Treatment

The treatment of prostate cancer depends on the size and location of the tumor, whether the cancer has spread, and the man’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, read the Clinical Trials section.

It is important to discuss the goals and possible side effects of treatment with your doctor before treatment begins, including the likelihood of success of that treatment, the potential side effects of therapy (including possible urinary, bowel, sexual, and hormone-related side effects), and the patient’s preferences. Men should talk with their doctor about how the various treatments affect recurrence (the return of the cancer after treatment), survival, and quality of life. In addition, the success of any treatment often depends on the skill and expertise of the physician or surgeon, so it is important to find doctors who have experience treating prostate cancer.

Descriptions of the most common treatment options for prostate cancer are listed below.

Active surveillance (watchful waiting), for early-stage cancer

If a prostate cancer is in an early stage, growing slowly, and if treating the cancer would cause more discomfort than the disease itself, a doctor may recommend watchful waiting, also called active surveillance or watch-and-wait. The cancer is monitored closely with periodic PSA testing, DRE tests, and watching for symptoms. Treatment would begin only when the tumor shows signs of becoming more aggressive or spreading, causes pain, or obstructs the urinary tract. This approach may be taken in much older patients, those with other serious or life-threatening illnesses, or those who wish to delay active treatment because of potential side effects. However, real caution must be taken not to make errors of judgment about the disease. In other words, doctors must collect as much information as possible about the patient’s other illnesses and potential life expectancy, so they don’t miss the chance to detect an early, aggressive prostate cancer. New information is becoming available all the time, and it is important for men to discuss these issues with their doctor to make the best decision about treatment.

Surgery

Surgery is used to try to cure cancer before it has spread outside the prostate. A surgical oncologist is a doctor who specializes in treating cancer using surgery; for prostate cancer, a urologist or urologic oncologist is the surgical oncologist involved in treatment. The type of surgery depends on the stage of the disease, the man’s general health, and other factors.

Radical (open) prostatectomy. A radical prostatectomy involves surgical removal of the whole prostate and accompanying seminal vesicles; lymph nodes in the pelvic area may also be removed . This operation has the risk of interfering with sexual potency. Nerve-sparing surgery, when possible, increases the chances that a man will remain sexually potent after surgery by avoiding surgical damage to the nerves that allow erections and orgasm to occur. Orgasm can occur even if some nerves are cut; these are two separate processes. Urinary incontinence (inability to control urine flow) is also a possible complication of prostatectomy. To help resume normal sexual function, men can receive drugs, penile implants, or injections. Sometimes, additional surgery can fix the complication of urinary incontinence.

Laparoscopic prostatectomy (with or without robotic assistance). This type of surgery is potentially much less invasive than an open radical prostatectomy and may potentially reduce recovery time. A camera and instruments are inserted through small, keyhole incision in the patient’s abdomen. The surgeon then directs the robotic instruments (if robotic assistance is being used) to remove the prostate gland and surrounding tissue. In general, laparoscopic prostatectomy has less bleeding and less pain, but sexual and urinary side effects can be similar to an open radical prostatectomy. This procedure has not been available for as long a time as open radical prostatectomy, so longer-term follow-up information, including permanent cure rates, are not yet certain. This procedure remains controversial among some specialists. As noted, more follow-up data are needed. Talk with your doctor about whether your treatment center offers this procedure and how it compares with the results to the conventional open radical prostatectomy.

Transurethral resection of the prostate (TURP). TURP is most often used to relieve symptoms of urinary obstruction, not to cure cancer. In this procedure, under a full anesthetic, a surgeon inserts a cystoscope (a narrow tube with a cutting device) into the urethra and into the prostate to remove prostate tissue. This is rarely used to treat prostate cancer in current clinical practice.

Cryosurgery. This procedure is commonly used for investigational studies. Cryosurgery (also called cryotherapy or cryoablation) involves freezing cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that contains the testicles. Cryosurgery may be useful for early-stage cancer and for men who cannot have a radical prostatectomy. A common side effect of cryosurgery is impotence, so this approach is not recommended for men who desire to preserve their sexual function. Another complication may be the development of fistulae (holes between the prostate and the bowel), although this complication appears to occur much less frequently with the development of newer cryosurgery techniques.

Learn more about cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy rays to kill cancer cells. Radiation therapy may be given externally, called external-beam radiation therapy, in which radiation is given from a machine outside the body, or internally, where a radioactive substance or seeds are placed inside the prostate, near the tumor. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Radiation therapy can be useful at all stages of localized cancer. It is also used to relieve symptoms, such as pain, for patients with advanced or metastatic cancer. Several treatments or “fractions” may be needed.

External-beam radiation therapy. External-beam radiation therapy focuses a beam of radiation on the area affected by cancer. Some cancer centers use conformal radiation therapy (CRT), where computers help precisely map the location and shape of the cancer. CRT reduces radiation exposure to healthy tissues and organs around the tumor by directing the radiation therapy beam from different directions with the intention of focusing the dose on the area of the tumor.

Intensity-modulated radiation therapy (IMRT). IMRT is a form of three-dimensional (3-D) CRT. CRT uses CT scans to form a 3-D picture of the prostate before treatment. IMRT enables high doses to be delivered to the prostate without increasing the risk of exposure to nearby organs.

Brachytherapy. Brachytherapy involves insertion of radioactive sources directly into the prostate. These sources (called seeds) give off localized radiation and may be used for hours (high-dose rate) or for weeks (low-dose rate). Low-dose rate seeds are left in the prostate permanently, even after all the radioactive material has been used up.

Radiation therapy may cause such side effects as diarrhea or other disruption of bowel function; increased urinary urge or frequency; fatigue; impotence; and rectal discomfort, burning, or pain. These side effects usually go away after treatment. Learn more about radiation therapy.

Hormone therapy

Because prostate cancer growth is driven by male sex hormones known as androgens, reducing levels of these hormones can help slow the growth of the cancer. Hormone treatment is also called androgen ablation or androgen deprivation therapy. The most common androgen is testosterone. The production of testosterone can be reduced either surgically, with surgical castration (removal of the testicles), or with drugs that turn off the function of the testicles (see below).

Hormone therapy is used to treat prostate cancer that has continued to grow after surgery and radiation therapy, or when it is widespread at the time of diagnosis. More recently, hormone therapy has also been used with radiation therapy for men with a cancer at a higher risk for recurrence. In some men, hormone therapy will be used first to shrink a prostate cancer tumor before radiation therapy or surgery. In some men with prostate cancer that has spread locally (and identified during a radical prostatectomy), hormone therapy is given after the surgery for two to three years as adjuvant therapy (treatment that is given after the first treatment).

Traditionally, hormone therapy was used until it stopped controlling the cancer. Then the cancer was said to be hormone refractory (meaning that the hormone therapy has stopped working), and other options were considered. Recently, researchers have begun studying intermittent hormone therapy, which is hormone therapy that is given for specified periods and then discontinued temporarily according to a schedule. Giving hormones in this way appears to lower the symptoms of this therapy. In addition, intermittent hormone therapy may possibly maintain hormone responsiveness for a longer time than standard (continuous) hormone treatment; this concept is currently being tested in clinical trials.

One important complication of hormonal therapy is the risk of developing metabolic syndrome. Metabolic syndrome refers to a set of conditions, such as high levels of blood cholesterol and high blood pressure that place a person at high risk of heart disease, stroke, and diabetes. At present, it is not certain how often is occurs, nor the exact mechanism, but it is quite clear that patients who undergo a surgical or medical castration with hormone therapy (even a temporary medical castration) are at increased risk for developing metabolic syndrome. The risks and benefits of castration should be carefully discussed with your doctor. For men with metastatic prostate cancer, especially if it is advanced and causing symptoms, most doctors believe that the benefits of castration far outweigh the risks of metabolic syndrome.

Types of hormone therapy

Bilateral orchiectomy. Bilateral orchiectomy involves surgical removal of both testicles. Even though this is surgery, it is called a hormone treatment because it removes the main source of testosterone production, the testicles. This surgery is permanent and cannot be reversed.

LHRH agonists. LHRH stands for luteinizing hormone-releasing hormone. LHRH agonists are drugs that reduce the body's production of testosterone by interfering with hormonal control mechanisms within the brain, which control the functioning of the testicles.

Anti-androgens. While LHRH agonists lower testosterone levels in the blood, anti-androgens block testosterone from binding to so-called “androgen receptors,” chemical structures in the cancer cells that allow testosterone and other male hormones to enter the cells.

LHRH antagonist. This type of drug, also called a gonadotropin-releasing hormone (GnRH) antagonist, stops the testicles from producing testosterone by mimicking the action of LHRH. The FDA has approved one drug, degarelix (Firmagon), given by injection, to treat advanced prostate cancer. This drug may cause a severe allergic reaction.

Female hormones. Estrogen can lower testosterone levels. When this drug is given as a pill, side effects can include heart problems and blood clots. More recently, estrogens have been administered as injections or as skin patches, and this type of treatment may be associated with a lower chance of heart and clotting side effects.

Combined androgen blockade. Sometimes, LHRH agonists are used in combination with peripheral-blocking drugs, such as anti-androgens, to more completely inhibit male hormones. Many doctors feel that this combined approach is the safest way to start hormone treatment, as this prevents a potential flare-up or increase in activity of the prostate cancer cells that sometimes occurs as a result of a temporary surge in testosterone production by the testicles (in response to the LHRH agonists). Major clinical trials have not shown a big difference in long-term survival results from the use of combined androgen blockade as permanent therapy; therefore, some doctors prefer to give combined drug treatment only for the first two to three months.

Hormone therapy may cause significant side effects. Side effects generally go away after hormone treatment is finished, except in men who have had an orchiectomy. Patients may experience impotence, loss of libido (sexual desire), hot flashes, gynecomastia (enlarged breasts), and osteoporosis (weakening bones). Men who have received LHRH agonists for more than two years will frequently have ongoing hormonal effects, even if the drugs are no longer given.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. Some people may receive chemotherapy in their doctor's office; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time.

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Chemotherapy can be taken orally (by mouth) or intravenously (injected into a vein), and it may help patients with advanced or hormone-refractory prostate cancer. There is no standard chemotherapy for use against prostate cancer, but a number of clinical trials are exploring chemotherapy for advanced prostate cancer. The most popular, current approach involves the use of a drug called docetaxel (Taxotere) given in conjunction with a steroid called prednisone (multiple brand names). This combination has been shown to help men with advanced prostate cancer live longer than another chemotherapy, mitoxantrone (Novantrone), which is most useful for controlling prostate cancer symptoms.

The FDA has approved the drugs mitoxantrone and docetaxel for use in men with prostate cancer that is resistant to hormone therapy. Also, the drugs paclitaxel (Taxol) and estramustine (Estracyt) have shown some beneficial effects in treating advanced prostate cancer. Estramustine is being used less often in current clinical practice because of its side effects, which includes an increased risk of blood clots. Although clinical trials have shown that docetaxel prolongs survival and has a higher rate of remission than mitoxantrone, the difference in survival is only an average of a few additional months, and the side effects of mitoxantrone are generally milder than for docetaxel. Many new medications for prostate cancer are in development and may be available in clinical trials.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications.

Learn more about your prescriptions by using searchable drug databases.

Advanced prostate cancer

Prostate cancer that develops the ability to grow without the presence of male sex hormones, and causes hormone treatments to stop working, is called androgen-independent cancer, or hormone-refractory prostate cancer. Although there is no cure for this type of cancer, it is often treatable with radiation therapy or chemotherapy.

If all treatments have failed to control prostate cancer, or if cancer comes back after treatment, a patient may experience pain, fatigue, and weight loss. At this point, the goal of treatment switches from curing the cancer to slowing it down and relieving symptoms.

It is important to note that many men outlive their prostate cancer, even those with advanced disease. Often, the prostate cancer grows slowly, and there are now effective treatment options that extend life even further. A few drugs can help treat the symptoms of advanced cancer.

Chemotherapy (see above). Chemotherapy is most commonly used for patients with advanced, hormone-refractory prostate cancer. It can be effective in relieving symptoms, such as pain, weight loss, and fatigue, and may prolong life for some patients.

Strontium and samarium. Given by injection, these radioactive agents are absorbed near the area of bone pain. The radiation that is released helps relieve the pain, probably by causing local tumor shrinkage.

Pamidronate (Aredia) and zoledronic acid (Zometa). Given by injection, these drugs reduce the level of calcium in the blood and cause a reduction of bone complications (such as pain, fracture, need for surgery) due to metastases. A high calcium level is called hypercalcemia and is sometimes present in men with advanced prostate cancer.

Hormone therapy. Some types of hormone therapy may be used to treat advanced cancer (see above). Read more about hormone therapy for advanced prostate cancer.

Find out more about common terms used during cancer treatment.