Overview
Prostate cancer is the most common cancer in men, with lung cancer the second most common. African-American men are known to have a greater risk for developing prostate cancer. Because of significant improvements in screening and early detection of prostate cancer over the past 30 years, the outlook for many men diagnosed with this disease has improved.
If you have been diagnosed with localized prostate cancer (stage I or II), you probably have many questions and concerns about your disease and its treatment. This treatment summary, which is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™), will help you understand the best available treatments for localized prostate cancer. Talk to your doctor about these options so that together you can decide on a treatment plan that is right for you.
Background
The prostate gland lies just below the bladder and produces a fluid that forms part of the semen. Men older than 65, those with a family history of prostate cancer (especially if a brother or father has been diagnosed with prostate cancer), and those of African descent are at higher risk for prostate cancer.
Prostate cancer is often detected at a very early stage with prostate-specific antigen (PSA) blood test and digital rectal examination (DRE).
The term localized refers to cancer that is confined to the gland in which it originated and that has not spread to other organs. For stage III or IV prostate cancer, which has spread beyond the prostate, see Prostate Cancer - Advanced.
Diagnosis
Some men worry that they may have prostate cancer when they develop a non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). This treatable condition may cause difficulties with urination but is not associated with cancer.
Because the initial signs and symptoms of BPH may be the same as prostate cancer, it is important that your prostate cancer diagnosis be confirmed with a biopsy, in which a specimen of your prostate tissue is removed and looked at under a microscope to determine whether it contains cancer cells.
If prostate cancer is present, it will be given a grade, which is based on whether the cancer can form normal-appearing glands when looked at by a pathologist under a microscope. The most commonly used grading system for prostate cancer is called the Gleason score, which ranges from 2 to 10. In general, the lower the Gleason score, the more likely that the tumor is growing slowly and that it is less likely to spread.
Staging
Doctors divide prostate cancer into stages I to IV. Each stage characterizes the size of the tumor and whether and how much it has spread to other parts of the body. Localized prostate cancer is stage I or II cancer, which means it has not spread beyond the prostate based on physical exam or X-ray studies.
Staging is an important part of developing the best treatment plan for you.
For a more detailed discussion of staging, see the Cancer Staging Guide.
Treatment
Because men with localized prostate cancer may live with the disease for many years, you and your doctor must carefully evaluate both the effectiveness of the treatments and their side effects. Factors to consider include:
- The likelihood that the cancer will recur (come back) after treatment, which is predicted by stage, Gleason score, and PSA level; localized prostate cancer usually has a low risk of recurring
- Your age and life expectancy
- Other diseases and conditions you may have that may make certain treatments risky or unnecessary
- The potential side effects of treatment
- Your personal preferences
You should expect to have a detailed conversation with your doctor regarding both your preferences for treatment and about your general health. The goal of this conversation is to determine whether your prostate cancer is likely to become life-threatening during your expected lifetime. Your doctor will use a set of statistical tables that estimate the typical life expectancy of someone your age with your general state of health. Your doctor will also look at the Gleason score for your tumor and how long it has taken for your PSA value to double.
All of these factors together will enable your doctor to estimate your life expectancy. Your doctor then will estimate how long a prostate cancer like yours might be expected to take to become life-threatening and the likelihood that either surgery or radiation therapy will cure your cancer. Although none of these estimations may be precisely correct for you, they provide information about what would happen to the average patient in your situation. Your doctor will also talk with you about treatment options and help you make an informed decision about whether and how to be treated.
Your doctor should provide you with a written care plan explaining what treatments you will have, when they will occur (and how often, if you are receiving radiation), and what type of side effects you may experience. Some side effects can be anticipated and you can undergo pretreatment to minimize them. You will be asked to sign an informed consent form indicating that you have been told about your treatment and the side effects one might expect. Your doctor should also tell you how often his or her patients have complications from treatment. The percentage of patients who eventually have bowel or bladder incontinence or impotence after therapy given by a particular doctor is an important consideration in selecting the doctor who will take care of you.
It is very important that you ask your doctor or nurse every question you have. Cancer and its treatment are complicated and most patients have questions.
Treatment
A number of approaches are used for managing localized prostate cancer, including active surveillance, radiation therapy, and surgery.
Active Surveillance
For men whose cancer is small, localized, and not causing any symptoms, and whose PSA and Gleason scores are in the low ranges, “active surveillance,” “watchful waiting,” or “expectant management,” may be an option. Active surveillance is also called observation.
Together, you and your doctor can carefully weigh several factors to determine whether active surveillance—that is, not treating the cancer, but instead watching for any indication that the cancer is growing—might be the best course of action. Prostate cancer often occurs in older men who may or may not have other serious health conditions.
Because prostate cancer often progresses very slowly, it may not be a significant threat to a man’s life or health. For this reason, one important consideration is whether treatment for localized prostate cancer might make other conditions more serious or whether the side effects of treatment might decrease your quality of life. You and your doctor should look at what effect treatment might have on your quality of life and life expectancy. Some men prefer to take a “wait-and-see” attitude, and feel comfortable that there is only a small chance that the cancer will become more serious; others prefer to undergo treatment. If your prostate cancer makes you a good candidate for active surveillance, or if you have other serious health concerns, the decision is up to you and your doctor. Each man has different concerns.
If you decide to forego treatment for a period of time, your doctor will actively monitor the course of your disease with the expectation that treatment will begin only if and when the cancer progresses or causes symptoms.
Active monitoring is an option for men whose cancer has a low risk of recurrence and for older or less-healthy men who have an intermediate, or moderate risk of recurrence. Men who are being actively monitored must make sure to see their doctor at regular, agreed-upon intervals, typically every 6 months, but of course should contact their doctor immediately if they begin having symptoms such as pain, swelling, or difficulty urinating. A digital rectal exam (DRE) and PSA testing should be performed during each visit. Sometimes a needle biopsy, in which tissue or fluid from the prostate is removed with a needle, may be required. Changes in the results of these tests and exams may indicate that treatment would be beneficial.
The advantage of active surveillance is that there are no side effects or complications from treatment. The disadvantages are that the tumor may be larger or more aggressive than originally thought or that the cancer may grow, and rarely spread, undetected between doctor visits.
Radiation Therapy (Radiotherapy)
Radiotherapy, the use of high-energy radiation from X-rays, gamma rays, and other sources to kill cancer cells and shrink tumors, is effective in treating localized prostate cancer. The types of radiotherapy include external beam radiation therapy and brachytherapy.
External Beam Radiation Therapy (EBRT)
With EBRT, high-energy rays are used to kill the prostate cancer cells and shrink the tumor. The equipment used is similar to an X-ray machine, and the treatment is often performed on an outpatient basis 5 days per week for several weeks.
With EBRT, the risks for bladder obstruction and bladder control problems are low. In the short term, the risk for erectile dysfunction (impotence) is also low, but problems with impotence may occur later.
In addition, other side effects may occur long after treatment is completed and last for an undetermined amount of time. These may include urinary or bowel problems involving frequency, urgency, or pain.
Brachytherapy
In this therapy, many small radioactive seeds are implanted into the prostate, usually under ultrasound guidance and anesthesia. Brachytherapy alone is appropriate only for men with a low risk for recurrence.
The time it takes to recover from brachytherapy is short, and this treatment produces very low rates of erectile dysfunction (impotence). Side effects may be similar to those seen with external radiation.
For men at low risk for cancer recurrence, either EBRT or brachytherapy is an appropriate treatment option. Men at moderate (intermediate) risk for recurrence may be treated with EBRT alone, or in combination with brachytherapy. Short-term androgen deprivation therapy (ADT), the use of drugs to block the hormones that promote tumor growth, may also be used in addition to radiation therapy for men at intermediate risk. These drugs can shrink the tumor and make EBRT more effective. High-risk prostate cancer requires EBRT and 2 to 3 years of androgen deprivation therapy.
Surgery
Radical Prostatectomy: Surgical Removal of the Prostate
Removing the entire prostate is a highly effective treatment for localized prostate cancer, but it is associated with more side effects in the short term than radiotherapy. It is an option for men with intermediate risk for recurrence, or young men at low risk who have many more years to live and want to ensure that the cancer does not come back. High risk prostate cancer may be treated with radical prostatectomy especially in younger men but additional treatment is often required.
The pelvic lymph nodes may also be removed during surgery to determine whether the cancer has spread outside the prostate.
There are three major types of operations to remove the prostate:
Open/traditional surgery
In open surgery, the surgeon makes an incision either through the lower abdomen or through the perineum (the area between the rectum and the scrotum) and removes the prostate and any nearby tissue where cancer may have spread. The success of this surgery depends on the skill and experience of the surgeon; ask your doctor how many of these operations he or she has performed.
In this technique, four or five tiny incisions are made in the abdomen, and a long tube-like camera (laparoscope) is used to view the area while the surgeon uses long instruments to remove the prostate and affected tissues. The smaller incisions allow for quicker healing than open surgery, but there is a risk of incomplete tumor removal. It is still unclear whether laparoscopic surgery can give a better outcome than open surgery. Again, success depends a great deal on the skill and experience of the surgeon; ask your doctor how many of these operations he or she has performed.
This method is also laparoscopic, as described above. However, in this technique, the doctor performs the operation by controlling a system made up of a laparoscope and two or three robotic arms. Robotic arms can make more precise movements with delicate instruments than can a surgeon’s hand. Such precise manipulation creates less damage to surrounding tissue and may more reliably leave the nerves intact that control erections, although the lack of the sense of touch may also affect the surgeon’s performance.
It is still unclear whether robotic surgery can give a better outcome than open or laparoscopic surgery. Again, success depends heavily on the skill and experience of the surgeon. If you opt for this surgery, ask the surgeon how many of these operations he or she has performed.
After surgery, the urethra, which is the tube through which urine leaves the body, needs time to heal. You will have a catheter, a tube that is put through the urethra into the bladder to drain urine. This will need to remain in place for 3 to 10 days. Your nurse or doctor will show you how to use it when you are at home.
If your prostate is removed, you will no longer produce semen. If you want to father children, talk to your doctor before your treatment about sperm banking before surgery or a sperm-retrieval procedure after surgery.
Removal of the prostate prevents the spread of cancer and cures the disease if cancer cells have not spread outside the prostate. Many men who undergo nerve-sparing surgery will be able to have erections. After surgery, some men may have urinary problems, but these are usually temporary. Although some men may become impotent, nerve-sparing surgery is done with the hope of avoiding this.
If any prostate surgery or treatment results in impotence, there are ways to manage and live well with this effect. Talk to your doctor about these before surgery.
Life After Treatment
Because prostate cancer can recur (come back) even after treatment, follow-up care is very important. After therapy, make sure you see your doctor for a PSA test and DRE at regular, agreed-upon intervals, usually every 6 to 12 months.
Prognosis
In determining a prognosis (the likely course or outcome of a disease and its treatment), a doctor may look at cancer survival statistics taken from studies of large groups of patients. However, such statistics:
- Are estimates only
- Can vary widely with each cancer stage
- Are sometimes based on older data that do not reflect recent advances in early detection and treatment
- Cannot be used to precisely predict your survival
Your individual prognosis will be affected by many factors, including:
- Your age
- Your overall health
- The type, stage, grade, and other characteristics of your cancer
- Your response to the treatment(s) used
New therapies and combinations of therapies are enabling people with cancer to live longer, better quality lives than ever before. Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life. You may want to find out whether you are eligible to participate in a clinical trial in which new and experimental therapies are compared against standard treatments.