Prior to selecting a treatment option, it is important you discuss your options with a physician. When diagnosed with prostate cancer, treatment options include surgery, radiation therapy, active surveillance, hormonal therapy, and cryosurgery. Your physician may make a recommendation based off your pathology or Gleason score to best treat your prostate cancer. The matrix below is a good resource for recommended treatment modalities by Gleason score.
To learn more about any of these treatment modalities, please click on the tabs below.
- Radiation Therapy
- External Beam Radiation Therapy
- Radioactive Seed Implants
- Active Surveillance
- Hormonal Therapy
Removal of the cancerous prostate gland and certain surrounding structures is known as a radical prostatectomy, which can be done using open surgery, or with the daVinci robot. In the United States, 91% of prostate cancer diagnoses are estimated to be clinically localized or confined to the prostate with no regional lymph node or distant metastasis, when first detected. Because the entire prostate gland is removed with radical prostatectomy, the major potential benefit of this procedure is a cancer cure in patients for whom the prostate cancer is truly localized.
Patients should discuss radical prostatectomy with their doctor to determine if they are an appropriate candidate. The two potential side effects that most concern patients considering a radical prostatectomy are incontinence and inability to achieve erections. Today, most patients are candidates for nerve-sparing radical prostatectomies when the cancer is detected early, and preventing nerve damage may significantly minimize the potential side effects of incontinence and impotence. The vast majority of patients that undergo a radical prostatectomy see a return of urinary continence and sexual function after a recovery period post-surgery, though there is no guarantee that these benefits will apply for every patient. The length of this recovery period depends on a variety of factors and patients should openly discuss what recovery they should individually expect with their doctor.
Patients may have the option of using radiation to treat their prostate cancer. The two forms of radiation are external beam radiation and radioactive seed implants (also known as brachytherapy). When prostate cancer is localized, radiation therapy serves as an alternative to surgery. External beam radiation therapy is also commonly used to treat men with regional disease, whose cancers have spread too widely in the pelvis to be removed surgically, but show no evidence of spreading to the lymph nodes. In men with advanced disease, radiation therapy can help to shrink tumors and relieve pain. Radiation, despite continuing improvements in targeting doses, may damage healthy tissues. There is also a documented risk of long-term impotence, urinary incontinence and elevated rates of secondary cancers (such as bladder or rectal cancer) following radiation treatment for prostate cancer. Patients should discuss the potential for effective cancer control, as well as side effects of radiation treatments with their doctor.
External Beam Radiation Therapy
External beam radiation therapy generally involves treatments 5 days a week for 6 or 7 weeks. In many cases, if the tumor is large, hormone therapy may be started at the time of radiation therapy and continued for several years. The primary target is the prostate gland itself. In addition, the seminal vesicles may be irradiated (since they are a relatively common site of cancer spread). Radiating the lymph nodes in the pelvis, once common practice, has not proven to produce any long-term benefits for most patients, but it may be necessary in certain circumstances.
Radioactive Seed Implants
Radiation can also be delivered to the prostate in the form of dozens of tiny radioactive seeds implanted directly into the prostate gland. This approach, known as interstitial implantation or brachytherapy, has the advantage of delivering a high dose of radiation to tissues in the immediate area.
As practiced today, internal radiation therapy relies on ultrasound or CT to guide the placement of thin-walled needles through the skin of the perineum. Seeds made of radioactive palladium or iodine are delivered through the needles into the prostate according to a customized pattern—using computer programs—to conform to the shape and size of each man's prostate.
Active surveillance may be an appropriate option in some cases of localized prostate cancers that may advance so slowly that it is unlikely going to cause any problems during the patient’s lifetime. Some men who opt for active surveillance have no active treatment unless symptoms appear or PSA starts to rise to a level of concern. Patients that choose observation usually follow with their urologist every 3-6 months with regular PSA checks and digital rectal examinations.
Active surveillance has the obvious advantage of sparing a man with clinically localized cancer, who typically has no symptoms, the pain and possible side effects of surgery or radiation. On the minus side, watchful waiting risks decreasing the chance to control disease before it spreads, or postponing treatment to an age when it may be more difficult to tolerate. Of course, treatments may also improve over time if watchful waiting is chosen. Another potential disadvantage is anxiety; some men don't want the worry of living with an untreated cancer.
Patients should educate themselves on the risks vs. benefits of not initiating definitive treatments for prostate cancer, and discuss the option of active surveillance with their doctor.
Hormonal therapy or androgen deprivation therapy may be used in conjunction with other treatments or alone as a primary treatment. Hormone therapy may act to halt or slow the growth of prostate cancer, and it is often used in men with advanced disease. A variety of hormonal drugs can produce a medical castration by cutting off supplies of male hormones. Female hormones (estrogens) block the release and activity of testosterone. Antiandrogens block the activity of any androgens circulating in the blood. Still another type of hormone, taken as periodic injections, prevents the brain from signaling the testicles to produce androgens.
Hormone therapy has the potential to cause a number of side effects including impotence. Over time it does also cause bone loss which may require additional medical therapy.
Cryosurgery uses liquid nitrogen to freeze and kill prostate cancer cells. Guided by ultrasound, the doctor places needles in pre-selected locations in the prostate gland. The needle tracks are dilated for the thin metal cryo probes to be inserted through the skin of the perineum into the prostate. Liquid nitrogen in the cryo probes forms an ice ball that freezes the prostate cancer cells; as the cells thaw, they rupture. The procedure takes about two hours, requires anesthesia (either general or spinal), and requires one or two days in the hospital.
During cryosurgery, a warming catheter inserted through the penis protects the urethra, and incontinence is seldom a problem. However, the overlying nerve bundles usually freeze, so most men become impotent.
The appearance of prostate tissue in ultrasound images changes when it is frozen. To be sure enough prostate tissue is destroyed without too much damage to nearby tissues, the surgeon carefully watches these images during the procedure. But compared with surgery or radiation therapy, doctors know far 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. Outcomes of long-term (10- to 15-year) follow-up must still be collected and analyzed. For this reason, most doctors do not include cryosurgery among the options they routinely consider for initial treatment of prostate cancer.