Treatment: the absolute basics

If your doctor tells you that you have prostate cancer, the first thing on your mind is likely to be treatment — and soon! But before we talk about the possible treatment options, understand one thing:

  • Treatment of prostate cancer is not usually urgent.

You almost always have time to ask questions, to learn more, and to get second opinions if you need them.

Do You Need Treatment at All?

The first question you need to answer is, “Do I need treatment at all?”

This might seem strange to you. After all, prostate cancer can be a very serious problem. However, if (for example) you are 75 years old, men in your family rarely live longer than 80-85 years, and you have just been diagnosed with early stage, low risk disease, there are very real issues about whether the possible benefits of treatment are as important as the potential harm from treatment.

If you have additional medical history that includes high blood pressure, heart disease, and other potentially serious medical problems, then these may be way more important than prostate cancer.

If you and your doctor decide that active intervention is perhaps not the thing for you at the time of diagnosis, it is likely that the doctor will still recommend either “active surveillance” or  “watchful waiting.” By careful, regular monitoring of your condition, your doctor will be able to know how fast your cancer is progressing (or not progressing) and will be able to talk to you about when treatment of some type might become appropriate (if ever). In such cases the urologist or the primary care physician will usually want to give you a physical exam and check your PSA every 3 or 6 months.

Looking Before You Leap

It is not always the best idea to jump into prostate cancer treatment. Look carefully before you leap. Before you decide to have treatment, talk very seriously with your doctor.

Having gotten a good sense of your medical situation, ask your doctor how aggressive your cancer is. Aggressiveness, which is the cancer’s potential to grow relatively quickly and cause you really serious problems, is based on two measures.

The first measure is the clinical stage of the disease (how big the original tumor is already and how far the cancer has spread). Be sure to ask about the stage of your prostate cancer.

The second measure is the cancer grade, based on what the cancer cells look like under a microscope. The most common grading system used today is the Gleason grading system, a numerical scale that runs from 2 to 10. Be sure to ask about the Gleason grade of your cancer.

What Type of Prostate Cancer Do You Have?

Depending on how widespread and aggressive your cancer seems to be, your doctor can crudely classify your cancer in one of three ways:

  • Early stage — localized to the prostate and therefore potentially curable
  • Locally advanced — still confined to the area close to the prostate but not localized to the prostate
  • Late stage — cancer that has spread way beyond the prostate (including metastatic disease)

In addition, patients can be categorized into one of three “risk groups” at the time of diagnosis, based on the so-called D’Amico risk criteria, (first proposed by D’Amico et al. in 1998):

  • Low-risk patients have a PSA of less than 10 ng/ml, and a Gleason score less than 7, and a clinical stage of T1/T2a — to be low risk you must meet all of these criteria.
  • Intermediate-risk patients have a PSA of 10-20 ng/ml or a Gleason score of 7 or a clinical stage of T2b/c — to be intermediate risk you need to meet only one of these criteria.
  • High-risk patients have a PSA of more than 20 ng/ml, or a Gleason score of 8, 9 or 10, or a clinical stage of T3a or higher — to be high risk you need to meet only one of these criteria.

In America today, the vast majority of cases of prostate cancer are initially diagnosed as early stage, but not all of them. Similarly, a very large percentage of patients will meet the criteria for “low-risk” disease. You need to talk carefully to your doctor about the precise nature of your disease because it will be very important to your treatment decisions. In other parts of the world, it is still common for few men to be diagnosed until they have metastatic disease.

One final thing, and then we can talk about possible treatment options. You need to understand three very, very important points:

  • No one treatment for early stage disease has been proven to be better than any other in a large, well-structured clinical trial. You are going to have more than one treatment option.
  • Every available type of treatment comes with potential side effects and carries the risk of serious complications.
  • No doctor can tell you with absolute certainty, either before or after treatment, that you have been cured! There is always the possibility that cancer cells have “escaped” somehow, and that they will start to grow again, maybe even many years later.

You can’t make good treatment decisions if you don’t understand the benefits and the risks of every type of treatment you think you might consider. Be sure to ask your doctor to explain all of the benefits and all of the risks of every type of treatment you might want to think about.

Common Treatments for Early Stage Disease

The two most common types of treatment for early stage (localized) prostate cancer are surgery and radiation therapy. However, there many ways to do the surgery and there are just as many ways to do radiation therapy.

Surgical removal of the entire prostate, known technically as radical prostatectomy, can be done as open surgery or as minimally invasive (“laparoscopic”) surgery. And laparoscopic surgery can be done with or without the use of a so-called “robot.” We’ll get into the details on other pages.

There is absolutely no good evidence that one form of prostate surgery is better than any other in removing the cancer or in minimizing the possible side effects of treatment. Most importantly, you should understand that the surgeon’s skill and his or her experience with the specific type of surgery he or she practices is the key to surgical success.

The decision to have prostate cancer surgery is very important. Before you take this step, find out everything you can about your surgeon:

  • Ask how many prostate cancer operations he does each month.
  • Ask about complications that his patients have had after surgery, and how often they occur.
  • Ask how often his patients need a blood transfusion during or immediately following the surgery.
  • Ask if he will be doing the operation himself (as opposed to a surgical resident).

You are looking for someone who does a LOT of radical prostatectomies with great success, and who does them often. You might want to have a look at “How to pick a prostate cancer surgeon.”

Radiation therapy can also be given using a whole variety of techniques. You will hear about various types of external beam radiation, in which X-rays or protons are “shot” into the prostate from outside the body. You will hear about radioactive seed therapy, properly known as brachytherapy, in which tiny radioactive pellets are implanted in the prostate. You may also hear about techniques where these are both combined. And sometimes they are combined with hormone treatment too.

Generally speaking, like surgery, when properly carried out, all forms of prostate radiation should be equally effective. However, technical considerations tend to restrict the use of seed therapy to smaller prostates. A man with a very large prostate may only be able to elect external beam radiation.

If you choose radiation, be sure to find a radiation therapy center that is really experienced with the technique they are recommending for you. As with the surgeons, it’s the experience that counts. In the case of surgery you are basically relying on the skill and experience of a single person — the surgeon. In the case of radiotherapy you are relying on the combined skills of a team of radiotherapy specialists (overseen by the radiation oncologist) and the quality of the equipment they are using. In this case, have a look at one or both of these two articles: “Nine tips for picking a radiation oncologist to treat your prostate cancer” and “How to select your brachytherapist.”

Other Treatments for Early Stage Disease

You will also come across other, less well established techniques used to treat early stage prostate cancer. Among them are prostate freezing (“cryotherapy”) and something called high intensity focused ultrasound (HIFU), which is not yet approved by the Food and Drug Association in the USA but which is already widely available in Europe and some other parts of the world.

Treatment of Locally Advanced Disease

If you are diagnosed with locally advanced prostate cancer, things become even more complicated. Locally advanced disease generally refers to prostate cancer that may involve tissues in the pelvis known as the seminal vesicles and the pelvic lymph nodes as well as other tissues immediately adjacent to the prostate.

Treatment of locally advanced disease is primarily focused on stopping or at least substantially delaying any further spread of the cancer. It may involve surgery and radiotherapy, or surgery and radiotherapy and hormone therapy. We will have more to say on this topic elsewhere.

Treatment of Late Stage Prostate Cancer

Late stage prostate cancer is cancer that has spread to the spine or to other tissues some distance from your pelvis. In late stage prostate cancer, the treatment objective is to delay further progression and to prevent or relieve any associated pain and suffering.

There are several basic “categories” of late stage prostate cancer: micrometastatic disease, metastatic disease, hormone-refractory disease, and terminal (progressive disease that is no longer responsive to any form of treatment).

At present there is no possibility of curing late stage prostate cancer. The approach to treatment of late stage prostate cancer is therefore quite different from the approach to treatment of early stage prostate cancer and even locally advanced disease. Hormone therapies, chemotherapy, radiotherapy, and palliative care are usually needed as the disease progresses, but progression can now be slowed down and delayed for many years in appropriate patients. many patients with late stage disease prefer to get treatment from an appropriately qualified medical oncologist, and might want to read the article entitled, “Finding the medical oncologist who is right for you: one specialist’s opinion.”

In Summary

To summarize, there are five key steps to making an informed prostate cancer treatment decision:

  • Understand that you have some time to think and learn.
  • Review your overall medical situation with your doctor(s).
  • Know the stage and grade of your cancer.
  • If you have early stage prostate cancer, consider active surveillance, surgery, radiation, and other forms of treatment — and get at least one second opinion.
  • Make sure to ask about side effects and complications of every treatment you consider.

There’s one more thing that many men find useful: talking to other men who have been where you are. If you cannot find any, ask your doctor to introduce you or contact a prostate cancer support organization. If your doctor will not make the introductions, find another doctor. You can also join The “New” Prostate Cancer InfoLink Social Network, which is already populated with many men who have been treated for prostate cancer, as well as some physicians and surgeons.

Content on this page last reviewed and updated February 8, 2010.
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