Prostate Cancer: Treatment Options

Medical Options for Prostate Cancer

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

Every option has potential risks and side effects. Before any new treatment or surgery, make sure your healthcare team tells you about what to expect. 

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 in these settings:

• low-grade (slow growing) cancer for people 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 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

What is hormone therapy for prostate cancer?

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.

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. 

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.