Treatment Options

How is prostate cancer treated?

The treatment of prostate cancer depends upon many factors.  These include the stage, tumor grade and PSA and the patient's general health status.

Download Treatment Options for Life Brochure

Active Surveillance (with delayed intervention)

It might seem strange that you have been diagnosed as having prostate cancer and your urologist has recommended that no treatment be given.  The reason is that while some prostate cancers grow rapidly and metastasize, others grow very slowly and are unlikely to metastasize.  Slow growing prostate cancer may not have time to cause significant problems.  Complications of treatment may outweigh the advantages of treatment.  Depending upon the size of your cancer, tumor grade, your age and general health, your urologist will discuss with you whether treatment should be postponed.  You will have regular PSA blood tests and Digital Rectal Exams (DRE) to determine if a repeat biopsy is required. Treatment can be given if the cancer is progressing.

Surgery-Radical Prostatectomy

Radical prostatectomy involves removal of the entire prostate, unlike the type of prostatectomy performed for benign prostatic hyperplasia (BPH) where only the inner obstructing part of the prostate is removed.  It is, therefore, a bigger operation and has more potential complications.  However, if the cancer is confined to the prostate it offers an excellent chance for cure.  It is usually performed through an incision in the lower abdomen.  Pelvic lymph nodes may be removed to check for metastases.  Radical prostatectomy will usually only be done if there are no metastases.  Potential complications include impotence and incontinence.  In the past, impotence almost always occurred due to damage to nerves, which lie very close to the prostate.  With improved surgical techniques these nerves may be spared, preserving sexual potency.  The likelihood of preserving potency will depend on a number of factors.  If you are potent, you should discuss this with your urologist.  Incontinence is common immediately after surgery. However, control is usually regained over the first few months.  Persistent, severe incontinence should occur in less than 5 percent of patients. Mild stress incontinence (e.g., with coughing or lifting) may persist in 10 to 15 percent of patients.  Other complications include narrowing at the junction of bladder and urethra and, very rarely, injury to the rectum.

Radical prostatectomy may also be performed with robotically assisted laproscopic surgery. This involves a longer anesthetic time, but usually a shorter recover time.

Radiation Therapy

Cancer cells can be killed using radiation.  Radiation may be given using external beam radiation or, in some centres, by the use of radioactive implants inserted into the prostate (brachytherapy).  Radiation treatment may also cause impotence, but incontinence is uncommon.  Some patients have problems with bowel and/or bladder function.  External beam radiation is generally given 5 days per week for about 6 weeks.  Brachytherapy is performed using general, spinal or local anesthesia.  Whether external beam radiation or brachytherapy is the appropriate treatment depends upon the tumor stage, grade and PSA level.  You should discuss which form of radiation is best for you with your urologist and radiation oncologist.

Patients who have cancer confined to the prostate have the choice of radical prostatectomy or radiation therapy.  Which is more suitable will depend upon factors such as the size of your tumor, your age and general health.  These options should be discussed with your urologist.  Radiation therapy is also useful for palliation (e.g., relief of pain due to metastases in the bone).

Cryotherapy

Cryotherapy uses extreme cold to destroy cancer cells. It is relatively new and only available in a few centres in Canada.  It is performed under spinal anesthesia and requires one night in the hospital.  Early results are comparable to surgery and radiation.  Impotence is common.  It is well tolerated and safe in older men.  It is an alternative for those men who cannot, or wish not, to have radical prostatectomy or radiation.  Cryotherapy is of particular value in men whose cancer has recurred following radiation therapy.  The risks of side effects are slightly higher in this group rather than when used as a primary treatment.

Hormonal Therapy

Most prostate cancers depend on the male hormone testosterone for their growth.  Removing testosterone, or blocking its action, causes prostate cancer cells to regress.  This is generally referred to as hormonal therapy.  Unfortunately, resistant cells eventually develop which can survive and grow in the absence of testosterone.  Hormonal therapy; therefore, does not cure prostate cancer, but can very effectively improve symptoms and quality of life.  As well, hormonal therapy may also prolong life.  Hormonal therapy is generally used in the treatment of more advanced prostate cancer, but may be useful in combination with surgery or radiation.

Hormonal therapy can be achieved in a variety of ways:

• Surgical removal of the testes
  
  This is called orchiectomy and is a relatively simple and effective way to remove testosterone.  If you are potent and sexually active you will likely notice decreased sexual desire and difficulty achieving erections.  You may also notice hot flashes.
• LH RH (Luteinizing Hormone Releasing Hormone) analogs
  
  These drugs are given by injection, usually every 3 or 4 months.  They prevent the release of testosterone from the testes and have similar benefits to orchiectomy.  Side effects are the same.
• Antiadrogens
  
  These are pills which block the stimulating effect of testosterone on prostate cancer.  There are a number of these drugs with similar methods of action.  Some permit preservation of sexual activity, but have other side effects and may be less effective in controlling the cancer when taken alone.  Most antiandrogens are used in combination with either orchiectomy or LHRL analogs.  Unlike orchiectomy, which is a one-time treatment, if drug therapy is used you will generally be required to continue with it indefinitely.  In some patients, intermittent (off and on) hormone therapy may be an option.  This alternative may reduce side effects but is still under investigation.  Should you require hormonal therapy, your urologist will discuss the advantages and disadvantages of the different options. You should also read the CPHC booklet on Hormonal Therapy for Prostate Cancer. 
• Chemotherapy
  
  Chemotherapy is the use of anticancer drugs, other than hormones.  Chemotherapy is very effective against some cancers.  Unfortunately, at present, we do not have very effective chemotherapy for prostate cancer, but new drugs continue to undergo investigation. Chemotherapy may aid in controlling symptoms and is sometimes used for patients whose disease is progressing despite hormonal therapy.  A great deal of research is ongoing to find effective therapy when hormonal therapy is no longer sufficient to control the cancer.