How Is Prostate Cancer Treated?

This content has been reviewed and approved by

Daniel P. Petrylak, MD
Associate Professor of Medicine
Director, Genitourinary Oncology Program
Columbia University Medical Center

If there is any good news involving prostate cancer, it is that there are a variety of ways to treat the disease. Among them are surgery, radiation, and chemotherapy. Treatments also include drugs to inhibit the production of male hormones (such as testosterone), which can aid the growth of cancer cells.

Treatment for prostate cancer depends on the stage and grade of the cancer. Other factors influencing decisions about treatment for prostate cancer include the patient's age, other existing health problems, the patient's goals for treatment, and the preferences of the treating physician. Another option is observing the patient, but not treating him, until signs of prostate cancer begin to emerge. This is called watchful waiting.

When considering treatment options, you should consider consulting more than one urologist for an opinion. This is particularly helpful when deciding between surgery or radiation therapy.

A urologist is a surgeon who specializes in treatment of disorders of the male genital tract, including prostate cancer. A urologist typically plays an important role in the diagnosis and treatment of prostate cancer.

Surgery for Prostate Cancer 

The following types of surgery are used to treat prostate cancer: 

• Radical prostatectomy - This surgery is done in the hospital and involves removal of the entire prostate gland and some tissue around it. The prostate is removed through an incision made in either the abdomen or the scrotum area. A portion of the tube that empties the bladder through the penis (urethra) is removed. The cut ends of the urethra are then reattached.
  
  To help heal the urethra, the patient will go home from the hospital with a catheter in place for bladder emptying. It usually remains in place for a few weeks.
  
  Radical prostatectomy is used to treat stage I, II, and III prostate cancer. It is most effective if the staging evaluation shows that the cancer has not spread outside the prostate. This is because surgery cannot remove cancer that has already spread outside of the prostate gland. In general, the higher the stage, the more likely the cancer has spread outside of the prostate. Candidates for radical prostatectomy should be in generally good health and young enough to have a 10- to 20-year life expectancy. 

Approximately 50 percent to 75 percent of men become impotent following radical prostatectomy, and approximately up to 5 percent experience permanent incontinence. Injury to the rectum can also occur in men treated with surgery. In-hospital death after radical prostatectomy is rare, occurring in less than 1 percent of cases. Complications from radical prostatectomy tend to be less frequent in younger patients. Severe complications from radical prostatectomy are relatively uncommon. 

• Nerve-sparing prostatectomy - A newer surgical technique, referred to as nerve-sparing prostatectomy, has been developed. This approach is designed to prevent injuring the nerves that control erection and the bladder. When this surgery is successful, impotence and urinary incontinence are only temporary. Nerve-sparing surgery preserves potency in 60 percent to 75 percent of patients, and less than 10 percent have urinary stress incontinence when an experienced surgeon performs the operation. 
  
• Lymph node dissection - Before a prostatectomy is performed, the urologist may surgically remove the lymph nodes to see if they contain cancer cells. If cancer is found in the lymph nodes, usually the urologist will not perform a radical prostatectomy because the cancer has already spread outside the prostate to the lymph nodes. Instead, another form of treatment—usually hormone therapy and/or radiation therapy—is given.
  
• Laparoscopic surgery - During this procedure, the surgeon uses special instruments, including a long, lighted tube with a camera on the end called a laparoscope, to remove the prostate gland and other tissue through small incisions in the patient's abdomen. This surgery is often performed using robotic instruments directed by the surgeon, and usually is able to spare the nerves as in the nerve-sparing prostatectomy.
  
• Transurethral resection of the prostate (TURP) - TURP is  surgery that removes the part of the prostate gland that surrounds the urethra. A small tool is placed inside the prostate through the urethra for the surgery, and no incision is made on the outside of the body. 
  
• Cryosurgery - Cryosurgery kills cancer cells by freezing them with a small, metal tool placed in the tumor. This procedure has some major advantages over conventional surgery, including outpatient treatment, less pain, less blood loss, and faster recovery times. Since healthy tissue is preserved in the cancer-involved organ, the cryosurgery procedure can be repeated if the cancer returns. 

Complications and Side Effects of Surgery 

Long-term, serious side effects from surgery are somewhat less common now than in the past, as experience is gained and new methods are introduced. Nerve-sparing surgical procedures may prevent permanent injury to the nerves that control erection and damage to the opening of the bladder. However, possible complications and side effects of prostate cancer surgery still exist. Be sure to discuss the following with your physician before a surgical procedure: 

• Incontinence - Incontinence is the inability to control urination and may result in leakage or dribbling of urine, especially just after surgery. Normal control returns for many patients within several weeks or months after surgery, although some patients become permanently incontinent. 
  
• Impotence - Impotence is the inability to maintain an erect penis. For a month or so after surgery, most men are not able to get an erection. Eventually, approximately 40 percent to 60 percent of men will be able to get an erection sufficient for sexual intercourse, but without ejaculation of semen because removal of the prostate gland prevents that process.
  
  This effect of surgery on the ability to achieve an erection is related to the stage of the cancer and the patient's age. However, most men who have surgery should expect some decrease in their ability to have an erection. For men who are completely impotent after surgery, several treatments are available. 

Radiation Therapy 

Radiation therapy uses high-energy x-rays to kill cancer cells or decrease their ability to reproduce. In early stage prostate cancer, radiation can be used as an alternative to surgery. It can also be used after surgery to destroy any remaining cancer cells. In advanced stages of prostate cancer, radiation therapy may be used to relieve pain from bone metastases. 

Radiation therapy can be given in a variety of ways. The two most common methods are external beam radiation therapy (EBRT) and implantation of radioactive seeds (brachytherapy) directly into the prostate gland. Most patients receive one or the other kind of radiation; some patients receive both kinds of radiation therapy. 

• External beam radiation therapy (EBRT) - EBRT is a treatment that uses an x-ray machine to precisely target the cancer cells with high levels of radiation. Because radiation kills cancer cells, the patient may wear special shields to protect the normal tissue surrounding the treatment area. Radiation treatments are painless and usually last a few minutes.
  
  EBRT is usually given as outpatient treatment every day for several weeks. EBRT begins with a planning session, or simulation, where marks are placed on the body and measurements are taken to line up the radiation beam in the correct position for each treatment. Patients lie on a table and are treated with radiation from multiple directions to the pelvis.
  
• Internal radiation (implant therapy) - Internal radiation is a procedure that implants small, radioactive seeds (each about the size of a grain of rice) directly into the cancerous prostate tumor. The implanted seeds may be left in permanently or may be only temporary. The seeds emit small amounts of radiation for a period of weeks or months. Internal radiation is known by a number of names: "interstitial brachytherapy," "seeds," or "implantation." 

For prostate cancer, the most common method of interstitial brachytherapy is permanent implantation of radioactive seeds into the prostate gland through the perineum (the area between the scrotum and the anus). The implantation procedure is performed in the operating room while the patient is asleep or numb from the waist down.

An imaging device—known as ultrasound—is inserted into the rectum to view and guide placement of the seeds with needles into the prostate. After the procedure, the patient will temporarily give off a small amount of radiation from the seeds, although this amount is not generally dangerous to most other people. Some doctors may advise patients to avoid close contact with young children or pregnant women for several weeks. 

Usually, the patient goes home several hours after the procedure, either on the same day or after an overnight hospital stay. Following the procedure, some patients may experience pain or aching in the perineum, and burning or discomfort during urination. Occasionally, a patient will be unable to urinate and may require a bladder catheter for several days or weeks to allow passage of urine. 

Also infrequently, a patient may lose control of passing urine; this seems to occur more often in men who have had a previous transurethral resection of the prostate (TURP). Men appear to maintain potency more often with interstitial seed radiation than with external radiation. 

• Combined EBRT and implant therapy - Another method of increasing the dose of radiation to the cancer is to combine EBRT with implant radiation placed directly into the prostate gland. When these two methods are combined, EBRT is given for 4 to 5 weeks, and the final "boost" of radiation to the prostate gland is given with the implant radiation. 

Hormone Therapy 

Testosterone is a male hormone produced mainly by the testicles. Testosterone stimulates cell growth in the prostate gland. The goal of hormone therapy in men with prostate cancer is to block or prevent cancer cells from exposure to testosterone and other male hormones, thereby preventing cancer from growing. Reducing testosterone levels can make the prostate cancer shrink and become less active. 

Hormone therapy primarily prevents cells from growing and also destroys them, whereas chemotherapy kills cancer cells. Hormone therapy does not cure prostate cancer and is often used to treat persons whose cancer has spread or recurred after other treatment. Most studies show that hormone therapy works better if it is started early. 

Two methods used to deliver hormone therapy are surgical orchiectomy and medical hormone therapy. 

Surgical Hormone Therapy 

• Orchiectomy - Orchiectomy refers to the  surgical removal of the testicles to prevent the production of male hormones, including testosterone. Orchiectomy is a common treatment for patients with metastatic (stage IV) prostate cancer who will likely require hormone therapy for life. Patients may experience a benefit in symptoms in a matter of days following surgery. 

Orchiectomy can cause side effects that include loss of sexual desire, impotence, hot flashes, and weight gain. The operation is relatively safe and is not associated with severe complications. It is a convenient and less costly method of hormone therapy; however, it is irreversible. 

• Medical hormone therapy - The second method of hormone therapy is to use medicines called LHRH analogs and antiandrogens that produce the same effect as an orchiectomy. 
  
• LHRH (luteinizing hormone-releasing hormone) analogs - These drugs decrease the amount of testosterone produced in a man's body by interfering with the normal chemical signals sent from the pituitary gland in the brain to the testicles. Drugs include Lupron^® and Eligard^® (leuprolide), Viadur^® (leuprolide acetate) implant, Zoladex^® (goserelin acetate) implant, and Trelstar^® (triptorelin pamoate). LHRH analogs are given as a small injection under the skin of the abdomen. These drugs are as effective as bilateral orchiectomy against prostate cancer.
  
  

  LHRH analogs can cause side effects that include loss of sexual desire, impotence, hot flashes, and bone loss (osteoporosis), which increases the risk of bone fractures. These drugs require an injection every 1 or 3 months or annually, and may not be as convenient as an orchiectomy. Unlike orchiectomy, LHRH analogs can be discontinued, and male hormone levels gradually return to normal, although this is not the case for every man. 

• Antiandrogens - These agents block the body's ability to use testosterone. Even after orchiectomy or LHRH-analog treatment, a small amount of testosterone may still be produced in the body. Other hormonal drugs may be used for periods of time during treatment, including Eulexin^® (flutamide), Casodex^® (bicalutamide), and Nilandron^® (nilutamide).
  
• Hormone therapy is usually given for a few months, depending on the individual situation. Some research suggests that patients should have a total of  3 years of therapy along with radiation therapy. Always consult your physician for more information regarding hormone therapy treatment. 

Possible side effects of hormone therapy for prostate cancer may include the following: 

• Hot flashes 
• Impotence (inability to achieve or maintain an erection) 
• Diminished libido (desire for sex) 
• Breast enlargement 

Chemotherapy 

Chemotherapy is the use of drugs to kill cancerous cells. Often chemotherapy is not the first-line of therapy for men with prostate cancer, but it may be used when prostate cancer has spread outside of the prostate gland or in combination with other therapies. 

Your physician will make treatment recommendations based on the following factors: 

• Your age, overall health, and medical history 
• The stage of the cancer 
• Your tolerance for specific medications and procedures 
• Expectations for the course of the disease 
• Your opinion or preference 

According to the American Cancer Society, chemotherapy is not effective against early prostate cancer. Although it may slow tumor growth and reduce pain, it also has had only limited success for the treatment of advanced prostate disease. 

However, in 2004 the U.S. Food and Drug Administration (FDA) approved the use of Taxotere^® (docetaxel) along with prednisone, a steroid for use in prostate cancer that is no longer responding to hormone therapy. This is the first chemotherapy regimen that has been shown to improve survival time. 

Administration of Chemotherapy

Your oncologist will determine how long and how often chemotherapy treatments are necessary, if at all. Chemotherapy can be administered intravenously (in the vein) or by pill, and usually involves a combination of drugs. Chemotherapy treatments are often given in cycles: a treatment period, followed by a recovery period, followed by another treatment period. 

Chemotherapy may be given in a variety of settings, including a hospital or hospital outpatient facility, a physician's office or clinic, or your home. A hospital stay may be necessary to monitor treatment and to control chemotherapy's side effects.

Side Effects of Chemotherapy 

Each person's individual medical profile and diagnosis is different, and so is his or her reaction to treatment. Side effects may be severe, mild, or absent. Be sure to discuss with your cancer care team any possible side effects of treatment before the treatment begins. 

Most side effects of chemotherapy disappear once treatment is complete. Common side effects of chemotherapy depend on the drug used, the dosage, and the length of treatment, and may include the following: 

• Fatigue 
• Nausea and vomiting 
• Hair loss 
• Anemia 
• Reduced ability of blood to clot 
• Mouth sores 
• Increased likelihood of infection
• Edema or weight gain