What Is Prostate Cancer? | Early Detection | Risk Factors | Symptoms and Screening | Diagnosing | Grading | Stages | Treatment Options | About Clinical Trials | Greenebaum Cancer Center | The Maryland Prostate Center
Prostate cancer can be treated in many ways. The choice of treatment depends on the patient's health, age, expected life span, and personal preferences as well as on the stage and grade of cancer and the anticipated effects of treatment. Sometimes a combination of treatments is used.
Treatment options include the following:
Surgery can be performed to remove the cancer from the prostate and from nearby areas where the cancer has spread. It is most often used during early stages, when prostate cancer is located only within the prostate. If the tumor is small and has not spread outside of the prostate, then surgery may cure the disease. Surgery may help prevent further spread of the cancer.
Surgical options include:
The latest advancement in surgical technology for prostate cancer is robot assisted laparoscopic prostatectomy. Robot assisted prostatectomy provides the benefits of laparoscopic surgery but with important technological improvements, including advanced optics that provide 10-times magnified, three-dimensional images of the prostate and surrounding nerves and tissues; robotic arms that eliminate even the slightest human hand tremors; and instruments with "wrists" that pivot 540 degrees for greater maneuverability than is possible with the human hands or laparoscopic instruments.
What to expect:
The surgeon sits at a console a few feet from the patient and operates the computerized controls. A camera and specialized instruments are mounted on the robotic arms, which are inserted through four small incisions in the patient's abdomen and connected to the robot. As the surgeon moves his or her hands, wrists and fingers, the robotic technology translates the motions into precise micro-movements that allow greater precision - especially critical to spare nearby nerves that control urinary continence and sexual function.
Following the surgery, patients are monitored overnight and usually go home the next day. A urinary catheter remains in place for about a week. Most patients return to normal activities in two to three weeks. For more information, see Robotic Prostatectomy.
Benefits of robot assisted prostatectomy include:
- smaller incisions and less scarring
- shorter hospital stay
- less pain
- better visualization for the surgeon
- less blood loss and transfusions
- faster recovery and return to normal activities
Open Prostatectomy Procedures
Radical retropubic prostatectomy and radical perineal prostatectomy are two types of radical prostatectomy procedures. The entire prostate gland, attached seminal vesicles, and some nearby tissue are removed during these surgeries.
A radical retropubic prostatectomy involves a surgical cut in the lower abdomen. The surgeon can then remove the cancer through this skin incision. The entire prostate and attached seminal vesicles are removed, along with a small part of the bladder next to the prostate.
If necessary, nearby pelvic lymph nodes are removed as well. Recent developments in surgery have led to a newer version of this technique, called nerve-sparing radical retropubic prostatectomy. This allows the surgeon to identify the nerves on either side so that they can be left alone, if possible.
The benefit to leaving these nerves alone is that some men will have a better chance of achieving erections after surgery. In general, there is a lower risk of certain adverse side effects if the nerve-sparing technique can be used.
Radical perineal prostatectomy is similar to radical retropubic prostatectomy except that the cancer is removed through an incision in the perineum, the area between the scrotum and the anus. The entire prostate is removed along with any nearby cancer.
What to expect:
Radical prostatectomy procedures often last anywhere from an hour and a half to about four hours. The perineal type is generally a shorter operation than the retropubic type. A catheter is usually inserted after these procedures while the patient is still asleep. This catheter will help make urination easier during the healing process and will only be needed for a few weeks or less. After the catheter is removed, you may be able to urinate on your own. Both types of radical prostatectomies require about three days of rest in the hospital, followed by three to five weeks of rest at home.
Prostatectomy is a one-time procedure that may cure prostate cancer in its early stages and may help extend life in the later stages. Surgery avoids some of the problems seen with radiation and other therapies.
Prostatectomy is a major operation that requires hospitalization and can produce side effects. The possible side effects include impotence, incontinence, and narrowing of the urethra, which can make urination difficult. Most men who have this surgery should expect some decrease in their ability to have an erection. However, the chance of impotence is lower with the new nerve-sparing technique. In general, impotence is more likely to occur in older patients, especially those older than 60 years of age. The risk of impotence is even greater for men older than 70 years of age. Incontinence occurs in only a small percentage of patients.
Transurethral Resection of the Prostate (TURP)
A transurethral resection of the prostate (TURP) is the removal of tissue from the prostate by inserting an instrument through the urethra in the penis.
An instrument is placed into the urethra and guided up into the prostate to cut some of the tissue that surrounds the urethra. TURP is most often recommended for men with noncancerous enlargement of the prostate.
In this case, the procedure is performed to relieve the symptoms associated with this condition. TURP also may be an option for men who have prostate cancer but cannot have a radical prostatectomy either because of advanced age or a serious illness (besides cancer). TURP was designed to relieve symptoms that a tumor can cause; it will not cure cancer and usually removes only part of a tumor.
What to expect:
A TURP operation takes about an hour. A catheter is inserted after the surgery and may remain in place for about two to three days to make urination easier. The patient probably will stay in the hospital for one or two days and may be able to return to work after one or two weeks.
A TURP requires less recovery time than a radical prostatectomy, and the side effects often are less severe.
Because TURP is not a curative procedure for prostate cancer, other forms of treatment may be required.
Radiation therapy uses high-energy rays to kill prostate cancer cells, shrink tumors, or prevent cancer cells from dividing and spreading.
Radiation doses are usually small and spread out over time. This allows the healthy cells to recover and survive, while the cancer cells eventually die. Radiation therapy is usually used when prostate cancer has not spread beyond the prostate. It can help prevent the cancer from spreading further.
Like surgery, radiation therapy works best when the cancer is located in a small area. In early stages of prostate cancer, radiation therapy may cure the disease. It may be used alone or in combination with hormone therapy when cancer cells have spread beyond the prostate to the pelvic area and for pain relief in prostate cancer that is no longer responding to hormone therapy and has spread to the bones.
Radiation therapy can be given either via external beams or with a type of internal radiation called brachytherapy. These types of radiation therapy are discussed below.
External Beam Radiation Therapy
In external beam radiation therapy, the rays are delivered by a machine, and the radiation is given in brief sessions, usually one session each weekday for several weeks. Many patients compare the treatments to having an x-ray. The procedure is painless and lasts for just a few minutes. External beam radiation therapy may be given alone or in combination with hormone therapy.
Recent advancements in external beam radiation therapy have led to two new methods of treatment: three-dimensional conformal radiation therapy and conformal proton beam radiation therapy. These developments may help reduce the side effects of external beam radiation therapy and increase treatment success. Newer treatments are often considered experimental until they can be shown to have the same success rate as more standard forms of therapy, and they may not be available at all radiation centers.
The Calypso System: GPS For the Body
The normal motion of the body's internal organs presents challenges in delivering precise radiation therapy to small targets. Organs naturally move during radiation treatment. In treating prostate cancer, it is important that all the necessary radiation gets to the tumor and all possible precautions available are taken to avoid unnecessary radiation to healthy tissues surrounding the bladder and rectum. The Calypso 4D Localization System, referred to as GPS for the Body, is a breakthrough technology providing doctors with a way to precisely set up prostate radiation therapy and then monitor the prostate's position during treatment.
The Calypso System uses tiny electromagnetic transponders, which are implanted into the prostate in an outpatient procedure prior to treatment. These beacon transponders emit radiofrequency waves which allow very accurate alignment of the prostate before each treatment session. It also lets doctors monitor the position of the prostate in real time during treatment delivery.
Three-dimensional Conformal Radiation Therapy (3D-CRT)
In three-dimensional conformal radiation therapy, high-tech computers are used to identify the location of the cancer inside the prostate gland.
The next step is the creation of a special protection device that the patient wears during the treatments. This device is similar to a body cast, but it is molded out of styrofoam and helps to keep the body still during treatment while the radiation is aimed at the cancer. When the patient wears the plastic mold during the treatments, the radiation beams can be aimed more accurately to target the prostate gland. The idea is to direct a high dose of radiation only toward the cancer cells, while reducing the amount of radiation that the surrounding noncancerous areas receive. If the healthy tissue can be spared from the effects of radiation, the patient will experience fewer side effects.
Conformal Proton Beam Radiation Therapy
Conformal proton beam radiation therapy is another new type of radiation therapy. This technique is similar to three-dimensional conformal radiation therapy, except that it uses protons to produce the radiation beam. Protons are microscopic particles that produce energy in the form of a radiation beam. The proton beams can pass through healthy tissue without damaging it, yet can still be aimed at cancerous tissue to destroy cells.
Major surgery usually can be avoided by using radiation therapy. Radiation therapy may cure prostate cancer in its early stages and may help extend life in later stages. It rarely causes loss of urinary control, and other side effects like impotence occur less often than with surgery. The newer techniques mentioned above look promising in terms of reducing the chance of adverse effects and increasing the chance of success.
Radiation therapy can cause a variety of side effects because healthy cells are often damaged along with the targeted cancer cells. Most of these are minor and disappear after therapy stops.
These side effects include:
- skin reactions in the treated areas
- frequent and painful urination
- upset stomach
- rectal irritation or bleeding
There is also a chance of some permanent side effects, including impaired bowel function and impotence.
Prostate Brachytherapy(also called prostate seed implants)
In prostate brachytherapy, the rays come from tiny, radioactive seeds inserted directly into the prostate.
Brachytherapy may be used by itself or in combination with external radiation therapy. The seeds are too small to be felt by the patient and do not cause any discomfort. They are inserted into the cancer during a surgical procedure after the patient has been given a local or general anesthetic.
Specialized equipment like CT scans, ultrasound, and MRI help the surgeon to place the seeds correctly. The seeds give off rays continually for weeks, months, or up to a year, and can remain safely in place for the rest of a person's life. The amount of time that the seeds remain radioactive depends on the dose and the type of radioactive material that is used.
Brachytherapy radiation is placed as close as possible to the cancerous cells so that less of the normal tissue is exposed to the radiation. Interstitial radiation therapy often allows the physician to use a higher dose of radiation for a shorter length of time than is possible with external radiation. It is usually performed within a hospital, and the patient may need to stay there for a few days or longer. Brachytherapy does not make the patient radioactive.
Because it is designed to target the cancerous cells and not harm the surrounding area, brachytherapy is rarely recommended when the cancer has spread beyond the prostate gland.
High-dose Rate Brachytherapy
High-dose rate brachytherapy is a newer form of interstitial radiation treatment involving seeds that are placed in the prostate only temporarily. These seeds stay in place for less than a day and contain more radioactive material than the seeds that stay in place longer. This type of brachytherapy may even be performed in a clinic and may not require hospitalization.
When interstitial radiation therapy is used, the procedure itself is generally painless. In fact, the newer types of brachytherapy, like high-dose rate brachytherapy, usually involve very little discomfort. This type of therapy requires fewer visits to the hospital or physician's office than other treatments.
Although brachytherapy may have fewer side effects than surgery, it has been associated with impotence, urinary incontinence, and bowel problems. Diarrhea, rectal pain, and burning are experienced by some patients, and these side effects may not be easy to treat.
Internal radiation therapy has side effects that are similar to external radiation therapy in general but with a few important differences. Brachytherapy causes impotence less often than do surgery and external beam radiation; however, it may be associated with decreased white blood cell and platelet counts.
In addition, seed insertion usually is not an option for treatment of prostate cancer that has spread beyond the prostate gland.
Hormone therapy most commonly is used to treat cancer that has spread (metastasized) outside the pelvic area.
Two types of hormone therapy can be used: (1) surgical removal of the testicles, the organs that produce male hormones, or (2) drugs that prevent the production or block the action of testosterone and other male hormones, called androgens. Hormone therapy cannot cure prostate cancer. Instead, it slows the cancer's growth and reduces the size of the tumor(s).
Hormone therapy may be combined with radiation therapy or surgery in advanced stages of cancer when the disease has spread locally beyond the prostate. This therapy may help to extend life and relieve symptoms. When the cancer has spread beyond the prostate, complete surgical removal of the prostate is not common.
In patients with early-stage cancer, hormone therapy may be used in combination with radiation therapy. A short course of hormone therapy can also be used prior to surgery to reduce the size of the prostate and may make it easier to remove.
The primary strategy of hormone therapy is to decrease the production of testosterone by the testicles. Regardless of the method of hormone therapy, this decrease in testosterone can result in certain side effects such as hot flashes, a loss of sexual desire, and impotence.
The specific methods used to reduce testosterone production or block the actions of testosterone and other male hormones are described below:
Surgical Removal of the Testicles
An orchiectomy is an operation to remove the testicles, which produce 95 percent of the body's testosterone.
Since the testicles are the major source of androgen in the body, this procedure is classified as hormone therapy rather than surgical treatment. The goal of an orchiectomy is to shrink the prostate cancer and/or prevent future growth of the tumor by removing the source it depends on (testosterone).
Orchiectomy is an effective procedure that is relatively simple. The patient is usually given a local anesthetic and allowed to go home the same day as the surgery.
Many patients prefer a nonsurgical option if the success rates are similar. Depending on the kind of anesthesia used, there may be special risks in certain types of patients.
Orchiectomy is not reversible, and in some cases, may require hospitalization. Patients will often experience side effects that result from the lack of male hormone in the body. Many men will notice decreased sexual desire following the procedure, and some will observe breast tenderness and/or growth over time. Other men may temporarily have hot flashes, similar to those experienced by women during menopause. Finally, there is a risk of impotence with orchiectomy procedures.
Another form of hormone therapy involves administering a female hormone such as estrogen. Female hormones reduce the production of testosterone by the testicles.
The most commonly used estrogen in prostate cancer is diethylstilbestrol or DES. Hormone therapy with estrogen has limited use and is generally considered only for patients who cannot have surgery or to relieve pain in patients with prostate cancer that is progressing. Estrogens were once considered standard treatment for prostate cancer, but this is not the case today. Other drugs with fewer side effects have replaced DES.
Estrogen therapy is simple and only involves taking a pill. Estrogen therapy preserves the testicles, and its effects are usually reversible.
Estrogen therapy produces various side effects of its own. Estrogens can cause water retention, breast growth and tenderness, and symptoms such as stomach upset, nausea, and vomiting. In addition, even low doses of estrogen may significantly increase the risk of heart and blood vessel problems.
LHRH Analog Therapy
LHRH analog therapy consists of administering a drug called a luteinizing hormone-releasing hormone (LHRH) analog, which leads to a drop in testosterone.
Taking an LHRH analog works as well as removal of the testicles but does not involve surgery. Some of these agents can be given in combination with an antiandrogen. In addition, LHRH analogs commonly are used to help relieve the symptoms associated with advanced prostate cancer. When used this way, this class of drugs may offer an alternative for the patient who either cannot, or chooses not to, have an orchiectomy or take estrogen therapy.
Administering LHRH analog therapy is simple; it involves an injection that is usually given at specified intervals of about one month or more depending on the dosage of hormone used. Treatment with LHRH analogs is as effective as orchiectomy, but it does not require surgical removal of the testicles. It also avoids some of the side effects of estrogen therapy.
Because LHRH analogs are usually given as long-acting injections, patients must follow the instructions for the dosage regimen and must remember to visit their physician on a regular basis. Some men may experience hot flashes, general body pain, and breast growth. Additional side effects may include a decrease in sexual desire and/or ability to have erections. In a small percentage of patients, LHRH analog therapy may cause a brief worsening of cancer symptoms, such as bone pain, for a few weeks before the testosterone level begins to fall. This pain may be eased with a pain reliever (such as aspirin or acetaminophen) or an antiandrogen drug. Finally, if an LHRH analog is used in combination with radiation therapy, or an antiandrogen, it can be difficult to know for sure which component of therapy, if any, is responsible for the side effects that a man may be experiencing. Sometimes a worsening of the actual disease may be confused for a side effect of a particular drug regimen.
Another type of hormone therapy used in prostate cancer is the administration of drugs that are called antiandrogens. An antiandrogen is a drug that blocks the action of male hormones. There are two different types of antiandrogens -- steroidal antiandrogens and nonsteroidal antiandrogens. Only the nonsteroidal antiandrogens are approved for use in the treatment of prostate cancer in the United States at this time.
Nonsteroidal antiandrogens are used in combination with an LHRH analog or orchiectomy in the treatment of advanced prostate cancer. When an antiandrogen drug is used in conjunction with an LHRH analog, this combination therapy is commonly known as maximal androgen blockade (MAB), total androgen blockade (TAB), or combined androgen blockade (CAB). Because there is still a small amount of androgen present in the body after an orchiectomy, antiandrogens also may be used in men who have already had this surgery.
Clinical trials suggest that some men treated with MAB therapy may live longer than men treated with LHRH analog therapy alone. This regimen of hormone therapy is convenient for the patient.
After taking an antiandrogen for a certain period of time, patients and their physicians may find that the prostate cancer is progressing despite treatment. When this occurs, the cancer is said to have become resistant to treatment. The patient may have to stop taking the antiandrogen for a while to help make the cancer respond to hormone therapy again. Other side effects from this type of hormone therapy will depend on which antiandrogen is used. Since antiandrogens are used in combination with LHRH analogs or just after an orchiectomy, it may be difficult to determine which component of the treatment is responsible for side effects.
Some of the more common adverse effects of an antiandrogens are sensitivity of the eyes to light (either natural or artificial), mild to moderate nausea, hot flashes, gynecomastia (growth of the breasts in males), nausea, vomiting, diarrhea, and an increase in liver enzymes. Patients must always consult their physician and/or health care practitioner before intentionally stopping or interrupting treatment with any of the antiandrogen medications.
Chemotherapy is the use of powerful drugs to attack cancer cells. The drugs circulate throughout the body in the bloodstream and kill any rapidly growing cells.
Chemotherapy drugs are carefully controlled in both dosage and frequency so that cancer cells are destroyed while minimizing the risk to healthy cells.
There are many different chemotherapy drugs, each with its own strengths and weaknesses. Often the drugs are used in combination. While some are injected directly into a vein or a muscle, others may be taken by mouth. Some of the drugs must be given in the doctor's office or clinic; others can be administered while the patient is at home.
Hospitalization may be needed for certain types of chemotherapy that require special monitoring of both the treatment and its possible side effects. Chemotherapy is generally reserved for patients with advanced stage prostate cancer that no longer responds to hormonal therapy and/or that has spread outside the prostate gland.
Although it has limited success as a treatment for prostate cancer, chemotherapy provides an additional means of relieving the symptoms of advanced prostate cancer. It can reduce pain and may slow tumor growth.
Because the drugs circulate throughout the whole body, they can affect both healthy and cancerous cells. This can lead to many side effects. The specific side effects will depend upon which drugs and regimens are used.
The most common adverse reactions include:
- hair loss
- lowered blood counts
- reduced ability of the blood to clot
- increased risk of infection
Some of these side effects occur only temporarily or are more noticeable when treatment is first started. Most of the side effects disappear when the drugs are stopped.
Electing not to receive immediate treatment may be an appropriate approach for some patients in the early stages of prostate cancer.
Elderly patients and/or those with other significant medical problems may experience greater side effects from treatment and are more likely to die from causes other than prostate cancer before their cancer progresses.
Watchful waiting requires that the cancer be closely monitored, and therapy is initiated only when the cancer shows signs of spreading. Hormonal therapy is often the preferred treatment following a period of watchful waiting. However, the best time to begin hormonal therapy is a subject of some controversy.