There are other prostate conditions which can mirror symptoms related to prostate cancer. It is important that you meet with your doctor if you are experiencing any of the symptoms listed below in order to determine what might be causing those symptoms.
Early prostate cancer generally does not exhibit any symptoms. Oftentimes, an initial diagnosis is made by a doctor during an annual exam of the prostate. Men who do experience symptoms will generally notice changes in urinary and/or sexual function. These types of changes warrant a visit with your physician to determine the cause. Prostate cancer symptoms may include:
- A frequent urge to urinate, including nighttime frequency or urgency
- Difficulty initiating urination
- A weak or interrupted urine flow
- Pain or burning while urinating (from cancer pressing on the spinal cord)
- Loss of bladder or bowel control
- Difficulty achieving/maintaining an erection
- Painful ejaculation
- Blood in the semen or urine
- Pain in the hips, back or chest (indicating metastasis to the bones)
- Weakness, numbness, or swelling in legs and feet
If you have been diagnosed with prostate cancer you are likely wondering what your treatment options are. Below are a number of different prostate cancer treatment options you may want to review and discuss with your doctor. Finding the right treatment option for you will depend on a number of different factors specific to your personal prostate cancer diagnosis.
Active surveillance is a potential treatment strategy often offered to men with slow-growing cancer. In some cases, your doctor may also offer this option if you are older or have other serious health problems.
In active surveillance, doctors monitor a patient more frequently than usual (usually every 3 to 6 months according to guidelines) with tests such as PSA and DRE and repeat biopsies. Biopsies may be done every year as well. If the Gleason score or PSA level starts to rise, or the patient develops symptoms, a move to more aggressive treatment, such as surgery or radiation therapy, may be needed.
What surgery options are there?
Surgery is a common choice in an attempt to cure prostate cancer if it is not thought to have spread outside the gland (stage T1 or T2 cancers). The main type of prostate cancer surgery is known as a radical prostatectomy. In this operation, the surgeon removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. A radical prostatectomy can be done in the following ways:
Open approaches to prostatectomy
In the more traditional approach to doing a prostatectomy, the surgeon operates through a single long incision to remove the prostate and nearby tissues. This is sometimes referred to as an open approach.
Radical retropubic prostatectomy
For this operation, the surgeon will make a skin incision in the lower abdomen, from the belly button down to the pubic bone, as shown in the picture below. The patient will be placed under general anesthesia or be given spinal or epidural anesthesia along with sedation during the surgery.
Radical perineal prostatectomy
During this operation, the surgeon will make an incision in the skin between the anus and scrotum (the perineum), as shown in the picture above. This approach is used less often because the nerves cannot easily be spared and lymph nodes cannot be removed. However, it is often a shorter operation and might be an option if the patient does not prefer the nerve-sparing procedure and does not require lymph node removal.
Laparoscopic and robotic-assisted radical prostatectomy
For a laparoscopic radical prostatectomy (LRP), the surgeon makes several small incisions, through which special long instruments are inserted to remove the prostate. One of the instruments has a small video camera on the end, which lets the surgeon see inside the abdomen. Whereas with the robotic-assisted laparoscopic prostatectomy, the surgeon sits at a control panel near the operating table and uses this to control robotic arms which perform the operation through several small incisions in the abdomen.
Transurethral resection of the prostate
This operation is most commonly used to treat men with non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). A TURP is never used in an attempt to cure prostate cancer, but it is occasionally used in men with advanced prostate cancer to help relieve symptoms, such as urinary problems.
For this operation, the surgeon removes the inner part of the prostate gland that surrounds the urethra (the tube through which urine exits the bladder). The skin is not cut for this surgery. An instrument called a resectoscope is passed through the end of the penis into the urethra to the level of the prostate. Once it is in place, either electricity is passed through a wire to heat it or a laser is used to cut or vaporize the tissue. Spinal anesthesia or general anesthesia is used.
Two main types of radiation therapy can be used: external beam radiation and brachytherapy (internal radiation).
External beam radiation therapy (EBRT)
In EBRT, beams of radiation are focused on the prostate gland from a machine outside the body. This type of radiation can be used to try to cure earlier stage cancers, or to help relieve symptoms such as bone pain if the cancer has spread to a specific area of bone.
Newer EBRT techniques focus on the radiation more precisely on the tumor. This has allowed doctors to give higher doses of radiation to the tumor while reducing the radiation exposure to nearby, healthy tissue.
Three-dimensional conformal radiation therapy (3D-CRT)
3D-CRT uses special computers to precisely map the location of the prostate. Radiation beams are then shaped and aimed at the prostate from several directions, which makes it less likely to damage normal tissues.
Intensity modulated radiation therapy (IMRT)
IMRT, an advanced form of 3D therapy, is the most common type of EBRT for prostate cancer. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the prostate from several angles, the intensity (strength) of the beams can be adjusted to limit the doses reaching nearby normal tissues. This lets doctors deliver an even higher dose to the cancer.
Some newer radiation machines have imaging scanners built into them. This advance, known as image guided radiation therapy (IGRT), lets the doctor take pictures of the prostate and make minor adjustments in aiming just before giving the radiation. This may help deliver the radiation even more precisely, which might result in fewer side effects, although more research is needed to prove this.
Another approach is to place tiny implants into the prostate that send out radio waves to tell the radiation therapy machines where to aim. This lets the machine adjust for movement (like during breathing) and may allow less radiation to go to normal tissues. In theory, this could lower side effects. So far, though, no study has shown side effects to be lower with this approach than with other forms of IMRT. The machines that use this are known as Calypso®.
A variation of IMRT is called volumetric modulated arc therapy (VMAT). It uses a machine that delivers radiation quickly as it rotates once around the body. This allows each treatment to be given over just a few minutes. Although this can be more convenient for the patient, it hasn’t yet been shown to be more effective than regular IMRT.
Stereotactic body radiation therapy (SBRT)
This technique uses advanced image guided techniques to deliver large doses of radiation to a certain precise area, such as the prostate. Because there are large doses of radiation in each dose, the entire course of treatment is given over just a few days.
SBRT is often known by the names of the machines that deliver the radiation, such as Gamma Knife®, X-Knife®, CyberKnife®, and Clinac®.
The main advantage of SBRT over IMRT is that the treatment takes less time (days instead of weeks). The side effects, though, are not better. In fact, some research has shown that some side effects might actually be worse with SBRT than with IMRT.
Proton beam radiation therapy
Proton beam therapy focuses beams of protons instead of x-rays on the cancer. Unlike x-rays, which release energy both before and after they hit their target, protons cause little damage to tissues they pass through and release their energy only after traveling a certain distance. This means that proton beam radiation can, in theory, deliver more radiation to the prostate while doing less damage to nearby normal tissues. Proton beam radiation can be aimed with techniques similar to 3D-CRT and IMRT.
Although in theory proton beam therapy might be more effective than using x-rays, so far studies have not shown if this is true. Right now, proton beam therapy is not widely available. The machines needed to make protons are very expensive, and they are not available in many centers in the United States. Proton beam radiation might not be covered by all insurance companies at this time.
Brachytherapy (internal radiation therapy)
Brachytherapy (also called seed implantation or interstitial radiation therapy) uses small radioactive pellets, or “seeds,” each about the size of a grain of rice. These pellets are placed directly into the prostate. Brachytherapy is generally used only in men with early stage prostate cancer that is relatively slow growing (such as low-grade tumors).
There are 2 types of prostate brachytherapy. Both are done in an operating room. Either spinal anesthesia (where the lower half of the body is numbed) or general anesthesia (where the patient is asleep) is typically used, and the patient rarely needs to stay in the hospital overnight.
Permanent (low dose rate, or LDR) brachytherapy
In this approach, pellets (seeds) of radioactive material (such as iodine-125 or palladium-103) are placed inside thin needles, which are inserted through the skin in the area between the scrotum and anus and into the prostate. The pellets are left in place as the needles are removed and give off low doses of radiation for weeks or months. Radiation from the seeds travels a very short distance, so the seeds can give off a large amount of radiation in a very small area. This limits the amount of damage to nearby healthy tissues.
Usually, around 100 seeds are placed, but this depends on the size of the prostate. Because the seeds are so small, they seldom cause discomfort, and are simply left in place after their radioactive material is used up. The patient may also get external beam radiation combined with brachytherapy, especially if there is a higher risk that the cancer has spread outside the prostate (for example, if there is a higher Gleason score).
Temporary (high dose rate, or HDR) brachytherapy
This technique is done less often. It uses higher doses of radiation that are left in place for a short time. Hollow needles are placed through the skin between the scrotum and anus and into the prostate. Soft nylon tubes (catheters) are placed in these needles. The needles are then removed but the catheters stay in place. Radioactive iridium-192 or cesium-137 is then placed in the catheters, usually for 5 to 15 minutes. Generally, about 3 brief treatments are given over 2 days, and the radioactive substance is removed each time. After the last treatment the catheters are removed. For about a week after treatment, there may be some pain or swelling in the area between the scrotum and rectum, and urine may be reddish-brown. These treatments are usually combined with external beam radiation given at a lower dose than if used by itself. The advantage of this approach is that most of the radiation is concentrated in the prostate itself, sparing nearby normal tissues.
Hormone therapy is also called androgen deprivation therapy (ADT) or androgen suppression therapy. The goal is to reduce levels of male hormones, called androgens, in the body, or to prevent them from reaching prostate cancer cells. Below are the several types of hormone therapy can be used to treat prostate cancer.
Orchiectomy (surgical castration)
Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where most of the androgens (testosterone and DHT) are made. With this source removed, most prostate cancers stop growing or shrink for a time.
Luteinizing hormone-releasing hormone (LHRH) analogs
These drugs lower the amount of testosterone made by the testicles. Treatment with these drugs is sometimes called chemical castration because they lower androgen levels just as well as orchiectomy. LHRH analogs are injected or placed as small implants under the skin. Depending on the drug used, they are given anywhere from once a month up to once a year.
Luteinizing hormone-releasing hormone (LHRH) antagonists
LHRH antagonists work like LHRH agonists, but they reduce testosterone levels more quickly and do not cause tumor flare like the LHRH agonists do. It is given as a monthly injection under the skin and quickly reduces testosterone levels.
Anti-androgens block the body’s ability to use any androgens. Even after orchiectomy or during treatment with LHRH analogs, the adrenal glands still make small amounts of androgens. Anti-androgens are not often used by themselves. An anti-androgen may be added to treatment if orchiectomy or an LHRH analog is no longer working by itself. An anti-androgen is sometimes given for a few weeks when an LHRH analog is first started to prevent a tumor flare.
Chemotherapy, otherwise known as chemo, uses anti-cancer drugs injected into a vein or given by mouth. These drugs enter the bloodstream and go throughout the body, making this treatment potentially useful for cancers that have spread (metastasized) to distant organs. Chemotherapy is sometimes used if prostate cancer has spread outside the prostate gland and hormone therapy isn’t working. Doctors give chemotherapy in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Each cycle typically lasts for a few weeks.
Immunotherapy 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 boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also known as biotherapy.
High Intensity Focused Ultrasound
High intensity focused ultrasound (HIFU), is the focusing of high intensity sound waves to create heat at a specific point, called the focal point. With state-of-the-art technology, HIFU can be used to destroy targeted tissue during a procedure that is individually customized for each patient’s prostate cancer treatment. When HIFU energy is delivered to a specific location within the body, the tissue temperature at the focal point is elevated to nearly 195 degrees Fahrenheit in a matter of seconds, resulting in tissue destruction, while the tissue outside the focal point remains unharmed.
Cryosurgery (also called cryotherapy or cryoablation) is sometimes used to treat early stage prostate cancer by freezing it. As with brachytherapy, this may not be a good option for men with large prostate glands. In this approach, several hollow probes are placed through the skin between the anus and scrotum. The doctor guides them into the prostate using transrectal ultrasound (TRUS). This type of procedure requires spinal or epidural anesthesia or general anesthesia.
To determine the right treatment option for you, your doctor will consider many different factors. No two cancers are exactly alike, so it is important to customize treatment options to best suit your personal needs. Things that your doctor may consider when determining the most appropriate treatment for your specific cancer include:
- Your age
- Prostate-Specific Antigen (PSA) Test results
- Grade of the tumor as determined by your Gleason score
- Number of biopsy tissue samples that contain cancer cells
- Stage of the cancer
- Your symptoms
- Your general health and well-being
- Your Prolaris ScoreTM
Your doctor should be able to describe your treatment choices, the expected results, and the possible side effects of each treatment. You should work with your doctor to develop a treatment plan that is right for you.
Before treatment starts, ask your doctor about possible side effects and how treatment may change your normal activities. For example, you may want to discuss the possible effects on sexual function and urinary continence.
Before starting treatment, it is generally a good practice to get a second opinion about your diagnosis and treatment plan. You may even want to talk to several different doctors about all of the treatment options, their side effects, and the expected results.
It may take some time and effort to gather your medical records and see another doctor. In most cases, it’s not a problem to take several weeks to get a second opinion. The delay in starting treatment usually will not make treatment less effective, and may result in a treatment plan you feel comfortable with. To make sure this delay will not affect your health, however, you should discuss it with your doctor. There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, a nearby hospital, or a medical school for names of specialists.
After treatment you’ll typically need regular checkups. Even if the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. If this happens, you and your doctor will need to discuss additional potential treatments.