Prostate Cancer Treatment

How do doctors decide on a treatment plan?

Treatment for prostate cancer depends on the stage and grade of the disease based on pathology results. Tumor biomarker testing and genetic testing can provide additional clues about which treatments may work best for your cancer. For people with metastatic or advanced cancer, these additional tests are usually recommended.

Make sure that you receive a copy of your cancer test results, including your pathology report and your stage. Ask your doctor to explain your diagnosis, test results and treatment options in terms that you can understand. This will allow you to work with your doctor to choose a treatment plan that is right for you. 

Standard treatment may include a combination of surgery, radiation and hormone therapy. Some people may also benefit from treatment with chemotherapy, immunotherapy or targeted therapy. Clinical trials may be available for any stage of cancer.

Active surveillance

Active surveillance involves watching the cancer and only treating it if there is any evidence that it is progressing. Doctors may recommend active surveillance based on factors such as life expectancy and the risk of cancer progressing. 

During active surveillance prostate cancer is closely watched using prostate-specific antigen (PSA) tests, digital rectal exams, ultrasound and biopsies. If a change indicates the cancer is progressing, other treatment options may be recommended.

Active surveillance may be an option for people with low-risk, low-grade (slow growing) cancer who wish to defer treatment and potential side effects until it is necessary.

Watchful waiting

Watchful waiting involves less testing than active surveillance. With watchful waiting, the patient and their doctor monitor any changes in symptoms.

Watchful waiting may be an option for people with prostate cancer who:

• have a life expectancy of less than 10 years.
• have a low-grade cancer and wish to defer treatment indefinitely.
• prefer not to undergo aggressive treatment.
• have other health problems that prevent them from being a candidate for other types of treatment.

Surgery

Prostatectomy is surgery to remove part or all of the prostate. Prostatectomy may be used to treat cancer that is only in the prostate.

• The most common surgery for prostate cancer is a radical prostatectomy.  During a radical prostatectomy the entire prostate gland is removed. In some situations, nearby lymph nodes are also removed.
• During a nerve-sparing radical prostatectomy, the surgeon tries to save the tiny bundles of nerves—one on each side of the prostate—that control the ability to have an erection. If the cancer is growing into or very close to the nerve bundles, these nerves may need to be removed.

Prostatectomy may be performed through an incision in the abdomen or using laparoscopy.

• With laparoscopy, the surgeon makes a small incision for a small flexible scope with a camera, which is used to see the prostate. Addition small incisions are made to insert surgical instruments needed to perform the prostatectomy.
• During laparoscopic surgery, the surgeon may use a robot. This is sometimes called robot-assisted or robotic prostatectomy.
• Less commonly, prostatectomy may be performed using an incision in the lower abdomen (retropubic prostatectomy) or through an incision between the anus and scrotum.

Hormone therapy

Testosterone is a type of male reproductive hormone known as an androgen. Androgens are produced by the testes and can cause prostate cancers to grow. Hormone therapy reduces androgen levels in the body or prevents androgen from reaching prostate cancer cells. Hormone therapy is sometimes called androgen-deprivation therapy or androgen-suppression therapy. 

Hormone therapy is among the most effective forms of systemic treatment for prostate cancer. Alone, it does not cure prostate cancer. However, it can slow the disease from getting worse.

How is hormone therapy used to treat prostate cancer? 

Hormone therapy is used in the following situations: 

• to treat advanced or high-risk prostate cancer.
• to treat prostate cancer when the PSA levels are rising despite previous treatment.
• for treatment in situations where surgery or radiation therapy is not possible. 
• to treat cancer which has spread outside of the prostate.

Which hormone therapies are used to treat prostate cancer?

Several types of hormone therapy are available, including:

• Luteinizing hormone-releasing hormone (LHRH) agonists and antagonists block the production of testosterone.
• Anti-androgens bind to androgen receptors and keep testosterone from stimulating the receptor. This helps slow cancer growth. They may be given before treatment in combination with LHRH agonists or LHRH antagonists.
• Androgen-synthesis inhibitors can drop testosterone levels lower than any other treatment. Androgen-synthesis inhibitors may be a better treatment option for advanced or high-grade disease. 
• Orchiectomy is surgery to remove the testicles. This is used less commonly than the therapies above. Although orchiectomy is a surgery, it is considered hormone therapy because removal of the testicles suppresses testosterone production. 

What is the difference between castration-resistant prostate cancer and castration-sensitive prostate cancer?

• Castration-sensitive prostate cancer is responds to treatment that reduces testosterone levels. 
• Castration-resistant prostate cancer no longer responds to these hormonal therapies and may continue to grow or spread. 

Radiation therapy

Radiation therapy is used to treat various stages of prostate cancer. Different types of radiation therapy are used for prostate cancer:

• Brachytherapy involves surgery to put radioactive seeds in the prostate to kill the cancer.  
• External-beam radiation therapy (EBRT) aims radiation beams from outside the body at the tumor to kill cancer cells. This treatment can be used to cure localized prostate cancers or help relieve symptoms if the cancer has spread. There are different types of external-beam radiation. In some situations, the doctor may inject a gel between the prostate and rectum before radiation treatment starts to separate the rectum from the prostate and protect the rectum from radiation.
• Radium 223 dichloride or Xofigo is used for advanced prostate cancer that is resistant to testosterone-lowering treatments and has spread to the bones. It is given by intravenous (IV) injection.
• Lutetium-177 vipivotide tetraxetan or Pluvicto is used for advanced prostate cancer that is resistant to testosterone-lowering treatments and has spread to the bones. It is given by intravenous (IV) injection. It binds to a molecule called Prostate Specific Membrane Antigen (PSMA) in order to target the radiation.

Cryotherapy

During cryotherapy, a small incision is made into which probes are inserted. These probes freeze and kill prostate tissue. Cryotherapy may be used for early-stage prostate cancer or when the cancer recurs after radiation therapy.

Targeted therapy

Targeted therapy is a type of cancer treatment designed to attack or kill cancer cells, while sparing normal cells as much as possible. These drugs are designed to target abnormal proteins, receptors or genes that are found in cancer cells or the surrounding tissue.  

PARP inhibitors 

PARP inhibitors are a type of targeted therapy that works by blocking a protein that the body uses to repair DNA damage. They were initially developed to treat cancers in people with an inherited BRCA1 or BRCA2 mutation. 

PARP inhibitors to treat metastatic castration-sensitive prostate cancer (mCSPC)

• Akeega is used with prednisone to treat mCSPC in people who have an inherited mutation or a tumor mutation in BRCA2 (found through tumor testing or liquid biopsy).

PARP inhibitors to treat metastatic castration-resistant prostate cancer (mCRPC). 

• The PARP inhibitor Talzenna (talazoparib) may be used in combination with Xtandi as a first-line treatment for mCRPC in people who have an inherited mutation found through genetic testing or tumor mutation found through tumor testing in BRCA1, BRCA2, ATM, ATR, CDK12, CHEK2, FANCA, MLH1, MRE11A, NBN, PALB2, or RAD51C.
• The PARP inhibitor, Lynparza (olaparib) may be used in combination with Zytiga and prednisone or prednisolone for the first-line or later treatment of mCRPC in patients with an inherited BRCA1 or BRCA2 mutation (found through genetic testing) or tumor BRCA1 or BRCA2 mutation (found through tumor testing or liquid biopsy). 
• The PARP inhibitor, Lynparza may be used to treat mCRPC after the cancer has progressed on the drugs Xtandi (enzalutamide) or Zytiga (abiraterone) in people with an inherited mutation in BRCA1, BRCA2 (found through genetic testing) or a tumor mutation in BRCA1, BRCA2, ATM, BARD1, BRIP1, CDK12, CHEK1, CHEK2, FANCL, PALB2, RAD51B, RAD51C, RAD51D, RAD54L (found through tumor testing).
• The PARP inhibitor, Rubraca (rucaparib) may be used to treat mCRPC, in people who have an inherited mutation in BRCA1 or BRCA2 (found through genetic testing) or a tumor mutation in BRCA1 or BRCA2 (found through tumor testing or liquid biopsy).
• Akeega combines the PARP inhibitor, Zejula (niraparib) with the hormone therapy, Zytiga. Akeega is used with prednisone to treat mCRPC in people who have an inherited mutation or a tumor mutation in BRCA1 or BRCA2 (found through tumor testing or liquid biopsy).

Other targeted therapies

• Pluvicto (lutetium Lu 177 vipivotide tetraxetan) is a type of targeted radiation used to treat mCRPC for men previously treated with with hormone therapy with an androgen receptor inhibitor and taxane-based chemotherapy. It targets a receptor called PSMA found on the surface of prostate cancer cells. 
• Enhertu (trastuzumab deruxtecan) is a type of targeted therapy approved for treatment many different types of advanced cancers (including prostate cancer) if tumor testing shows a biomarker called HER2-positive.

Researchers are studying new ways to use targeted therapies to treat prostate cancer, including:  Visit our Featured Research section for more information.

Immunotherapy

Immunotherapies are cancer treatments that help the body’s immune system detect and attack cancer cells. 

• Immune checkpoint inhibitors are a type of immunotherapy most often used to treat advanced/metastatic prostate cancer that have MSI-H or dMMR; usually after other treatments have been tried.
  • Keytruda (pembrolizumab) may be used to treat patients with castration resistant prostate cancer that is MSI-H or dMMR and have had one line of therapy affecting the whole body.
• Cancer treatment vaccines are a type of immunotherapy that uses a patient’s own cancer cells to boost their immune system.
  • Provenge (sipuleucel-T) may be used to treat patients with metastatic prostate cancer whose disease has progressed after hormonal treatment and who have minimal symptoms related to the prostate cancer.