Over the past 20 years, overall survival rates for all stages of prostate cancer combined have increased from 67% to 89%. Some of the possible reasons for the increase in survival rates include public education, new techniques of early detection, and aggressive therapy. The major treatment options for prostate cancer include surgery, radiation, medical therapy and watchful waiting. A patient's treatment options will depend upon his age, the stage of the disease, and the advice of a physician.
The immune system is made up of immune cells that circulate the body in the blood; these cells are our body's natural defense system against most diseases, including prostate cancer. Immunotherapy is a treatment that encourages the body's own immune system to fight cancer. One such treatment is Sipuleucel-T, an FDA approved cancer vaccine. Unlike traditional vaccines, which promote the development of immunity by imitating an infection, this vaccine transforms the patient's own cells to specifically recognize and attack prostate cancer cells. This process involves filtering out the white blood cells from a blood sample, stimulating them to fight prostate cancer in a lab, and then giving those cells back to the patient via an IV infusion. This process is repeated every two weeks for three treatments. The goal is to stimulate the patient's immune system to fight the cancer cells.
Immunotherapy does not lower PSA, treat symptoms, or delay disease progression. However, this treatment has been shown to prolong life. This treatment is often for individuals with prostate cancer that has spread outside of the prostate and is resistant to standard hormone treatment.
The side effects of sipuleucel-T are usually limited to the few days following an infusion of the stimulated cells. Patients may sometimes experience flu-like symptoms with fever, chills, nausea, and bone and muscle aches. These symptoms generally resolve within three days and can be treated with acetaminophen.
Chemotherapy is the use of drugs to stop tumor growth by destroying cancer cells and/or preventing them from rapidly growing and dividing. Chemotherapy is typically reserved for patients whose cancer has spread beyond the prostate and may be given with hormone therapy or after hormone therapy stops working. While chemotherapy does not cure prostate cancer, it has been shown to reduce symptoms and prolong life for patients with advanced disease, or metastatic castrate-resistant prostate cancer.
Chemotherapy is given as an injection for six, three-week long cycles of treatment. Below is a list of common chemotherapy drugs:
- Taxotere (Docetaxel)
- Javtana (Cabazitaxel)
- Novantron (Mitoxantrone)
- Emcyt (Estramustine)
Chemotherapy drugs target cancer cells by attacking cells that grow and divide quickly. Unfortunately, there are other cells in the body that can also be affected, including, red blood cells in the bone marrow, hair follicles, and cells in the mouth and intestines. The side effects of chemotherapy depend on the type and dose of drug given. These side effects are usually temporary and go away after treatment. Some common side effects include:
- Mouth Sores
- Hair Loss
- Low White Blood Cell Count
- Increased risk of infection
- Weakness/numbness in fingers and toes
Prostate cancer cells need fuel to grow and survive. The male hormone testosterone is the main fuel for prostate cancer cell growth, which makes it a common target for therapeutic intervention. Hormone therapy is also referred to as androgen deprivation therapy (ADT) because testosterone is a type of androgen. The goal of ADT is to deprive cancer cells the testosterone they use to grow. This can be accomplished by reducing testosterone levels or by preventing the actions of testosterone. ADT often slows tumor growth and may shrink prostate tumors.
Hormonal therapy can be used before radiation therapy or surgery to shrink the prostate cancer tumor, in conjunction with radiation as an initial treatment or in cases of recurrent disease. There are two types of hormone therapies.
Treatments that reduce testosterone levels:
Bilateral Orchiectomy (surgical castration):
As the majority of testosterone is produced by the testicles, bilateral orchiectomy, or the surgical removal of both testicles, results in much lower testosterone levels in the body.
Lutenizing hormone-releasing hormone (LH-RH) analogs:
LH-RH analogs shut down testosterone production by the testicles. LH-RH analogs can reduce testosterone production to castration levels. LH-RH analogs are injected or implanted under the skin. Below is a list of some LH-RH therapies:
- Lupron (Leuprolide)
- Eligard (Leuprolide)
- Zoladex (Goserelin)
- Trelstar (Triptorelin)
- Vantas (Histrelin)
- Suprefact (Buserelin)
LH-RH antagonists also shut down testosterone production by the testicles. Similar to LH-RH analogs, LH-RH antagonists can reduce testosterone production to castration levels. LH-RH antagonists are given as monthly injections and are often used to treat advanced prostate cancer. Below is a list of LH-RH antagonist therapies:
- Firmagon (Degarelix)
Androgen Synthesis Inhibitors:
Small amounts of testosterone are produced outside of the testicles. For example, testosterone can be made by the adrenal gland and is sometimes even made by the prostate cancer cells themselves. Androgen synthesis inhibitors can block the production of androgens, like testosterone, from being made throughout the body. These drugs can interfere with the production of other hormones and therefore are often prescribed with a corticosteroid such as prednisone. Below is a list of androgen synthesis inhibitor therapies:
- Zytiga (Abiraterone)
- Nizoral (Ketoconazole)
Treatments that block actions of testosterone:
Androgens work by binding to a protein called an androgen receptor. Antiandrogen therapies block this receptor from functioning, which prevents androgens from promoting the growth and survival of prostate cancer cells. These drugs are typically taken daily as pills and are often taken alongside another form of ADT. Below is a list of antiandrogen therapies:
- Erleada (Apalutamide)
- Nubeqa (Darolutamide)
- Eulexin (Flutamide)
- Casodex (Bicalutamide)
- Nilutamide (Nilandron)
- Xtandi (Enzalutamide)
There are many factors that contribute to the risk of side effects from hormone therapy, including age, fitness level, and duration of treatment. However, many side effects of hormone therapy can be prevented or treated. Some symptoms of hormone therapy are:
- Reduced or absent sexual desire
- Erectile dysfunction
- Shrinkage of testicles and penis
- Hot flashes
- Breast tenderness and growth of breast tissue
- Decreased mental sharpness
- Loss of muscle mass
- Weight gain
- Nausea and diarrhea
- Increased cholesterol levels
Radiation therapy uses high-energy beams, such as X-rays or protons, to kill cancer cells. These beams damage DNA inside cells, which can result in the death of cancer cells and/or the slowing of cancer growth. While radiation is also toxic to healthy cells, cancer cells are especially vulnerable to DNA damage because of their quick division. Radiation Therapy is often used as the first treatment for cancer found in the prostate gland. Some forms of radiation are also beneficial for men with advanced disease or recurring prostate cancer.
External Beam Radiation:
EBRT is the most common method of radiation used to treat prostate cancer. Radiation is delivered from outside the body using a large machine that aims radiation at tumor cells. The radiation passes through skin and other tissues to reach the tumor. There are several different types of ERBT, the most common types are discussed below.
3D Conformal Radiation Therapy (3D CRT):
This form of radiation targets tumor cells with X-ray radiation. To minimize the exposure of healthy cells to radiation, MRI, CT, and/or PET images are used to generate a three-dimensional (3D) image of the tumor. A computer program then shapes the radiation beams to match the shape of the tumor so the highest dose of radiation can destroy the cancer cells within the prostate with minimal exposure to the healthy cells nearby.
Intensity Modulated Radiation Therapy (IMRT):
IMRT is a more advanced form of 3D CRT which uses multiple X-ray beams that can be adjusted in their intensity or strength to limit the dose of radiation reaching healthy tissues. IMRT can more precisely and accurately target tumor cells which may result in fewer side effects and higher cure rates.
Volumetric modulated arc therapy (VMAT):
VMAT is a variation of IMRT that delivers radiation quickly as a machine rotates around the body. VMAT reduces treatment duration, however, its effectiveness compared to IMRT has not yet been studied.
Image Guided Radiation Treatment (IGRT):
As the prostate can move slightly within the body, and tumors may change shape between radiation treatments, IGRT, or imaging of the tumor just before or during radiation treatments, can improve the accuracy of 3D CRT and IMRT.
Proton Beam Therapy:
Proton beam therapy focuses beams of protons instead of x-rays onto cancer. In comparison to x-rays, protons cause less damage to tissues they pass through and release their energy only after traveling a certain distance. This means that proton beam radiation can deliver more radiation to tumors while doing less damage to nearby healthy tissues. Proton beam radiation can be aimed with techniques similar to 3D CRT and IMRT. Proton treatment is especially useful for treating localized tumors before they spread beyond the prostate. Unfortunately, very few medical institutions are equipped to use proton beam therapy in the United States, and the treatment can be expensive. There are no studies yet showing if proton beam therapy is more effective than x-ray based treatments.
Stereotactic Body Radiotherapy (SBRT):
Before treatment with SBRT, markers are placed around the tumor to faciliate the delivery of large doses of radiation precisely to the tumor. During treatment, the intensity and direction of the beams are constantly adjusted to target the tumor and spare healthy tissue. The beams can also be adjusted to accommodate breathing and digestive movements. SBRT is often used to deliver a course of treatment in a few visits. There is some research to suggest that side effects may be worse with SBRT compared to IMRT, however further studies are needed.
Brachytherapy or Internal Radiation Therapy:
This treatment uses small radioactive implants, often called "seeds" which are placed in the prostate through a surgical procedure. Like with EBRT, 3D CRT is used to map the tumor and to calculate the dose and placement of the seeds. There are two approaches to brachytherapy, low-dose rate (LDR) and high-dose rate (HDR). LDR brachytherapy uses placement of seeds, which give off low doses of radiation for weeks or months. Radiation from the seeds travels a very short distance, so the seeds can give off a large amount of radiation in a very small area, which limits the amount of damage to nearby healthy tissues. Because the seeds are so small, they rarely cause discomfort, and are left in place after their radioactive material is used up. Conversely, HDL brachytherapy uses seeds, which give off higher doses of radiation and are only left in place for several minutes. HDL brachytherapy is typically given as several exposures over the course of a few days, after the last treatment, the seeds are removed.
Along with any medical procedure radiation can have side effects. The following are some common side effects of radiation treatment:
- Upset Stomach
- Frequent & Painful Urination
- Skin Irritation in Treatment Areas
- Rectal Irritation or Rectal Bleeding
The goal of surgery is to remove the entire prostate gland and all of the cancer. What follows is a description of a number of techniques used by surgeons when operating on the prostate.
Transurethral Resection of the Prostate (TURP):
TURP is a procedure that involves removing tissue from the prostate by inserting an instrument through the urethra. A resectoscope, which is an electrically heated wire loop, is used to scoop out the unhealthy prostate tissue. This procedure is sometimes necessary to relieve the symptoms of prostate cancer and make urinating easier. It is also performed on men who cannot have a radical prostatectomy due to age or other illnesses. This type of surgery has several advantages. Because no surgical incision is required, hospital stays are brief and recovery is usually uneventful. In most cases, urinary function returns to normal after the procedure and sexual function is not affected by the procedure.
Orchiectomy is a surgical procedure that completely removes the testicles. This procedure is also a type of hormonal therapy because, like certain prescription drugs, orchiectomy provides an immediate and permanent reduction in testosterone. Treatment with LH-RH analog therapy has been shown to be comparable to orchiectomy in decreasing the body's supply of testosterone. Most patients prefer LH-RH analog therapy over orchiectomy to treat their prostate cancer, however, orchiectomy is a routine surgical procedure that usually has no long-term complications. Orchiectomy may require being hospitalized for approximately 2 days or more. While many patients respond favorably to orchiectomy, for those patients for whom this surgical procedure fails, the operation is often viewed as unnecessary, expensive, and possibly psychologically damaging. Common side effects of orchiectomy are hot flashes, impotence, and loss of sexual desire.
A prostatectomy is a surgical approach to remove all (radical prostatectomy) or part of the prostate. Prostatectomy is usually performed to remove early-stage prostate cancer before it has spread to the other parts of the body. Often, the pelvic lymph nodes are also sampled to see if the cancer has spread. Patients who undergo a radical prostatectomy should expect at least a 2-4 day stay in the hospital, however a full recovery can take up to 12 weeks. In most cases, taking out the prostate removes the cancerous tumor as well. Unfortunately, if the cancer has spread beyond the prostate it cannot be cured with surgery.
Hormonal therapy is sometimes used before surgery to shrink the prostate cancer tumor so it can be removed more effectively. Prostatectomy has become safer and less likely to leave men impotent or incontinent, although results vary from surgeon to surgeon. As with all major surgeries, there are risks. The most common risks of a prostatectomy are impotence, the inability to achieve or maintain an erect penis, and incontinence, the involuntary urination. The likelihood for these complications depend on a patient's age, health, and the stage of his cancer.
To reduce the risk of impotence, surgeons aim to spare the erectile nerves that run alongside the prostate. If the surgeon finds that the nerves cannot be spared because the cancer has spread, it may be possible for the surgeon to create a nerve graft with nerves from other parts of the body. The surgeon will not know if the nerve-sparing procedure is possible until the extent of the cancer can be observed.
Prostatectomy is a very delicate procedure and the success of the procedure is strongly determined by the skill of the surgeon. When deciding on surgeon to perform your procedure, be sure to assess their success record and experience level and choose someone you trust.
The Complete (Radical) Prostatectomy
Surgical removal of the entire prostate gland is called radical prostatectomy. Radical prostatectomy is usually performed to remove early-stage prostate cancer before it can spread to other parts of the body. Often, the pelvic lymph nodes are also sampled for a biopsy as a precautionary measure. In most cases, taking out the prostate takes out the cancerous tumor as well. If the cancer spreads outside of the prostate, it cannot be cured with surgery. Patients who undergo radical prostatectomy should expect at least a 2- to 4-day stay in the hospital, while full recovery can sometimes take up to 12 weeks. As with all major surgeries, prostatectomy patients may require a blood transfusion. Hormonal therapy is sometimes used before surgery to shrink the prostate cancer tumor so it can be removed more effectively. Radical prostatectomy has become safer and less likely to leave men impotent or incontinent, although results vary from surgeon to surgeon. The risk of impotence, which is the inability to achieve or maintain an erect penis, often depends on a patient’s age, health, and the stage of his cancer. Incontinence, which is involuntary urination, appears to occur less often than impotence in patients after radical prostatectomy.
Nerve-Sparing: The surgeon cuts to the edges of the prostate and aims to spare the erectile nerves that run alongside the prostate. If the surgeon finds that the nerves cannot be spared because they found that the cancer has spread then it may be possible for the surgeon to create a nerve graft with nerves from other parts of the body to the ends of the erectile nerves that were cut out. The surgeon will not know if the nerve-sparing procedure is possible until the patient is opened up to see if the cancer has spread. If this procedure is an option though it will offer the best chance to preserve erectile function.
Laparoscopic: Small incisions are made in the abdomen with the robotic interface and the surgeon inserts narrow instruments with fitted cameras or surgical tools allowing the surgeon to see and operate on the prostate without cutting open the abdomen.
Prostatectomy is a very delicate procedure and the success of the procedure is strongly determined by the skill of the surgeon. When deciding which surgeon to have perform your procedure make sure to look at their success record, experience level and that it is someone you greatly trust.
Prostatecomy procedures have become safer and less likely to cause lasting side effects, however results do vary from surgeon to surgeon. There are potential side effects to having a prostenctomy and those include
- Erectile function
- Damage to the urethra
- Damage to the rectum
Active surveillance or watchful waiting is a treatment option that involves careful observation and monitoring via PSA blood testing, digital rectal exams, and annual biopsies to measure cancer progression.
Active surveillance may be an accurate treatment choice for men who:
- Are found to have less aggressive tumors, which often tend to grow slowly
- Are older than 70 years of age
- Have significant coexisting illnesses
- Are fearful of the side effects of more aggressive therapies