Treatment of Stage II 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

Stage II prostate cancer can be detected with a digital rectal exam (physical exam). In stage II, there is no evidence of spread of cancer outside the prostate to other organs. Stage II disease may also be further categorized as follows, depending on how much tissue is involved in the tumor (cancer):

• T2a -The tumor involves half or less of one lobe (section) of the prostate.
• T2b -The tumor involves half or more of one lobe of the prostate, but not the other lobe.
• T2c -The tumor involves both lobes of the prostate.

Prostate cancer is typically a disease of aging. It may persist undetected for many years without causing symptoms. In fact, most people with prostate cancer die of old age, not the cancer. Choosing between treatment options is difficult in early-stage prostate cancer. Patients with stage II prostate cancer are curable and have a number of treatment options, including surgical removal of the cancer, radiation therapy, or watchful waiting. You should know about expected results for each treatment and consult more than one physician for a recommendation about treatment, especially when deciding between surgery and radiation therapy.

If prostate cancer is confined to the prostate, it is curable with surgery or radiation. However, to benefit from treatment, a patient's life expectancy may need to be 10 to 15 years. Patients may ask themselves: If a cure is possible, is it necessary? Treatment of prostate cancer is a personal decision, and some patients will choose to undergo aggressive treatment, while others will not.

If you are diagnosed with early-stage prostate cancer, you have a choice between "watchful waiting," which is observation until there are signs that the cancer is progressing; more 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 these questions:

• What is my life expectancy and risk of cancer progression without treatment?
• Will my prognosis be improved with radiation? With surgery? With watchful waiting?
• 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 spread emerge. At this point, the treatment is usually hormonal therapy.

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 uses high energy x-rays to kill cancer cells. Standard radiation therapy uses either external beam radiation (EBRT) consisting of daily treatments on an outpatient basis for approximately 6 to 8 weeks 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. 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.