What treatments are available for prostate cancer?

Treatment options for prostate cancer include: 'watchful waiting', surgery, radiation treatment, hormone therapy, or a combination of these treatments. Treatment considerations vary from one man to another, depending on the age of the man, the stage of the cancer, the tumour grade, and the presence or absence of other serious medical conditions.

Relevant factors include the volume or size of the prostate, the Gleason score (a system for grading prostate cancer tumours according to size and severity), the pattern of growth, the PSA (level of prostate-specific antigen in the blood), and the area where the cancer is located.

Age is a consideration

In general, radical (or curative) treatment for prostate cancer will be required by patients aged 70 years or younger who have no evidence of metastases (cancer has not spread to other parts of the body), and who are otherwise in reasonable general health.

Most patients aged 80 years or more do not need treatment, unless their cancer is an aggressive one or it is causing symptoms.

For patients aged 70-79 years, the side effects of treatment for prostate cancer and the impact on a person’s quality of life are important factors to consider, and some patients may elect for a ‘watchful waiting’ policy.

The treatment team

From the time you are first diagnosed with prostate cancer you will be cared for by one or more of a team of health professionals, including:

• your family doctor, who will often be the first person you see 
• a urologist, a surgeon who specialises in genito-urinary conditions
• radiation oncologists, doctors who specialise in the use of radiation in the treatment of cancer
• hormonal treatment is managed by urologists and radiation oncologists
• radiation therapists, people who prepare you and give you your treatment
• oncology nurses, urology nurses, continence and impotence advisers who will help you through all stages of your cancer experience
• dietitians, who will recommend the most suitable foods to eat
• social workers, physiotherapists and occupational therapists, who will advise you of the support services available and help you get back to normal activities.

Ideally, your hospital should have all available means of diagnosis and treatment, although this will not be the case in some areas.

Management of localised prostate cancer

Watchful waiting

Some older patients with prostate cancer prefer to take a watchful waiting approach. These patients need to consider their general state of health, the stage of the cancer and its rate of growth.

The possible risks in delaying treatment have to be compared with the impact of the treatment.

You will need to be examined regularly to check the cancer is not growing more quickly than expected. If watchful waiting is suggested for you, ask your doctor:

• how often you will need to schedule check-up appointments?
• which tests will be done and at what intervals?

Surgery - radical prostatectomy

If the cancer has not spread beyond the prostate, the whole prostate gland may be surgically removed. This is called a 'radical prostatectomy' and the operation is done to try to cure the cancer.

The surgery is performed through an incision in the lower abdomen and the entire prostate is removed from the body, with the bladder being joined back on to the bladder outflow pipe (urethra).

This operation requires a stay of 5 to 7 days in hospital. It would be usual to go home with a urinary catheter in place for 2 to 3 weeks. You should be able to resume normal activities within 6 weeks.

Advantages of radical prostatectomy
If the cancer is located within the prostate, a surgical operation may cure the disease because surgery removes the prostate, including the tumour. Once the prostate is totally removed, the PSA (prostate-specific antigen level in the blood) should remain undetectable.

Side effects of radical prostatectomy
A radical prostatectomy can cause urinary incontinence (loss of bladder control) to a greater or lesser degree in some patients. Sexual impotence (erectile dysfunction) can be a result of this surgery. Even though the operation can be performed in a nerve-sparing way in order to protect the nerves that are important for the erection of the penis, impotence may still occur.  Also see: prostate cancer issues after treatment

Radiation treatment

Radiation treatment uses high-energy x-rays to destroy cancer cells and may be used as an alternative or additional treatment to surgery. This form of treatment works best when the cancer is confined to the prostate. [Radiation treatment is sometimes called radiation therapy or radiotherapy.]

The radiation can be precisely targeted on to cancer sites. Treatment is carefully planned to do as little harm as possible to your normal body tissues.

The treatment is usually given over a period of several weeks. The length of treatment will depend on the size and type of the cancer and on your general health.

Radiation treatment may also be used to relieve pain caused by secondary cancers in the bones, or to shrink obstructions in your lymphatic or urinary systems.

There are three types of radiation treatment for prostate cancer:

• external beam radiation [external radiation treatment]- a beam of x-rays from a linear accelerator machine is focused on the area affected by cancer. Therapy is usually given daily for 5 days each week, for a period of about 7 weeks.
• low-dose rate brachytherapy [internal radiation treatment] - tiny radioactive seeds are inserted permanently into the prostate gland. This form of treatment may be successful for small tumours which are located within the gland. This therapy may also be used with a shortened course of external beam radiation in patients with more advanced cancer.
• high-dose rate brachytherapy [internal radiation treatment] - needles are placed in the prostate and radioactive sources can then be temporarily placed into the prostate down the hollow needles.

High-dose rate brachytherapy is always used after a shortened course of external beam radiation. Low-dose rate brachytherapy is currently only available outside the public hospital system.

Also see: Radiation treatment

Advantages of radiation treatment

Radiation treatment may cure prostate cancer that is localised to the prostate. It avoids removal of the prostate and problems associated with radical prostatectomy. Patients receiving brachytherapy are able to return to usual activities soon after the implant.

Side effects of radiation treatment

Some men may experience the following side effects when undergoing radiation treatment:

• tiredness
• bowel symptoms such as pain and bleeding from proctitis (inflammation of the rectum) and diarrhoea. Although these symptoms usually disappear after the end of treatment, a small number of men will continue to experience bleeding from the bowel.
• urinary disturbances such as increased frequency and a burning sensation. Discuss these symptoms with your doctor.
• about 50% of men experience difficulty achieving or maintaining an erection following a course of radiation.

Also see: Radiation treatment side effects

Hormone treatment in conjunction with radiation treatment

Hormone treatment in conjunction with radiation treatment may be offered. Clinical trials are running to determine the advantages of this treatment. Early results indicate this form of treatment successfully reduces the number of cancer cells at the start of radiation treatment.

Treatment for advanced prostate cancer

If the cancer has spread, then your doctor will discuss various treatments for specific problems caused by the cancer.

Hormone treatment

Hormones are substances that occur naturally in the body. They control the growth and activity of cells and may be used to treat prostate cancer.

Prostate cancer needs the male hormone testosterone for growth, so it is possible to slow down or shrink the cancer by reducing the body's testosterone levels. All hormonal therapy is aimed at either removing from the body or counteracting the effect of the male hormone testosterone.

There are a number of different approaches:

Orchidectomy
Orchidectomy or orchiectomy (American spelling) is a procedure where the testicles are surgically removed through a cut in the scrotum. An orchidectomy permanently deprives the body of testosterone. 

The advantage of orchidectomy is that it is a one-off procedure but the disadvantage is that any side effects are permanent.

Side effects include impotence and loss of sex drive. Hot flushes and mild weight gain are also common side effects.

LHRH therapy
Luteinising hormone-releasing hormones (LHRH) lower the amount of testosterone in the body. LHRH therapy is usually given as a monthly or three-monthly injection. The side effects of LHRH therapy are similar to those of orchidectomy.

Anti-androgen therapy
Anti-androgens block the action of testosterone in stimulating a cancer. The advantage of this type of therapy is that some men maintain their erections and sexual drive.

They are occasionally used in combination with one of the other forms of hormonal treatment, although there are questions about whether this combination approach is as effective as was previously thought.

Side effects of hormone treatment

Hormone treatment for prostate cancer can cause loss of libido, weight gain, hot flushes, swelling of the breasts, fluid retention and progressive hardening of the arteries.

A possible side effect of long term anti-androgen therapy is osteoporosis (weakening of the bone due to the loss of bone density). Men on this therapy should discuss with their doctors ways to preserve bone density, eg, adequate dietary calcium, vitamin D, and regular exercise.

Surgery - transurethral resection of prostate (TURP)

Surgery may sometimes be carried out to remove blockages in the urinary tract. This operation is called a transurethral resection of prostate (TURP) and is performed by passing a resectoscope up the urethra. This type of operation is also used to treat benign prostatic hyperplasia.

Making decisions about treatment

If you are offered a choice of treatments, including no treatment for now, you will need to weigh their advantages and disadvantages. If only one type of treatment is recommended, ask your doctor to explain why other treatment choices have not been advised.

The risk of not having treatment needs to be weighed against the risk of side effects from treatment. You may want to ask your doctor questions like: “Can I expect to live longer if I have treatment?”, “If I have treatment, is there a risk that my quality of life could worsen because of the side effects?” and “Are there other treatment options for me?”

Once you have discussed treatment options with your doctor, you may want to talk them over with someone else, such as family or friends, specialist nurses, your family doctor, the Cancer Society, the hospital social worker or chaplain, your own religious or spiritual adviser, or another person who has had an experience of prostate cancer. Talking it over can help you to sort out what course of action is right for you.

You may want to ask for a second opinion from another specialist. Your specialist or general practitioner can refer you to another specialist and you can ask for your records to be sent to the second doctor.

Taking part in a clinical trial

Research into the causes of prostate cancer and into ways to prevent, detect and treat it, is continuing. Your doctor may suggest that you consider taking part in a clinical trial. If you do not want to take part, your doctor will discuss the best current treatment options with you.

Related topics

Also see Prostate cancer issues after treatment and Prostate cancer screening

What does that term mean? See Cancer glossary See Questions to ask your doctor when you have cancer and Cancer: Getting support

Original material provided by the Cancer Society of New Zealand, 2008. Reviewed and edited by everybody, July 2010.