Treatment Options
According to the National Cancer Institute, prostate cancer is the second most common type of cancer among men in the United States. Men with certain risk factors are more likely than others to develop the disease.
Published data suggests that one of the most important factors in treating prostate cancer is early diagnosis and accurate treatment by experienced surgeons.
Before a treatment plan is determined, however, it is important to understand the disease and to research all the options available.
treatment approach
Visit the resources section for prevention tips, support groups, and more! There are many things that men can do to aid in the recovery and treatment of prostate cancer.
There is no "one size fits all" treatment for prostate cancer. Every man faces a wide array of options on how to treat their disease and the course of care they choose can vary greatly. You should learn as much as possible about the many treatment options available and, in conjunction with your physicians, decide what's best for you. Because men diagnosed with localized prostate cancer today may live for many years, any decision made now will probably reverberate for a long time. The suitability of prostate cancer treatment options must be based on several factors, including:
Stage of prostate cancer
Current state of health and age
Personal preferences
Side effects of the different treatment options
For each man, the potential benefits versus risks and side effects of treatment should be considered. Your desire for a certain therapy should be based on risks, benefits, and your intuition. Consultation with all three types of prostate cancer specialists — a urologist, a radiation oncologist, and a medical oncologist — will give you the most comprehensive assessment of the available treatments and expected outcomes. Many hospitals and universities have multidisciplinary prostate cancer clinics that can provide this three-part consultation service.
In conclusion, do not be afraid to talk to your doctor about new emerging therapies. There are many exciting clinical trials ongoing around the country, involving novel agents that have great promise to help men with prostate cancer and many may be appropriate for your current condition.
Take your health care into your own hands, as no one can be as strong an advocate for you as you or your family can.
side effects
Many men understand that when prostate cancer is caught early, it can be treated effectively, and the primary treatment options for localized disease are all excellent choices. However, many men also have significant concerns about the side effects of these treatments. While some side effects may be temporary, others can be permanent and may not improve over time.
Urinary Disfunction
Erectile Disfunction
Bowel Disfunction
Loss of Fertility
Hot flashes and/or Decreased Sexual Desire
Fatigue, Loss of Energy and/or Memory Loss
Fever
Not all side effects occur in every patient since they depend on the type of treatment and the individual patient response. Some side effects may significantly impact the man with prostate cancer and his family, so it is important to keep an open dialogue with your doctor about the potential side effects of each treatment.
The concerns are justified, but there are many misunderstandings about how often side effects occur, how severe they really are and what can be done to manage them and counteract their occurrence.
Urinary Dysfunction
A large proportion of men experience urinary issues in association with surgery or external beam radiation therapy (EBRT). The most common urinary issue after surgery is incontinence, or the inability to control the flow of urine from the bladder. Generally, the degree of incontinence will improve over the first year following surgery, but some men may be left with a permanent problem. There are procedures (ex. slings and artificial urinary sphincter implants) that can help men with permanent or bothersome urinary incontinence. Additional urinary issues include pain or difficulty urinating, an urgency to urinate, and hematuria (blood in the urine); these may be more common after radiation therapy for prostate cancer.
Erectile Dysfunction
Following surgery or radiation therapy, as well as during hormonal therapy, most of prostate cancer patients experience some degree of erectile dysfunction (ED) – the inability to attain and/or maintain an erection that is sufficient for satisfying sexual activity. Newer, surgical nerve-sparing techniques used during surgery for certain patients can reduce some of this side effect, but it is common for at least some degree of ED to be present after treatment. If ED becomes a problem, your doctor can prescribe ED medications that can be helpful for some patients.
Bowel Dysfunction
Fecal incontinence (also referred to as bowel dysfunction) is the inability to control defecation (bowel movements). It may occur in patients who undergo radiation therapy, especially external beam radiation therapy (EBRT). This is typically a short-term side effect and less common in the modern era of radiation treatment.
Proctitis (the inflammation of the rectum and anus) is an issue most men undergoing EBRT will experience; it includes some degree of irritation to the rectum during treatment and sometimes bleeding from the rectum/anus. For most men, this is temporary and can be treated with suppositories and gentle enemas.
Loss of Fertility
Loss of natural fertility and ejaculation is an unavoidable side effect of surgery (radical prostatectomy). Loss of fertility may also occur in association with radiation therapy and chemotherapy due to disruption of normal semen production and ejaculation. Hormone therapies such as ADT and particularly surgical castration also produce complete infertility. For this reason, prostate cancer patients who wish to father children in the future may elect to bank their sperm.
Emerging Therapies
All around the world, researchers are busy identifying new drugs, new regimens, and new treatment approaches that might prove beneficial to men with prostate cancer. Most of these investigational agents are being tested in men with advanced prostate cancer because treatment options for men at this stage of disease are often not effective, and men are typically affected by side effects from the disease. It is the perfect stage at which to test out new drugs because any improvement will likely be rapidly noticed and much appreciated.
Targeted Therapies
Targeted therapies are drugs that are specifically designed to interfere with the way cancer cells grow, with the way cancer cells interact with each other, and/or with the way that the immune system interact with the cancer without damaging a man's normal cells. There are several different kinds of targeted therapies being investigated for prostate cancer. None have yet been approved by the FDA for use in prostate cancer, but the excitement generated by some of the early studies have led many researchers to believe that it’s only a matter of time before a targeted therapy is found that can result in better overall outcomes.
Interfering with Cancer Cell Growth
All cells in the body, including cancer cells, rely on a complex communication system to know when to grow, when to divide, and when to die. This system uses specialized proteins, fats, and other substances to tell the different cells or parts of cells how to act. Over the years, cancer researchers have been studying ways to interfere with the signaling system that regulates the growth of cancer cells.
Interfering with Cancer Cell Spread
As cancer cells divide and start to spread, new blood vessels sprout from the old ones to help supply the necessary nutrients to the new tumor site via a process called angiogenesis. If angiogenesis could be inhibited, researchers theorized, the new tumor cells would die, and the cancer's growth would be halted.
In 2004, the angiogenesis inhibitor bevacizumab (Avastin) was approved by the FDA for use in colorectal cancer. Since then, it has been shown to improve outcomes in women with breast cancer, kidney cancer, brain tumors, and is currently being studied in a few other cancer types, including prostate cancer. As of 2018, there are now multiple early-phase clinical trials in prostate cancer of antiangiogenic agents. Several of these agents are now in Phase III development. Combined therapy with two antiangiogenic compounds may improve the activity of either compound alone. Multiple targets in the angiogenesis pathway continue to be clarified and should remain an active area of investigation for the treatment of prostate cancer.
robotic-assisted radical prostatectomy
Highly advanced technology has led to the development of a revolutionary new form of prostate surgery, the robotic-assisted radical prostatectomy. Prostatectomy is the most common prostate cancer treatment for early-stage localized cancer in the United States today. Sometimes, physicians choose to use other therapies in conjunction with surgery.
Robotic-assisted radical prostatectomy surgery has become very popular over the past 10 years due to the smaller incision and shorter post-operative recovery period (typically 1-2 days). Experienced surgeons transfer their skills into a laparoscopic environment that employs highly precise instruments and magnified vision. This minimally-invasive procedure is quickly gaining popularity as the most preferred cancer treatment for surgical removal of the prostate.
Robotic-assisted prostate surgery is designed to promote a quicker recovery and an overall optimal patient experience and has consistently demonstrated superior outcomes in cancer control, incontinence and impotence.
What to Expect
Robotic Radical Prostatectomy requires small incisions to be made in the abdomen by the surgeon. With a robotic interface, the surgeon then controls the robot’s arms, which in turn control the cameras and instruments.
Although robotic surgery creates much smaller incisions than open surgery, there is still a large surgery occurring inside the body. For this reason, there is an important healing process that must occur post-operatively. After the usual 1 to 2-night stay in the hospital, patients typically go home with some form of catheter to help drain urine for 7-10 days. The initial weeks to months after surgery, it is expected and common to have incontinence or leakage of urine and you will need to wear diapers or pads, but this generally improves significantly over the first year following surgery. During the first 2 months after surgery, exercise, golf, and most physical activities are prohibited while the abdominal muscles heal from the incisions.
The Importance of Surgical Skill
Prostatectomy, like many surgical procedures, is very delicate work, and the difference between a good surgeon and a great surgeon can affect outcomes. As many studies have shown, surgeons who are at the top percentiles of prostatectomies performed have the best outcomes.
When choosing a surgeon, at a minimum, ensure that he or she is someone in whom you have confidence and trust, and someone who has enough experience to not only perform the operation, but also to make an informed clinical judgment if necessary.
Nerve-Sparing Surgical Techniques
In a nerve-sparing prostatectomy, the surgeon cuts to the very edges of the prostate, taking care to spare the erectile nerves that run alongside the prostate. Sometimes the nerves cannot be spared because the cancer extends beyond the prostate requiring a more extensive resection.
Primary Hormone Therapy
Hormone therapy, also known as androgen-deprivation therapy or ADT, is designed to stop testosterone from being released or to prevent it from acting on the prostate cells. Although hormone therapy plays an important role in men with advancing prostate cancer, it is increasingly being used before, during, or after local treatment as well.
Most commonly given with radiation therapy, hormone therapy usually consists of a shot that lowers your testosterone given every 1 to 6 months, and sometimes a daily pill that blocks testosterone from reaching the cancer cells. Prostate cancer cells are like other living organisms — they need fuel to grow and survive. Because the hormone testosterone serves as the main fuel for prostate cancer cell growth, it's a common target for therapeutic intervention in men with the disease.
Most cells in prostate cancer tumors respond to the removal of testosterone. But some cells grow independent of testosterone and remain unaffected by hormone therapy. As these hormone-independent cells continue to grow unchecked, hormone therapies have less and less of an effect on the growth of the tumor over time.
For this reason, hormone therapy is not a perfect strategy in the fight against prostate cancer, and it does not cure the disease. It also carries some unwanted toxicities. But it remains an important step in the process of managing advancing disease, and it will likely be a part of every man's therapeutic regimen at some point during his fight against recurrent or advanced prostate cancer.
clinical trials
Clinical trials bring life extending and curative new treatments to cancer patients. Clinical drug trials play a vital role in moving new treatments to patients who need them most, securing data so that regulatory approvals can be obtained, and new drugs can move into widespread clinical practice. Patients who participate in clinical trials provide an invaluable service both to science and fellow patients.
There are currently over 90 Phase III drug trials and more than 400 Phase I/II trials in process for prostate cancer in North America and Europe. Those that are approved will join the five new drugs that have been approved for men with advanced metastatic disease since 2010 and further improve outcomes for patients:
Jevtana (cabazitaxel)
Provenge (sipuleucel-T)
Xgeva (denusomab)
Xofigo (radium 223 dichloride)
Xtandi (enzalutimide)
Zytiga (Abiraterone)
The Prostate Cancer Clinical Trials Consortium (PCCTC) is a clinical research group sponsored by the Prostate Cancer Foundation and the Department of Defense Prostate Cancer Research Program (PCRP), with its Coordinating Center headquartered at Memorial Sloan Kettering Cancer Center. The PCCTC is currently composed of 11 participating clinical research sites and 21 affiliated clinical research sites.
Visit the PCCTC site for trial information: www.pcctc.org
Bisphosphonate therapy
The bone cells in our bodies are constantly being slowly removed and replaced with new bone cells. This happens throughout our entire life. Osteoclasts are cells in our bodies that remove old bone and the osteoblast cells replace it with new bone.
Cancers that spread to the bones damage the bones as they grow. The cancer cells that have spread into the bones also release proteins that interfere with the normal bone shaping process. These proteins are cytokines and growth factors. The proteins stimulate the cells that break down bone (osteoclasts) and make them overactive, so bone is destroyed faster than it's rebuilt.
Bisphosphonates work by stopping the removal of old bone osteoclast activity. As we age and in certain diseases, the bone is being removed or damaged faster than your body can replace it. This leaves the bone thin/weak and much more likely to fracture with a significant impact or fall. Bisphosphonate medications damage/kill the osteoclasts and stop removal of old bone to try and preserve your bone strength. They can also help to treat some types of cancer that cause bone damage.
The family of Bisphosphonates includes:
Oral: Alendronate (Fosamax), Risedronate (Actonel), and Ibandronate (Boniva).
IV drip: Pamidronate, and Zoledronic acid (Reclast/Zometa).
These medications are given as an infusion every 3-4 weeks and may be given at the same time as ADT and chemotherapy. Bone-targeted therapy may be associated with fatigue, nausea, anemia, and pain.
Most of the research so far has looked at using bisphosphonates with secondary breast cancer, secondary prostate cancer and myeloma. The type of bisphosphonate your doctor prescribes for you will depend on the type of cancer you have. You will have one that works for your type of cancer.
There might sometimes be a choice of bisphosphonates for your type of cancer. Your doctor will give you the bisphosphonate best suited to your medical and practical needs. For example, you might prefer to take a bisphosphonate tablet at home rather than travel to hospital every month for treatment by drip.
RADIATION THERAPY
Radiation involves the killing of cancer cells and surrounding tissue with ionizing radiation or photons. Radiation damages the cancer cells’ DNA, the genetic material of the cancer cell, so it can’t survive or grow and spread, and subsequently the cancer cells die. Radiation therapy, like surgery, is very effective in killing localized or locally-advanced prostate cancer and has the same cure rate as surgery. Some forms of radiation therapy can also be used in men with advanced or recurrent prostate cancer.
Regardless of the form of external radiation therapy, it is non-invasive and is done on an outpatient basis. Because it is non-invasive (no cutting) there is no down time or healing time as there is with surgery. You can be physically active every day of treatment and the months following. It is common though to have increased frequency of urination or bowel movements during the weeks of treatment, and 4-6 weeks after treatment is done, these symptoms generally improve over the months following radiation therapy.
Many studies have shown that while surgery results in a more immediate loss of erectile function followed by a period of recovery, radiation therapy results in a slower loss of erectile function over time in men who have good erectile function before treatment. By the end of five years, the risks of erectile dysfunction appear to be similar in men who have chosen radiation or surgery.
External Beam Radiation Therapy
This is the most common type of radiation therapy. CT scans and MRIs are used to map out the location of the tumor cells, and X-rays are targeted to those areas. With 3-D conformal radiotherapy, a computerized program maps out the exact location of the prostate tumors so that the highest dose of radiation can reach the cancer cells within the gland.
Regardless of the form of external radiation therapy, treatment courses usually run five days a week for about seven or eight weeks and are typically done on an outpatient basis.
Proton Beam Therapy
Protons are like x-rays or photons, in that they are both essentially radiation and they kill the cancer similarly. There are mixed reports as to whether there are increased or decreased side effects with the proton beam. Protons for prostate cancer should be viewed as an area of active research, and you should talk to your Doctor about them. Insurance companies often do not cover proton beam therapy and it is the most expensive form of treatment for prostate cancer.
The advantage of using protons over other external beam sources is precision. Protons of energetic particles can hit a targeted prostate cancer tumor without affecting surrounding tissue. This direct attack on cancerous cells ultimately causes their death, as the cells are particularly vulnerable to attack due to their rapid division.
Proton treatment is suitable for treating localized, isolated, solid tumors before they spread to other tissues and the rest of the body. However, to date, proton beam therapy has never been compared directly to standard IMRT techniques, so we do not truly know if this offers an advantage over standard approaches.
Brachytherapy Therapy
Brachytherapy is internal radiation therapy, rather than external radiation therapy. It involved placing different types of radiation therapy inside the prostate the emit radiation a very short distance. Tiny metal pellets (also referred to as seed implants) containing radioactive iodine or palladium are inserted into the prostate via needles that enter through the skin behind the testicles. As with 3-D conformal radiation therapy, maps are used to ensure that the seeds are placed in the proper locations. Over the course of several months, the seeds give off radiation to the immediate surrounding area, killing the prostate cancer cells. By the end of the year, the radioactive material degrades, and the seeds that remain are harmless.
Radioactive seeds (LDR or low dose rate) or catheters (HDR or high dose rate) are placed directly into the prostate while you are asleep under anesthesia. It is usually done in 1 to 4 treatment sessions depending on the method used. The seeds are permanently placed into your prostate, while the catheters are only temporarily placed inside the prostate and then removed after treatment is done.
Compared with external radiation therapy, brachytherapy is less commonly used, but it's rapidly gaining ground, primarily because it doesn't require daily visits to the treatment center. Side effects can include erectile dysfunction, urinary frequency and obstruction, and, rarely, rectal injury. Patients with large prostates or those patients with a lot of urinary problems are usually poor candidates for brachytherapy.
Chemotherapy
The term "chemotherapy" refers to any type of therapy that uses chemicals to kill or halt the growth of cancer cells. The drugs work in a variety of ways but are all based on the same simple principle: stop the cells from dividing and you stop the growth and spread of the tumor.
Until recently, chemotherapy was used only to relieve symptoms associated with very advanced or metastatic disease. With the publication of two studies in 2004 showing that the use of docetaxel (Taxotere) can prolong the lives of men with prostate cancer that no longer responds to hormone therapy, more and more doctors are recognizing the potential benefits of chemotherapy for the men they treat with advanced prostate cancer.
Building on these successes, there are now dozens of clinical trials studying various combinations of chemotherapy drugs, some using new mixes of older drugs and some using newer drugs. Some trials are looking to find a chemotherapy regimen that's more tolerable or more effective than docetaxel in men with metastatic disease, others are looking to find a chemotherapy regimen that can delay the onset of metastases, and still others are seeking to improve upon the results with docetaxel by adding other novel agents and testing the combination. Currently, the standard of care for men with metastatic prostate cancer and is progressing despite low levels of testosterone is docetaxel every 3 weeks, given with prednisone. If the cancer has spread to the bones, giving zoledronic acid with docetaxel is recommended.
In addition, several agents are approved or widely available for use in prostate cancer, including estramustine and mitoxantrone. Estramustine (Emcyt) is an oral medication with hormonal and chemotherapeutic properties that has anti-cancer activity and can be safely combined with other chemotherapies. Mitoxantrone (Novatrone) is a chemotherapy agent given intravenously every three weeks and, from earlier studies, is known to delay and reduce pain from prostate cancer metastasis. It remains an effective weapon against prostate cancer.
Cryosurgery
Cryotherapy is a minimally invasive prostate cancer treatment that does not involve open surgery or radiation to destroy prostate cancer. The procedure destroys cancerous cells by delivering freezing temperatures of minus 40° Celsius to the prostate.
This procedure involves applying cold argon gas via a thin needle into the prostate tumor, freezing the prostate tumors to kill the cancer cells. Cryosurgery is FDA-approved but not widely used at this time. It is also sometimes used as salvage therapy (meaning all other treatment options have failed) for patients who have residual disease that is still confined to the prostate.
The use of hollow probes introduces cold gases into the affected area of the prostate, destroying cancer cells. A physician who has thoroughly evaluated a patient’s case may recommend this procedure instead of a radical prostatectomy, in which the entire prostate (and any surrounding tissues that are affected) is removed.
This lethal freeze immediately destroys cancerous cells by:
Causing membrane damage
Cutting off the oxygen supply
Biological therapy
Harnessing the Immune System to Fight Off Cancer Cells For the immune system to fight off foreign invaders, it has to learn to recognize what's normal and what's not normal. Unfortunately, because cancer cells start out as normal healthy cells, the immune system never has a chance to learn to distinguish between the normal cell and the cancer cell.
Unlike preventive vaccines, which are designed to teach the immune system to develop a way to fight off a specific virus should it encounter that same virus again, therapeutic vaccines stimulate the immune system to recognize and fight certain proteins specific to cancer cells. Each of the therapeutic vaccines currently being tested in men with advanced prostate cancer works in a slightly different fashion, but all are designed to harness the immune system's ability to fight off disease and teach it to fight off prostate cancer cells. One such vaccine, Provenge (sipuleucel-T) was recently approved by the FDA for prostate cancer.