Treatment Options for Prostate Cancer

Active surveillance is the close following a patient's condition without giving any treatment unless there are changes in test results. It is used to find early signs that the prostate cancer is growing. Patients are seen more often for PSA tests and a digital rectal exam. If it appears that the cancer is progressing, additional testing may be done. 

This approach is used when the Gleason score is 6 or under, if the patient is older, or he has other medical conditions that would make treatment or the side effects difficult to manage at this time. 

If you and your doctor agree that active surveillance is a good idea, your doctor will check you regularly (such as every three to six months, at first). After about one year, your doctor may order another biopsy to check the Gleason score. If you choose active surveillance but grow concerned later, you should discuss your feelings with your doctor. Another approach is an option for most men.

Surgery is an option for men with early (Stage I or II) prostate cancer. It’s sometimes an option for men with Stage III or IV prostate cancer. The surgeon may remove the whole prostate or only part of it.

Before the surgeon removes the prostate, the lymph nodes in the pelvis may be removed. If prostate cancer cells are found in the lymph nodes, the disease may have spread to other parts of the body. If cancer has spread to the lymph nodes, the surgeon does not always remove the prostate and may suggest other types of treatment.

There are several types of surgery for prostate cancer. Each type has benefits and risks. You and your doctor can talk about the types of surgery and which may be right for you:

• Open surgery: The surgeon makes a large incision (cut) into your body to remove the tumor. There are two approaches:
  • Through the abdomen: The surgeon removes the entire prostate through a cut in the abdomen. This is called a radical retropubic prostatectomy.
  • Between the scrotum and anus: The surgeon removes the entire prostate through a cut between the scrotum and the anus. This is called a radical perineal prostatectomy.
• Laparoscopic prostatectomy: The surgeon removes the entire prostate through small cuts, rather than a single long cut in the abdomen. A thin, lighted tube (a laparoscope) helps the surgeon remove the prostate.
• Robotic laparoscopic surgery: The surgeon removes the entire prostate through small cuts. A laparoscope and a robot are used to help remove the prostate. The surgeon uses handles below a computer display to control the robot’s arms.
• Cryosurgery: For some men, cryosurgery is an option. The surgeon inserts a tool through a small cut between the scrotum and anus. The tool freezes and kills prostate tissue. Cryosurgery is under study.
• TURP: A man with advanced prostate cancer may choose TURP (transurethral resection of the prostate) to relieve symptoms. The surgeon inserts a long, thin scope through the urethra. A cutting tool at the end of the scope removes tissue from the inside of the prostate. TURP may not remove all of the cancer, but it can remove tissue that blocks the flow of urine.

Surgery can damage the nerves around the prostate. Damaging these nerves can make a man impotent (unable to have an erection). In some cases, your surgeon can protect the nerves that control erection. But if you have a large tumor or a tumor that’s very close to the nerves, surgery may cause impotence. Impotence can be permanent. You can talk with your doctor about medicine and other ways to help manage the sexual side effects of cancer treatment.

If your prostate is removed, you will no longer produce semen. You’ll have dry orgasms. If you wish to father children, you may consider sperm banking or a sperm retrieval procedure before surgery.

Radiation therapy is an option for men with any stage of prostate cancer. Men with early-stage prostate cancer may choose radiation therapy instead of surgery. It also may be used after surgery to destroy any cancer cells that remain in the area. In later stages of prostate cancer, radiation treatment may be used to help relieve pain.

Radiation prostate cancer therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area.

There are many different types of radiation therapy that can be used to treat prostate cancer. Your oncologist will recommend the treatment that’s right for you based on your cancer stage, type of tumor, and many other factors. Below are some of the most common radiation treatment types used for prostate cancer.

• Intensity Modulated Radiation Therapy (IMRT): IMRT uses advanced technology to manipulate beams of radiation to conform to the shape of a tumor. This also allows for the intensity of the radiation to be varied based on the tissue being treated. With IMRT, the radiation oncologist is able to control the radiation dose within each field of the treatment area. IMRT is especially useful when treating tumors that are surrounded by critical organs or normal tissue, such as prostate cancer.
• Image Guided Radiation Therapy (IGRT):  IGRT is the use of imaging before each radiation therapy treatment. IGRT allows for very precise delivery of radiation, which is ideal for tumors and cancers located very close to sensitive structures and organs, such as prostate cancer. IGRT is often used in conjunction with IMRT for the most optimal treatment.
• Stereotactic Body Radiation Therapy (SBRT): SBRT is a non-surgical procedure that delivers high doses of very targeted radiation in only one or few treatment sessions. The highly precise form of radiation therapy has such a dramatic impact at reducing the tumor that the post-treatment results are often considered to be as effective as surgery, even for tumors that may have been considered inoperable.
• High-Dose Rate (HDR) Brachytherapy: Brachytherapy is the delivery of internal radiation. It allows the delivery of a prescribed dose of radiation within a small area while sparing surrounding normal tissue from radiation exposure. During HDR brachytherapy, radiation is delivered through catheters (slender tubes) that are inserted into or near the tumor. This gives us the ability to control the dose within a specific region, allowing more radiation where needed and protecting normal tissue. HDR brachytherapy may be given as a primary treatment or in conjunction with external beam radiation.

Recent Advances In Prostate Cancer Treatment

• Xofigo Therapy: Radium 223 is a targeted cancer therapy given as an injection that contains radioactive material and is used to treat prostate cancer that as spread to the bones.
• SpaceOAR® Hydrogel:  SpaceOAR hydrogel reduces rectal injury in men receiving prostate cancer radiation therapy. Placed between the prostate and rectum, the hydrogel pushes the rectum out of the high dose radiation region. The hydrogel spacer is injected during a minimally invasive procedure, and — once in place — patients typically can’t feel it. It remains in place for three months during radiation treatment, and is then absorbed and leaves the body in the patient’s urine.

Both internal and external radiation can cause impotence. You can talk with your doctor about ways to help cope with this side effect.

A patient with prostate cancer may have hormone therapy before, during, or after radiation therapy. Hormone therapy is also used alone for prostate cancer that has returned after treatment.

Male hormones (androgens) can cause prostate cancer to grow. Hormone therapy keeps prostate cancer cells from getting the male hormones they need to grow. The testicles are the body’s main source of the male hormone testosterone. The adrenal gland makes other male hormones and a small amount of testosterone.

Hormone therapy drugs are used to block the production of androgens and/or testosterone which help fuel the growth of the prostate cancer cells.

Doctors usually treat prostate cancer that has spread to other parts of the body with hormone therapy. For some men, the cancer will be controlled for two or three years, but others will have a much shorter response to hormone therapy. In time, most prostate cancers can grow with very little or no male hormones, and hormone therapy alone is no longer helpful. At that time, your doctor may suggest chemotherapy or other forms of treatment that are under study. In many cases, the doctor may suggest continuing with hormone therapy because it may still be effective against some of the cancer cells.

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to help restore the body’s natural defenses against cancer.

Chemotherapy may be used for prostate cancer that has spread and no longer responds to hormone therapy.