Prostate cancer guide
Welcome to Prostate cancer guide
Being diagnosed with prostate cancer can be scary. It can lead you to fear, panic and hurried decisions. You may feel that you need to make a quick decision and begin treatment right away. However, prostate cancer is usually slow growing, so in most cases there's no need to rush.
Before deciding on the best course of treatment, it's important that you understand the pros and cons of the various options and how they relate to your specific situation. Give yourself time to gather information. Find out about all treatment options that are available to you before deciding what to do. Talk to or read about other men who've been in a similar situation. Consider seeking opinions from doctors in specialties such as urology, oncology and radiotherapy. Not all doctors agree about the best treatment choices for prostate cancer. Some doctors are more inclined to recommend a treatment in their area of specialty. Gathering several specialists' opinions may give you a better understanding of your treatment options.
You may need to evaluate conflicting advice from different doctors to make a treatment decision. But when you're involved in making choices about your treatment, you're more likely to feel better about it. You'll have an increased sense of control and less anxiety. You'll feel more secure about your choices, and you'll be more able to cope and more able to talk about your cancer and its effects with your loved ones.
The information here is designed to help you understand some of your treatment choices. This information is designed specifically for men with early-stage prostate cancer, not advanced prostate cancer.
Treatment options for prostate cancer
There are several prostate cancer treatment options, and choosing the best course of action is not always a clear-cut decision. Talking with specialists about your specific situation is the best way to understand the risks and benefits of your treatment choices.
The main approaches to treating early-stage prostate cancer include:
- Active surveillance (watchful waiting)
- External beam radiation therapy
- Radioactive seed implants (brachytherapy)
- Surgery to remove the prostate (radical prostatectomy)
- Cryosurgery
- Hormone therapy
Active surveillance (watchful waiting) may be a good choice if your cancer is a less aggressive type, hasn't spread and isn't very big. On the other end of the spectrum, if your cancer has spread beyond the prostate, you may need surgery to remove your prostate (prostatectomy), radiation therapy and possibly additional treatments such as hormone therapy. For some men with more extensive cancer, a combination of treatments works best, such as surgery followed by radiation or radiation paired with hormone therapy.
The treatment you choose may depend on several factors:
- Whether your cancer is confined to your prostate gland
- How fast your cancer is growing
- The volume of cancer within your prostate
- How far it has spread
- Your age
- Your overall health
- The benefits and potential side effects of treatments
Before reaching a definitive treatment decision, make sure you understand the pros and cons of your treatment options. In deciding on the treatment that's right for you, consider not only the likely outcomes of treatment but also the potential side effects and how they will affect your life. Treatment results and side effects are unique for surgery, radiation therapy, radioactive seed implants and cryotherapy. Keep in mind that while side effects can be serious and ongoing, there are treatments to reduce their impact. For many men, side effects of prostate cancer treatments improve with time.
By learning as much as you can about the risks and benefits of your treatment options, you can feel confident about the choices you make to treat your cancer.
Active surveillance (watchful waiting) for prostate cancer
During active surveillance, no medical treatment is provided — meaning medications, radiation and surgery aren't used. You avoid the risks and side effects associated with other treatment options. Active surveillance may be a good choice if your cancer isn't causing signs and symptoms, is expected to grow very slowly, and is small and confined to one area of your prostate. For this treatment option, you need to be willing to assume the risk that you may possibly miss the window of opportunity for effective treatment.
With active surveillance, periodic prostate-specific antigen (PSA) tests are used to check for signs the cancer is growing. Follow-up prostate biopsies also may be used to evaluate whether there are any changes. If there is a sudden rise in PSA levels or a biopsy reveals an increased grade or aggressiveness of the cancer, you may decide to change your treatment approach.
Active surveillance may be particularly appropriate if you're older or in poor health and your prostate cancer is very small and not very aggressive (low grade). Many men who choose active surveillance live out their normal life span without treatment and without the cancer spreading or causing other problems. However, active surveillance is usually a better choice for older men. Younger men are usually more likely to benefit from a more aggressive treatment approach. Active surveillance may not be the best option for you if you think you'll become overly anxious about your cancer and fear that you may be gambling with your life.
Active surveillance for prostate cancer: Pros and cons
Active surveillance may be an effective way to deal with your prostate cancer. Consider the following pros and cons before making your decision:
| Pros of active surveillance | Cons of active surveillance |
|---|---|
| It avoids the side effects associated with other treatment options, such as erectile dysfunction or incontinence. | Cancer can grow and spread while you wait. |
| Prostate cancer may grow and spread very slowly, so surgery, radiation or other treatments may never be needed. | It may leave you with a sense of uncertainty about the status of your cancer. |
| It requires regular PSA testing — PSA isn't an infallible test, and some cancers spread before PSA rises. |
External beam radiation therapy for prostate cancer
External beam radiation therapy (EBRT) is a standard treatment option for prostate cancer that has not spread beyond the prostate gland, with the goal of eliminating the cancer. Radiation therapy is also used to help shrink the tumor or to reduce symptoms and improve quality of life when eliminating prostate cancer isn't possible.
EBRT uses high-energy X-rays that are precisely focused on the prostate gland. The X-rays interfere with cancer cells' ability to reproduce and kill the cancer. This method has been used to treat prostate cancer for decades with good long-term results. Improvement in technology such as intensity-modulated radiation therapy (IMRT) has allowed the delivery of higher doses of radiation while avoiding damage to the surrounding normal organs.
Radiation treatments are generally given five days a week for about seven to nine weeks on an outpatient basis. Each treatment appointment takes about 15 to 25 minutes. However, much of this is preparation time, and radiation is received for only several minutes. Anesthesia is not needed with external beam radiation because there's no pain during treatment.
Side effects of radiation therapy can include urinary and rectal problems, a decrease in sexual function, and fatigue. Some side effects are long term, and others, such as fatigue, usually go away a few weeks after treatment. Although surgery is more commonly done in younger people, radiation therapy may be a good choice if you prefer to avoid surgery. Meet with both an urologist as well as a radiation oncologist before making a treatment decision.
External beam radiation therapy for prostate cancer: Pros and cons
External beam radiation may be an effective way to treat early-stage prostate cancer. Consider the following pros and cons of this method before making your decision:
| Pros of external beam radiation | Cons of external beam radiation |
|---|---|
| It's as effective as surgery over a 10-year period. | It usually needs to be done five days a week for seven to nine weeks. |
| It's done on an outpatient basis, and usually doesn't cause as much discomfort or require as much recovery time as surgery. | It can have a delayed but long-term effect on your sexual function. |
| It's a noninvasive treatment. Advances in treatment technology such as intensity-modulated radiation therapy (IMRT) help to minimize side effects of treatment. | It commonly causes urinary symptoms such as frequency and urgency. Rarely, it can cause urinary leakage. |
| It's designed to decrease exposure of normal tissues to radiation. | It can result in bowel problems such as rectal bleeding and urgency that are worse than those caused by seed-implant therapy or surgery. |
| It has no anesthesia risks. | It may cause a temporary decrease in energy levels and appetite. |
| It can damage healthy tissue in areas near your prostate. Rarely, radiation can lead to bladder or rectum injuries that require surgery to repair. | |
| The decline in PSA after treatment is slow, and PSA test results sometimes may fluctuate after treatment. This makes it more difficult for your doctor to determine the status of the tumor following radiation. |
Radioactive seed implants (brachytherapy) for prostate cancer
Brachytherapy for prostate cancer delivers radiation directly into the prostate with radioactive pellets. This method delivers a higher dose of radiation to the prostate gland than does external beam radiation, while less surrounding tissue is damaged by radiation.
Radioactive seed implants can be either temporary or permanent.
- Temporary seed implants, called high-dose radiation (HDR) brachytherapy, deliver radiation via tiny wires placed into the prostate and then immediately removed. It usually requires several treatments.
- Permanent seed implants, called low-dose radiation (LDR) brachytherapy, places tiny metal pellets into the prostate gland. These pellets release radiation over a few months and kill the cancer cells.
The procedure to implant radioactive seeds typically lasts one to two hours and is done on an outpatient basis while you're under spinal or general anesthesia. Seed implant causes short-term as well as long-term urinary and rectal side effects, although most of them are tolerable. Sometimes brachytherapy may be used together with external beam radiation.
Radioactive seed implants (brachytherapy) for prostate cancer: Pros and cons
Radioactive seed implants (brachytherapy) may be an effective way to treat your prostate cancer. Consider the following pros and cons of this method before making your decision:
| Pros of radioactive seed implant therapy | Cons of radioactive seed implant therapy |
|---|---|
| It delivers a higher dose of radiation than does external beam radiation. | It can have a delayed effect on your sexual function. |
| It may cause less damage to your rectum and other surrounding tissues than does external beam radiation. | It may not be a good choice for men who already have a lot of urinary symptoms. |
| It requires about one to two hours for the implantation procedure, which is done on an outpatient basis. Overnight hospital stay is not needed. | It causes more urinary side effects in most men than external beam radiation. Rarely, urinary incontinence may develop several years after treatment. |
| Sexual side effects may not be as severe soon after the procedure as they are after surgery. | It carries a small risk of seeds moving to the lungs or other parts of the body. |
| It requires a spinal or general anesthetic. | |
| Narrowing (stricture) of the urethra is more common than with external beam radiation. This can lead to difficult urination. | |
| There's a small chance of serious injury to the bladder and rectum that may require surgery to repair. | |
| It doesn't treat the area around the prostate as well as does external radiation. In people with more extensive cancer, seed implants may need to be combined with external beam radiation. |
Surgery: Radical prostatectomy
During a radical prostatectomy, your surgeon removes the entire prostate and if necessary, the nearby lymph nodes, while trying to spare the muscles and nerves that control urination and sexual function (nerve-sparing techniques).
The procedure is usually done under general or spinal anesthesia. Surgical approaches for a radical prostatectomy include:
- Open radical retropubic prostatectomy. With this approach an incision is made below the navel down to the pubic bone. Through this incision the prostate is removed by making an incision in the urethra and the part of the bladder surrounded by the prostate gland (bladder neck). The doctor can then lift out the prostate gland. Nerve-sparing techniques may be used to help preserve urinary control and sexual function. Your doctor may also remove lymph nodes, if necessary. You will need to stay in the hospital two to three days and have a urinary tube (catheter) in place one to two weeks.
- Radical perineal prostatectomy. With the perineal approach, which is less commonly used, your doctor removes the entire prostate through a half-moon incision between the anus and scrotum. Perineal surgery generally results in less bleeding, but has a higher risk of rectal injury. Also, your surgeon isn't generally able to remove nearby lymph nodes unless a second incision is made. Although nerve sparing can be performed, it is more difficult and less successful with this approach. The hospital stay is one to two days, and the catheter will need to stay in place one to two weeks.
- Robot-assisted radical prostatectomy. With the robotic approach, the operation is performed utilizing laparoscopic techniques through five or six "keyhole" incisions. Nerve sparing and lymph node removal can be done as well. The prostate is removed through a small incision in the navel area. The main advantage is a shortened hospital stay, shortened recovery time and less blood loss, compared with open prostatectomy. Most men stay in the hospital overnight and have a urinary catheter in place for five to seven days.
Radical prostatectomy: Pros and cons
Radical prostatectomy may be an effective way to treat your prostate cancer. Consider the following pros and cons before making your decision:
| Pros of radical prostatectomy | Cons of radical prostatectomy |
|---|---|
|
If the cancer is confined to your prostate, this is the most effective treatment to remove cancer. |
All operations carry some risk, including a low risk of death, which increases with age. |
| Your doctor is able to gather information about the extent of your cancer during surgery and after a laboratory examination of the removed prostate tissue. Lymph nodes can be analyzed to determine if additional treatment is required. | It takes time for you to regain urinary continence and return of erectile function. You may have permanent issues with urinary continence and erectile function. |
| Surgery can also treat pre-existing problems with urination caused by enlarged prostate. | If people have a problem with erectile function before surgery, they'll usually have permanent problems after surgery. |
| Without the prostate to produce PSA, PSA testing will show no PSA in your system immediately after your surgery. If your cancer comes back, your PSA levels will increase. An increase would be an accurate way to tell your cancer has returned. | Surgery requires a hospital stay and longer recovery period than does radiation therapy. |
| You can still use radiation after the surgery, whereas surgery after prior radiation is much more difficult and not offered in most cases. |
Hormone therapy for prostate cancer
Male sex hormones (androgens) stimulate the growth of prostate cancer cells. The main type of androgen is testosterone. Hormone therapy may stop your body from producing testosterone or block testosterone from entering cancer cells. Hormone therapy on its own doesn't get rid of cancer. That is, simply depriving prostate cancer of testosterone usually doesn't kill all of the cancer cells.
Three methods of hormone therapy are:
- Luteinizing hormone-releasing hormone (LH-RH) agonists
- Anti-androgens
- Testicle removal (also called orchiectomy and castration)
The first two options are temporary. The surgical removal of the testicles is permanent and irreversible.
Luteinizing hormone-releasing hormone (LH-RH) agonists
LH-RH agonists stop the testicles from producing testosterone. They do this by preventing the pituitary gland from releasing hormones that stimulate the production of testosterone from the testicles. Drugs typically used in this type of hormone therapy include leuprolide (Lupron, Eligard), goserelin (Zoladex) and triptorelin (Trelstar). These medications are injected into your buttocks (leuprolide) or abdomen (goserelin) monthly, every three or four months or once a year, depending on the type of injection you get.
Anti-androgens
These drugs block the prostate cancer cells' ability to use testosterone and are given in pill form. A small amount of testosterone comes from the adrenal glands and won't be suppressed by LH-RH agonists, and these drugs are useful to block this adrenal testosterone. Drugs typically used for this type of therapy include bicalutamide (Casodex) and nilutamide (Nilandron). These drugs are usually used to treat cancer that has spread beyond the prostate.
Testicle removal
In this procedure, testicles are removed and the scrotum is left intact. Men sometimes opt for surgery to insert testicle-shaped prostheses. This procedure permanently removes the source of about 90 percent of testosterone production in the body, which comes from the testicles (about 10 percent of testosterone comes from the adrenal glands).
Surgical removal of the testicles may be the best treatment for men who want a permanent procedure to reduce their testosterone level. It is much less expensive than LH-RH or anti-androgen therapy.
Specialized approaches to hormone therapy
- Intermittent therapy. Within a few years, your cancer may become resistant to androgen deprivation therapy. Once this happens, your doctor may suggest other forms of treatment. In some people, intermittent hormonal drug therapy may be considered. During this type of therapy, the hormonal drugs are stopped after your PSA drops to a low level and remains steady. The drugs are resumed if and when your PSA level rises again. This allows a break from the side effects of hormone treatment. Studies are being done to compare how well intermittent hormonal treatment works vs. continuous treatment.
- Combined therapy. In men with more aggressive prostate cancer (higher stage or higher grade), temporary hormone therapy using injections or oral drugs may be used in combination with radical prostatectomy or radiation. One type of hormone therapy (neoadjuvant) shrinks large tumors so that surgery or radiation can remove or destroy them more easily. And after these treatments, adjuvant hormone therapy can reduce or stop the growth of any cells left behind at the tumor site.
Hormone therapy for prostate cancer: Pros and cons
| Pros of hormone therapy | Cons of hormone therapy |
|---|---|
| It can temporarily slow the growth of prostate cancer and shrink existing tumors, reducing your symptoms and prolonging life in some cases. | It doesn't get rid of cancer on its own. It must be used in conjunction with another form of treatment if it's being used with the intent to cure. |
| With the exception of testicle removal, hormone therapy can be stopped, allowing the return of normal hormone production. | The potential side effects of hormone therapy include nausea, diarrhea and fatigue. Other possible side effects include hot flashes, breast enlargement, loss of muscle mass and bone mass (osteoporosis), loss of sex drive, and impotence. |
| If you stop hormone therapy, as is often done during intermittent therapy, side effects may go away. | Your cancer eventually might become resistant to hormonal drug therapy. |
| Some medications can cost hundreds of dollars a month and may not be covered by insurance. | |
| It increases your risk of diabetes and heart disease and may cause liver damage. |
Cryotherapy for prostate cancer
Cryotherapy is an alternative to surgery or radiation for prostate cancer. Cryotherapy kills prostate cancer by freezing prostate tissue. This method has been shown to effectively control cancer in men with early-stage prostate cancer, though more studies are needed to determine the long-term results of this procedure. This treatment was primarily introduced as a "surgical" alternative to radiation without having to remove the prostate.
Cryotherapy involves inserting several thin metal rods through the perineum (between the scrotum and the anus) and into the prostate. An ultrasound probe in the rectum helps guide your doctor to position the rods. Once the rod tips are in place, liquid nitrogen or argon gas is released into the rods, where it circulates and freezes the nearby tissue. This causes the cancerous cells to rupture and die. To keep the urethra from freezing along with the prostate, a catheter is placed inside the urethra and filled with a warming solution.
The procedure is done in the hospital. You may have general anesthesia, so you are unconscious during the procedure, or your doctor may just numb the surgery area (local anesthesia). It takes about two to three hours, and results in very little blood loss. It takes about two to four weeks to recover from the procedure. You may be able to leave the hospital the day of the procedure. It takes your body about nine months to a year to shed the dead cells. The procedure may have to be repeated if all cancer cells aren't killed during the first treatment. The nerves that control erections are damaged, almost always resulting in long-term erectile dysfunction in order to adequately treat the entire prostate.
Pros and cons of cryotherapy for prostate cancer
| Pros of cryotherapy | Cons of cryotherapy |
|---|---|
| It has been shown to control cancer confined to the prostate in specific situations. | The procedure may have to be repeated. |
| Usually, you'll need to stay in the hospital only one day or less. | Side effects such as injury to the rectum or urethra can be severe. It is these risks that have limited widespread use of this procedure. |
|
You'll have little blood loss, compared with surgery. |
It is expected to cause erectile dysfunction in most cases, though some results from studies of more technologically advanced treatment methods show a slightly lower rate. |
| Most men recover normal bowel function. | You may have trouble urinating for several weeks. |
| You'll have temporary soreness where the rods were inserted. | |
|
Long-term survival rates appear lower than do those with surgery or radiation therapy. |
|
| It's not yet clear how well this procedure controls cancer in the long term. |
Combination therapy for prostate cancer
With combination (multimodal) therapy, treatments are combined in various ways. One of the most common techniques for more advanced stage prostate cancer is to use external beam radiation along with seed implants (brachytherapy). Other methods may combine hormonal drug treatment, radiation and surgery.
The interaction between radiation and hormone therapy isn't clearly understood. For people with more aggressive cancer, combined external beam radiation and hormone treatment has been shown to result in better survival rates than external beam radiation alone. Studies are under way to examine this issue and the use of drug hormone therapy before radiation treatment in men with early-stage disease.
Radiation therapy may be recommended after surgery in some high-risk men in an attempt to decrease the risk of cancer coming back.
Things to consider about prostate cancer treatment
Choosing the treatment that's best for you means weighing all options in relation to your values and situation. As you make the decision about how your prostate cancer should be treated, here are some issues to consider and questions to ask yourself and your doctor.
- How much time should you take to make your decision? Consider the aggressiveness of your prostate cancer — is it likely to grow rapidly or slowly? If it's growing quickly, it's important to make a reasonably quick decision and proceed with treatment. Many prostate cancers grow slowly and don't require immediate or aggressive treatment, so there may be no need to rush your decision.
- How healthy are you? Do you have other diseases or conditions that may change your state of health over the next few years? If you're relatively healthy, you may want to consider aggressive treatment options, which may help you maintain that level of health. However, if you have other conditions affecting your health, you may choose to not treat your prostate cancer as aggressively because you're less likely to experience many of the long-term side effects of prostate cancer.
- How old are you? Prostate cancer in your 40s is different from prostate cancer in your 80s. If you're a man in your later years, aggressive treatment may not extend your life and thus may not be warranted. A younger man may fare better with aggressive treatment, as not only will it extend his life but recovery is usually better in younger men. It's also important to consider how you feel about life. Do you think of yourself as young and active? If so, you may find it worthwhile to consider more-aggressive treatments, regardless of your chronological age.
- How will your treatment choice and its potential side effects affect your lifestyle? How much will your chosen treatment affect your current lifestyle? Does the prospect of side effects — particularly impotence and urinary incontinence — bother you enough to sway your decision? Can your lifestyle accommodate a course of daily external beam radiation therapy?
- Are you willing to commit to follow-up care? Are you willing to undergo routine blood tests, digital rectal exams and perhaps repeat biopsies? Are you willing to schedule follow-up appointments with your doctor as necessary? Are you committed to a close partnership with your doctor, who will likely be your partner in fighting this disease?
- Is your doctor's experience and training having undue influence on your treatment decision? Make sure you and your doctor decide on the treatment that's judged to be best for you, not just the treatment that your doctor is trained in or has the most experience with.
- Once your treatment ends, how much will you continue to worry about recurrent cancer? If you choose watchful waiting, how will you feel knowing that untreated cancerous cells are inside your body? If you choose radiation — either seed implants or external beam radiation — will you feel confident that the cancer is under control? Or, will you feel more secure with surgery to remove the cancer?
- How do you find a doctor who's skilled in the procedure? Before deciding on a procedure, talk with a doctor who can help explain the complexity of the choices you're facing and one who will listen to your concerns and values about health-related quality-of-life issues. You may feel more comfortable with making a decision after you've heard a second opinion. Doctors who treat prostate cancer are urologists, radiation oncologists and medical oncologists. You may want to talk with a specialist in each of these areas because each may have a different opinion on how best to proceed. If you choose a treatment option other than watchful waiting, select a doctor who has extensive experience with it. In many cases, your primary care doctor may refer you to one or more specialists. You can also get the names of specialists from a nearby hospital or medical school, or contact the National Cancer Institute's Cancer Information Service at 800-4-CANCER, or 800-422-6237. Any of these sources can give you information about cancer centers and programs supported by the National Cancer Institute.
- How will your decision affect the relationship with your life partner? If you're married or in a relationship, you may want to think about how your choice will affect your partner. It's your life, but both of you will have to live with the decision. Treatment for prostate cancer can be a life-changing event. An open, honest discussion before making a treatment choice can help you both cope afterward if urinary or sexual dysfunction results. Discuss the trade-offs between short-term and long-term effects. Your partner can help you talk through the value you place on certain benefits and risks. Your decision has biological, psychological and social aspects and may very well affect your sexual relationship and your daily life for years after therapy is complete.
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