About This Booklet
As a man with early-stage prostate cancer, you will be able to choose which kind of treatment is best for you. And while it is good to have choices, this fact can make the decision hard to make. Yet, each choice has benefits (how treatment can help) and risks (problems treatment may cause).
Treatment often begins a few weeks to months after diagnosis. While you are waiting for treatment, you should meet with different doctors to learn about your treatment choices. Use this booklet to help you talk over treatment choices with your doctor before deciding which is best for you.
You will want to think about what is important to you. It’s also a good idea to include your spouse or partner in your decision. After all, having prostate cancer and the treatment choice you make affect both of you.
This booklet is a starting point.
Its purpose is to help you learn about early-stage prostate cancer, different treatments, and the benefits and risks of each type of treatment. Most men will need more information than this booklet gives them to make a decision about treatment. For a list of groups that provide more information and support, please see the Ways to Learn More section. Also, see that section if you have prostate cancer that has spread beyond the prostate or that has returned after treatment.
Things to Remember
There are many men with prostate cancer who have been in your shoes. Here are some things they would like you to know:
- There are treatment choices—be sure to know them all.
- Treatments and medical procedures keep getting better.
- Make the treatment choice that is right for you.
- Get the opinions of several different doctors, since some may suggest only the option they know best.
- Take the time you need to research your treatment choices before making a decision. There’s often no need to rush.
- Your spouse or partner plays an important role in the treatment that you choose and will be affected by your choice. Try to be open and honest with each other about your concerns.
- Organizations and support groups can help you learn how others in your situation are coping with prostate cancer.
- It is possible to live a full life after prostate cancer.
Facts about Prostate Cancer
What is the prostate?
The prostate is a gland that helps make semen. Semen is the milky fluid that carries sperm from the testicles through the penis during ejaculation. The prostate is part of the male reproductive system.
The prostate is about the size and shape of a walnut. It has sections, which are called lobes. The prostate lies low in the pelvis, below the bladder and in front of the rectum. The prostate surrounds part of the urethra, the tube that carries urine out of the bladder and through the penis.
Early-stage prostate cancer means that cancer cells are found only in your prostate. Compared with many other cancers, prostate cancer grows slowly. This means that it can take 10 to 30 years before a prostate tumor gets big enough to cause symptoms or for doctors to find it. Most men who have prostate cancer will die of something other than prostate cancer.
- Prostate cancer is most common in men age 65 and older, although younger men can be diagnosed with it as well.
- By age 80, more than half of all men have some cancer in their prostate.
- African American men tend to be diagnosed at younger ages and with faster-growing prostate cancer than men of other races.
Prostate cancer is most often found in early stages. When it is found early, there are a number of treatment choices available.
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.
Comparing Your Treatment Choices
The charts below list 9 common questions and answers for the 3 treatment choices discussed in this booklet. As mentioned before, most men will need more information than found in this booklet to reach their decisions. You may use the questions in these charts as a guide for talking with your doctor or learning more about your choices.
- Which treatment is a good choice for me?
- What can I expect during treatment?
- What are the benefits of each treatment?
- What are the side effects and other drawbacks of each treatment?
- How will this treatment affect my sex life?
- What can be done to help with side effects?
- Will I have pain?
- Will I need other treatments?
- How long can I expect to live after I have this treatment?
For more information about dealing with problems caused by radiation therapy, seeRadiation 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).
Medicines can help with pain or discomfort. Be sure to talk with your doctor or nurse about your pain.
For more information about pain and how to manage it, see Pain Control: 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).
For more information about treatment choices or clinical trials for prostate cancer, visit NCI’s Web site at www.cancer.gov/cancertopics/types/prostate or call the National Cancer Institute’s Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).
|Active Surveillance, Surgery, and Radiation Therapy|
Making a Choice About Treatment
Most prostate cancers found in the early stages grow slowly. This means that you usually do not have to rush to make a treatment choice. Often, you have many weeks to many months from the time you first learn you have prostate cancer until you have to make a choice.
Many men use this time to find out more about the different types of prostate cancer treatment. Be sure to find all of the information you need to answer your questions and be comfortable with your decision.
It may be helpful to use this extra time to attend a prostate cancer support group to talk with other men who have faced the same decision-making process. Think about calling the National Cancer Institute’s toll-free number to request contact information for prostate cancer organizations. See Ways to Learn More for ways to reach them.
Research shows that men feel better about their treatment choice when they take part in making their own treatment decision. Making this decision can be hard to do. The following are some ideas that may help.
Be prepared when you talk with your doctor.
- Ask Questions. Ask your doctor or nurse questions that you are
thinking about, even if you are not comfortable asking them. These
questions can be about topics that are new to you or side effects that
concern you. Write your questions down and bring them to your
doctor visit. (See Asking Questions for ideas of questions to ask.)
- Know your health history. Your doctor or nurse will want to know about your health history. This history includes your family history, whether you have already had prostate surgery, and whether you have any other illness, such as diabetes or heart problems.
- Talk about your treatment choices. It’s important to ask your doctors about all the treatment choices that are open to you. This includes benefits (how each treatment can help) and long- and short-term side effects.
- Take part in making a choice. Men who take an active part in their treatment tend to feel better about their treatment than men who let others decide for them. Let your doctor know how active you want to be in making this choice.
- Think about what is important to you. Keep in mind what’s important to you and what worries you. This is also a good time for you and your spouse or partner to have an open, honest discussion with each other about your treatment choices and their possible side effects.
- Ask a family member or trusted friend or caregiver to come to doctor visits with you. This person can help listen, ask questions, take notes, and talk with you about what your doctor or nurse said.
- Get a copy of your pathology report. Ask your doctor for a copy of this report and bring a copy with you when you see new doctors. Your pathology report includes the results of tests that describe details about your cancer. If you are seeing a new doctor, it’s important to bring all the information he or she requests to your visit.
- Get a 2nd or even 3rd opinion. Seeking other opinions means talking about prostate cancer treatment with other doctors. You may want to talk with other prostate cancer specialists, such as those listed in the Types of Doctors box.
Getting 2nd and 3rd opinions can be confusing because you may get different advice. Because of this, many men find it helpful to see a medical oncologist for a general view of prostate cancer treatment choices. Talking with other doctors can give you ideas to think about or help you feel better about the choice you are making. Most insurance companies pay for 2nd opinions. Some companies even require them. It is better to get a 2nd opinion than to worry that you made the wrong choice.
Many cancer centers allow men to meet with a urologist, radiation oncologist, medical oncologist, and pathologist in one visit. Check to see if your treatment center provides this type of care.
Types of Doctors
Here is a list of types of doctors who treat prostate cancer:
- Medical oncologist. A doctor who specializes in diagnosing and treating cancer using chemotherapy, hormone therapy, and biological therapy. This doctor is often the main health care provider for people with cancer. He or she can also treat side effects and may coordinate treatment given by other specialists.
- Pathologist. A doctor who finds diseases by studying cells and tissue under a microscope. Although you won’t meet with this doctor, he or she writes up a pathology report, which contains the information about your cancer from your biopsy or prostate surgery.
- Radiation oncologist. A doctor who treats cancer with radiation.
- Urologic oncologist. A doctor who treats cancers of the urinary system.
- Urologist. A doctor who treats diseases of the urinary system and male sex organs.
Learning as Much as You Want to Know
Many men with prostate cancer find that it helps to learn a lot about their cancer and its treatment. Doing so can help you feel more in control and at ease with the treatment you choose.
You can learn more by reading books and articles, searching the internet, or calling organizations that focus on prostate cancer. But keep in mind that too much information can be overwhelming as you are adjusting to your diagnosis. Instead, learn as much as you want to know when you are ready. Later, you can always find out more. Let your doctor or nurse know what else you need to know to be comfortable reaching a decision.
Some men want to read books and articles about the current research on prostate cancer treatment choices. Others prefer to meet with men in support groups who have had prostate cancer to learn how they made their treatment choices. Some men may not want to talk or think about it, at first. But later, they are they ready for more information. All of these approaches are natural ways to cope with a diagnosis of prostate cancer.
Thinking About Your Feelings and Values
It’s normal to have many feelings at this time. You may have many strong feelings at once. You may feel overwhelmed or angry. Your spouse or partner will also feel a range of feelings, but not have the same ones at the same time as you do.
Finding out you have cancer can bring up fears of the cancer getting worse or of dying. You may also worry about changes to your body or being intimate with your spouse or partner. Many men describe a feeling of loss—loss of the life they had before cancer, loss of energy levels, or the physical loss of the prostate. These feelings are a normal part of the coping process.
Your spouse or partner may be worried about losing you, changes to your lives, and how to best give you the support you need. At first, your loved one may want to talk about it more than you do. If you find that you need time to adjust and sort out your feelings and values, let your spouse or partner and family know your needs. Chances are that they are also trying to cope with the news and may not know how best to help you. If you are holding your worries and feelings inside for too long and your silence is hurting you or your family, ask your doctor, counselor, or religious leader for suggestions about getting help.
Reaching a decision about how you want to treat your prostate cancer is very personal—it is a balance of what is important to you, what you value the most, what types of treatment choices are available to you, and what the benefits and risks are.
Talking With Others
Along with talking with their doctors and spouse or partner, many men find it helpful to talk with others, such as:
- Family. This includes your relatives and close friends who care about you. They can support your treatment choice.
- Men who have faced prostate cancer. There is a lot to learn from other men who have faced these same prostate cancer treatment decisions. You may want to join a support group or meet with others to talk about the choices they made and what life is like now that treatment is over. Remember that while your stage of prostate cancer may be the same as someone else’s, your life and desires may be very different.
- Others who can help. You may have other people in your life who can help. This may be a neighbor, counselor, social worker, or religious leader you like and trust.
You may find it helpful to ask the following questions:
- What is the clinical stage and Gleason score of my cancer?
- Is my cancer low-, medium-, or high-risk?
- What treatment do you recommend?
Surgery (What type of surgery? Can the nerves be spared? How often do you do this procedure?)
Radiation (What type of radiation? What can be done to reduce side effects?)
- What are the short- and long-term side effects of this treatment?
- What are my chances of:
Becoming incontinent _______________________________
Developing ED? ___________________________________
Having other bladder or bowel problems? ________________
- What are the chances of the cancer coming back if I have this treatment?
- What are my chances of survival?
- May I have a copy of my pathology report? _____________
- If I want to have another pathologist look at my prostate biopsy results, how do I get the slides?
Making a Choice
“Prostate cancer gives you the opportunity to make a deliberate, considered choice. In the majority of cases, the disease is very slow growing and is never a medical emergency. With prostate cancer, you have ample time to assess the situation, evaluate your particular needs and resources, and devise the most sensible, strategic plan of action. Doctors can and should help you to understand your medical situation, but only you can decide what trade-offs you can tolerate, what level of risk you find acceptable, and which potential sacrifices you’re willing to make.”
—Dr. Peter Scardino, Chairman of the Department of Urology, Memorial Sloan Kettering Cancer Center
Ways to Learn More
National Cancer Institute (NCI)
You can find out more from these free NCI services:
Free booklets that are available include:
- What You Need To Know About Prostate Cancer
- Radiation Therapy and You: Support for People With Cancer
- Pain Control: Support for People With Cancer
- When Someone You Love Is Being Treated for Cancer: Support for Caregivers
Other Federal Resources
Call: 1-800-MEDICARE (1-800-633-4227)
National Kidney and Urologic Diseases Information Clearinghouse
American Cancer Society Man-to-Man Program
This support group of the American Cancer Society offers advice on coping with illness and the side effects of treatment, along with newsletter archives and a directory of prostate cancer publications.
Call: 1-800-ACS-2345 (1-800-227-2345)
The Cancer Support Community
Dedicated to providing support, education, and hope to people affected by cancer.
CancerCare is a national nonprofit agency that offers free support, information, financial assistance, and practical help to people with cancer and their loved ones. Services are provided by oncology (cancer) social workers and are available in person, over the telephone, and through the agency’s Web site. A section of the Cancer-Care Web site and some publications are available in Spanish, and staff can respond to calls and e-mail in Spanish.
Call: 1-800-813-HOPE (1-800-813-4673)
Fertile Hope is a national organization that provides reproductive information, support, and hope to cancer patients whose medical treatments present the risk of infertility. The organization offers fertility preservation financial assistance choices for patients.
Prostate Cancer Foundation
The Prostate Cancer Foundation is a nonprofit organization that provides funding for research projects to improve methods of diagnosing and treating prostate cancer. It also offers printed resources for prostate cancer survivors and their families. The mission of the Prostate Cancer Foundation is to find better treatments and a cure for prostate cancer.
Call: 1-800-757-CURE (1-800-757-2873)
Urology Care Foundation
The Urology Care Foundation is committed to promoting urology research and education. They work with researchers, healthcare professionals, patients and caregivers to improve patients' lives. The Urology Care Foundation is the official foundation of the American Urological Association (AUA)—an organization of roughly 19,000 urologists.
Us TOO International
Us TOO International Prostate Cancer Education and Support Network is a nonprofit education and support group organization with more than 325 chapters throughout the world. It provides men and their families with fellowship, peer counseling, and timely, personalized, unbiased, and reliable information about prostate cancer, enabling informed choices about detection, treatment choices, and quality of life after treatment.
Call: 1-800-80-USTOO (1-800-808-7866)