There are many treatment options available for prostate cancer based on the stage of the disease progression. Work together with your doctor to weigh the risks, advantages, and disadvantages of each option and its side effects to determine what treatment is right for you or your loved one.
Read the NCCN Guidelines for Prostate Cancer Patients from the National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 21 of the world’s leading cancer centers. Developed by hundreds of medical experts to provide step-by-step strategies that many doctors follow, the NCCN Guidelines are the most comprehensive and most frequently updated clinical practice guidelines available for any area of medicine.
Prostate cancer is diagnosed as early-stage when cancer cells have not spread outside of the prostate. If you’ve been diagnosed with early-stage prostate cancer with a low risk of progression—or you’re not expected to tolerate other therapies—your doctor may recommend watchful waiting or active surveillance. Aggressive treatment options include various types of prostatectomy, radiation therapy, cryosurgery or high intensity focused ultrasound. The goal of all invasive options is to remove or destroy cancer cells before they can spread to other tissues in the body.
Watchful waiting describes a less invasive follow-up, where the patient forgoes implementing therapy or treatment, with fewer tests, unless symptoms arise or the prostate cancer spreads to other parts of the body.
Active surveillance involves closely monitoring prostate cancer with routine digital rectal exams (DREs), prostate specific antigen (PSA) tests - usually every 6 months, and periodic biopsies - often yearly. Active treatment, such as surgery or radiation therapy, does not occur unless there is evidence that the cancer is growing. Active surveillance is considered appropriate for some men with very low- or low-risk prostate cancer.
The surgical treatment for localized prostate cancer is a radical prostatectomy, an operation that removes the entire prostate along with both seminal vesicles and a portion of both vas deferens. Since it’s possible to perform this procedure without injuring the two pelvic nerves that enable an erection, the operation is referred to as a nerve-sparing radical prostatectomy and can be performed by a surgeon using any of the following four prostatectomy options. Outcomes may vary depending on the skill level and experience of the surgeon.
Most often used during early stages (Stages Tl and T2), when cancer cells are located only within the prostate
Some surgeons are skilled in nerve-sparing techniques to maximize the preservation of nerves, muscles, organs, and other structures surrounding the prostate. If the nerves are not damaged during surgery, men have a better chance of having erections again between two and 18 months after the operation. Potency rates following nerve-sparing radical prostatectomy vary widely among surgeons and academic centers. In the hands of a highly skilled surgeon performing the technique in a center with extensive experience in the procedure, potency rates are much higher than the rates seen in community practice.
Read more or join discussions about prostatectomy at the RP bulletin board
An incision is made from just below the navel to the pelvic bone without damaging muscles. This allows the surgeon access to feel the prostate, surrounding tissues, and the pelvic lymph nodes, which can help the surgeon decide if a nerve-sparing radical prostatectomy is the best option based on the extent of the cancer. If all areas feel smooth, the nerves can be saved because they probably are not cancerous. However, if the surgeon feels a lump, hardness, or any other abnormality near the nerve, the safest approach is to remove one or both nerves. There is no completely accurate way to confirm whether or not cancer is present in a pelvic nerve unless the nerve is removed and analyzed by a pathologist.
The incision for this procedure is between the scrotum and the anus. While there is less blood loss with this operation compared to the retropubic procedure outlined above, the surgeon still has the ability to feel along the pelvic nerves to determine whether they can be saved or must be removed. Recovery is generally faster compared to the RRP and patients have less blood loss.
Also referred to as “minimally invasive” or “keyhole surgery,” the operation begins by inserting a needle into the abdomen to inflate it with carbon dioxide thereby separating the abdominal wall from the organs and providing the space necessary to perform the surgery. Three or four small incisions are made in the lower abdomen as access for surgical instruments and a telescopic lens that projects images onto a video monitor. After the prostate has been cut away from the bladder and the urethra, it’s removed from the body through an incision made above the pubic bone.
As with the laparoscopic procedure described above, this operation also begins by inserting a needle into the abdomen to inflate it with carbon dioxide thereby separating the abdominal wall from the organs and providing the space necessary to perform the surgery. Three or four small incisions are made in the lower abdomen as access for surgical instruments and a telescopic lens that are attached to robotic arms, which are connected through special cables to instruments providing the surgeon with robotic control of the procedure through a three-dimensional view of the inside of the abdomen shown on a video monitor. After the prostate has been cut away from the bladder and the urethra, it’s removed from the body through an incision above the pubic bone.
Advantages of Prostatectomy
May prevent spread of cancer to other tissues
May cure early-stage prostate cancer (if cancer cells are only located in the prostate)
Removes the prostate gland and the problem of future overgrowth of the prostate (called BPH—benign prostate hyperplasia—the non-malignant enlargement of the prostate)
May help extend life
When this operation is performed by an expert, the advantages are much more likely to occur, and the disadvantages are less likely to occur
Disadvantages of Prostatectomy
May cause impotence (also known as erectile dysfunction, ED, the inability to get an erection of sufficient quality to penetrate or to fulfill the sexual act)
May cause incontinence (loss of urinary control)
May cause narrowing of the urethra, making urination difficult
When this operation is performed by a non-expert/caregiver, the disadvantages are more likely to occur
External beam radiation is a treatment for prostate cancer that uses a machine to deliver rays of high energy. It works on the DNA, which is contained in all living cells. DNA controls the ability of cells to divide. Cancer cells harm us because they continue to divide without stopping. The energy from radiation machines is so strong that it can damage the DNA in cancer cells, causing them to die or making them unable to divide. Cancers are treated with alpha, beta, proton and neutron particles; and gamma and x-ray waves. Prostate cancer is most commonly treated using gamma rays.
Used to treat prostate cancer that has not spread beyond the prostate (Stages T1 and T2)
Often used in combination with hormone therapy if cancer cells have spread beyond the prostate to nearby tissues (Stage T3) or if the cancer is intermediate risk (PSA 10-20 ng/ml, Gleason 7, T2B)
May be used for pain relief in prostate cancer that is no longer responding to hormone therapy and has spread to other tissues in the body, primarily bones (Stage M+)
External Beam Radiation Therapy (EBRT): radiation is generated and administered by a machine outside the body, usually in brief daily sessions for several weeks. You can read or join discussions about EBRT at the EBRT bulletin board.
Intensity-Modulated Radiation Therapy (IMRT) minimizes radiation damage to normal tissues by using a large number of narrow beams rather than a single wide beam thereby allowing for greater control of the dose of radiation.
3-Dimensional Conformal Radiation Therapy (3DCRT) treatment allows closer targeting of the prostate gland. Uncontrolled studies suggest better outcomes with IMRT compared to 3dCRT; however, definitive proof is lacking at this time.
CyberKnife Robotic System is a non-invasive treatment option for prostate cancer that has the ability to deliver targeted and destructive doses of radiation from almost any angle to the body. It tracks tumor motion and automatically corrects the aim of the treatment beam when movement is detected. Studies have not determined if it offers clear clinical advantages. Read additional information at: http://www.cyberknife.com/
The Calypso Tracking System (GPS for the body) was designed to improve IMRT radiation by adjusting for any movement of the prostate by placing tiny sensors in the gland before the treatment begins to emit radiofrequency waves that allow for the very accurate alignment of a man’s prostate before each treatment session. It can also be used to monitor the position of the prostate at all times during radiation treatment delivery, objectively pinpointing the location of tumors and helping to minimize the amount of healthy tissue surrounding the prostate or prostate tumor that might be radiated due to organ movement.
Proton Beam Therapy (PBT) uses proton beams instead of x-rays to kill cancer. Proponents believe it offers an ability to deliver more precise radiation; however, so far no well-done study has demonstrated any clinical advantage over IMRT. In addition, it is far more costly. Recently, the American Society of Therapeutic Radiation (ASTRO) recommended that PBT for prostate cancer only be done as part of a randomized study or a multi-institutional data base. Learn more about PBT by visiting The National Association of Proton Therapy website.
Permanent Brachytherapy (“seeds”) introduces radiation from small radioactive seeds (about the size of a grain of rice),which are inserted directly into the prostate. The radiation emitted from the seeds gradually declines until they are no longer active. Seeds are inserted with the patient under anesthesia, and are too small to cause discomfort.
High-Dose Rate (HDR) Brachytherapy provides short-term internal radiation that uses higher dosage, non-permanent seeds. Learn more about brachytherapy by visiting the seed pods website.
Systemic Radiation Therapy uses radiation delivered by the injection of a radioactive compound to control pain caused by metastasized (Stage M+) prostate cancer that no longer responds to hormone therapy.
Advantages of Radiation Therapy
Avoids major surgery
May cure prostate cancer in its early stages and may help extend life or eliminate symptoms in later stages
Most side effects are minor and disappear after therapy stops, especially when the latest IMRT and seeds techniques and equipment are used
Disadvantages of Radiation Therapy
Organs naturally move during treatment and your doctor can’t predict which way or how much your organs will move. Organ movement can be caused by breathing, gas in the intestines or rectum, blood flow through the circulatory system and other natural bodily functions. When your organs move, the tumor may not get the right amount of radiation or other nearby organs may receive radiation they shouldn’t get.
May cause damage to healthy cells, leading to side effects
High-Intensity Focused Ultrasound (HIFU) is a relatively new, minimally invasive treatment that uses high frequency ultrasound waves to produce very high temperatures to destroy targeted cancer cells. In some cases, it can reduce the need for more aggressive treatments. HIFU uses real-time imagery to reach specific, targeted areas with less impact on surrounding areas.
The procedure has been used in Europe for over 10 years, but it has only recently been approved by the FDA in the US for ablation of cancerous tissue. That being said, it will still be quite a few years until the efficacy of the treatment can be officially gauged.
About the Procedure
The HIFU procedure is generally performed in a single session on an outpatient basis, requiring no hospital stay. It typically takes between 1-3 hours. Treatment is usually performed under general anesthesia but spinal anesthesia is sometimes possible.
In the procedure, a probe is inserted through the rectum that will produce a detailed, 3D image of the prostate – showing the prostate and the cancerous areas. Those specific, targeted areas are then treated with high intensity ultrasonic waves that emit from the same probe. The area destroyed by each wave is very small and precise. By repeating the process and moving the focal point, it is possible to destroy the cancerous tissue in the prostate.
Advantages of HIFU
The patient does not undergo any radiation exposure
Treatment can be repeated if necessary
Other therapeutic alternatives can be considered in case of incomplete results
HIFU can be used for the treatment of local recurrences (i.e. after external beam radiotherapy)
Disadvantages of HIFU
Does not treat the whole prostate, so recurrence is possible
Androgen deprivation therapy is also sometimes used for large glands
Risk of major complications include: urinary tract infection, urinary retention, impotence, incontinence, urethral stricture and recto-urethral fistula
- Payment by insurance companies is variable
Literature reviews from 2010 and 2012 show very limited long-term results with only one center reporting projected 10 year overall survival with a small percentage of men followed between 5-10 years
Things to Know – Pre-Treatment
The patient will not be able to eat or drink six hours prior to the procedure. Once in the doctor’s office, they will be given an enema to empty their bowels before the procedure. A transurethral resection of the prostate (TURP) may sometimes also be required prior to treatment or at the time of the HIFU.
Things to Know – Post-Treatment
After the procedure, the doctor will insert a catheter which might be left in for about a week. At that point, another office visit will be necessary to have the catheter removed.
HIFU can potentially reduce side effects related to sexual function or urinary continence. These effects may still be there, but they are usually comparatively mild and temporary. There is also the possibility of blood in urine or urinary infection. There is usually some discomfort or pain for 3-4 days after the procedure.
Who is a Candidate for HIFU?
Ideal candidates for HIFU are those who have early stage (Gleason 6), low-grade cancer that is confined to the prostate, and that is visible on an MRI. A PSA level below 20ng/mL is also preferred. HIFU is used to treat a single tumor or part of a large tumor and is not meant for those whose cancer has spread.
If you are interested in HIFU, please talk to your doctor.
Approval and Reimbursement
The cost of HIFU ranges from $15,000 to $25,000. Medicare has approved treatment reimbursement under “C-code” for hospital outpatient department services and procedures. Other insurance coverage is variable, and interested parties should contact their specific providers for more information.
Prostate cancer cells require male hormones (such as testosterone) to grow. Hormone therapy decreases production of testosterone by the testicles so that cancer cell growth slows down. The term most commonly used for this treatment is called androgen deprivation therapy or ADT.
May also be used in early stage prostate cancer (Stage T2) in combination with radiation therapy or prior to surgery to reduce the size of the prostate and make it easier to remove
Types of hormone therapy:
Surgical removal of the testicles (bilateral orchiectomy)
Drug treatment that reduces testosterone levels, reduces the effect of testosterone or adrenal androgens from acting on the prostate, or reduces conversion of testosterone to dihydrotestosterone (DHT), a powerful stimulus for prostate cell growth
Common side effects of reducing male hormone activity by hormone therapy (listed in order of most to least common):
Prostate cancer is advanced when cancer cells have spread to other parts of the body—or metastasized. When cancer has spread beyond the prostate, complete removal of the prostate or destruction of cancer tissue by radiation or cryosurgery is uncommon. For stage T3 and T4 prostate cancer, studies show that combining ADT with radiation can improve survival.
Types of Hormone (Androgen Deprivation) Therapies
Bilateral orchiectomy is an operation that removes both testicles, which produce 95% of the body's testosterone.
Advantages of Orchiectomy
Effective, permanent reduction in testosterone
Patients typically go home the same day as the surgery
Cost (relatively inexpensive) and convenience
Disadvantages of Orchiectomy
Side effects, such as reduced or absent sexual desire, impotence, and hot flashes and emotional impact make this procedure difficult for some patients to accept, although side effects are the same as with medical castration
Irreversible surgical procedure
In some cases, may require hospitalization
Will not allow for intermittent androgen deprivation (IAD) therapy
The administration of an injectable gonadotropin-releasing hormone (GnRH) receptor antagonist provides rapid, profound and sustained, suppression of testosterone.
Currently available GnRH receptor antagonists:
Firmagon® (degarelix for injection) – indicated for the treatment of advanced prostate cancer (similar indication as LHRH agonists)
Advantages of GnRH Receptor Antagonists
Reduces testosterone levels quickly without the initial "testosterone surge" seen with an LHRH agonist
Antiandrogen therapy is not needed to prevent possible flare symptoms
Reversibly binds to the GnRH receptors in the pituitary gland, immediately suppressing the secretion of the luteinizing hormone (LH), follicle-stimulating hormone (FSH), and subsequently, testosterone and PSA levels
GnRH receptor antagonists are at least as effective as LHRH agonists in sustaining castrate levels or lowering of testosterone
Easy subcutaneous (just under the abdomen skin) injections monthly
Disadvantages of GnRH Receptor Antagonist
Overall rate of adverse reactions is similar to leuprolide
Injection site reactions were mostly transient and of mild to moderate intensity, except for initial treatment
The administration of a drug called an antiandrogen that blocks the action of male hormones, including testosterone and androgens released by the adrenal glands.
Used in combination with LHRH agonist therapy in a strategy called maximal androgen blockade (MAB) or combined androgen blockade (CAB). The anti-androgen is continued until the PSA rises. Studies show longer survival with MAB compared to ADT alone. When PSA rises, stopping anti-androgen can result in short-term benefit. You can read or join discussions about CAB at the CHB bulletin board.
Currently available antiandrogens in the U.S.:
Advantages of Antiandrogen Therapy
May provide a small survival advantage over either orchiectomy or LHRH analog therapy alone
Disadvantages of Antiandrogen Therapy
In addition to common side effects of hormone therapy, you also may develop
Breast pain or enlargement
Adverse effects on liver function (possible elevation of liver enzymes that must be monitored)
5-alpha Reductase (5-AR) Inhibitors
Block conversion of testosterone to DHT, a more potent stimulator of prostate cell growth than testosterone.
Currently available 5-AR inhibitors:
Proscar®, Propecia® (finasteride) – reduces DHT levels in the blood by 70% and 80%-90% on prostate
Avodart® (dutasteride)– reduces DHT levels in the blood by 98% and can slow prostate cell growth
Advantages of 5-AR Inhibitors
Reduces the normal prostate cell growth and prostate size
May reduce the risk of recurrence following surgery
Disadvantages of 5-AR Inhibitors
Not approved as a treatment for prostate cancer
No evidence it influences survival of men
Causes only modest reductions in PSA levels (15-20%) when used alone
Administration of estrogen hormones lowers testosterone production and has some direct apoptotic effects on both androgen-dependent and androgen-independent prostate cancer cells.
Currently available estrogen therapies:
Stilphosterol® (stilbestrol diphosphate)
Estraderm® patch (estradiol) – only one small-scale trial has investigated the benefits of delivering estrogen through the skin (transdermal) to block testosterone production in men with prostate cancer. In that study, the patch was successful in reducing testosterone levels, with fewer cardiovascular or other side effects (gynomastia). Phase III trials are currently comparing the effects of patch and injected forms of estrogen in men with prostate cancer.
Advantages of Estrogen Therapy
Does not cause bone loss
Dose not induce androgen-independent cancer growth
Can dramatically slow the growth of some prostate cancer cell types
Disadvantages of Estrogen Therapy
Will cause gynecomastia, unless prevented by breast irradiation
Depending on the route of administration, it may promote hypercoagulation of blood, causing blood clots in the legs, lungs, heart, and brain
May cause heart attacks
No evidence that blood thinners significantly reduce risk of clots
Causes decreased libido and impotence
Risk of cardiovascular side effects is reduced when treatment is given as patch or injectable drug rather than by mouth
The P450 enzymes are involved in the synthesis of several hormones, including testosterone, that stimulate prostate cancer cell growth. Inhibitors of these enzymes can decrease the levels of testosterone and adrenal androgens, and have direct cytotoxic effects on prostate cancer cells.
Available P450 enzyme inhibitors:
Nizoral® (ketoconazole used in combination with hydrocortisone)
Advantages of P450 Enzyme Inhibitors
May still be useful in men for whom CAB has failed (who are androgen resistant)
Reduces both testicular testosterone and adrenal androgen production
Additional cytotoxic effect on prostate cancer cells
Disadvantages of P450 Enzyme Inhibitors
Not approved in U.S. for treatment of prostate cancer
Requires continued use of LHRH agonists or estrogen therapy to block pituitary stimulation of testicular hormone production (unless the patient had an orchiectomy)
Non-selective effects on other cells may cause discomfort (nausea, gastric irritation)
May have significant adverse effects on liver function (must measure liver enzymes)
Prostate cancer that is no longer responsive to hormone therapy is referred to as hormone-resistant prostate cancer, hormone refractory prostate cancer (HRPC), castrate resistant prostate cancer (CRPC) or androgen-independent prostate cancer. Several new therapies have been approved in the past several years to treat CRPC. More studies are needed to determine the optimal sequencing of these new treatments.
Zytiga® (Abiraterone Acetate)
Oral agent that has been approved in combination with prednisone for CRPC. It acts by inhibiting an enzyme complex called CYP-17 that is necessary for producing testosterone. Studies show that this enzyme is present in the adrenal gland and in prostate cancer cells.
Prolongs survival in men with CRPC
Must be given with prednisone
Must be taken on an empty stomach
Side effects occur including hypertension, increased potassium level and fluid retention
Oral agent that has been approved for men with CRPC after they progress on chemotherapy. The FDA is currently considering an approval for men prior to chemotherapy. It works by interfering with androgen receptor signaling in prostate cancer cells.
Side effects can occur including asthenia/fatigue, back pain, diarrhea, arthralgia, hot flush, peripheral edema, musculoskeletal pain
Provenge® (sipuleucel-T) can be prescribed for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer. Provenge is the first in a new class of autologous cellular immunotherapies that use a patient’s own antigen-presenting cells (APCs) to stimulate the body’s immune system against prostate cance. Provenge is given by intravenous (IV) infusion in three doses, approximately two weeks apart over the span of a month. Blood is collected a few days prior to each infusion. Total course of therapy is generally completed in four to six weeks.
Minimal typical side effects compared to other treatment options
Prolongs survival of men with CRPC
Does not interfere with effectiveness of other therapies
Therapy completed quickly
The most common side effects reported with Provenge treatment (usually occurring within the first few days of treatment) are: chills, fatigue, fever, back pain, nausea, joint ache and headache; other side effects are also possible
In a very small number of men, Provenge can cause severe acute reactions resulting from the infusion, which typically occur within one day of infusion
Does not lower PSA or produce measurable objective response
Costly, but covered by most insurance companies, including Medicare
The administration of powerful toxic drugs that circulate throughout the body and eliminate rapidly growing cancer cells
Also affect rapidly growing healthy cells, which can lead to side effects
Dose and frequency of chemotherapy treatments are carefully controlled to minimize harm to healthy cells
Reserved for patients with advanced stage cancer (Stage M+) that does not respond to hormone therapy
Currently available chemotherapy drugs indicated for prostate cancer:
Taxotere® (docetaxel)- Phase III randomized studies have shown that Taxotere in combination with either Prednisone or Estramustine can significantly improve survival on average by 2 months in patients with hormone resistant prostate cancer
Jevtana®(cabazitaxel) - indicated in combination with prednisone for the treatment of patients with metastatic hormone-refractory prostate cancer (mHRPC) previously treated with a docetaxel-based treatment regimen
Novantrone® (mitoxantrone; specifically approved for hormone resistant prostate cancer)- Studies show it improves quality of life but does not increase survival
Advantages of Chemotherapy
May prolong survival
Provides cancer symptom improvement
Disadvantages of Chemotherapy
Reduced blood clotting
Increased risk of infection
Lowered white cell count
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