What are my treatment options?
Understanding Active Surveillance as a Treatment Option
Active surveillance is a potential treatment strategy for men with slow-growing cancer. Your doctor may also offer this option if you are older or have other serious health problems.
In active surveillance, your doctor will monitor you much more frequently than usual (such as every 3 to 6 months) with tests such as PSA and DRE and even biopsies. If your Gleason score or your PSA level starts to rise, or you develop symptoms, you may need to have more aggressive treatment, like surgery or radiation.
Surgery options as a prostate cancer treatment
What surgery options are there?
Surgery is a common choice to try to cure prostate cancer if it is not thought to have spread outside the gland (stage T1 or T2 cancers).
The main type of surgery for prostate cancer 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 different 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 makes a skin incision in your lower abdomen, from the belly button down to the pubic bone. You will be either under general anesthesia (asleep) or be given spinal or epidural anesthesia (numbing the lower half of the body) along with sedation during the surgery.
If there is a reasonable chance the cancer may have spread to the lymph nodes (based on your PSA level, DRE, and biopsy results), the surgeon may remove lymph nodes from around the prostate at this time. The nodes are usually sent to the pathology lab to see if they have cancer cells (it takes a few days to get results), but in some cases the nodes may be looked at right away. If this is done during surgery and any of the nodes have cancer cells, which means the cancer has spread, the surgeon may not continue with the surgery. This is because it is unlikely that the cancer can be cured with surgery, and removing the prostate could still lead to serious side effects.
When removing the prostate, the surgeon will pay close attention to the 2 tiny bundles of nerves that run on either side of the prostate. These nerves control erections. If you are able to have erections before surgery, the surgeon will try not to injure these nerves (known as a nerve-sparing approach). If the cancer is growing into or very close to the nerves the surgeon will need to remove them. If they are both removed, you will be unable to have spontaneous erections. This means that you will need help (such as medicines or pumps) to have erections. If the nerves on one side are removed, you still have a chance of keeping your ability to have erections, but the chance is lower than if neither were removed. If neither nerve bundle is removed you may be able to function normally. Usually it takes at least a few months to a year after surgery to have an erection because the nerves have been handled during the operation and won’t work properly for a while.
After the surgery, while you are still under anesthesia, a catheter will be put in your penis to help drain your bladder. The catheter usually stays in place for 1 to 2 weeks while you are healing. You will be able to urinate on your own after the catheter is removed.
You will probably stay in the hospital for a few days after the surgery and be limited in your activities for about 3 to 5 weeks. The possible side effects of prostatectomy are described below.
Radical perineal prostatectomy
In this operation, the surgeon makes the 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 can’t be removed. But it is often a shorter operation and might be an option if you don’t want the nerve-sparing procedure and you don’t require lymph node removal, and is often easier to recover from. It also might be used if you have other medical conditions that make retropubic surgery difficult for you. It can be just as curative as the retropubic approach if done correctly. The perineal operation usually takes less time than the retropubic operation, and may result in less pain afterward.
After the surgery, while you are still under anesthesia, a catheter will be put in your penis to help drain your bladder. The catheter usually stays in place for 1 to 2 weeks while you are healing. You will be able to urinate on your own after the catheter is removed.
You will probably stay in the hospital for a few days after the surgery and be limited in your activities for about 3 to 5 weeks. The possible side effects of prostatectomy are described below.
Laparoscopic approaches to prostatectomy
Laparoscopic approaches use several smaller incisions and special surgical tools to remove the prostate. This can be done with the surgeon either holding the tools directly, or using a control panel to precisely move robotic arms that hold the tools.
Laparoscopic 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.
Laparoscopic prostatectomy has some advantages over the usual open radical prostatectomy, including less blood loss and pain, shorter hospital stays (usually no more than a day), and faster recovery times (although the catheter will be needed for about the same amount of time).
LRP has been used in the United States since 1999 and is done both in community and university centers. In experienced hands, LRP appears to be as good as open radical prostatectomy, although we do not yet have long-term results from procedures done in the United States.
Early studies report that the rates of side effects from LRP seem to be about the same as for open prostatectomy. (These side effects are described below.) Recovery of bladder control may be slightly delayed with this approach. A nerve-sparing approach is possible with LRP, increasing the chance of normal erections after the operation.
Robotic-assisted laparoscopic radical prostatectomy
A newer approach is to do the laparoscopic surgery remotely using a robotic interface (called the da Vinci system), which is known as robotic-assisted laparoscopic prostatectomy (RALRP). The surgeon sits at a panel near the operating table and controls robotic arms to perform the operation through several small incisions in the patient’s abdomen.
Like direct LRP, RALRP has advantages over the open approach in terms of pain, blood loss, and recovery time. So far though, there seems to be little difference between robotic and direct LRP for the patient.
In terms of the side effects men are most concerned about, such as urinary problems or erectile dysfunction (described below), there does not seem to be a difference between robotic-assisted LRP and other approaches to prostatectomy.
For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. Still, the most important factor in the success of either type of LRP is the surgeon’s experience, commitment, and skill.
Robotic LRP has been in use since 2003 in the United States. Because this is still a relatively new way of doing the surgery, reports of long-term outcomes are not yet available. Still, this approach has become more popular in recent years, and is now the most common way to do a prostatectomy.
If you are thinking about treatment with either type of LRP, it’s important to understand what is known and what is not yet known about this approach. Again, the most important factors are likely to be the skill and experience of your surgeon. If you decide that either type of LRP is the treatment for you, be sure to find a surgeon with a lot of experience.
Possible risks and side effects of radical prostatectomy (including LRP)
There are possible risks and side effects with any type of surgery for prostate cancer.
The risks with any type of radical prostatectomy are much like those of any major surgery, including risks from anesthesia. Among the most serious, there is a small risk of heart attack, stroke, blood clots in the legs that may travel to your lungs, and infection at the incision site.
If lymph nodes are removed, a collection of lymph fluid (called a lymphocele) can form and may need to be drained.
Because there are many blood vessels near the prostate gland, another risk is bleeding during and after the surgery. You may need blood transfusions, which carry their own small risk. Rarely, part of the intestine might be cut during surgery, which could lead to infections in the abdomen and might require more surgery to correct.
In extremely rare cases, people die because of complications of this operation. Your risk depends, in part, on your overall health, your age, and the skill of your surgical team.
The major possible side effects of radical prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). It should be noted that these side effects can also occur with other forms of treatment for prostate cancer, although they are described here in more detail.
Urinary incontinence: You may develop urinary incontinence, which means you are not able to control your urine or have leakage or dribbling. There are different degrees of incontinence. Being incontinent can affect you not only physically but emotionally and socially as well. There are 3 major types of incontinence:
- Stress incontinence is the most common type of incontinence after prostate surgery. Men with stress incontinence leak urine when they cough, laugh, sneeze, or exercise. It is usually caused by problems with the muscular valve that keeps urine in the bladder (the bladder sphincter). Prostate cancer treatments may damage the muscles that form this valve or the nerves that keep the muscles working.
- Men with overflow incontinence cannot empty the bladder well. They take a long time to urinate and have a dribbling stream with little force. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by scar tissue.
- Men with urge incontinence have a sudden need to go to the bathroom and pass urine. This problem occurs when the bladder becomes too sensitive to stretching as it fills with urine.
Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence.
After surgery for prostate cancer, normal bladder control usually returns within several weeks or months. This recovery usually occurs gradually, in stages.
Doctors can’t predict for sure how any man will be affected after surgery. In general older men tend to have more incontinence problems than younger men. In one study of men aged 55 to 74 who were treated in all different types of hospitals, researchers found that 5 years after radical prostatectomy:
- 15% of the men had no bladder control or had frequent leaks or dripping of urine
- 16% leaked at least twice a day
- 29% wore pads to keep dry
(Some of the men were in 2 or 3 of these groups, so adding these percentages together overstates the likelihood of urinary problems.)
Most large cancer centers, where prostate surgery is done more often and surgeons have more experience, report fewer problems with incontinence.
Treatment of incontinence depends on its type, cause, and severity. If you have problems with incontinence, let your doctors know. You might feel embarrassed about discussing this issue, but remember that you are not alone. This is a common problem. Doctors who treat men with prostate cancer should know about incontinence and be able to suggest ways to improve it, such as:
- Special exercises, called Kegel exercises, which might help strengthen your bladder muscles. These exercises involve tensing and relaxing certain pelvic muscles. Not all doctors agree about their usefulness or the best way to do them, so ask your doctor about doing Kegels before you try them.
- Medicines to help the muscles of the bladder or sphincter. Most of these medicines affect either the muscles or the nerves that control them. These medicines are more effective for some forms of incontinence, such as urge incontinence, than for others.
- Surgery to correct long-term incontinence. Material such as collagen can be injected to tighten the bladder sphincter. If the incontinence is severe and not getting better on its own, an artificial sphincter can be implanted, or a small device called a urethral sling may be implanted to keep the bladder neck where it belongs. Ask your doctor if these treatments might help you.
Even if your incontinence cannot completely be corrected, it can still be helped. You can learn how to manage and live with incontinence. Incontinence is more than a physical problem. It can disrupt your quality of life if it is not managed well. There is no one right way to cope with incontinence. The challenge is to find what works for you so that you can return to your normal daily activities.
There are many incontinence products that can help keep you mobile and comfortable, such as pads that are worn under your clothing. Adult briefs and undergarments are bulkier than pads but provide more protection. Bed pads or absorbent mattress covers can also be used to protect the bed linens and mattress.
When choosing incontinence products, keep in mind the checklist below. Some of these questions may not be important to you, or you may have others to add.
- Absorbency: How much does the product provide? How long will it protect?
- Bulk: Can it be seen under normal clothing? Is it disposable? Reusable?
- Comfort: How does it feel when you move or sit down?
- Availability: Which stores carry the products? Are they easy to get to?
- Cost: Does your insurance pay for these products?
Another option is a rubber sheath called a condom catheter that can be put over the penis to collect urine in a bag. There are also compression (pressure) devices that can be placed on the penis for short periods of time to help keep urine from coming out.
For some types of incontinence, self-catheterization may be an option. In this approach, you insert a thin tube into your urethra to drain and empty the bladder at regular intervals. Most men can learn this safe and usually painless technique.
You can also follow some simple precautions that may make incontinence less of a problem. For example, empty your bladder before bedtime or before strenuous activity. Avoid drinking too much fluid, particularly if the drinks contain caffeine or alcohol, which can make you have to go more often. Because fat in the abdomen can push on the bladder, losing weight sometimes helps improve bladder control.
Fear, anxiety, and anger are common feelings for people dealing with incontinence. Fear of having an accident may keep you from doing the things you enjoy most – taking your grandchild to the park, going to the movies, or playing a round of golf. You may feel isolated and embarrassed. You may even avoid sex because you are afraid of leakage. Be sure and talk to your doctor so you can begin to manage this problem, as many solutions, described above, exist.
Impotence (erectile dysfunction):
This means you cannot get an erection sufficient for sexual penetration. The nerves that allow men to get erections may be damaged or removed by radical prostatectomy. Other treatments (besides surgery) may also damage these nerves or the blood vessels that supply blood to the penis to cause an erection.
Your ability to have an erection after surgery depends on your age, your ability to get an erection before the operation, and whether the nerves were cut. Everyone can expect some decrease in the ability to have an erection, but the younger you are, the more likely it is that you will keep this ability.
A wide range of impotency rates have been reported in the medical literature, from as low as about 1 in 4 men under age 60 to as high as about 3 in 4 men over age 70. Doctors who perform many nerve-sparing radical prostatectomies tend to report lower impotence rates than doctors who do the surgery less often.
Each man’s situation is different, so the best way to get an idea of your chances for recovering erections is to ask your doctor about his or her success rates and what the outcome is likely to be in your particular case.
If your ability to have erections does return after surgery, it often occurs slowly. In fact, it can take up to 2 years. During the first several months, you will probably not be able to have a spontaneous erection, so you may need to use medicines or other treatments.
If potency remains after surgery, the sensation of orgasm should continue to be pleasurable, but there is no ejaculation of semen – the orgasm is “dry.” This is because during the prostatectomy, the glands that made most of the fluid for semen (the seminal vesicles and prostate) were removed, and the pathways used by sperm (the vas deferens) were cut.
Most doctors feel that regaining potency is helped along by attempting to get an erection as soon as possible once the body has had a chance to heal (usually several weeks after the operation). Some doctors call this penile rehabilitation. Medicines (see below) may be helpful at this time. Be sure to talk to your doctor about your situation.
Several options may help you if you have erectile dysfunction:
- Phosphodiesterase inhibitors such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are pills that can promote erections. These drugs will not work if both nerves that control erections have been damaged or removed. The most common side effects are headache, flushing (skin becomes red and feels warm), upset stomach, light sensitivity, and runny or stuffy nose. Rarely, these drugs can cause vision problems, possibly even blindness. Nitrates, which are drugs used to treat heart disease, can interact with these drugs to cause very low blood pressure, which can be dangerous. Some other drugs may also cause problems, so be sure your doctor knows which medicines you are taking.
- Alprostadil is a man-made version of prostaglandin E1, a substance naturally made in the body that can produce erections. It can be injected almost painlessly into the base of the penis 5 to 10 minutes before intercourse or placed into the tip of the penis as a suppository. You can even increase the dosage to prolong the erection. You may have side effects, such as pain, dizziness, and prolonged erection, but they are usually minimal.
- Vacuum devices are another option that may create an erection. These mechanical pumps are placed around the entire penis before intercourse to produce an erection.
- Penile implants might restore your ability to have erections if other methods do not help. An operation is needed to put them in place. There are several types of penile implants, including those using silicone rods or inflatable devices.
For more detailed information on coping with erection problems and other sexuality issues, see the Cancer.org document, Sexuality for the Man With Cancer.
Changes in orgasm: In some men, orgasm becomes less intense or goes away completely. A few men report pain with orgasm. Even if you have problems with impotence, you may still be able to have an orgasm.
Loss of fertility: Radical prostatectomy cuts the connection between the testicles (where sperm are produced) and the urethra. Your testicles will still produce sperm, but it can’t get out as a part of the ejaculate. This means that a man can no longer father a child by natural means. Often, this is not an issue, as men with prostate cancer tend to be older. But if it is a concern for you, you might want to ask your doctor about “banking” your sperm before the operation.
Lymphedema: A rare but possible complication of removing many of the lymph nodes around the prostate is a condition called lymphedema. Lymph nodes normally provide a way for fluid to return from all areas of the body to the heart. When nodes are removed, fluid may collect in the legs or genital region over time, causing swelling and pain. Lymphedema can usually be treated with physical therapy, although it may not go away completely.
Change in penis length: A possible minor effect of surgery is a decrease in penis length. This is probably due to a shortening of the urethra when a portion of it is removed along with the prostate.
Inguinal hernia: A prostatectomy increases a man’s chances of developing an inguinal (groin) hernia in the future.
Transurethral resection of the prostate (TURP)
This operation is more commonly used to treat men with non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). A TURP is not used to try to cure prostate cancer, but it is sometimes used in men with advanced prostate cancer to help relieve symptoms, such as urination problems.
During 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 with 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 (which numbs the lower half of your body) or general anesthesia (where you are asleep) is used.
The operation usually takes about an hour. After surgery, a catheter is inserted through the penis into the bladder. It remains in place for about a day to help urine drain while the prostate heals. You can usually leave the hospital after 1 to 2 days and return to normal activities in 1 to 2 weeks.
You will probably have some blood in your urine after surgery. Other possible side effects from TURP include infection and any risks that come with the type of anesthesia that was used.
Understanding radiation therapy and its use in prostate cancer treatment
What is radiation therapy?
Radiation therapy uses high-energy rays or particles to kill cancer cells. Radiation may be used:
- As the initial treatment for low-grade cancer that is still confined within the prostate gland. Cure rates for men with these types of cancers are about the same as those for men getting radical prostatectomy.
- As part of the first treatment (along with hormone therapy) for cancers that have grown outside of the prostate gland and into nearby tissues.
- If the cancer is not completely removed or comes back (recurs) in the area of the prostate after surgery.
- If the cancer is advanced, to reduce the size of the tumor and to provide relief from present and possible future symptoms.
Two main types of radiation therapy can be used: external beam radiation and brachytherapy (internal radiation). Both appear to be good methods of treating prostate cancer, although there is more long-term information about the results of treatment with external beam radiation. (Another type of radiation therapy, in which a medicine containing radiation is injected into the body, is described in the following section on Cancer.org, “Preventing and treating prostate cancer spread to the bone.”)
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.
To reduce the risk of side effects, doctors carefully figure out the exact dose of radiation needed and aim the beams as accurately as they can to hit the carefully outlined target. Before treatments start, imaging tests such as MRIs, CT scans, or plain x-rays of the pelvis are done to find the exact location of your prostate gland. The radiation team may then make some ink marks on your skin that they will use later as a guide to focus the radiation in the right area.
You will usually be treated 5 days a week in an outpatient center for 7 to 9 weeks. Each treatment is much like getting an x-ray. The radiation is stronger than that used for an x-ray, but the procedure is painless. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — takes longer.
Standard (conventional) EBRT is used much less often than in the past. Newer techniques let doctors give higher doses of radiation to the prostate gland while reducing the radiation exposure to nearby healthy tissues. These techniques have fewer side effects than standard EBRT. They may also have a better chance of curing the cancer, but this has not yet been proven in studies. Many doctors now recommend using these newer techniques when they are available.
Three-dimensional conformal radiation therapy (3D-CRT)
3D-CRT uses special computers to precisely map the location of your prostate. Radiation beams are then shaped and aimed at the prostate from several directions, which makes it less likely to damage normal tissues. You will most likely be fitted with a plastic mold resembling a body cast to keep you in the same position each day so that the radiation can be aimed more accurately. This method seems to be at least as effective as standard radiation therapy with lower side effects.
Intensity modulated radiation therapy (IMRT)
IMRT is an advanced form of 3D therapy. It uses a computer-driven machine that actually moves around the patient as it delivers radiation. In addition to shaping the beams and aiming them at the prostate from several angles, the intensity (strength) of the beams can be adjusted to minimize the dose reaching the most sensitive normal tissues. This lets doctors deliver an even higher dose to the cancer areas. Many major hospitals and cancer centers now routinely use IMRT.
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 may result in fewer side effects, although more research is needed to prove this.
A variation of IMRT is called volumetric modulated arc therapy. It uses a machine that delivers the 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.
Conformal proton beam radiation therapy
Proton beam therapy is related to 3D-CRT and uses a similar approach. But instead of using x-rays, this technique focuses proton beams on the cancer. Protons are positive parts of atoms. Unlike x-rays, which release energy both before and after they hit their target, protons cause little damage to tissues they pass through and then release their energy after traveling a certain distance. This means that proton beam radiation may be able to deliver more radiation to the prostate and do less damage to nearby normal tissues. Although early results are promising, studies are needed to see if proton beam therapy is better in the long-run than other types of external beam radiation. Right now, proton beam therapy is not widely available. The machines needed to make protons are expensive, and there are only a handful of them in use in the United States. Proton beam radiation may not be covered by all insurance companies at this time.
Possible side effects of EBRT therapries
Any numbers below used to describe the possible side effects relate to standard external radiation therapy, which is now used much less often than in the past. The risks of the newer treatment methods described above are likely to be lower.
Bowel problems: During and after treatment with EBRT, you may have diarrhea, sometimes with blood in the stool, rectal leakage, and an irritated large intestine. Most of these problems go away over time, but in rare cases normal bowel function does not return after treatment ends. In the past, about 10% to 20% of men reported bowel problems after EBRT, but the newer conformal radiation techniques may be less likely to cause these problems.
Bladder problems: You might need to urinate more often, have a burning sensation while you urinate, and/or find blood in your urine. Bladder problems usually improve over time, but in some men they never go away. About 1 man out of 3 continues to need to urinate more often.
Urinary incontinence: Overall, this side effect is less common than after surgery, but the chance of incontinence goes up each year for several years after treatment.
Erection problems, including impotence: After a few years, the impotence rate after radiation is about the same as that after surgery. It usually does not occur right after radiation therapy but slowly develops over a year or more. This is different from surgery, where impotence occurs immediately and may improve over time.
In older studies, about 3 out of 4 men were impotent within 5 years of having EBRT, but some of these men had erection problems before treatment. About half of men who had normal erections before treatment became impotent at 5 years. It’s not clear if these numbers will apply to newer forms of radiation as well. As with surgery, the older you are, the more likely it is you will have problems with erections. Impotence may be helped by treatments such as those listed in the “Surgery for prostate cancer” section, including erectile dysfunction medicines.
Feeling tired: Radiation therapy may cause fatigue that may not go away until a few months after treatment stops.
Lymphedema:Fluid buildup in the legs or genitals (described in the “Surgery for prostate cancer” section of this document) is possible if the lymph nodes receive radiation.
Urethral stricture: The tube that carries urine from the bladder out of the body may, rarely, be scarred and narrowed by radiation. This can cause problems with urination, and may require further treatment to open it up again.
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 your prostate.
Brachytherapy is generally used only in men with early stage prostate cancer that is relatively slow growing (such as low-grade tumors). Its use may also be limited by other factors. For men who have had a transurethral resection of the prostate (TURP) or for those who already have urinary problems, the risk of urinary side effects may higher. Brachytherapy may not be as effective in men with large prostate glands because it may not be possible to place the seeds into all of the correct locations. Doctors are now looking at ways to get around this, such as giving men a short course of hormone therapy beforehand to shrink the prostate.
Imaging tests such as transrectal ultrasound, CT scans, or MRI are used to help guide the placement of the radioactive pellets. Special computer programs calculate the exact dose of radiation needed. Without these, the cancer might get too little radiation or the normal tissues around it could get too much.
There are 2 types of prostate brachytherapy. Both are done in an operating room and require some type of anesthesia.
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 put out a very large amount of radiation to a very small area. This lowers the amount of damage done to the healthy tissues that are close to the prostate. Usually, anywhere from 40 to 100 seeds are placed. Because they are so small, the seeds cause little discomfort, and they are simply left in place after their radioactive material is used up. This type of radiation therapy requires spinal anesthesia (where the lower half of your body is numbed) or general anesthesia (where you are asleep) and may require an overnight stay in the hospital.
You may also receive external beam radiation along with brachytherapy, especially if there is a risk that your cancer has spread outside of the prostate (for example, if you have a higher Gleason score).
Temporary (high dose rate, or HDR) brachytherapy
This is a newer technique. 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, and the radioactive substance is removed each time. The treatments are usually given over 2 days. After the last treatment the catheters are removed. For about a week after treatment, you may have some pain or swelling in the area between your scrotum and rectum, and your 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 total dose of radiation is computed so that it is high enough to kill all the cancer cells. The advantage of this approach is that most of the radiation is concentrated in the prostate gland itself, sparing the urethra and the tissues around the prostate such as the nerves, bladder, and rectum.
Possible risks and side effects of brachytherapy
If you receive permanent brachytherapy seeds, they will give off small amounts of radiation for several weeks. Even though the radiation doesn’t travel far, your doctor may advise you to stay away from pregnant women and small children during this time. You may be asked to take other precautions as well, such as wearing a condom during sex.
There is also a small risk that some of the seeds may move (migrate). You may be asked to strain your urine for the first week or so to catch any seeds that might come out. Be sure to carefully follow any instructions your doctor gives you. There have also been reports of the seeds moving through the bloodstream to other parts of the body, such as the lungs. As far as doctors can tell, this doesn’t seem to cause any ill effects and happens very rarely.
Like external beam radiation, brachytherapy can also cause bowel problems, urinary problems, and problems with erections.
Bowel problems: Significant long-term bowel problems (including rectal pain, burning, and/or diarrhea) occur in less than 5% of patients.
Urinary problems: Severe urinary incontinence is not a common side effect. But frequent urination may persist in about 1 out of 3 men who have brachytherapy. This may be caused by irritation of the urethra, the tube that drains urine from the bladder. Rarely, this tube may actually close off (known as urethral stricture) and need to be opened with surgery.
Erection problems: Some studies have found rates of erection problems to be lower after brachytherapy, but other studies have found that the rates were no lower than with external beam radiation or surgery. Again, the younger you are and the better your sexual function before treatment, the more likely you will be to regain function after treatment.
What is hormone therapy?
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.
The main androgens are testosterone and dihydrotestosterone (DHT). Androgens, which are made mainly in the testicles, stimulate prostate cancer cells to grow. Lowering androgen levels or stopping them from getting into prostate cancer cells often makes prostate cancers shrink or grow more slowly for a time. However, hormone therapy alone does not cure prostate cancer.
Hormone therapy may be used:
- If you are not able to have surgery or radiation or can’t be cured by these treatments because the cancer has already spread beyond the prostate gland
- If your cancer remains or comes back after treatment with surgery or radiation therapy
- Along with radiation therapy as initial treatment if you are at higher risk of the cancer coming back after treatment (based on a high Gleason score, high PSA level, and/or growth of the cancer outside the prostate)
- Before radiation to try to shrink the cancer to make treatment more effective
Types of hormone therapy
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.
This is done as a simple outpatient procedure. It is probably the least expensive and simplest way to reduce androgen levels in the body. But unlike some of the other methods of lowering androgen levels, it is permanent, and many men have trouble accepting the removal of their testicles.
Some men having the procedure are concerned about how it will look afterward. If wanted, artificial silicone sacs can be inserted into the scrotum. These look much like testicles.
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.
Even though LHRH analogs (also called LHRH agonists) cost more than orchiectomy and require more frequent doctor visits, most men choose this method. These drugs allow the testicles to remain in place, but the testicles will shrink over time, and they may even become too small to feel.
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. The LHRH analogs available in the United States include leuprolide (Lupron®, Eligard®), goserelin (Zoladex®), triptorelin (Trelstar®), and histrelin (Vantas®).
When LHRH analogs are first given, testosterone levels go up briefly before falling to very low levels. This effect is called flare and results from the complex way in which LHRH analogs work. Men whose cancer has spread to the bones may have bone pain. If the cancer has spread to the spine, even a short-term increase in growth could compress the spinal cord and cause pain or paralysis. Flare can be avoided by giving drugs called anti-androgens for a few weeks when starting treatment with LHRH analogs. (Anti-androgens are discussed further on.)
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.
Degarelix (Firmagon®) is an LHRH antagonist used to treat advanced prostate cancer. It is given as a monthly injection under the skin and quickly reduces testosterone levels. The most common side effects are problems at the injection site (pain, redness, and swelling) and increased levels of liver enzymes on lab tests. Other side effects are discussed in detail below.
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.
Drugs of this type, such as flutamide (Eulexin®), bicalutamide (Casodex®), and nilutamide (Nilandron®), are taken daily as pills.
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.
Anti-androgen treatment may be combined with orchiectomy or LHRH analogs as first-line hormone therapy. This is called combined androgen blockade (CAB). There is still some debate as to whether CAB is more effective in this setting than using orchiectomy or an LHRH analog alone. If there is a benefit, it appears to be small.
Some doctors are testing the use of anti-androgens instead of orchiectomy or LHRH analogs. Several recent studies have compared the effectiveness of anti-androgens alone with that of LHRH agonists. Most found no difference in survival rates, but a few found anti-androgens to be slightly less effective.
If hormone therapy including an anti-androgen stops working, in some men the cancer will stop growing for a short time from simply stopping the anti-androgen. Doctors call this the anti-androgen withdrawal effect, although they are not sure why it happens.
Other androgen-suppressing drugs
Estrogens (female hormones) were once the main alternative to orchiectomy for men with advanced prostate cancer. Because of their possible side effects (including blood clots and breast enlargement), estrogens have been largely replaced by LHRH analogs and anti-androgens. Still, estrogens may be tried if androgen deprivation is no longer working.
Ketoconazole (Nizoral®), first used for treating fungal infections, blocks production of androgens. It is most often used to treat men just diagnosed with advanced prostate cancer who have a lot of cancer in the body, as it offers a quick way to lower testosterone levels. It can also be tried if other forms of hormone therapy are no longer effective.
Ketoconazole can block the production of cortisol, an important steroid hormone in the body. People treated with ketoconazole often need to take a corticosteroid (like hydrocortisone) to prevent the side effects caused by low cortisol levels.
Newer forms of hormone therapy
Researchers have developed newer forms of hormone therapy in recent years that may prove to be more effective than some of those now in use.
Abiraterone (Zytiga®): Drugs such as LHRH agonists can stop the testicles from making androgens, but other cells in the body, including prostate cancer cells themselves, can still make small amounts, which may fuel cancer growth. Abiraterone blocks an enzyme called CYP17, which helps stop these cells from making certain hormones, including androgens.
Abiraterone can be used in men with advanced castrate-resistant prostate cancer (cancer that is still growing despite low testosterone levels either from LHRH agonists or orchiectomy). Abiraterone has been shown to shrink or slow the growth of some of these tumors and help some of these men live longer.
This drug is taken as a pill every day. Since this drug doesn’t stop the testicles from making testosterone, men who haven’t had an orchiectomy need to continue with LHRH agonist therapy. Because abiraterone lowers the level of certain other hormones in the body, prednisone (a cortisone-like drug) needs to be taken as well during treatment.
Enzalutamide (Xtandi®): This drug is a newer type of anti-androgen. In order for androgens like testosterone to affect prostate cancer cells, they bind to a protein in the cells called the androgen receptor. The receptor then sends a signal for the cells to grow and divide. Enzalutamide (also known as MDV3100) blocks this signal from the androgen receptor to the cell.
In men with castrate-resistant prostate cancer who have already been treated with the chemotherapy drug docetaxel (Taxotere, enzalutamide has been shown to lower PSA levels, shrink or slow the growth of tumors, and help them live longer. This drug is also being studied to see if it can help men earlier in treatment.
Enzalutamide is a pill, with the most common dose being 4 pills each day. In studies of this drug, men stayed on LHRH agonist treatment, so it isn’t clear how helpful this drug would be in men with non-castrate levels of testosterone.
Other new drugs: Other new medicines such as orteronel have shown promise in early studies. They are now being tested against prostate cancer, but are only available through clinical trials at this time. These drugs are discussed in the section, “What’s new in prostate cancer research and treatment?”
Possible side effects of hormone therapy
Orchiectomy, LHRH analogs, and LHRH antagonists can all cause similar side effects due to changes in the levels of hormones such as testosterone and estrogen. These side effects can include:
- Reduced or absent libido (sexual desire)
- Impotence (erectile dysfunction)
- Hot flashes, which may get better or even go away with time
- Breast tenderness and growth of breast tissue
- Osteoporosis (bone thinning), which can lead to broken bones
- Anemia (low red blood cell counts)
- Decreased mental sharpness
- Loss of muscle mass
- Weight gain
- Increased cholesterol
Some research has suggested that the risk of high blood pressure, diabetes, strokes, heart attacks, and even death from heart disease is higher in men treated with hormone therapy, although not all studies have found this.
Anti-androgens have similar side effects. The major difference from LHRH agonists and orchiectomy is that anti-androgens may have fewer sexual side effects. When these drugs are used alone, libido and potency can often be maintained. When these drugs are given to men already being treated with LHRH agonists, diarrhea is the major side effect. Nausea, liver problems, and tiredness can also occur.
Abiraterone does not usually cause major side effects, although it can cause joint or muscle pain, high blood pressure, fluid buildup in the body, hot flashes, upset stomach, and diarrhea.
Enzalutamide can cause diarrhea, fatigue, and worsening of hot flashes. This drug can also cause some neurologic side effects, including dizziness and, rarely, seizures. Men taking this drug are more likely to have problems with falls, which may lead to injuries.
Many side effects of hormone therapy can be prevented or treated. For example:
- Hot flashes can often be helped by treatment with certain antidepressants.
- Brief radiation treatment to the breasts can help prevent their enlargement, but it is not effective once breast enlargement has occurred.
- Several different drugs are available to help prevent and treat osteoporosis.
- Depression can be treated by antidepressants and/or counseling.
- Exercise can help reduce many side effects, including fatigue, weight gain, and the loss of bone and muscle mass.
There is growing concern that hormone therapy for prostate cancer may lead to problems with thinking, concentration, and/or memory. But this has not been studied well in men getting hormone therapy for prostate cancer. Studying the possible effects of hormone therapy on brain function is hard, because other factors may also change the way the brain works. A study has to take all of these factors into account. For example, both prostate cancer and memory problems become more common as men get older. Hormone therapy can also lead to anemia, fatigue, and depression – all of which can affect brain function. Still, hormone therapy does seem to lead to memory problems in some men. These problems are rarely severe, and most often affect only some types of memory. More studies are being done to look at this issue.
Current issues in hormone therapy
There are many issues around hormone therapy that not all doctors agree on, such as the best time to start and stop it and the best way to give it. Studies are now looking at these issues. A few of them are discussed here.
Treating early stage cancer: Some doctors have used hormone therapy instead of watchful waiting or active surveillance in men with early (stage I or II) prostate cancer who do not want surgery or radiation. Studies have not found that these men live any longer than those who do not receive any treatment at first, but instead wait until the cancer progresses or symptoms develop. Because of this, hormone treatment is not usually advised for early stage prostate cancer.
Early versus delayed treatment: For men who need (or will eventually need) hormone therapy, such as men whose PSA level is rising after surgery or radiation or men with advanced prostate cancer who do not yet have symptoms, it is not always clear when it is best to start hormone treatment. Some doctors think that hormone therapy works better if it is started as soon as possible, even if a man feels well and is not having any symptoms. Some studies have shown that hormone treatment may slow down the disease and perhaps even lengthen survival.
But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the likely side effects of hormone therapy and the chance that the cancer could become resistant to therapy sooner, treatment should not be started until a man has symptoms from the cancer. Studies looking at this issue are now under way.
Intermittent versus continuous hormone therapy: Nearly all prostate cancers treated with hormone therapy become resistant to this treatment over a period of months or years. Some doctors believe that constant androgen suppression may not be needed, so they advise intermittent (on-again, off-again) treatment.
In one form of intermittent therapy, hormone treatment is stopped once the PSA drops to a very low level. If the PSA level begins to rise, the drugs are started again. Another form of intermittent therapy uses hormone therapy for fixed periods of time – for example, 6 months on followed by 6 months off.
Clinical trials of intermittent hormonal therapy are still in progress. It is too early to say whether this new approach is better or worse than continuous hormonal therapy. However, one advantage of intermittent treatment is that for a while some men can avoid the side effects of hormonal therapy such as decreased energy, impotence, hot flashes, and loss of sex drive.
Combined androgen blockade (CAB): Some doctors treat patients with both androgen deprivation (orchiectomy or an LHRH agonist or antagonist) plus an anti-androgen. Some studies have suggested this may be more helpful than androgen deprivation alone, but others have not. Most doctors are not convinced there’s enough evidence that this combined therapy is better than one drug alone when treating metastatic prostate cancer.
Triple androgen blockade (TAB): Some doctors have suggested taking combined therapy one step further, by adding a drug called a 5-alpha reductase inhibitor – either finasteride (Proscar) or dutasteride (Avodart) – to the combined androgen blockade. There is very little evidence to support the use of this “triple androgen blockade” at this time.
“Castrate resistant” vs. “hormone refractory” prostate cancer: These terms are sometimes used to describe prostate cancers that are no longer responding to hormones, although there is a slight difference between the two.
“Castrate resistant” means the cancer is still growing despite the fact that hormone therapy (either an orchiectomy or an LHRH agonist or antagonist) is keeping the testosterone in the body at very low, “castrate” levels. Some men may be uncomfortable with this term, but it is specifically meant to refer to these cancers, some of which may still be helped by other forms of hormone therapy (and are therefore not completely “hormone refractory”).
“Hormone refractory” refers to prostate cancer that is no longer helped by any type of hormone therapy, including the newer medicines.
Understanding Chemotherapy as a treatment option for prostate cancer
Chemotherapy (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. Chemo is not a standard treatment for early prostate cancer, but some studies are looking to see if it could be helpful if given for a short time after surgery.
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.
For prostate cancer, chemo drugs are typically used one at a time. Some of the chemo drugs used to treat prostate cancer include:
- Docetaxel (Taxotere®)
- Cabazitaxel (Jevtana®)
- Mitoxantrone (Novantrone®)
- Estramustine (Emcyt®)
- Doxorubicin (Adriamycin®)
- Etoposide (VP-16)
- Vinblastine (Velban®)
- Paclitaxel (Taxol®)
- Carboplatin (Paraplatin®)
- Vinorelbine (Navelbine®)
In most cases, the first chemo drug given is docetaxel, combined with the steroid drug prednisone. If this drug does not work (or stops working), a newer drug called cabazitaxel is often the next chemo drug tried (although there may be other treatment options as well).
Both of these drugs have been shown to help men live several months longer, on average, than older chemotherapy drugs. They may slow the cancer’s growth and also reduce symptoms, resulting in a better quality of life. Still, chemotherapy for prostate cancer is very unlikely to result in a cure.
Possible side effects of chemotherapy
Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemotherapy, which can lead to side effects.
The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are taken. These side effects may include:
- Hair loss
- Mouth sores
- Loss of appetite
- Nausea and vomiting
- Lowered resistance to infection (due to low white blood cell counts)
- Easy bruising or bleeding (due to low blood platelets)
- Fatigue (due to low red blood cells)
Most of these side effects are usually short-term and go away once treatment is finished. There is help for many of these side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting. Other drugs can be given to boost blood cell counts, if needed.
Along with the risks above, some side effects are seen more often with certain chemo drugs. For example:
- Docetaxel and cabazitaxel can sometimes cause severe allergic reactions. Medicines are given before each treatment to help prevent this problem. These drugs can also cause numbness, tingling, or burning sensations in the hands or feet, which is known as peripheral neuropathy.
- Mitoxantrone can rarely cause leukemia several years later.
- Estramustine carries an increased risk of blood clots.
- Doxorubicin can weaken the heart muscle over time, so doctors must limit the amount of this drug that is used.
New therapies for prostate cancer treatment
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 called biotherapy.
High Intensity Focused Ultrasound
HIFU, which is short for high intensity focused ultrasound, 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.
HIFU is a revolutionary form of treatment for organ-confined disease that allows treatment of prostate cancer without radiation and without having to make a surgical incision in the body.
How HIFU Works
In order to understand the basic concept of how HIFU works an analogy can be drawn between HIFU burning prostate tissue and sun rays entering a magnifying glass to burn a leaf. When a magnifying glass is held above a leaf in the correct position on a sunny day the sun’s rays intersect below the lens and cause the leaf to burn at the point of intersection.
If you insert your hand into the path of either one of the sun’s rays individually, away from the point of intersection, there is no significant heat felt or harm caused. Alternatively, if you place your hand at the point of intersection you will be burned.
The scientific principles at work in this example are the same as those with HIFU. Instead of light as the energy source, HIFU utilizes sound. Instead of a magnifying glass, HIFU uses a transducer. Just as the individual ray does not burn the hand, the individual sound wave does not burn the tissue it travels through.
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 (needles) 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 (where the lower half of your body is numbed) or general anesthesia (where you are asleep).
Very cold gases are then passed through the needles, creating ice balls that destroy the prostate gland. To be sure the prostate is destroyed without too much damage to nearby tissues, the doctor carefully watches the ultrasound images during the procedure. Warm saltwater is circulated through a catheter in the urethra during the procedure to keep it from freezing. The catheter is kept in place for about 3 weeks afterward to allow the bladder to empty while the man recovers.
After the procedure, there will be some bruising and soreness in the area where the probes were inserted. You might need to stay in the hospital overnight, but many patients leave the same day.
Cryosurgery is less invasive than radical prostatectomy, so there is usually less blood loss, a shorter hospital stay, shorter recovery period, and less pain than with surgery. But compared with surgery or radiation therapy, doctors know much less about the long-term effectiveness of cryosurgery. Current techniques using ultrasound guidance and precise temperature monitoring have only been available for a few years.
For this reason, most doctors do not often use cryosurgery as the first treatment for prostate cancer. It is sometimes recommended if the cancer has come back after other treatments.
Possible side effects of cryosurgery
Side effects from cryosurgery tend to be worse if it is done in men who have already had radiation therapy, as opposed to men who have it as the first form of treatment.
Most men have blood in their urine for a day or two after the procedure, as well as soreness in the area where the needles were placed. Swelling of the penis or scrotum is also common. The freezing may also affect the bladder and intestines, which can lead to pain, burning sensations, and the need to empty the bladder and bowels often. Most men recover normal bowel and bladder function over time.
Freezing damages nerves near the prostate and causes impotence in up to 4 out of 5 men who have cryosurgery. Erectile dysfunction is more common after cryosurgery than after radical prostatectomy.
Urinary incontinence is rare in men who have cryosurgery as their first treatment for prostate cancer, but it is more common in men who have already had radiation therapy.
After cryosurgery, less than 1% of men develop a fistula (an abnormal connection) between the rectum and bladder. This rare but serious problem can allow urine to leak into the rectum and often requires surgery to repair.
How Do I Know What Treatment Option is Best For Me?
To determine the right treatment option for you, your doctor will consider many different things. 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 and your doctor should work together to develop a treatment plan.
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 any treatment, it is 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, you should discuss this delay 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 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.