What treatments are available?

Your doctor will use a range of criteria to help determine the type of treatment to recommend. They 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, and the area where the cancer is located.

Treatment considerations vary enormously from one man to another, depending on the age of the man, the stage of the cancer and its rate of growth. Certain types of prostate cancer grow very slowly and may not affect life expectancy but other types are fast-growing, do spread, and become life threatening.

Options your doctor will consider include:

• watchful waiting
• surgery
• radiation therapy
• hormone therapy
• a combination of the treatments listed above.

The choice of treatment depends on the stage of disease, how fast the cancer is growing, as well as the man's age, physical condition and personal wishes.

Side effects of treatment and the impact on a person's quality of life are important factors to consider.

Treatment for localised prostate cancer

Watchful waiting
In some instances it is considered preferable to take a watchful waiting approach. Various factors would be considered, such as your age, your general state of health, the stage of the cancer and its rate of growth.

The possible risks in delaying treatment would be considered alongside the impact of the treatment itself on the individual patient.

You will need to be examined regularly to check the cancer is not growing. 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
If the cancer has not spread beyond the prostate, the whole gland may be surgically removed. This is called a radical prostatectomy and is done to cure the cancer.

This operation 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 outflow pipe (urethra).

This operation requires a stay of five to seven days in hospital. It would be usual to go home with a urinary catheter in place for two to three weeks. You should be able to resume normal activities within six 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, preventing any recurrence within the gland itself.

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) is common. See "Sexuality and prostate cancer" heading below for more information on this.

Radiation therapy
Radiation therapy 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.

Nowadays x-rays can be precisely targeted on to cancer sites in your body to minimise damage to surrounding tissue. Treatment is carefully planned to kill cancer cells while doing as little harm as possible to your normal body tissues.

The treatment is usually given over a period of up to seven weeks. This will depend on the size and type of the cancer and on your general health.

Radiation therapy 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 therapy for prostate cancer:

• external beam radiation - a beam of x-rays from a linear accelerator machine is focused on the area affected by cancer. Therapy is usually given daily for five days each week, for a period of about seven weeks.
• low-dose rate brachytherapy - 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 - 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 may be used at the same time as external beam radiation. This treatment is always used after a shortened course of external beam radiation.  Brachytherapy is currently only available in the private sector.

Advantages of radiation therapy
Radiation therapy 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 therapy
Some men may experience the following side effects when undergoing radiation therapy:

• tiredness
• about 40% of men experience difficulty achieving and maintaining an erection
• bowel symptoms such as 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. You need to report these symptoms to eliminate the possibility of a urinary infection. Symptoms usually disappear after the end of treatment.
• some men experience varying degrees of skin irritation. Your cancer treatment team will advise on how to manage this.

Hormone treatment in conjunction with radiation therapy
Hormone treatment in conjunction with radiation therapy is available but usually as part of a clinical trial. 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 therapy.

Treatment for advanced prostate cancer

If the cancer has spread and it is not possible to cure it, 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 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
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.

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.

Clinical trials are a vital part of the search to find better treatments for cancer. Doctors conduct clinical trials to test new or modified treatments and see if they are better than existing treatments.

If your doctor asks you to take part in a clinical trial, make sure that you fully understand the reasons for the trial and what it means for you.

Before deciding whether or not to join the trial, you may wish to ask your doctor:

• What treatments are being tested and why?
• What tests are involved?
• What are the possible risks or side effects?
• How long will the trial last?
• Will I need to go into hospital for treatment?
• What will I do if any problems occur while I am in the trial?

If you decide to join a randomised clinical trial, you will be given either the best existing treatment or a promising new treatment. You will be chosen at random to receive one treatment or the other, but either treatment will be appropriate for your condition.

If you do join a clinical trial, you have the right to withdraw at any time. Doing so will not jeopardise your treatment for cancer.  It is always your decision to take part in a clinical trial.

After treatment

During your illness you will be monitored frequently. After the completion of your treatment, you may need to have regular check-ups. Your doctor will decide how often you will need these checkups as everyone is different.

Check-ups will gradually become less frequent if you have no further problems. If the disease flares up, or relapses, you may need further treatment. It is important to report any new symptoms to your doctor without delay.

The treatment used for the relapse is often different from the first treatment.

Many people worry that any pain or illness is a sign that the cancer is coming back. This is usually not the case but if you are worried about whether the cancer is going to come back, ask your doctor what to expect.

You may feel less worried if you know exactly what to look for out for and what you do not have to worry about.

Most side effects from the treatment you have had will go fairly soon, although some will last for a couple of months and some may be with you forever. You might feel worried or depressed when your treatment is over and have time to realise what has happened to you.

Because you will see your doctors less often it can feel as though no one is looking after you. You may find it helpful to continue in or join a cancer support group to help you through the months ahead.

Continence advice

A man may become incontinent after a radical prostatectomy. Kegel exercises that involve exercising the muscles of the pelvic floor help many men regain control after prostate surgery.

 It is advisable to start these exercises before starting treatment as normal sensations may be confused for several weeks afterwards.

Other men may need further surgery to implant an artificial sphincter (shut-off valve).Very few people continue to have significant incontinence on a long-term basis. Ask your doctor, a nurse or a physiotherapist for information about pelvic floor exercises.

In some areas there are specialist continence advisory nurses. For more information see Incontinence.

Sexuality and prostate cancer

Men who have had treatment for prostate cancer may experience changes in their sexual functioning. These may include impotence. However, this may not be permanent and can sometimes be caused by anxiety rather than the treatment.

It is often assumed that sexual intercourse involves the successful penetration of one's partner and that this is the only way to achieve the pleasure of an orgasm. However, men can still enjoy a sexual relationship and have an orgasm without the need to have an erection or achieve penetration.

Following a radical prostatectomy a man will no longer produce semen so he will have a "dry" orgasm. Some men say this feels totally normal, while others say the orgasm does not feel as strong, long lasting or pleasurable.

One needs to develop different skills to achieve a non-penetrative orgasm. It will probably take longer to reach an orgasm, which means there will be more time to enjoy the mutual pleasures of intimate bodily contact.

This is often dismissed as foreplay when penetrative sexual intercourse is seen as the goal of sexual activity.

Keep in mind that no matter what kind of cancer treatment you have, you will almost always be able to feel pleasure from touching.

Men may also find it difficult to talk to their partners for fear of failure or rejection but these fears are often mistaken. Sexual relationships are built on many things, like love, trust and common experiences.

There are practical ways to help overcome impotence including:

• Physical devices such as vacuum pumps and constriction rings can help you to achieve and maintain an erection
• Drug treatments such as injections given straight into the penis to achieve an erection work for many men. Viagra is another option to discuss with your doctor, although this drug cannot be used by men who take nitrate based medicine for heart problems.

If you find the loss of your sex life or changes in your sex life disturbing you should discuss this with your doctors and, if you are in a relationship, with your partner. It may be helpful to have some sexual counselling - ask your specialist, or your GP or your local Cancer Society if there are any counsellors in your area who specialise in sexual counselling.

There may also be a specialist impotence advisory service in your area where you can discuss treatment options. Talking to another man who has had this experience following treatment for prostate cancer may be helpful.

Related topics

What is prostate cancer? See Prostate cancer

How is prostate cancer diagnosed? See Diagnosing prostate cancer

Are there any issues about screening or treatment for prostate cancer? See Prostate cancer screening

What does that term mean? See Cancer glossary

What should I ask my doctor? See Questions to ask your doctor when you have cancer

What support services are available? See Cancer: Getting support

Original material provided by the Cancer Society of New Zealand, 2001. Reviewed by everybody, February 2005.