Treatment:

Treatment choices are generally based on the patient's age, the stage and grade of the cancer, overall health status, and the patient's personal preferences for the risks and benefits of each therapy.

Patients should be aware that doctors may be biased to prefer a specific treatment depending on their specialty, with urologists tending to recommend surgery and radiation oncologists recommending radiation therapy. It is always wise to seek a second opinion. Delaying treatment, while having the cancer monitored for signs of progression, is also an acceptable option.

Stages indicate the extent of the cancer:

• Stage I and stage II cancer are considered early stage. The cancer is localized and has not spread outside the prostate gland.
• Stage III, locally advanced cancer, means that the cancer has spread into the seminal vesicles (glands at the base of the bladder, which are connected to the prostate gland and help produce semen).
• Stage IV is advanced cancer. The cancer has spread to the lymph nodes and other tissues or organs.

Depending on the cancer stage and other factors, patients have four main treatment options:

• Active surveillance, also called watchful waiting, involves monitoring the tumor for cancer progression to determine if and when treatment should be started.
• Surgery (radical prostatectomy) removes the prostate gland. The vessels that carry semen and surrounding tissue may also be removed. Studies indicate that compared to watchful waiting, radical prostatectomy may lower the risk of cancer recurrence and death, particularly for younger men with aggressive tumors. It is usually not appropriate for older men. Radical prostatectomy may be done either through open surgery or laparoscopic techniques.
• Radiation therapy targets the tumor either externally (external beam radiation) or internally (implanted “seeds”).
• Androgen deprivation therapy, also called hormone therapy, uses orchiectomy (surgical removal of the testicles) or drugs to stop production of male hormones.

The U.S. National Cancer Institute recommends the following treatment options by cancer stage:

Stage I Treatment Options (Localized Cancer)

Tumors: T1a, N0, M0, G1, Stage A

• Active surveillance
• Radical prostatectomy, with or without radiation therapy after surgery
• External beam radiation therapy
• Implant radiation therapy (brachytherapy)
• Clinical trial options

Stage II Treatment Options (Localized Cancer)

Tumors: T1a - c, N0, M0, any G, Stage A2, B1, or B2

• Radical prostatectomy, with or without radiation therapy after surgery
• Active surveillance
• External beam radiation therapy with or without hormone therapy
• Implant radiation therapy (brachytherapy)
• Clinical trial options

Overview of Treatment Options for Localized Prostate Cancer. To date, neither treatment nor active surveillance has emerged with a definitive survival advantage for localized prostate cancer. However, several recent studies have suggested that treatment provides a survival advantage over watchful waiting for some men with early-stage prostate cancer.

Recent guidelines recommend that patients with localized cancer should be classified as low, intermediate, or high risk. Doctors determine the risk category by using criteria such as PSA tests, tumor aggressiveness, and the clinical stage of the tumor. Based on these risk groups, evidence indicates that:

• Compared with active surveillance, radical prostatectomy may lower the risk of cancer recurrence and death, at least in men younger than age 65 at the time of diagnosis.
• For men at intermediate and high risk, adding androgen deprivation (hormonal) therapy to external beam radiation may improve survival but increase adverse side effects. Adding hormonal therapy to radical prostatectomy does not improve survival or cancer recurrence rates.
• Initial (first-line) androgen deprivation therapy is seldom recommended for localized prostate cancer except for the relief of symptoms in patients with poor prognoses. Androgen deprivation therapy can increase the risks for diabetes and heart disease.
• Patients with localized prostate cancer should have the opportunity to enroll in clinical trials investigating new types of therapy.

Stage III Treatment Options (Locally Advanced Cancer)

Tumors: T3, N0, M0, any G, Stage C

• External beam radiation with or without androgen deprivation therapy (hormone therapy)
• Androgen deprivation therapy
• Radical prostatectomy, usually with pelvic lymphadenectomy, with or without radiation therapy following surgery
• Radiation therapy, androgen deprivation therapy or transurethral resection of the prostate (TURP) to relieve symptoms
• Clinical trial options

Stage IV Treatment Options (Advanced Cancer)

Tumors: Any T, any N, any M, any G, Stage D1 - D2

• Androgen deprivation therapy
• External beam radiation therapy with or without androgen deprivation therapy
• Radiation therapy or transurethral resection of the prostate (TURP) to relieve symptoms
• Active surveillance
• Clinical trial options

Recurrent or Persistent Prostate Cancer

If prostate cancer has been eliminated after initial treatment, PSA levels should drop after surgery. After radiation, they may not drop as far because some of the prostate gland may remain. A sudden rise or persistently elevated PSA levels after treatment are often indications that prostate cancer persists.

It is common for PSA levels to temporarily rise following radiation seed implantation without signaling cancer recurrence. Rising PSA levels do not necessarily mean that the cancer has spread or even that clinical cancer will recur during a man's lifetime.

Treatment options for recurrent cancer depend on various factors, including prior treatment, site of recurrence, coexistent illnesses, and individual patient considerations.

• Patients whose cancer recurs locally after prostatectomy: Radiation therapy, androgen deprivation therapy.
• Patients whose cancer recurs locally after radiation therapy: Androgen deprivation therapy, prostatectomy (very select patients).
• Patients whose recurrent cancer has spread: See treatment options for stage IV.

Comparing Side Effects of Treatments

Prostate cancer treatments can cause distressing side effects by impairing sexual function (erectile dysfunction), urination (incontinence or difficulty urinating), bowel function (incontinence), and energy levels (fatigue). A man must weigh his own emotional responses to the possibility of these side effects versus the possible stress of active surveillance.

Side effects vary among patients and it is difficult to predict how an individual patient will respond. In general, the side effects most likely to occur by treatment modality are:

• External beam radiation therapy provides the best initial results for recovery of sexual function.
• Nerve-sparing prostatectomy generally produces better sexual function than conventional radical prostatectomy.
• External beam radiation therapy produces better urinary control and sexual function than brachytherapy, but brachytherapy has better results for these side effects than radical prostatectomy.
• Radiotherapy (both brachytherapy and external beam radiation) generally causes more bowel problems than surgery, although this side effect usually improves after 1 year. Urinary incontinence is less common after radiation than surgery.