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There are many types of treatment for men who have prostate cancer. These options depend on the grade (ie, aggressiveness) and stage (ie, how far the cancer has spread) of the cancer, factors which are specific to each patient. In addition to grade and stage of the cancer, other factors affecting treatment choice are the age and life expectancy of the patient as well as the potential side effects and benefits related to each treatment. Prostate cancer treatment generally involves surgery, radiation and hormone therapy either singly or in combination. Another option is called “watchful waiting.” For older men this may be the most appropriate if the cancer is determined to be slow growing, as these patients have a higher risk of dying from something other than the prostate cancer. Cancers that have spread outside the prostate are not curable and hormone therapy is often used in such instances to slow the cancer’s growth.
A radical prostatectomy is complete removal of the prostate gland and the adjacent lymph nodes. This surgery is performed when the cancer is confined solely to the gland itself. Because this surgery can affect the muscles and nerves that control urination and sexual function, some postoperative side effects are possible. There are two approaches used to perform a radical prostatectomy: 1) Perineal (an incision is made between the anus and scrotum), and 2) Retropubic (the gland is removed through an incision in the lower abdomen that runs from just beneath the navel to an inch above the base of the penis). The retropubic approach is the most common because the same incision can be used to remove the pelvic lymph nodes. In addition the procedure allows clear and unobstructed access to the prostate, making it easier for the physician to save nerves that control erections and bladder function.
There are two types of radiation used to treat prostate cancer. External beam radiation therapy (EBRT) is delivered by a machine that emits high-powered x-rays to kill the cancer cells. This therapy is time consuming with treatments usually administered 5 days a week for 7 to 8 weeks. No anesthesia is necessary, and the side effects from EBRT are less than with brachytherapy, the second delivery method. With brachytherapy radioactive pellets are injected directly into the prostate gland. This procedure requires anesthesia and takes about one to two hours. Higher doses of radiation can be delivered via brachytherapy and there is more discomfort following the treatment; however, most patients return home the same day. For about one year the pellets then release radiation that attacks the cancer cells. Both forms of radiation therapy leave the prostate gland and lymph nodes intact, therefore some uncertainty goes along with this treatment regarding long-term prognosis, because the cancer could return several years after radiation therapy.
Hormone therapy involves lowering the levels of androgens (ie, the male sex hormones), which are known to stimulate the growth of cancer cells. Androgens are produced primarily in the testicles. For this type of therapy, drugs (eg, leuprolide, goserelin) that block hormone production are given via monthly injections, or the testicles are surgically removed. Hormone treatments are generally given to patients with aggressive cancer that has spread outside the prostate gland. Prostate cancer usually responds to hormone therapy for a few years, but after that time most cancers redevelop because they learn to thrive without the hormone. Intermittent hormone therapy programs have been devised to combat this tendency. In these programs the hormonal drugs are discontinued after the PSA level drops and remains steady. When the PSA level rises, the patient resumes taking the drugs. The side effects of hormone therapy include breast enlargement, hot flashes, weight gain and reduced sex drive. Some hormone therapy medications can cause fatigue, nausea, diarrhea and liver damage.
Watchful waiting is most often used with patients who have a small, slow-growing and asymptomatic cancer. Regular follow-up tests including blood tests, rectal examinations and biopsies are performed to monitor the cancer’s progress. Watchful waiting is also appropriate for men who are elderly, in poor health, or both. Many such men can live a normal life-span without the cancer spreading or causing problems. Younger men can also choose watchful waiting, as long as they stay up-to-date with recommended tests to monitor their cancer. They must also be willing to accept the risk that the cancer could grow and become incurable without treatment.