Treatment Overview

Choosing treatment for prostate cancer can be confusing. Any treatment probably will cause serious side effects. It's important to learn all you can about your choices and talk to your doctor about them.

Your treatment options will depend on:

• What kind of cancer cells you have. This is called the grade or Gleason score of your cancer. Some prostate cancer cells grow more quickly than others.
• Your age.
• Any serious health problems you might have, including urinary, bowel, or sexual function problems.
• Your PSA level.

Treatment for locally advanced or metastatic prostate cancer may include hormone therapy, surgery, radiation therapy, and chemotherapy. You may want to talk with your doctor about entering a clinical trial of new cancer treatment options.

Some treatments being studied in clinical trials for advanced prostate cancer include ultrasound-guided cryosurgery, proton beam radiation, mixed beam radiation, and high-intensity-focused ultrasound (HIFU). For metastatic prostate cancer, treatments in clinical trials include new forms of chemotherapy and immunotherapy, including vaccines.

Prostate cancer and its treatment may cause nausea, pain, or other side effects. You can manage some side effects at home. 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 also may prescribe medicines to control nausea and vomiting. Constipation and diarrhea may be eased if you drink enough fluids.

Pain from cancer that has spread to the bones can be managed. If pain becomes a problem, talk to your doctor about seeing a pain management specialist. For tips on handling pain, see:

Cancer: Controlling Cancer Pain.

For more information, see the topic Cancer Pain.

Localized prostate cancer is cancer that has not spread outside the prostate. For more information on treatment of localized prostate cancer, see the topic Prostate Cancer.

Treatment for locally advanced prostate cancer

Prostate cancer that has spread to tissue around the prostate may be treated with:

• Radiation therapy. This treatment uses high-energy X-rays or protons to destroy the cancer. Radiation treatments, both external and internal radiation, have been improved with newer technologies, so there are fewer side effects and complications than in the past. Radiation therapy usually is combined with hormone therapy.
  • 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. For men with locally advanced cancers, ERBT may be given along with brachytherapy. 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 cause your symptoms to get worse. The two most common forms of external radiation are listed below:
    • 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.
• Surgery.
  • Radical prostatectomy. This operation takes out your prostate gland and the cancer in and around it. After surgery, men usually are started on hormone therapy.
  • Transurethral resection of the prostate (TURP). This surgery can help relieve bladder problems, because it removes part of the tumor that may be blocking the urethra, the tube that carries urine from your bladder through your penis. The procedure is done under general anesthesia. This can keep the tumor from growing for a while. But TURP does not take out the whole tumor.
• Hormone therapy, also called androgen deprivation therapy (ADT). Prostate cancer needs male hormones (testosterone) in order to survive. Hormone therapy decreases the amount of testosterone and other male hormones in your body. This often causes tumors to shrink. Shrinking the tumors can ease severe bone pain caused by the spread of cancer to the bones. Hormone therapy usually is combined with radiation therapy. The most common methods are:
  • LH-RH agonists and GnRH agonists. These drugs, such as goserelin (Zoladex), leuprolide (Lupron), and triptorelin (Trelstar), stop the body from making testosterone.
  • GnRH antagonists. These drugs stop the body from making testosterone. They work right away and avoid the flare caused by GnRH agonists that can make symptoms worse for several weeks. One GnRH antagonist is degarelix (Firmagon).
  • Antiandrogens. These drugs, such as bicalutamide (Casodex), often are used along with LH-RH agonists. Antiandrogens help block the body's supply of testosterone.
  • Orchiectomy. This is surgery to remove the testicles, which produce more than 90% of the body's male hormones (androgens), including testosterone.

In some cases, men will have radiation therapy after a prostatectomy, especially if the tumor could not be completely removed by surgery.

Some men choose to start hormone therapy only after they have symptoms. But many doctors recommend starting hormone therapy right away if cancer is found in the lymph nodes during surgery to remove the prostate. Early treatment may allow men to live a little longer. Other doctors say to wait, because waiting delays the bothersome and serious side effects of hormone therapy.

Treatment for metastatic prostate cancer

Treatment for prostate cancer that has spread to the bones and/or other organs in the body is aimed at relieving symptoms and slowing the cancer's growth. Treatment may include:

• Hormone therapy to slow cancer growth.
• Radiation therapy to shrink tumors and ease pain.
• Chemotherapy to stop the growth of cancer cells.
• Surgery to remove blockages that are causing problems (TURP).
• Immunotherapy to help a man's own immune system to fight the cancer.

Hormone therapy works by decreasing the amount of testosterone in your body. This can be done with medicine or with surgery to remove the testicles (orchiectomy). Hormone therapy can also relieve pain by shrinking tumors and easing urinary problems.

Sometimes androgen deprivation (orchiectomy or an LH-RH agonist) and an antiandrogen are used together. This is called a combined androgen blockade (CAB). But the slight benefit of CAB may be offset by side effects.

Both orchiectomy and hormone therapy medicine make testosterone levels drop, causing some of the same side effects. These include larger breasts, hot flashes, loss of sexual desire, and the inability to have an erection. Treatment options for these problems include:

• Taking a temporary break from hormone therapy. This can make some side effects go away. (Side effects after orchiectomy are permanent.)
• Radiation treatment of the breasts to prevent breast growth. This is done before starting hormone therapy.
• Radiation treatment or the anti-estrogen breast cancer medicine called tamoxifen to relieve breast pain. Tamoxifen can also help reverse breast growth. It also causes hot flashes.
• Taking medicines to control hot flashes, such as venlafaxine or paroxetine. If these don't work, sometimes estrogen or megestrol may help reduce hot flashes. But all of these medicines have different side effects, so if you are having a problem with hot flashes, talk with your doctor.

Other serious side effects of hormone therapy may include thin or brittle bones (osteoporosis), reduced muscle mass, increased body mass (BMI), low red blood cell counts (anemia), fatigue, cognitive impairment (trouble thinking clearly), depression, and an increased risk for diabetes and heart disease.

Hormone therapy usually works well at first to stop cancer growth. But in most cases the cancer returns in a few years. At this point, the cancer is described as hormone-resistant, meaning it is not responding to standard hormone therapy. When this happens, other kinds of hormone treatment may be tried. If the cancer continues to grow, chemotherapy may be recommended.

Other hormone therapies may include the use of medicines such as megestrol acetate, estrogen, ketoconazole, aminoglutethimide combined with hydrocortisone, and corticosteroids (prednisone, dexamethasone, and hydrocortisone).

Some men choose to start hormone therapy only after they have symptoms. But many doctors recommend starting hormone therapy right away if cancer is found in the lymph nodes during surgery to remove the prostate. Early treatment may allow men to live a little longer. Other doctors say to wait, because waiting delays the bothersome and serious side effects of hormone therapy.

Alternatives to conventional hormone therapy include intermittent ADT, known as IAD, where men take cycles of hormone therapy medicines. Taking breaks between hormone therapy cycles gives men the chance to recover their ability to function sexually. It also gives relief from the other side effects of hormone therapy, including the loss of energy, loss of bone and muscle mass, and hot flashes. The long-term survival outcome of IAD compared to conventional ADT is not yet known, but from early studies, it looks like they both work about the same.⁵

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

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

What to think about

You may experience a wide variety of emotions after being diagnosed. Most men feel some denial, anger, and grief. Others feel nothing at all. It is normal to have a wide range of feelings. And it is normal for your feelings to change quickly. There are many things you can do to help with your emotional reaction to prostate cancer. You may find that talking with family and friends helps you with your emotions. Some men find that spending time alone is what they need.

If your reaction is interfering with your ability to make decisions about your health, be sure to talk with your doctor. Your cancer treatment center may offer psychological or financial services. You may also ask 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 help a lot.

Long-term hormone therapy can also lead to osteoporosis, which causes bones to become brittle and more likely to break. Drugs are available to help prevent this side effect. For more information, see the topic Osteoporosis.

There are many studies (clinical trials) focusing on finding ways to prevent, detect, diagnose, and treat prostate cancer in all stages. Talk to your doctor about whether entering a clinical trial is a good option for you to explore.

Palliative care

If your cancer gets worse, look into your options for palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different from trying to cure your illness. Palliative care focuses on improving your quality of life-not just in your body but also in your mind and spirit. Some people combine palliative care with curative care.

With prostate cancer, palliative care may involve treatments to reduce tumors or bone pain, such as chemotherapy, radiation therapy, radionuclides (medicine used in external radiation) for bone metastasis, and bisphosphonates, which slow the breakdown of bone and help relieve bone pain. Surgery to relieve bladder problems (transurethral resection of the prostate, or TURP) is also an option.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

You may wish to discuss health care and other legal issues that arise near the end of life with your family and your doctor. You may find it helpful and comforting to state your health care choices in writing-with an advance directive or living will-while you are still able to make and communicate these decisions.

Think about your treatment options and which kind of treatment will be best for you. You may want to choose a health care agent to make and carry out decisions about your care if you should become unable to speak for yourself. Be sure to share your wishes with your family or close friends. You can get forms from Caring Connections (www.caringinfo.org or 1-800-658-8898) or Aging With Dignity (www.agingwithdignity.org or 1-888-594-7437).

For more information, see the topic Care at the End of Life.

Hospice care provides medical services, emotional support, and spiritual resources for people who are at the end of life. Hospice care also helps family members manage the practical details and emotional challenges of caring for a dying loved one. For more information, see the topic Hospice Care.