Prostate cancer – treatment
Treatment for localised prostate cancer
How is the type of prostate cancer treatment decided?
Once a diagnosis of prostate cancer has been made a man and his doctor must decide what steps to take next for management and treatment. The decision will depend on a number of factors including:
- Gleason score – high (more aggressive), intermediate (Gleason 7), or low grade
- stage of the cancer – localised in the prostate gland or spread to other parts of the body
- level of PSA in the blood and the rate of change of PSA over time (velocity)
- age and general health
- side-effects of treatment
- personal preference.
To help with making decisions about treatment, patients can be placed into high, intermediate or low risk groups with respect to likely cancer outcome. This is done using a combination of factors.
How is localised prostate cancer treated?
If the cancer is localised, that is, only in the prostate gland, the options available include observation monitoring (watchful waiting), active surveillance, radical prostatectomy (surgery) and radiation therapy (external beam radiotherapy or brachytherapy).
Surgery and radiation therapy both work well in treating localised prostate cancer but they have different side-effects.
What is observation monitoring (watchful waiting)?
Some men decide to have no treatment for localised prostate cancer because of the unwanted side-effects of surgery and radiotherapy. These men prefer to take a ‘watchful waiting’ approach to see if their prostate cancer changes. This approach is often used for men who are 75 years or older or men who have other health problems. The PSA test can be used to see whether the cancer gets worse.
What is active surveillance?
Active surveillance may be chosen when PSA level, digital rectal examination (DRE) and biopsy findings show the man has low-risk prostate cancer with a low chance of the cancer getting worse in the short to medium term.
Further biopsies, PSA tests and DRE are done to check whether there may be more aggressive cancer that was missed with the first biopsy. If a man is in the small sub-group with more aggressive cancer, he may need to think about treatment to try to cure the cancer. However, most of the time there are no signs of more aggressive disease, so that surveillance continues indefinitely.
Surgery & radiation therapy
What is a radical prostatectomy (surgery)?
A radical prostatectomy (surgery) involves taking out the whole of the prostate gland along with the part of the urethra within the gland and the seminal vesicles. The rest of the urethra, from below the prostate, is then joined to the bladder. Radical prostatectomy can be done as an open operation or by laparoscopy or ‘keyhole’ surgery. Robotic prostatectomy is a form of ‘keyhole’ surgery that uses more complex technology.
There are some risks linked to surgery including:
- urinary incontinence: leakage of urine may still be a problem in about five to 10 per cent of men one year after a radical prostatectomy
- erectile dysfunction: 75 to 85 per cent of men may have problems with getting and keeping an erection after surgery. However, preventing damage to the nerves that allow erections can lower the chance of this happening. There are also effective treatments for erectile problems.
What is radiation therapy?
Radiation therapy can be given externally or internally (brachytherapy). As with radical prostatectomy, radiation therapy will often cure the cancer.
Patients with high-risk disease have androgen deprivation therapy (ADT <0x2013> also called hormone therapy) before radiotherapy to improve the results. However, ADT has its own side-effects.
External beam radiation therapy is where small doses of radiation are given over many weeks resulting in a high total dose to the prostate by the end of the treatment.
Radiation damage to other tissues near the prostate can cause bowel problems and inflammation of the bladder, but these usually settle quickly. Erectile dysfunction is a common problem after radiation therapy; it tends to develop gradually and becomes worse over time.
Brachytherapy is usually done by inserting permanent radioactive ‘seeds’ straight into the prostate gland (low-dose brachytherapy). Another approach is to use radioactive rods which stay in position for only a couple of days (high-dose brachytherapy).
Brachytherapy results in a high dose of radiation directly to the cancer cells. The aim is to reduce some of the side-effects of external beam radiation therapy, particularly damage to the rectum (back passage).
Treatment for advanced prostate cancer
How is advanced prostate cancer treated?
If the prostate cancer is aggressive and has spread to other parts of the body, the standard treatment is removal of the male hormones which help the tumour grow. This treatment is called androgen deprivation therapy (ADT).
What is androgen deprivation therapy (hormone therapy)?
The growth of normal prostate cells and prostate cancer cells relies on male hormones (androgens). The most important androgen is testosterone. ADT acts by either stopping testosterone production or by blocking the action of testosterone on the cells and tissues.
ADT is not a ‘cure’ but it may keep the unwanted effects of the prostate cancer ‘in check’ for a period of time.
What are the side-effects of ADT?
Most men having ADT will have a reduced libido (a lack of interest in sexual activity) and some trouble with getting or keeping erections. Other common side-effects include hot flushes, tiredness and sweating, gradual decrease in body hair, thinning of the bones (osteoporosis), reduced muscle strength, and cognitive changes such as memory problems and difficulty doing more than one thing at a time. Liver function may be affected if taking tablet forms of ADT and some men gain weight and have some breast development and/or sore nipples.
Weight-bearing exercises such as walking, jogging, climbing stairs or training with weights can help to improve muscle and bone strength for men on ADT.
Castrate-resistant prostate cancer
What is castrate-resistant (formerly called hormone-resistant) disease?
Most prostate cancers will shrink or stop growing with ADT. However, after some time, which is different for each man, the prostate cancer will start to grow again. These tumours become very sensitive to any remaining androgens produced by the adrenal glands and the cancer cells themselves.
Measurement of PSA levels is used to monitor the response to ADT. For most patients an increase in PSA levels means the prostate cancer has progressed.
How is castrate-resistant prostate cancer treated?
Chemotherapy (docetaxel) has been shown to give a modest improvement in survival and quality of life. Also, changing to different forms of ADT can help for a period of time.
When castrate-resistant prostate cancer spreads to other parts of the body, the pain associated with the cancer is treated. The following treatments can help with pain and quality of life:
External Beam Radiotherapy is often given for pain relief to any area of the body where the cancer has spread.
Radio-isotopes (an injectable form of radiotherapy) may be given to destroy cancer cells which have spread to the bone and to relieve pain.
Bisphosphonates are medicines to help reduce bone loss and therefore lower the chance of bone fracture. An injected form may lessen the chance of secondary cancers in the bones.
Corticosteroids: prednisolone and other members of this family of medicines may be given together with other pain medicines.
Weight-bearing exercises can help to improve muscle and bone strength and improve well-being.
Palliative and pastoral care is important when life expectancy is limited. A Palliative Care Clinician can help at this time.
Clinical trials of new treatments are available. To be approved for general use, the new treatment must show equal or greater benefit compared with the current management. Participating in a trial can offer new treatments only available for research, but these treatments may not necessarily help your cancer.
For further information see Andrology Australia’s other fact sheets about prostate cancer: