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Last updated May 30, 2019. 8 minute read

Prostate cancer treatments—weighing the options

A handful of factors demand careful consideration when deciding on the right approach to treatment. These include a patient’s risk factors, goals and values as well as tumor stage and level of comfort with possible side effects.

Dr Tzvi Doron Do Written by Dr. Tzvi Doron, DO
Reviewed by Dr. Melynda Barnes, MD

Cancer is one of the most frightening diagnoses a person can hear. Among men, prostate cancer is one of the most feared. It forces men to confront the possibility of dying and the risk of treatment robbing them of their vitality, even as it saves their lives. That said, a lot of the fear men feel about the disease is based on enduring misconceptions. So let’s dispel a couple of those now.

First off, while around one in nine men will receive a prostate cancer diagnosis at some point in their lives, most will not die from the disease. In part, this is because often, prostate cancer is not aggressive. That means it grows very slowly and may not even require treatment. Even the more aggressive forms that must be treated can be managed much more effectively than in the past, and there is now a wide range of effective options.

Second, the side effects of treatment, including incontinence and erectile dysfunction, are not as common as they used to be. And if these and other side effects do occur, there are now more effective management options available to deal with them.

If you have been diagnosed with prostate cancer, it’s essential to learn all you can. With the help of a sound support system and modern medicine, most men can get through this challenging time in their lives.

Vitals

  • There is an ever-expanding range of options for treating prostate cancer.
  • Among these are radiation therapy, the surgical removal of the prostate, immunotherapy, and hormone therapy.
  • A handful of factors demand careful consideration when deciding on the right approach to treatment. These include a patient’s risk factors, goals and values as well as tumor stage and level of comfort with possible side effects.
  • Men who consult their friends and family about their prostate cancer are more likely to choose curative treatment.

Prostate cancer basics

Prostate cancer is the most common cancer in men besides skin cancer. The American Cancer Society (ACS) estimates (ACS, 2019) there will be about 174,650 new prostate cancers in 2019, and approximately 31,620 men will die from prostate cancer this year. Early detection can improve survival, but many men with prostate cancer will never experience symptoms, much less die from their disease. This fact, along with the anxiety associated with the diagnosis and the side effects of treatment, makes prostate cancer screening both complicated and controversial.

The American Urological Association (AUA) recommends (Detection, 2018) that men aged 55–69 should engage in shared decision-making when deciding whether to screen for prostate cancer. Shared-decision making is a process in which healthcare providers share the best available evidence, weighing the risks and benefits so that men can make an informed decision with their healthcare provider’s support.

The AUA also recommends that decisions about screening men aged 40–54 be individualized, with risk factors for prostate cancer (e.g., family history, African American heritage) taken into consideration. The AUA does not recommend routine screening before age 40 or after age 70. Screening is performed by measuring prostate-specific antigen (PSA) levels and may also include a digital prostate exam.

Once a man receives a prostate cancer diagnosis, he and his healthcare provider must decide which treatment approach they will take to maximize treatment goals and quality of life. Each individual’s goals and values should be weighed when making this choice.

Treatment options for prostate cancer

It’s easy to get overwhelmed with the number of treatment options available for prostate cancer. In general, a few factors demand careful consideration.

  • Tumor stage: It is tempting to think treatment options are determined by the cancer stage, but this is only one factor. Tumor stage takes into account the tumor size, the PSA level, Gleason Score (a score of how abnormal the tumor cells are), and how far the tumor has spread.
  • Treatment side effects: Two of the most concerning side effects from prostate cancer treatments are erectile dysfunction and urinary incontinence. These side effects can have a major impact on a man’s quality of life and are important factors when weighing treatment options.
  • Age and health: Some people who are older and/or in poor health may choose to be less aggressive with treatment because they are more likely to die of causes other than prostate cancer, while others will still opt for more aggressive treatment.
  • Individual goals and values: Some people may prefer less aggressive treatment to avoid side effects. Others may choose more aggressive treatment because they don’t like the anxiety of not knowing whether their cancer will spread.

Here’s an overview of different treatment options for prostate cancer.

Watchful waiting and active surveillance/active monitoring

The terms watchful waiting and active surveillance/active monitoring are often used interchangeably, but they are actually two distinct strategies.

Watchful waiting is a strategy used when there is no intention to cure prostate cancer. Patients are monitored over time and treated if they develop symptoms. Watchful waiting is often used in people with very advanced disease (when a cure is not possible) or in people with a shortened life expectancy for other reasons. In these cases, people may feel that the risks or side effects of treatment are not worth the benefits of treatment.

Active surveillance/active monitoring is often used in stage I or stage II, the earlier stages of the disease. Over time patients undergo physical exams, PSA tests, and often prostate ultrasounds and/or biopsies. healthcare providers only begin treatment if there is evidence that the cancer is progressing. Unlike with watchful waiting,  active surveillance/active monitoring aims to cure the cancer. It’s designed to minimize the side effects in men with slow-growing tumors that may never cause any problems while curing cancers that show signs of progressing. 

Radical prostatectomy

Radical prostatectomy is a surgery in which the entire prostate gland is removed. It’s usually used for healthy people with stage I or II prostate cancer with the aim of curing the cancer. Once the cancer has spread beyond the prostate gland (stage III or higher), a radical prostatectomy cannot cure the cancer. There are a few different techniques used for this surgery, and sometimes urologists perform this surgery robotically. 

Studies comparing radical prostatectomy to radiation and active surveillance/ active monitoring show conflicting results. Some demonstrate better survival with radical prostatectomy in stage I and II prostate cancer, while others do not. Side effects of radical prostatectomy include:

  • Complications of the surgery itself, such as bleeding, infection, blood clots, and injury to nearby organs.
  • Erectile dysfunction (ED): Many men develop ED after radical prostatectomy. Newer techniques that preserve the nerves may be better, but the rates of ED are still high. In many cases, ED from radical prostatectomy can be treated effectively with medication (Qiu, 2016). Many healthcare providers prescribe these medications for daily use as “penile rehabilitation” after radical prostatectomy.
  • Urinary incontinence: Up to 63% of men develop some degree of urinary incontinence after radical prostatectomy. This often decreases over time but can still be common years after the procedure.
  • Penile shortening: Some men complain of penile shortening of 1–2 cm (0.4–0.8 inches) after surgery. This side effect is much less common than ED and urinary incontinence.
  • Inguinal hernia: Men may have higher rates of groin hernias after radical prostatectomy.
  • Fecal incontinence: Some men may have fecal incontinence after radical prostatectomy, depending on the surgical technique. As with urinary incontinence, this may resolve over time.

Radiation therapy

There are a few different types of radiation that can treat prostate cancer. As with radical prostatectomy, radiation therapy is used for people who do not have cancer that has spread to lymph nodes or distant organs.

  • External beam radiation therapy (EBRT): This type of radiation (using x-rays) is delivered from a machine that is outside the body. There are several methods used to deliver the radiation to the prostate as precisely as possible, and limiting damage to surrounding tissues. 
  • Brachytherapy: This type of radiation is delivered by tiny seeds, about the size of a grain of rice, that are placed directly in the prostate. These seeds release radiation into the prostate over the course of several weeks to months. Brachytherapy can also deliver higher doses of radiation over the course of a few days, although this is less common. In some cases, brachytherapy can be combined with EBRT.

Like radical prostatectomy, radiation therapy for prostate cancer can also cause side effects.

  • ED: Radiation therapy causes less ED than radical prostatectomy in the short term, but erectile function declines over time. In many cases however, ED from radiation therapy can be treated effectively with medication (Incrocci, 2015).
  • Urinary incontinence: Radiation therapy can also cause urinary incontinence but less so than radical prostatectomy.
  • Fecal incontinence: Radiation therapy causes more rectal incontinence than radical prostatectomy.
  • Inflammation: Radiation therapy causes injury to surrounding tissues and organs, which can include the bladder (cystitis), the rectum and anus (proctitis), and the intestines (enteritis). This can cause diarrhea, rectal pain and bleeding, urinary urgency, and blood in the urine (hematuria).

Hormone therapy

Testosterone and dihydrotestosterone (DHT) cause prostate cells to grow. We can stop prostate cancer from growing, or even shrink it, by lowering these hormones in the body. Hormone therapy is also called androgen deprivation therapy (ADT) because it deprives the body (and the cancer) of male hormones, called androgens.

There are a few different methods used to decrease androgen levels.

  • GnRH (Gonadotropin Releasing Hormone) agonists: These are drugs that cause the brain to stop signaling the testicles to produce androgens. Examples of GnRH include leuprolide (Leupron), goserelin (Zoladex), buserelin, and degarelix Frigamon).
  • Androgen receptor blockers: These drugs block androgens from attaching to receptors on cells. Some examples include Flutamide (Eulexin), bicalutamide (Casodex), nilutamide (Nilandron), enzalutamide (Xtandi) and apalutamide (Erleada).
  • Enzyme blockers: These drugs block the enzymes needed to make androgens. Some examples include abiraterone acetate (Zytiga) and ketoconazole (Nizoral).
  • Orchiectomy: This is the surgical removal of both testicles. Since the testicles produce most of the body’s androgens (male hormones), this lowers the levels to almost zero.

Side effects of ADT are related to extremely low levels of testosterone and are predictable. ADT can cause:

  • ED
  • Low libido
  • Loss of muscle mass and strength
  • Weight gain
  • Hot flashes
  • Osteoporosis and bone fractures
  • Depression
  • Anemia
  • High cholesterol–ADT may increase the risk of cardiovascular disease

Chemotherapy

Chemotherapy is not used as often for prostate cancer as it is for many other cancers. It’s usually used when prostate cancer is not responding to ADT. Drugs used in chemotherapy regimens for advanced prostate cancer are docetaxel (Taxotere), cabazitaxel (Jevtana), mitoxantrone (Novantrone), estramustine (Emcyt). Side effects are similar to chemotherapy side effects in other cancers:

  • Hair loss
  • Mouth sores
  • Loss of appetite
  • Nausea and vomiting
  • Diarrhea
  • Increased risk of infections 
  • Easy bruising or bleeding 
  • Fatigue

Some of these side effects are treatable. For example, some medications are effective in treating chemotherapy-induced nausea. Hair loss can be decreased by wearing a cooling cap that reduces circulation to the scalp during chemotherapy infusions.

Cryotherapy (Cryosurgery)

Cryotherapy (aka cryosurgery) uses cryoprobes to freeze the prostate, destroying cancer cells. It is considered an experimental treatment and is not commonly used. There are still many questions about its safety and efficacy compared with radical prostatectomy and radiation therapy. However, it is possible that it will be another standard treatment for prostate cancer in the future.

Prostate cancer vaccine

Sipuleucel-T (Provenge) Injection (Anassi, 2011) is a vaccine designed to help the body fight cancer cells with its own immune system. Special immune cells, called dendritic cells, are removed from the body and incubated with a protein called Protein Acid Phosphatase (PAP). PAP is made by prostate cancer cells. When the cells are put back into the body, they stimulate the body’s immune system to fight the cancer. 

Sipuleucel-T is used in advanced prostate cancer that is not responsive to ADT. It has not been shown to cure prostate cancer, but it can prolong survival in some men. Immunotherapy stimulating the body’s immune system to fight off cancers is an exciting area that is rapidly evolving. The hope is that in the future cancer treatments will be more effective with fewer side effects when cancers are targeted more precisely.

Receiving a prostate cancer diagnosis can be scary and challenging. There are many choices to be made, and predicting how things will turn out is incredibly difficult. It’s important to get connected with a urologist who has expertise in treating prostate cancer. A consultation with a radiation oncologist is also important although some men will choose a treatment regimen that does not include radiation.

Most people find the support of their friends and families to be crucial when navigating a cancer diagnosis and treatment. It’s especially important to involve romantic partners in the discussion as they are often your primary support system and they may also be affected by the disease or its treatment. With a good support system, a good medical team, and the right education, you can better navigate life with prostate cancer.