctor can prescribe medications to help manage some side effects.

Immunotherapy

Immunotherapy (biologic therapy) uses medicines that stimulate the body’s immune system to attack cancer cells. One type of immunotherapy, called Provenge (sipuleucel-T), is a vaccine that is used to treat advanced prostate cancer that has stopped responding to hormone therapy and causes few (or no) symptoms. Spiuleucel-T does not shrink the tumor, lower PSA levels, or prevent cancer from growing, but it can prolong life. 

The vaccine is tailored for each individual patient by mixing a person’s white blood cells with an enzyme produced by the prostate called prostatic acid phosphatase. The mixture is then given intravenously every two weeks for a total of three treatments. 

Targeted Therapy 

Targeted therapy uses drugs that identify and attack specific cancer cells without harming healthy cells. Poly(ADP)-ribose polymerase inhibitors, or PARP inhibitors, are drugs that block an enzyme that normally helps cells repair DNA damage. These drugs are designed to kill cancer cells by preventing them from repairing their damaged DNA. 

PARP drugs may be used if a person has BRCA1 or BRCA2 gene mutations and when other treatments have been ineffective. PARP inhibitors used to treat metastatic prostate cancer include:

• Lynparza (Olaparib)
• Rubraca (Rucaparib)

PARP inhibitors are taken orally and may cause side effects such as joint and muscle pain, anemia, and nausea. 

Clinical Trials 

Clinical trials for prostate cancer are research studies that test new and potentially better ways to treat the disease. Some people with prostate cancer may choose to participate in a clinical trial to get early access to promising new therapies. Others may join a clinical trial if standard treatments have been ineffective for their cancer. 

Talk to your healthcare provider if you are interested in joining a clinical trial. They can help you decide if a clinical trial is right for you, and help you find one that may be a good fit.

Living With and Managing Prostate Cancer

Prostate cancer and its treatment can impact every part of your life. You may be feeling a wide range of emotions, from shock to fear and anger to anxiety. You may feel worried about your health, finances, and the impact your diagnosis has on your family and career. Having support from your family, friends, and cancer care team can go a long way in helping you cope with your diagnosis and treatments. 

The good news is that the overall 5-year survival rate for prostate cancer is nearly 97%, and 100% when the cancer is detected in its early stages. There are many resources available to help you cope with the emotional and physical effects of living with prostate cancer both during treatment and after. Talk to your healthcare provider about the support available to you. This may include prostate cancer support groups, financial resources to help cover the costs of treatment, and medications to manage symptoms and side effects. 

A Quick Review

Prostate cancer treatment options depend on several factors, including the type and stage of the disease, your age, overall health, and personal preferences. Treatment options include active surveillance, surgery, radiation therapy, chemotherapy, immunotherapy, hormone therapy, and targeted therapy. 

If your prostate cancer is discovered in an early stage, your cancer care team will recommend treatments to try and cure the cancer. If you have advanced prostate cancer, treatments may help stop the cancer from growing and spreading and prolong your life.