Treatment for prostate cancer

Most prostate cancer is treated with one or more of the following:

• Active Surveillance
• Watchful Waiting
• Surgery
• Radiation therapy
• Cryotherapy
• Hormone therapy
• Chemotherapy
• Targeted therapy 
• Immunotherapy

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 men with prostate cancer who:

• have a low-grade (slow growing) cancer and 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 his doctor monitor any changes in symptoms.

Watchful waiting may be an option for men who:

• have a life expectancy of less than 10 years.
• have a low-grade cancer and wish to defer treatment and potential side effects until treatment is necessary.
• 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 the prostate. Prostatectomy may be used to treat early-stage 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 - where a small incision is made 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

Radiation therapy

Radiation therapy is used to treat men with 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.  Two types of brachytherapy are used; 1) implants are placed into the prostate for one or two days and then removed. 2) radioactive seeds are permananetly implanted which deliver low doses of radiation for weeks or months.
• 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:
  • Proton therapy very precisely targets the cancer, reducing radiation to surrounding healthy tissues like the bladder and rectum.
  • Intensity modulated radiation therapy (IMRT) uses a computer-controlled accelerator to move around the patient to deliver radiation to the tumor from several angles. With IMRT the intensity of the beams can be adjusted to lessen the dose that reaches sensitive normal tissue.
  • Volumetric modulated arc therapy (VMAT) is a type of IMRT. Similar to IMRT, the beam shape and intensity are varied so that the radiation goes directly to the tumor. However, VMAT is delivered in one continuous arc of the linear accelerator around the patient. This maximizes getting the radiation to the tumor and typically takes less time than IMRT.

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.

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.

Hormone therapy

Testosterone is a type of hormone known as an androgen. In men, testosterone is produced by the testes. Androgens 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 (total body) treatment for prostate cancer. Alone, it does not cure prostate cancer. However, it can slow the disease from getting worse for a while.

Hormone therapy is used to treat men with prostate cancer:

• who have advanced or high-risk prostate cancer.
• who have rising PSA level despite previous treatment.
• who cannot have surgery or radiation therapy
• who have cancer which has spread outside of the prostate

Several types of hormone therapy are available, including:

• Luteinizing hormone-releasing hormone (LHRH) agonists block the production of testosterone. LHRH agonists include:
  • Leuprolide, leuprorelin (Lupron, Viadur, Eligard)
  • Goserelin (Zoladex)
  • Triptorelin (Trelstar)
  • Histrelin (Vantas)
• Luteinizing hormone-releasing hormone (LHRH) antagonists are drugs that block the action of testosterone. LHRH antagonists include:
  • Degarelix (Firmagon)
  • Relugolix (Orgovyx): Note that Orgovyx is the first oral LHRH antagonist approved by the FDA. 
• Anti-androgens bind to androgen receptors and keep testosterone from stimulating the receptor. This helps slow cancer growth. Anti-androgens are not typically used alone. They may be given before treatment in combination with LHRH agonists or LHRH antagonists. Anti-androgens include:
  • Bicalutamide (Casodex)
  • Flutamide (Eulexin)
  • Enzalutamide (Xtandi)
  • Aapalutamide (Erleada)
  • Darolutamide (Nubeqa)
• Androgen-synthesis inhibitors can drop testosterone levels in a man's body lower than any other treatment. Androgen-synthesis inhibitors may be a better treatment option for men with advanced, castration-resistant disease. Androgen-synthesis inhibitors include:
  • Abiraterone (Zytiga) is usually used with prednisone (an anti-inflammatory drug)
• 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 in the same way as LHRH agonists or antagonists and does not require ongoing treatment with those medications. 

Chemotherapy

Chemotherapy does not cure prostate cancer.  Chemotherapy for prostate cancer is used in advanced or recurrent prostate cancer to extend life or improve quality of life. Chemotherapy for prostate cancer may be recommended for:

• Men with advanced prostate cancer.
• Men who's cancer has returned after treatment.

Chemotherapy for prostate cancer may include one of the following:

• Docetaxel (Taxotere)
• Cabazitaxel (Jevtana)
• Mitoxantrone (Novantrone)
• Carboplatin (Paraplatin)