Prostate Cancer - Treatment Overview

Treatment Overview

Prostate cancer is often curable. About 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. Not all men are treated the same way. Any treatment can cause serious side effects.

You and your doctor have two choices: You can treat your cancer, most likely with surgery or radiation, or you can wait and watch to see what happens.

Watchful waiting may be a good option if you are around age 70 or older. During watchful waiting, you have regular checkups with your doctor to see if your cancer has changed.

In general, healthy men who are younger than 60 and whose cancer has not spread are treated with surgery or radiation. Surgery removes the prostate gland and its cancer. Radiation destroys the cancer and may damage nearby healthy cells. With these treatments, there is a chance of having erection problems, some chance of having urine leakage problems, and a small chance of having bowel problems.

Because of these side effects, some men, especially some older men, may decide that the cure is worse than the disease. Studies show that some men are willing to accept the risk of a shorter life span in return for a better quality of life than what they would have with treatment.¹⁰

Your treatment decision will depend on:

• Your age, overall health, and life expectancy.
• 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 is curable if it is discovered and treated early. Unlike many other cancers, it is usually slow-growing. Most men will die with prostate cancer but not of prostate cancer. This slow growth means you have time to learn all you can before deciding whether to have treatment or which treatment to have.

Initial treatment

There are three main choices for treating prostate cancer: surgery, radiation, and watchful waiting, also called observation.

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.

There are nerves along the side of the prostate that affect your ability to have an erection. Sometimes these nerves are removed along with the prostate to make sure that all the cancer is removed. Sometimes a surgeon may be able to avoid damaging those nerves; this is called nerve-sparing surgery. The surgeon will only do that if he or she feels sure that there is little chance of leaving some cancer cells behind.

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.²

Age is not a reason to avoid surgery. However, if you are 70 or older, other medical conditions, such as heart disease, may affect your decision. This is especially important if you have early-stage cancer, which generally grows slowly.

External radiation.Radiation therapy uses high-energy rays, such as X-rays, to destroy the cancer. It is usually given 5 times a week for 4 to 8 weeks. Each treatment lasts only a minute or two. Radiation destroys tissue, so it may damage the nerves along the side of the prostate that affect your ability to have an erection.

Internal radiation (brachytherapy). Brachytherapy is a one-time radiation treatment that uses tiny radioactive seeds. A needle is used to inject the seeds into your prostate, where they slowly release radiation directly into the cancer.

Hormone therapy is sometimes used with radiation treatment. Less often, it is used by itself. Taking a hormone-therapy drug lowers your level of testosterone and other male hormones. A prostate tumor usually needs male hormones to survive. This is why hormone therapy can cause the tumor and the prostate to shrink.

Watchful waiting.Watchful waiting is a treatment choice, especially among men who are in their 70s or older. This is a period of time during which you are checked and tested regularly by your doctor but you are not being treated. This choice may be good if you are in your later years, tests show your cancer has been caught early and is the slow-growing kind, and you do not want to have the side effects of surgery or radiation.

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. However, radiation sometimes causes diarrhea and bowel problems.² 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.

Should I have a prostatectomy or radiation therapy to treat 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 develop 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 different emotions after being diagnosed with prostate cancer. Most men feel some denial, anger, and grief. Others may have fewer emotions. 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, it is important to 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 indicate 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. 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 instead of having treatment, you will have regular checkups with your doctor to keep an eye on your cancer. You will have digital rectal exams and PSA tests every 3 to 6 months. 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 to watch and wait. If the cancer begins to grow or spread, you may consider medications, 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

Cryosurgery freezes the prostate gland to kill the cancer. It can be used to treat early prostate cancer. But cryosurgery is not a top treatment choice—more research is needed. Compared with radiation treatment, cryosurgery may be more likely to cause impotence. (But this is common with both treatments.) Like radiation, cryosurgery does not always keep cancer from coming back.¹¹

Researchers also are studying ways to kill cancer cells with heat. One treatment being studied is high-intensity focused ultrasound, or HIFU. The sound waves produced by HIFU are 10,000 times stronger than regular ultrasound. The sound waves are aimed at the prostate and its cancer, and the intense heat destroys the prostate. Other forms of heat treatment under study use electrodes, microwaves, and magnetic metal rods to heat and destroy the prostate.