Thinking About Treatment Choices
Active surveillance, surgery, and radiation therapy are the standard therapy choices for men with early-stage prostate cancer (see Types of Treatment). Each has benefits (how treatments can help) and risks (problems treatment may cause). There is seldom just one right treatment choice.
The choice of treatment depends on many factors:
- Your prostate cancer risk group. Doctors use details about your cancer to place you into a low-, medium-, or high-risk group.
- Low-risk prostate cancer is not likely to grow or spread for many years.
- Medium-risk prostate cancer is not likely to grow or spread for a few years.
- High-risk prostate cancer may grow or spread within a few years.
Doctors define low-, medium-, and high-risk groups as follows:
|PSA Level*||Less than 10 ng/ml**||10 to|
|More than 20 ng/ml|
(see Medical Tests)
|6 or lower||7||8 or higher|
(see Tumor Stages)
|T1 or T2a||T2b||T2c|
*PSA stands for prostate-specific antigen (see Medical Tests)
**ng/ml stands for nanograms per milliliter of blood
Reprinted with permission from:
- Macmillan Publishers Ltd: Mazhar & Waxman. (2008) Nature Clinical Practice Urology 5: 486-493.
- The American Medical Association: D'Amico, et al. (1998) JAMA 280 (11):969-974. Copyright © 1998 American Medical Association. All rights reserved.
- Health problems other than prostate cancer. Having heart problems, diabetes, or other illnesses may affect your treatment options.
- If you have already had surgery for an enlarged prostate. If you have had prostate surgery, this may affect the treatment choices you have.
- Age. The benefits and risks of different treatments may vary with age.
- Type of care available to you. The skills and experience of specialists and types of treatment available in your area may vary. You will need to ask tough questions to make sure you receive the best possible care. See Asking Questions.
- Thinking about what you value most. Your unique experiences in life shape your feelings and thoughts about how to deal with prostate cancer. Keeping in mind what is important to you will help guide your decision.
Many men may ask their doctor, "What would you do, if you were me?" Try to remember, the doctor isn't you, and his or her personal values may be different from yours.
Here are some things to think about:
- How do you view the benefits and risks of the treatment choices that have been offered to you?
- Can you cope with knowing cancer is in your body?
- Would you rather have treatment to remove or shrink the cancer, knowing that there could be side effects?
- Do you know other men who have had prostate cancer? If so, their experiences may help you make your decision.
- Spouse or partner. Even though the treatment choice is yours, involving your spouse, partner, or other loved ones can help you sort out what is most important to you and your family.
By now you may have had many tests and exams to find out details about your cancer. As we discussed in the section above, your doctor will take into account your general health, the results of your tests and exams, and the Gleason score of your cancer when talking with you about your treatment choices. What are these tests? What do their results mean?
- Prostate-Specific Antigen (PSA) test. PSA is a protein that is made by both normal prostate cells and prostate cancer cells. PSA is found in the blood and can be measured with a blood test. Because the amount of PSA in the blood often rises with prostate cancer, doctors may check your PSA level over time. If you have a score of 4ng/ml (which stands for nanograms per milliliter of blood) or higher, your doctor may want to do other tests, such as a prostate biopsy.
- Gleason score of your cancer. When you have a biopsy, samples are taken from many areas of your prostate. A doctor called a pathologist uses a microscope to check the samples for cancer. He or she assigns a Gleason score on a scale of 2 to 10 to your cancer. This score tells how different the prostate cancer tissue looks from normal prostate tissue and how likely it is that the cancer will grow or spread. Most men with early-stage prostate cancer have a Gleason score of 6 or 7.
- Digital Rectal Exam (DRE). In this exam, your doctor feels your prostate by inserting a gloved and lubricated finger into your rectum.
Stages of Early Prostate Cancer
The clinical stage of your cancer is important in choosing a treatment. The clinical stage tells how much the cancer may have grown within the prostate and whether it has spread to other tissues or organs. If you decide to have surgery, your prostate, nearby lymph nodes, and seminal vesicles will be removed and samples of them studied under a microscope. This exam gives the pathologist the information he or she needs to find out the pathological stage to your cancer.
Your doctor may do one or more of the following tests or exams to help figure out the stage of your cancer:
- Prostate biopsy
- Bone scan
- CT scan
- Biopsy of the lymph nodes in the pelvis
- Biopsy of the seminal vesicles
T1 means that the cancer is so small it can't be felt during a DRE. T1a and T1b cancer is most often found by accident, when men have surgery to relieve symptoms of BPH (which stands for benign prostatic hyperplasia).
T1c is most often found when a prostate biopsy is done because of a PSA test result that showed a high PSA blood level. This is the most commonly diagnosed stage of prostate cancer.
A stage of T2 means that prostate cancer can be felt during a DRE, but is still only in the prostate. Your doctor may also assign a, b, or c to the stage, depending on the cancer's size and whether it is in 1 or more lobes of the prostate.
Active surveillance is closely watching for any sign that the cancer may be growing or changing. You don't have to decide on a treatment right away. You will have frequent doctor visits and tests, such as DRE, PSA tests, and biopsies. If these tests show that your cancer is growing or changing in any way, your doctor will offer you radiation therapy or surgery to treat the cancer. You can also change your mind and decide to have treatment at any time.
Active surveillance can be used for men with early-stage prostate cancer because the cancer often grows so slowly that it may not cause problems during a man's lifetime. For some men, active surveillance may be a way to avoid the side effects and costs of treatment without shortening their life.
You may want to talk with your surgeon about techniques that may spare the nerves that control your bladder and erections.
Surgery is a treatment choice for men with early-stage prostate cancer who are in good health. Surgery to remove the prostate is called prostatectomy. There are different types of surgery for prostate cancer. They include:
- Open prostatectomy. Also called retropubic prostatectomy. In this surgery, your doctor removes the prostate through a single long cut made in your abdomen from a point below your navel to just above the pubic bone. He or she might also check nearby lymph nodes for cancer (see drawing below). This type of surgery can be used for nerve-sparing surgery. Nerve-sparing surgery lessens the chances that the nerves near your prostate will be harmed. These important nerves control erections and normal bladder function.
- Laparoscopic surgery. In this type of surgery, your doctor uses a laparoscope to see and remove the prostate. A laparoscope is a long slender tube with a light and camera on the end. This surgery is done through 4 to 6 small cuts in the navel and the abdomen, instead of a single long cut in the abdomen. The laparoscope is inserted through one of the cuts, and surgery tools are inserted through the others. A robot can be used to do this type of surgery. This type of surgery can also be used for nerve-sparing surgery.
- Perineal prostatectomy. In this type of surgery, your doctor removes the prostate through an incision between your scrotum and anus. With this method, the surgeon is not able to check the lymph nodes for cancer and nerve-sparing surgery is more difficult to do. This type of surgery is not used very often.
This type of treatment uses high doses of radiation energy to treat cancer. Radiation therapy is a good choice for many men with early-stage prostate cancer. It is also the best treatment for older men or those who have other health problems. There are different types of radiation therapy:
- External beam radiation. In this type of radiation therapy, a machine aims radiation at your cancer. The machine moves around your body, sending radiation from many directions. Before you start treatment, your doctor will map out the exact location of your prostate. Then you will have treatment once a day, 5 days a week, for 6 to 9 weeks. Each treatment session usually lasts about 15 minutes.
3-D conformal radiation therapy is a type of external beam radiation that is often used to treat prostate cancer. It allows doctors to carefully plan the shape of the radiation beam so it targets the cancer more precisely, while avoiding healthy tissues nearby.
- Brachytherapy is a type of internal radiation therapy in which a doctor places radioactive material inside the prostate. Brachytherapy is a choice for men with low-risk prostate cancer. There are two main types of brachytherapy used for prostate cancer, low-dose rate (also called LDR) and high-dose rate (also called HDR).
- LDR brachytherapy. In this type of brachytherapy, a doctor will place low-dose sources of radiation, or seed implants, throughout your prostate. Each seed implant is smaller than a grain of rice. The number of seeds will depend on the size of your prostate. The radiation will get weaker each day and run out in 2 to 10 months. Once the radiation is gone, the seeds will remain in your prostate, but they should not bother you. You will probably have the seeds implanted as an outpatient, without a hospital stay.
- HDR brachytherapy. Before treatment starts, a doctor will place tiny catheters (hollow tubes) throughout your prostate. For each treatment, the doctor will place 1 or more sources of high-dose radiation in the prostate through the catheters. Then, he or she will remove the radioactive material after a few minutes. The catheters will remain in place for the entire course of your treatment. But once you have received all of your treatments, the catheters will be removed. You will stay in the hospital or radiation clinic for the entire course of treatment.
External beam radiation therapy and brachytherapy can be used together.
For more informationabout external beam radiation and brachytherapy, see Radiation Therapy and You: Support for People with Cancer, a booklet from the National Cancer Institute. You can order a free copy at www.cancer.gov/publications or 1-800-4-CANCER (1-800-422-6237).
Until clinical trials are complete, we do not know if new treatments will be effective in the long-term.
New treatments for prostate cancer are being studied in clinical trials, which are research studies with people. Clinical trials give people with any stage of cancer the chance to try a new treatment that is not yet available outside the trial. But until the clinical trials are complete, we do not know if the new treatments will be effective in the long-term.
Some treatments that researchers are studying for early-stage prostate cancer include:
- Intensity-Modulated Radiation Therapy (IMRT). IMRT is a type of external beam radiation. It uses computers to deliver radiation precisely to the cancer. It also reduces damage to the healthy tissue nearby, such as the rectum and bladder.
- Proton beam therapy is also a type of external beam radiation. It uses protons rather than x-rays. The use of protons may allow a very high dose of radiation to reach the prostate while reducing the amount of normal tissue that is affected.
- Cryosurgery (also called cryoablation or cryosurgical ablation) is a type of treatment that involves freezing the prostate to destroy cancer cells. In this type of treatment, the doctor delivers liquid nitrogen to the prostate through a special probe. The doctor inserts the probe into the prostate through an incision between the scrotum and anus. Sometimes, the doctor may also use needles to deliver liquid nitrogen to the prostate. He or she can insert the needles through the skin without making an incision.
For more information about these treatments and other clinical trials, visit www.cancer.gov/clinicaltrials or call 1-800-4-CANCER (1-800-422-6237).
A Note About Hormone Therapy
Male sex hormones, such as testosterone, can help prostate cancer grow. Hormone therapy slows prostate cancer's growth by reducing the body's ability to make testosterone or by blocking testosterone's action in prostate cancer cells.
Hormone therapy can play a role in treating early-stage prostate cancer. For men with high-risk early-stage prostate cancer, it may be used along with radiation therapy. You can also receive it instead of surgery or radiation if:
- You are in your 70's or older or have other health problems
- Your cancer begins to change or grow while you are on active surveillance
Your doctor may suggest that you take hormone therapy for as little as 6 months or up to many years. Side effects may include loss of sex drive, erectile dysfunction (also called ED), hot flashes, and osteoporosis.