Traditional Treatments
Active Surveillance
As many prostate cancers found at prostate biopsy are small and appear under the pathologist's microscope to have features to suggest that they are slow-growing, some patients have a low risk of ever requiring treatment. Additionally, in older men or in men with medical conditions that could be adversely affected by treatment or which may limit life expectancy, prostate cancer risk during their lifetime may be small. For such tumors in which the risk of cancer complications or death is expected to be low during a man's lifetime, active surveillance is a commonly-recommended approach. Active surveillance refers to monitoring the tumor on a regular basis (often, every 6 to 12 months or so) with digital rectal examination, PSA blood test, an Axumin® (fluciclovine F 18) PET/CT scan and/or a periodic prostate cancer biopsy -- potentially in combination with a Magnetic Resonance Scan (MRI) of the prostate.
Radical Prostatectomy
Radical prostatectomy is an operation in which the entire prostate, along with the seminal vesicle glands (which are attached to the prostate), is removed. The operation often includes removal of adjacent lymph nodes. After the prostate is removed, the bladder is reconnected to the urinary channel (urethra). In men whose tumors appear to have not spread locally, the surgeon may preserve the two sets of erectile nerves that are present along the sides of the prostate; this maneuver increases the likelihood that erections will be present after surgery. If the prostate cancer is completely confined to the prostate, the cure rate is high. For some men with larger prostate cancer, radical prostatectomy may be followed by radiation therapy. During surgery, there is a risk of bleeding, organ injury, or postoperative infection. During the period after surgery, there is a risk of impotence (problems with erections), urinary leakage (incontinence), development of narrowing in the urinary channel (stricture), or recurrence of cancer. Long-term follow-up generally requires only PSA testing as (1) PSA should be zero after all cancer is removed and (2) a detectable PSA after radical prostatectomy generally indicates cancer recurrence.
External Beam Radiation Therapy
External beam radiation therapy is a well-established method to treat prostate cancer. Using imaging studies such as a CT scan, computer programs allow the Radiation Oncology physician to plan a series of treatments with ionizing radiation from a machine that are delivered through a large number of beams, focusing on treating just the prostate. With current technology, often using Intensity Modulated Radiation Therapy (IMRT), very high doses are delivered to the prostate with minimal dose to adjacent organs. In general, external beam radiation therapy is felt to be as effective as surgery in curing localized prostate cancer. For men who have a risk of cancer spread to the local lymph nodes, radiation can be given to the lymph nodes as well. Traditional radiation therapy requires treatments every day, Monday through Friday (with weekends off), for about eight weeks. It is also possible to give higher daily amounts of radiation to reduce the number of treatments (hypofractionated radiation therapy). Side effects can include impotence (problems with erections), urinary symptoms (difficulty emptying, burning with urination, urinary leakage), rectal or bladder irritation or bleeding, and there has been reported a small potentially increased risk of cancer of the bladder or rectum. For higher-risk prostate cancer, radiation is generally combined with medications that lower testosterone levels to improve cancer cure rates. Hormone therapy may be used for periods of 6-36 months, depending on the aggressiveness of the tumor. Side effects of hormone therapy include hot flashes, impotence, loss of sex drive, weight gain, fatigue, anemia, osteoporosis (weakening of the bone), loss of muscle mass, and other, less-common side effects.
Brachytherapy ('Radiation Seeds')
Brachytherapy is an alternative approach to delivery of radiation therapy that uses small radioactive pellets or "seeds" that are placed inside the prostate allowing the cancer to receive radiation "internally". The pellets are typically placed inside the prostate using small needles and the pellets remain in the prostate permanently but become inert over time. After treatment, patients are advised to stay away from pregnant women and small children for a period of time. Side effects of brachytherapy are similar to those of external beam radiation. Unlike external beam radiation which is given without sedation or anesthesia, brachytherapy is a surgical procedure that requires anesthesia or sedation.