Treatment Overview

Prostate cancer is often curable. More than 90% of new cases of prostate cancer are caught early. Almost 100% of men with these early cancers survive 5 years or more after being diagnosed.¹

Choosing treatment for prostate cancer can be confusing. Any treatment can cause serious side effects.

The main choices for treating prostate cancer include surgery to remove the prostate gland (prostatectomy), radiation, cryosurgery, hormone therapy, and active surveillance (watchful waiting).

Active surveillance may be a good option if you have cancer that is low-risk and has not spread (early stage). With active surveillance, you will have regular checkups with your doctor to see if your cancer has changed.

Active surveillance may also be a good option if you are an older man with serious health problems or close to the end of your life. If this is true in your case, you may not want to have any treatment to remove the cancer. You may decide to have treatment only if it is needed to keep you comfortable (palliative care).

Active surveillance allows a man to wait or avoid treatments that may have serious side effects. But a man who has cancer that is more likely to spread will need to have other treatments such as surgery or radiation unless he is expected to live only a short time.

Your treatment decision will depend on:

• Your age.
• Any serious health problems, including any urinary, bowel, or sexual function problems.
• Your PSA level.
• What kind of cancer cells you have. This is called the grade or Gleason score of your cancer. Most prostate cancer cells grow very slowly, but some types of cells grow quickly and spread to other areas of the body.
• How far your cancer has spread. This is called the stage of your cancer.
• The side effects of treatment.
• Your personal feelings and concerns.

Prostate cancer may be curable if it is detected and treated early. Unlike many other cancers, it is usually slow-growing. For most men, this slow growth means they have time to learn all they can before deciding whether to have treatment or which treatment to have.

Initial treatment

The main choices for treating prostate cancer include active surveillance, prostatectomy, radiation, cryosurgery, and hormone therapy.

• Active surveillance is a treatment choice for any man who has low-risk cancer that has not spread (early stage). Or it can be a treatment choice for a man who is close to the end of his life.
• Surgery involves removing the cancer by removing the prostate gland. This operation is called a prostatectomy. Before removing the prostate, the surgeon may remove some lymph nodes in the area to see if the cancer has spread.
  • Nerve-sparing surgery helps preserve the nerves that are along the side of the prostate and that are needed for an erection. This surgery is only done when there is little chance of leaving cancer cells behind. If you already have sexual function issues, nerve-sparing surgery may not be the best choice for you.
  • Laparoscopic radical prostatectomy is surgery done through several very small incisions in the belly. Laparoscopic surgery is done with a tiny camera and special instruments to remove the prostate.
  • Robotic-assisted laparoscopic radical prostatectomy is surgery done through small incisions in the belly with robotic arms that translate the surgeon's hand motions into finer and more precise movements. This surgery requires specially trained doctors.
• Radiation treatments, which include external and internal radiation, have been improved with newer technologies that reduce side effects and other problems caused by radiation in the past.
  • External radiation. Also called external beam radiotherapy, or EBRT, radiation therapy uses high-energy rays, such as X-rays, to destroy the cancer. It is usually given in multiple doses over several weeks. Radiation destroys tissue, so it may damage the nerves along the side of the prostate that affect your ability to have an erection. If you already have bowel problems, external radiation may make your symptoms worse. The two most common forms of external radiation are listed here:
    • Conformal radiotherapy (3D-CRT) uses a three-dimensional planning system to target a strong dose of radiation to the prostate cancer. This helps to protect healthy tissue from radiation.
    • Intensity-modulated radiation therapy (IMRT) uses newer 3D-CRT technology to target the cancer.
  • Internal radiation (brachytherapy). Brachytherapy is a one-time radiation treatment that uses tiny radioactive seeds. After you are given anesthesia, the doctor uses a needle to inject the seeds into your prostate, where they slowly release radiation directly into the cancer. Sometimes external radiation or hormone therapy is added to brachytherapy. If you already have urinary problems, brachytherapy may make your symptoms worse.
    • High-dose rate brachytherapy (HDR brachytherapy). For this form of brachytherapy, radioactive material is placed into the prostate for a very brief period of time (seconds to minutes) and then removed. The radiation is delivered this way several times. Early results from studies show that HDR brachytherapy is as helpful as other kinds of internal radiation.⁷
• Cryosurgery, also called cryoablation, freezes the prostate gland to kill the cancer. This is often done when surgery is not an option and when the cancer is advanced but still inside the prostate gland. And the results, including side effects such as incontinence or an injury to the rectum, depend very much on the doctor's skill and experience. With cryosurgery, the prostate gland is not removed.
• Hormone therapy, also called androgen deprivation therapy or (ADT), is used in most cases with either surgery or radiation. Hormone therapy cannot cure prostate cancer. But it will usually shrink the tumor and slow the rate of cancer growth, sometimes for years. Taking a hormone-therapy medicine lowers your level of testosterone and other male hormones. Another way to lower male hormones is by having surgery to remove the testicles, called an orchiectomy.

The side effects of treatment are important to think about. Removing the prostate gland during surgery can cause impotence (not being able to have an erection) and urinary incontinence (not being able to control urination). Destroying the prostate gland with radiation may cause impotence and incontinence, but not as much as surgery can. But radiation sometimes causes diarrhea and bowel problems.⁵ Hormone therapy can cause loss of sex drive and erections, risk of weak bones (osteoporosis), hot flashes, and weight gain.

The ability to have an erection sometimes returns or at least improves over time. So does the ability to control urine leakage.

Prostate Cancer: Should I Have Radiation or Surgery for Localized Prostate Cancer?

A diagnosis of prostate cancer usually means that you will be seeing your doctor regularly for years to come, so it is a good idea to build a relationship that is based on full and honest information. Ask your doctor questions about your cancer so that you can make the best decision about treatment. Your doctor also may give you some advice on changes to make in your life to help treatment be successful.

Your treatment options will be different if you are diagnosed with prostate cancer that has come back or has spread outside the prostate. For more information, see the topic Prostate Cancer, Advanced or Metastatic.

Dealing with your emotions

You may feel many emotions after being diagnosed with prostate cancer. Most men feel some denial, anger, and grief. There is no "normal" or "right" way to react. There are many things you can do to help yourself deal with your emotional reaction to prostate cancer. Talking with family and friends helps some people. Others find that they need to spend time alone.

If your reaction is interfering with your ability to make decisions about your health, talk to your doctor. Your cancer treatment center may offer psychological or financial services. You may also contact your local chapter of the American Cancer Society to help you find a support group. Talking with other men who have had similar feelings can be very helpful.

For more information about specific treatments, see the following topics:

• Prostate Cancer — Health Professional Information [NCI PDQ]
• Prostate Cancer — Patient Information [NCI PDQ]

Ongoing treatment

If you choose surgery or radiation to treat your prostate cancer, it will be important to have regular checkups. If your cancer comes back, this will help your doctor catch it early. It will also help your doctor treat any complications you may have from your treatment. Your regular follow-up program may include:

• Physical exams.
• PSA tests, to measure the levels of prostate-specific antigen (PSA) in your blood. A higher level of PSA may point to an enlargement, infection, or cancer of the prostate. A rising PSA level after treatment for prostate cancer can mean your cancer has come back.
• Digital rectal exams, to check for changes in and around your rectum.
• Urinalysis, to check for blood in your urine.
• Biopsies, to examine suspicious tissue.

Prostate cancer and its treatment also may cause nausea, pain, or other side effects. You can use home treatment to manage some of these side effects. If you experience nausea, wait for 1 hour after vomiting has stopped and then sip a rehydration drink to restore lost fluids and nutrients. Your doctor may prescribe medicines to control nausea and vomiting. Constipation and diarrhea may be eased if you drink enough fluids.

For more information about managing pain, see the topic Cancer Pain.

If you decide to watch and wait (active surveillance) instead of having treatment, you will have regular checkups with your doctor to check on your cancer. Your checkups may include digital rectal exams, PSA tests, or biopsies. It is possible that a curable cancer could spread and become incurable during a 6-month period, but this is not common. If there is no change in your condition, you may continue active surveillance. If the cancer begins to grow or spread, you may consider medicines, surgery, or radiation.

Treatment if the condition gets worse

For information on prostate cancer that spreads or comes back, see the topic Prostate Cancer, Advanced or Metastatic.

What to Think About

One kind of radiation therapy used mostly in clinical trials is proton therapy. Proton therapy uses a different type of energy (protons) rather than X-rays. This allows a higher amount of specifically directed radiation, which protects nearby healthy tissues (especially the rectum). Sometimes proton therapy is combined with X-ray therapy.

Another treatment is high-intensity focused ultrasound (HIFU), which uses an intense heat from focused sound waves to kill cancer cells. HIFU is also used for men who have cancer inside the prostate but who cannot have surgery. HIFU is a treatment that is used in Canada, Europe, and the United States. In the U.S., HIFU is being used in clinical trials. It is not yet FDA-approved.

Age is not a reason to avoid surgery. But if you are 70 or older, other medical conditions, such as heart disease, may affect your decision. Men who are older also have a higher rate of incontinence and impotence after surgery. Age is especially important to think about if you have early-stage cancer, which generally grows slowly.

Get a second or even a third opinion before making your treatment decisions. You may hear differing advice or opinions, which may seem confusing. But talking with other doctors can help you make your decision. If your doctor is a medical oncologist, you may want to talk with other prostate cancer specialists, such as a urologist, a radiation or urologic oncologist, or a surgeon.

Studies show that fewer side effects are reported at large medical centers, where the surgeons do prostatectomies more often and so are more experienced and skilled.⁵