There is no “one size fits all” treatment for prostate cancer. You should learn as much as possible about the many treatment options available and, in conjunction with your physicians, make a decision about what’s best for you. Because men diagnosed with localized prostate cancer today may live for many years (or decades), it is important to discuss not only cure, but also quality of life.
Your decision-making process will likely include a combination of clinical and psychological factors, including:
- The need for therapy
- Your level of risk
- Your personal circumstances
- Your desire for a certain therapy based on risks, benefits, and your intuition
For most men with newly diagnosed prostate cancer they should always be seen in consultation with a radiation oncologist and a urologist. For men with more aggressive disease, or metastatic disease, patients should also have a consultation with a medical oncologist. Multi-disciplinary care will give you the most comprehensive assessment of the available treatments and expected outcomes. Each physician has expertise in different areas and are likely less familiar with what the other physicians do. Many hospitals and universities have multidisciplinary prostate cancer clinics that can provide this consultation service.
Prostate Cancer Treatment Options
Treating Localized or Locally Advanced Prostate Cancer
A man diagnosed with localized or locally advanced prostate cancer has four major treatment options: observation, active surveillance, surgery, and radiation. There are other nonstandard treatment options that patients may consider, which include cryotherapy, high-intensity focused ultrasound, and primary hormone therapy. Choosing the best treatment for localized or locally advanced prostate cancer is generally based on the man’s age, the stage and grade of the cancer, the man’s general health, and the man’s evaluation of the risks and benefits of each therapy option.
- Observation/ Watchful Waiting
- Active Surveillance
- Radiation Therapy
- Prostatectomy vs. Radiation Therapy
- Other Treatment Options
Physicians think about localized or locally advanced prostate cancer is in terms of “risk groups”. are 3 general risk groups, that can further be subdivided to better personalize treatment for each patient.
- Low risk: Tumor confined to the prostate, PSA is <10, and grade 1 (or Gleason score 6)
- Intermediate risk: Tumor is confined to the prostate, PSA is 10-20, or grade 2 or 3 (or Gleason score 7)
- High risk: Tumor extends outside the prostate, PSA >20, or grade 4 or 5 (or Gleason score 8-10)
The treatment options for each risk group are very different and you should ask your Doctor what risk group of prostate cancer you have so you can better understand the most appropriate treatment options.
In general, for most cases of newly diagnosed localized or locally advanced prostate cancers, the chance of “cure” is equal whether you have radiation therapy or surgery.
Data from ProtecT for low and intermediate risk prostate cancer patients showing risk of dying from prostate cancer is the same with either surgery or radiation therapy:
Data from ProtecT for high risk prostate cancer showing risk of dying from prostate cancer is the same with either surgery or radiation therapy:
Putting it simply, if there were a treatment with a better chance of cure, that would be what every national guideline would recommend and we would never recommend you meet the other specialty. Some cancers are treated with radiation without surgery, some cancers are treated with surgery without radiation, some cancers are treated with both, and some cancers are treated with neither.
The main difference between surgery and radiation therapy relates to quality of life and side effects. Every patient has different priorities in regards to what aspects of quality of life means most to them. So before we discuss the various treatments in detail, let’s make sure your understand common treatment related changes that occur with surgery, radiation therapy, and hormone therapy.
Local Treatments for Recurrent Prostate Cancer
The goal after surgery is for the PSA to become undetectable and after radiation therapy for it to become very low (often less than 1 ng/mL; it doesn’t go to zero because the normal prostate still makes some PSA). In this section, we’ll look at what happens when PSA first starts to rise after surgery or radiation therapy, and why a secondary local treatment might be right for you.
In general, the most common site of failure after surgery or radiation therapy is local, meaning in or nearby the prostate. For this reason, treating the prostate region may provide a second chance of cure. However, in some men the PSA in being produced from disease outside the pelvis, such as cancer in the lymph nodes or bone, so additional local therapy is not right for everyone. Furthermore, a second form of local therapy has some degree of additional side effects in addition to the first local therapy one chooses.
- The Role of PSA
- Radiation Therapy Following Prostatectomy
- Prostatectomy Following Radiation Therapy
- Brachytherapy Following External Beam Radiation Therapy
- Cryotherapy Following Radiation Therapy
The 2018 Patient Guide is here
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Treatment Options for Advanced Disease
We typically refer to Advanced Disease as the state of prostate cancer that has grown beyond the prostate and is unlikely to be cured with surgery or radiation alone. After a man experiences PSA Progression after surgery or radiation, hormonal therapy is often given at some point, and often for many years. Some men will not require any therapy, however, if their PSA doubling time is quite prolonged. However, many men will continue to progress at some point despite the above hormonal treatments and require more aggressive therapy. This comes in the form of additional second and third-line hormonal therapies, chemotherapy, immunotherapy, bone-targeted agents, and investigational agents (many are in trials right now from new hormonal therapies to prostate cancer vaccines to bone-targeting drugs).
- Hormone Therapy
- Radiation Therapy
- Sipuleucel-T Immunotherapy (Provenge)
- Managing Bone Metastases and Pain
- Emerging Therapies
Important to Note
There is still some uncertainty about the exact right therapies for many men, and whether some even need immediate therapy. Clinical trials are being conducted to address these questions for future generations.
FDA Approved Drugs
For a list of FDA drugs approved to treat prostate cancer, please see here.
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Terms to know from this article:
A doctor who specializes in treating cancer. Some oncologists specialize in a particular type of cancer treatment. For example, a radiation oncologist specializes in treating cancer with radiation.
A doctor who has special training in diagnosing and treating diseases of the urinary organs in females and the urinary and reproductive organs in males.
Active surveillance is an option offered to patients with very low-risk prostate cancer (low grade, low stage, localized disease). Patients are monitored carefully over time for signs of disease progression. A PSA blood test and digital rectal exam (DRE) and prostate biopsy are performed at physician-specified intervals. Signs of disease progression will trigger immediate active treatment.
A chemical made by glands in the body. Hormones circulate in the bloodstream and control the actions of certain cells or organs. Some hormones can also be made in a laboratory.
The grade of a tumor depends on how abnormal the cancer cells look under a microscope and how quickly the tumor is likely to grow and spread. Grading systems are different for each type of cancer.
A mass of excess tissue that results from abnormal cell division. Tumors perform no useful body function. They may be benign (not cancerous) or malignant (cancerous).
Gleason Score (GS) - Gleason Grade: A system of grading prostate cancer cells based on how they look under a microscope. Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread. A low Gleason score means the cancer cells are similar to normal prostate cells and are less likely to spread; a high Gleason score means the cancer cells are very different from normal and are more likely to spread.
A rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Lymph nodes filter lymph (lymphatic fluid), and they store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called a lymph gland.
Increase in the size of a tumor or spread of cancer in the body.
Treatment that adds, blocks, or removes hormones. For certain conditions (such as diabetes or menopause), hormones are given to adjust low hormone levels. To slow or stop the growth of certain cancers (such as prostate and breast cancer), synthetic hormones or other drugs may be given to block the body's natural hormones. Sometimes surgery is needed to remove the gland that makes hormones. Also called hormone therapy, hormone treatment, or endocrine therapy.
Immunotherapy is a type of treatment that boosts or restores the immune system to fight cancer, infections and other diseases. There a several different agents used for immunotherapy; Provenge is one example.
prostate-specific antigen (PSA): A substance produced by the prostate that may be found in an increased amount in the blood of men who have prostate cancer, benign prostatic hyperplasia, or infection or inflammation of the prostate.