Treatment of Stage I Prostate Cancer

This content has been reviewed and approved by

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

Prostate cancer is referred to as stage I if it cannot be felt during a digital rectal exam and there is no evidence that cancer has spread outside the prostate. Stage I prostate cancer is further classified into the following categories, depending on how it was found and how large it is.

• T1a - The tumor (cancer) is found when a biopsy of the prostate is taken for another reason and involves 5 percent or less of the prostate sample.
• T1b -The tumor is found when the prostate biopsy is taken for another reason and involves more than 5 percent of the prostate sample.
• T1c -The tumor is detected by needle biopsy or because the patient has a high blood level of PSA.

If prostate cancer is confined to the prostate, it is curable with surgery or radiation. However, elderly patients with early-stage prostate cancer may decide not to undergo treatment because prostate cancer grows slowly. If you are an elderly patient and are in this situation, you should ask yourself whether it is worthwhile for you to undergo the discomfort of treatment.

Otherwise, if you are diagnosed with early-stage prostate cancer, you have a choice between "watchful waiting" which means your doctor will keep you under observation until there are signs that the cancer is progressing, aggressive treatment with radiation, surgery (radical prostatectomy), or participation in a clinical study. Unfortunately, well-controlled clinical studies comparing these treatment approaches have not been conducted. Before deciding on whether to be treated, you should be sure you know the answers to three questions:

• What is my life expectancy and risk of cancer progression without treatment?
• How will my prognosis be improved with treatment?
• What are the risks of the various treatment alternatives?

Watchful Waiting

Some physicians and patients prefer to delay any treatment of prostate cancer until symptoms from the cancer appear. This delayed approach is referred to as watchful waiting. Because treatment with radiation or surgery may be associated with temporary (and some permanent) side effects, in addition to inconvenience, choosing not to be treated immediately may be appropriate for selected patients. In fact, doctors in many European countries use a strategy of watchful waiting and do not treat early-stage prostate cancer with radiation or surgery.

Watchful waiting requires close follow-up of the cancer. Therapy begins only when signs and symptoms of cancer emerge. For the most part, this is usually just local growth within the prostate. At this point, the treatment is dependent on the extent of disease and the physical condition of the patient.

It is not known for certain whether it is better to treat prostate cancer early or to wait until progression of the disease occurs. To help you decide on treatment, ask your physician to explain your chances of survival without treatment and to explain the risk of the cancer having spread beyond the prostate gland.

Surgery: Radical Prostatectomy

Radical prostatectomy involves surgical removal of the prostate gland and a small amount of surrounding normal tissue. Surgical removal of the prostate is effective if the cancer has not spread beyond the prostate.

Some patients diagnosed with stage I cancer already have small amounts of cancer that have spread outside the prostate and were not removed by surgery because the amounts were undetectable.

Undetectable areas of cancer outside the prostate gland are referred to as micrometastases. The presence of micrometastases may cause the relapses that follow treatment with surgery alone.

Both radiation therapy and surgery are considered local therapies. They do not treat cancer that has spread beyond the prostate gland. An effective treatment is needed to cleanse the body of micrometastases to improve the cure rate achieved with surgical removal of the cancer. Efforts are currently under way to find such a therapy.

Radiation Therapy

Radiation therapy is treatment with high energy x-rays that have the ability to kill cancer cells. Standard radiation therapy uses either external beam radiation (EBRT) or interstitial brachytherapy, which involves permanent placement of radioactive seeds directly into the prostate gland. Radioactive implants are increasingly being used instead of radical prostatectomy or EBRT. Unfortunately, clinical studies directly comparing EBRT to implants have not been performed. Early results with implants suggest good control of the disease with limited side effects. Long-term results are not widely available, but early results are promising, especially in patients with low-risk disease.

Because radiation implants focus the radiation closely around the prostate, this form of radiation works best in patients with early-stage prostate cancer. If the PSA level or Gleason score is high, another form of treatment may be better suited for the patient. Patients with a large prostate gland, prior history of prostate infections, or recent transurethral resection of the prostate (TURP) may not be able to undergo the implantation procedure for brachytherapy.

Research is in progress to refine existing treatments and develop new ones. For information on some of the techniques currently under investigation, see Strategies to Improve Treatment.