Prostate cancer can be treated in many ways. The choice of treatment depends
on the patient's health, age, expected life span, and personal preferences as
well as on the stage and grade of cancer and the anticipated effects of treatment.
Sometimes a combination of treatments is used.
Treatment options include the following:
Surgery can be performed to remove the cancer from the prostate and from nearby areas where the cancer has spread. It is most often used during
early stages, when prostate cancer is located only within the prostate.
If the tumor is small and has not spread outside of the prostate, then surgery
may cure the disease. Surgery may help prevent further spread of the cancer.
Surgical options include:
The latest advancement in surgical technology for prostate cancer is robot
assisted laparoscopic prostatectomy. Robot assisted prostatectomy provides
the benefits of laparoscopic surgery but with important technological improvements,
including advanced optics that provide 10-times magnified, three-dimensional
images of the prostate and surrounding nerves and tissues; robotic arms that
eliminate even the slightest human hand tremors; and instruments with "wrists"
that pivot 540 degrees for greater maneuverability than is possible with the
human hands or laparoscopic instruments.
What to expect:
The surgeon sits at a console a few feet from the patient and operates the computerized controls. A camera and specialized
instruments are mounted on the robotic arms, which are inserted through four small incisions
in the patient's abdomen and connected to the robot. As the surgeon moves his or her hands,
wrists and fingers, the robotic technology translates the motions into precise
micro-movements that allow greater precision - especially critical to spare
nearby nerves that control urinary continence and sexual function.
Following the surgery, patients are monitored overnight and usually go home
the next day. A urinary catheter remains in place for about a week. Most patients
return to normal activities in two to three weeks. For more information, see Robotic Prostatectomy.
Benefits of robot assisted prostatectomy include:
- smaller incisions and less scarring
- shorter hospital stay
- less pain
- better visualization for the surgeon
- less blood loss and transfusions
- faster recovery and return to normal activities
Open Prostatectomy Procedures
Radical retropubic prostatectomy and radical perineal prostatectomy are two
types of radical prostatectomy procedures. The entire prostate gland, attached seminal vesicles, and some nearby tissue
are removed during these surgeries.
A radical retropubic prostatectomy involves a surgical cut in the lower abdomen.
The surgeon can then remove the cancer through this skin incision. The entire
prostate and attached seminal vesicles are removed, along with a small part
of the bladder next to the prostate.
If necessary, nearby pelvic lymph nodes are removed as well. Recent developments
in surgery have led to a newer version of this technique, called nerve-sparing
radical retropubic prostatectomy. This allows the surgeon to identify the
nerves on either side so that they can be left alone, if possible.
The benefit to leaving these nerves alone is that some men will have a better
chance of achieving erections after surgery. In general, there is a lower
risk of certain adverse side effects if the nerve-sparing technique can be
Radical perineal prostatectomy is similar to radical retropubic prostatectomy
except that the cancer is removed through an incision in the perineum, the
area between the scrotum and the anus. The entire prostate is removed along
with any nearby cancer.
What to expect:
Radical prostatectomy procedures often last anywhere from an hour and a half
to about four hours. The perineal type is generally a shorter operation than
the retropubic type. A catheter is usually inserted after these procedures
while the patient is still asleep. This catheter will help make urination
easier during the healing process and will only be needed for a few weeks
or less. After the catheter is removed, you may be able to urinate on your
own. Both types of radical prostatectomies require about three days of rest
in the hospital, followed by three to five weeks of rest at home.
Prostatectomy is a one-time procedure that may cure prostate cancer in its
early stages and may help extend life in the later stages. Surgery avoids
some of the problems seen with radiation and other therapies.
Prostatectomy is a major operation that requires hospitalization and can
produce side effects. The possible side effects include impotence, incontinence,
and narrowing of the urethra, which can make urination difficult. Most men
who have this surgery should expect some decrease in their ability to have
an erection. However, the chance of impotence is lower with the new nerve-sparing
technique. In general, impotence is more likely to occur in older patients,
especially those older than 60 years of age. The risk of impotence is even
greater for men older than 70 years of age. Incontinence occurs in only a
small percentage of patients.
Transurethral Resection of the Prostate (TURP)
A transurethral resection of the prostate (TURP) is the removal of tissue
from the prostate by inserting an instrument through the urethra in the penis.
An instrument is placed into the urethra and guided up into the prostate
to cut some of the tissue that surrounds the urethra. TURP is most often recommended
for men with noncancerous enlargement of the prostate.
In this case, the procedure is performed to relieve the symptoms associated with this condition. TURP also may be an option for men who have prostate
cancer but cannot have a radical prostatectomy either because of advanced
age or a serious illness (besides cancer). TURP was designed to relieve symptoms
that a tumor can cause; it will not cure cancer and usually removes only part
of a tumor.
What to expect:
A TURP operation takes about an hour. A catheter is inserted after the surgery
and may remain in place for about two to three days to make urination easier.
The patient probably will stay in the hospital for one or two days and may
be able to return to work after one or two weeks.
A TURP requires less recovery time than a radical prostatectomy, and the
side effects often are less severe.
Because TURP is not a curative procedure for prostate cancer, other forms
of treatment may be required.
Radiation therapy uses high-energy rays to kill prostate cancer cells, shrink
tumors, or prevent cancer cells from dividing and spreading.
Radiation doses are usually small and spread out over time. This allows the
healthy cells to recover and survive, while the cancer cells eventually die.
Radiation therapy is usually used when prostate cancer has not spread beyond
the prostate. It can help prevent the cancer from spreading further.
Like surgery, radiation therapy works best when the cancer is located in a
small area. In early stages of prostate cancer, radiation therapy may cure the
disease. It may be used alone or in combination with hormone
therapy when cancer cells have spread beyond the prostate to the pelvic area and
for pain relief in prostate cancer that is no longer responding to hormone therapy and
has spread to the bones.
Radiation therapy can be given either via external beams or with a type of
internal radiation called brachytherapy. These types of radiation therapy are
External Beam Radiation Therapy
In external beam radiation therapy,
the rays are delivered by a machine, and the radiation is given in brief sessions,
usually one session each weekday for several weeks. Many patients compare the
treatments to having an x-ray. The procedure is painless and lasts for just a
few minutes. External beam radiation therapy may be given alone or in combination
with hormone therapy.
Recent advancements in external beam radiation therapy have led to two new
methods of treatment: three-dimensional conformal radiation therapy and conformal
proton beam radiation therapy. These developments may help reduce the side
effects of external beam radiation therapy and increase treatment success.
Newer treatments are often considered experimental until they can be shown
to have the same success rate as more standard forms of therapy, and they
may not be available at all radiation centers.
The Calypso System: GPS For the Body
The normal motion of the body's internal organs presents challenges in delivering
precise radiation therapy to small targets. Organs naturally move during radiation
treatment. In treating prostate cancer, it is important that all the necessary radiation
gets to the tumor and all possible precautions available are taken to avoid unnecessary
radiation to healthy tissues surrounding the bladder and rectum. The Calypso
4D Localization System, referred to as GPS for the Body, is a breakthrough technology
providing doctors with a way to precisely set up prostate radiation therapy and then monitor
the prostate's position during treatment.
The Calypso System uses tiny electromagnetic transponders, which are implanted into
the prostate in an outpatient procedure prior to treatment. These beacon transponders
emit radiofrequency waves which allow very accurate alignment of the prostate before
each treatment session. It also lets doctors monitor the position of the prostate in
real time during treatment delivery.
Three-dimensional Conformal Radiation Therapy (3D-CRT)
In three-dimensional conformal radiation therapy, high-tech computers are
used to identify the location of the cancer inside the prostate gland.
The next step is the creation of a special protection device that the patient
wears during the treatments. This device is similar to a body cast, but it
is molded out of styrofoam and helps to keep the body still during treatment
while the radiation is aimed at the cancer. When the patient wears the plastic
mold during the treatments, the radiation beams can be aimed more accurately
to target the prostate gland. The idea is to direct a high dose of radiation
only toward the cancer cells, while reducing the amount of radiation that
the surrounding noncancerous areas receive. If the healthy tissue can be spared
from the effects of radiation, the patient will experience fewer side effects.
Conformal Proton Beam Radiation Therapy
Conformal proton beam radiation therapy is another new type of radiation
therapy. This technique is similar to three-dimensional conformal radiation
therapy, except that it uses protons to produce the radiation beam. Protons
are microscopic particles that produce energy in the form of a radiation beam.
The proton beams can
pass through healthy tissue without damaging it, yet can still be aimed at
cancerous tissue to destroy cells.
Major surgery usually can be avoided by using radiation therapy. Radiation
therapy may cure prostate cancer in its early stages and may help extend life
in later stages. It rarely causes loss of urinary control, and other side
effects like impotence occur less often than with surgery. The newer techniques
mentioned above look promising in terms of reducing the chance of adverse
effects and increasing the chance of success.
Radiation therapy can cause a variety of side effects because healthy cells
are often damaged along with the targeted cancer cells. Most of these are
minor and disappear after therapy stops.
These side effects include:
- skin reactions in the treated areas
- frequent and painful urination
- upset stomach
- rectal irritation or bleeding
There is also a chance of some permanent side effects, including impaired
bowel function and impotence.
Prostate Brachytherapy(also called prostate seed implants)
In prostate brachytherapy,
the rays come from tiny, radioactive seeds inserted directly into the prostate.
Brachytherapy may be used by itself or in combination with external radiation
therapy. The seeds are too small to be felt by the patient and do not cause
any discomfort. They are inserted into the cancer during a surgical procedure
after the patient has been given a local or general anesthetic.
Specialized equipment like CT scans, ultrasound, and MRI help the surgeon to place the seeds correctly. The seeds give off rays continually for weeks,
months, or up to a year, and can remain safely in place for the rest of a
person's life. The amount of time that the seeds remain radioactive depends
on the dose and the type of radioactive material that is used.
Brachytherapy radiation is placed as close as possible to the cancerous cells
so that less of the normal tissue is exposed to the radiation. Interstitial
radiation therapy often allows the physician to use a higher dose of radiation
for a shorter length of time than is possible with external radiation. It
is usually performed within a hospital, and the patient may need to stay there
for a few days or longer. Brachytherapy does not make the patient radioactive.
Because it is designed to target the cancerous cells and not harm the surrounding
area, brachytherapy is rarely recommended when the cancer has spread beyond
the prostate gland.
High-dose Rate Brachytherapy
High-dose rate brachytherapy is a newer form of interstitial radiation treatment
involving seeds that are placed in the prostate only temporarily. These seeds
stay in place for less than a day and contain more radioactive material than
the seeds that stay in place longer. This type of brachytherapy may even be
performed in a clinic and may not require hospitalization.
When interstitial radiation therapy is used, the procedure itself is generally
painless. In fact, the newer types of brachytherapy, like high-dose rate brachytherapy,
usually involve very little discomfort. This type of therapy requires fewer
visits to the hospital or physician's office than other treatments.
Although brachytherapy may have fewer side effects than surgery, it has been
associated with impotence, urinary incontinence, and bowel problems. Diarrhea,
rectal pain, and burning are experienced by some patients, and these side
effects may not be easy to treat.
Internal radiation therapy has side effects that are similar to external
radiation therapy in general but with a few important differences. Brachytherapy
causes impotence less often than do surgery and external beam radiation; however,
it may be associated with decreased white blood cell and platelet counts.
In addition, seed insertion usually is not an option for treatment of prostate
cancer that has spread beyond the prostate gland.
Hormone therapy most commonly is used to treat cancer that has spread (metastasized) outside the pelvic area.
Two types of hormone therapy can be used: (1) surgical removal of the testicles,
the organs that produce male hormones, or (2) drugs that prevent the production
or block the action of testosterone and other male hormones, called androgens.
Hormone therapy cannot cure prostate cancer. Instead, it slows the cancer's
growth and reduces the size of the tumor(s).
Hormone therapy may be combined with radiation therapy or surgery in advanced
stages of cancer when the disease has spread locally beyond the prostate. This
therapy may help to extend life and relieve symptoms. When the cancer has spread
beyond the prostate, complete surgical removal of the prostate is not common.
In patients with early-stage cancer, hormone therapy may be used in combination
with radiation therapy. A short course of hormone therapy can also be used prior
to surgery to reduce the size of the prostate and may make it easier to remove.
The primary strategy of hormone therapy is to decrease the production of testosterone
by the testicles. Regardless of the method of hormone therapy, this decrease
in testosterone can result in certain side effects such as hot flashes, a loss
of sexual desire, and impotence.
The specific methods used to reduce testosterone production or block the actions
of testosterone and other male hormones are described below:
Surgical Removal of the Testicles
An orchiectomy is an operation to remove the testicles, which produce 95
percent of the body's testosterone.
Since the testicles are the major source of androgen in the body, this procedure
is classified as hormone therapy rather than surgical treatment. The goal
of an orchiectomy is to shrink the prostate cancer and/or prevent future growth
of the tumor by removing the source it depends on (testosterone).
Orchiectomy is an effective procedure that is relatively simple. The patient
is usually given a local anesthetic and allowed to go home the same day as
Many patients prefer a nonsurgical option if the success rates are similar.
Depending on the kind of anesthesia used, there may be special risks in certain
types of patients.
Orchiectomy is not reversible, and in some cases, may require hospitalization.
Patients will often experience side effects that result from the lack of male
hormone in the body. Many men will notice decreased sexual desire following
the procedure, and some will observe breast tenderness and/or growth over
time. Other men may temporarily have hot flashes, similar to those experienced
by women during menopause. Finally, there is a risk of impotence with orchiectomy
Another form of hormone therapy involves administering a female hormone such
as estrogen. Female hormones reduce the production of testosterone by the
The most commonly used estrogen in prostate cancer is diethylstilbestrol
or DES. Hormone therapy with estrogen has limited use and is generally considered
only for patients who cannot have surgery or to relieve pain in patients with
prostate cancer that is progressing. Estrogens were once considered standard
treatment for prostate cancer, but this is not the case today. Other drugs
with fewer side effects have replaced DES.
Estrogen therapy is simple and only involves taking a pill. Estrogen therapy
preserves the testicles, and its effects are usually reversible.
Estrogen therapy produces various side effects of its own. Estrogens can
cause water retention, breast growth and tenderness, and symptoms such as
stomach upset, nausea, and vomiting. In addition, even low doses of estrogen
may significantly increase the risk of heart and blood vessel problems.
LHRH Analog Therapy
LHRH analog therapy consists of administering a drug called a luteinizing
hormone-releasing hormone (LHRH) analog, which leads to a drop in testosterone.
Taking an LHRH analog works as well as removal of the testicles but does
not involve surgery. Some of these agents can be given in combination with
an antiandrogen. In addition, LHRH analogs commonly are used to help relieve
the symptoms associated with advanced prostate cancer. When used this way,
this class of drugs may offer an alternative for the patient who either cannot,
or chooses not to, have an orchiectomy or take estrogen therapy.
Administering LHRH analog therapy is simple; it involves an injection that
is usually given at specified intervals of about one month or more depending
on the dosage of hormone used. Treatment with LHRH analogs is as effective
as orchiectomy, but it does not require surgical removal of the testicles.
It also avoids some of the side effects of estrogen therapy.
Because LHRH analogs are usually given as long-acting injections, patients
must follow the instructions for the dosage regimen and must remember to visit
their physician on a regular basis. Some men may experience hot flashes, general
body pain, and breast growth. Additional side effects may include a decrease
in sexual desire and/or ability to have erections. In a small percentage of
patients, LHRH analog therapy may cause a brief worsening of cancer symptoms,
such as bone pain, for a few weeks before the testosterone level begins to
fall. This pain may be eased with a pain reliever (such as aspirin or acetaminophen)
or an antiandrogen drug. Finally, if an LHRH analog is used in combination
with radiation therapy, or an antiandrogen, it can be difficult to know for
sure which component of therapy, if any, is responsible for the side effects
that a man may be experiencing. Sometimes a worsening of the actual disease
may be confused for a side effect of a particular drug regimen.
Another type of hormone therapy used in prostate cancer is the administration
of drugs that are called antiandrogens. An antiandrogen is a drug that blocks
the action of male hormones. There are two different types of antiandrogens
-- steroidal antiandrogens and nonsteroidal antiandrogens. Only the nonsteroidal
antiandrogens are approved for use in the treatment of prostate cancer in
the United States at this time.
Nonsteroidal antiandrogens are used in combination with an LHRH analog or
orchiectomy in the treatment of advanced prostate cancer. When an antiandrogen
drug is used in conjunction with an LHRH analog, this combination therapy
is commonly known as maximal androgen blockade (MAB), total androgen blockade
(TAB), or combined androgen blockade (CAB). Because there is still a small
amount of androgen present in the body after an orchiectomy, antiandrogens
also may be used in men who have already had this surgery.
Clinical trials suggest that some men treated with MAB therapy may live longer
than men treated with LHRH analog therapy alone. This regimen of hormone therapy
is convenient for the patient.
After taking an antiandrogen for a certain period of time, patients and their
physicians may find that the prostate cancer is progressing despite treatment.
When this occurs, the cancer is said to have become resistant to treatment.
The patient may have to stop taking the antiandrogen for a while to help make
the cancer respond to hormone therapy again. Other side effects from this
type of hormone therapy will depend on which antiandrogen is used. Since antiandrogens
are used in combination with LHRH analogs or just after an orchiectomy, it
may be difficult to determine which component of the treatment is responsible
for side effects.
Some of the more common adverse effects of an antiandrogens are sensitivity
of the eyes to light (either natural or artificial), mild to moderate nausea,
hot flashes, gynecomastia (growth of the breasts in males), nausea, vomiting,
diarrhea, and an increase in liver enzymes. Patients must always consult their
physician and/or health care practitioner before intentionally stopping or
interrupting treatment with any of the antiandrogen medications.
Chemotherapy is the use
of powerful drugs to attack cancer cells. The drugs circulate throughout the body
in the bloodstream and kill any rapidly growing cells.
Chemotherapy drugs are carefully controlled in both dosage and frequency so
that cancer cells are destroyed while minimizing the risk to healthy cells.
There are many different chemotherapy drugs, each with its own strengths and
weaknesses. Often the drugs are used in combination. While some are injected
directly into a vein or a muscle, others may be taken by mouth. Some of the
drugs must be given in the doctor's office or clinic; others can be administered
while the patient is at home.
Hospitalization may be needed for certain types of chemotherapy that require
special monitoring of both the treatment and its possible side effects. Chemotherapy
is generally reserved for patients with advanced stage prostate cancer that
no longer responds to hormonal therapy and/or that has spread outside the prostate
Although it has limited success as a treatment for prostate cancer, chemotherapy
provides an additional means of relieving the symptoms of advanced prostate
cancer. It can reduce pain and may slow tumor growth.
Because the drugs circulate throughout the whole body, they can affect both
healthy and cancerous cells. This can lead to many side effects. The specific
side effects will depend upon which drugs and regimens are used.
The most common adverse reactions include:
- hair loss
- lowered blood counts
- reduced ability of the blood to clot
- increased risk of infection
Some of these side effects occur only temporarily or are more noticeable
when treatment is first started. Most of the side effects disappear when the
drugs are stopped.
Watchful Waiting (expectant therapy)
Electing not to receive immediate treatment may be an appropriate approach
for some patients in the early stages of prostate cancer.
Elderly patients and/or those with other significant medical problems may experience
greater side effects from treatment and are more likely to die from causes other
than prostate cancer before their cancer progresses.
Watchful waiting requires that the cancer be closely monitored, and therapy
is initiated only when the cancer shows signs of spreading. Hormonal therapy
is often the preferred treatment following a period of watchful waiting. However,
the best time to begin hormonal therapy is a subject of some controversy.