Treatment for prostate cancer may involve active surveillance, surgery, radiation therapy – including brachytherapy (prostate brachytherapy) and external-beam radiation therapy, proton therapy, high-intensity focused ultrasound (HIFU), cryosurgery, hormonal therapy, chemotherapy, or some combination. Treatments also extend to survivorship based interventions. These interventions are focused on five domains including: physical symptoms, psychological symptoms, surveillance, health promotion and care coordination. However, a published review has found only high levels of evidence for interventions that target physical and psychological symptom management and health promotion, with no reviews of interventions for either care coordination or surveillance. The favored treatment option depends on the stage of the disease, the Gleason score, and the PSA level. Other important factors include the man's age, his general health, and his feelings about potential treatments and their possible side-effects. Because all treatments can have significant side-effects, such as erectile dysfunction and urinary incontinence, treatment discussions often focus on balancing the goals of therapy with the risks of lifestyle alterations.
If the cancer has spread beyond the prostate, treatment options change significantly, so most doctors who treat prostate cancer use a variety of nomograms to predict the probability of spread. Treatment by watchful waiting/active surveillance, HIFU, external-beam radiation therapy, brachytherapy, cryosurgery, and surgery are, in general, offered to men whose cancer remains within the prostate. Clinicians may reserve hormonal therapy and chemotherapy for disease that has spread beyond the prostate. However, there are exceptions: radiation therapy can treat some advanced tumors, and hormonal therapy some early-stage tumors. Doctors may also propose cryotherapy (the process of freezing the tumor), hormonal therapy, or chemotherapy if initial treatment fails and the cancer progresses.
Active surveillance
Active surveillance is observation and regular monitoring without invasive treatment. In the context of prostate disease this usually comprises regular PSA blood tests and prostate biopsies. Active surveillance is often used when an early stage, slow-growing prostate cancer is suspected. However, watchful waiting may also be suggested when the risks of surgery, radiation therapy, or hormonal therapy outweigh the possible benefits. Other treatments can be started if symptoms develop, or if there are signs that the cancer growth is accelerating .
Approximately one-third of men who choose active surveillance for early-stage tumors eventually have signs of tumor progression, and they may need to begin treatment within three years. Men that choose active surveillance avoid the risks of surgery, radiation, and other treatments. The risk of disease progression and metastasis (spread of the cancer) may be increased, but this increase risk appears to be small if the program of surveillance is followed closely, generally including serial PSA assessments and repeat prostate biopsies every 1–2 years depending on the PSA trends.
Study results in 2011 suggest active surveillance is the best choice for older 'low-risk' patients.
Surgery
Surgical removal of the prostate, or prostatectomy, is a common treatment either for early-stage prostate cancer or for cancer that has failed to respond to radiation therapy. The most common type is radical retropubic prostatectomy, when the surgeon removes the prostate through an abdominal incision. Another type is radical perineal prostatectomy, when the surgeon removes the prostate through an incision in the perineum, the skin between the scrotum and anus. Radical prostatectomy can also be performed laparoscopically, through a series of small (1 cm) incisions in the abdomen, with or without the assistance of a surgical robot.
Radical prostatectomy Radical prostatectomy is effective for tumors that have not spread beyond the prostate; cure rates depend on risk factors such as PSA level and Gleason grade. However, it may cause nerve damage that may significantly alter the quality of life of the prostate cancer survivor. Radical prostatectomy has been associated with a greater decrease in sexual function and increased urinary incontinence (mainly stress incontinence) than external beam radiotherapy, an alternative treatment.
Radical prostatectomy has traditionally been used alone when the cancer is localized to the prostate. In the event of positive margins or locally advanced disease found on pathology, adjuvant radiation therapy may offer improved survival. Surgery may also be offered when a cancer is not responding to radiation therapy. However, because radiation therapy causes tissue changes, prostatectomy after radiation has higher risks of complications.
To avoid the adverse side effects of a radical prostatectomy, doctors may recommend deferred treatment which can involve observation and palliative treatment or active monitoring with some local treatments as needed. When compared with observation and palliative treatment, radical prostatectomy probably reduces the risk of dying for any reason, including dying from prostate cancer. Between radical prostatectomy and active monitoring, the risk of dying for any reason, including from prostate cancer, is likely the same. The surgery also probably reduces the risk of the cancer spreading or becoming more aggressive. Erection problems and urine leakage are probably more likely for patients who receive surgery than those who receive active monitoring or observation.
Laparoscopic approach Laparoscopic radical prostatectomy (LRP) is a new way to approach the prostate surgically with intent to cure. Contrasted with the open surgical form of prostate cancer surgery, laparoscopic radical prostatectomy requires a smaller incision. Relying on modern technology, such as miniaturization, fiber optics, laparoscopic radical prostatectomy is a minimally invasive prostate cancer treatment but is technically demanding and seldom performed in the United States.
Robot assisted Radical Prostatectomy (RARP) Some believe that in the hands of an experienced surgeon, robotic-assisted radical prostatectomy (RARP) may reduce positive surgical margins when compared to radical retropubic prostatectomy (RRP) among patients with prostate cancer according to a retrospective study. The relative risk reduction was 57.7%. For patients at similar risk to those in this study (35.5% of patients had positive surgical margins following RRP), this leads to an absolute risk reduction of 20.5%. 4.9 patients must be treated for one to benefit (number needed to treat = 4.9). Other recent studies have shown RALP to result in a significantly higher rate of positive margins. Other studies showed no difference of robotic to open surgery. A review comprehensively analyzed the evidence from studies in men with prostate cancer that compared RALP with open radical prostatectomy and found no difference in the reduction of mortality from this cancer, the recurrence or all-cause mortality. The quality of life with both procedures would be similar in relation to urinary and sexual function, and there appear to be no differences in postoperative surgical complications. Robotic surgery can have a small effect on postoperative pain between right after surgery, a shorter hospital stay and a lower requirement for blood transfusions.
One common problem associated with this surgery is incontinence, or urinary leakage, which occurs for 6–12 months after the removal of the catheter placed during surgery. When using RALP, surgeons can either proceed with a standard approach or use an approach that doesn't cut the tissue connections between the front of the bladder and the back of the abdominal wall, Retzius-sparing RALP. Retzius-sparing RALP probably improves continence within one week after catheter removal but may be more likely to leave positive surgical margins that could allow the cancer to come back. Retzius-sparing RALP may also reduce urinary leakage between 3–6 months after surgery, but by 12 months continence is likely similar.
Transurethral resection Transurethral resection of the prostate, commonly called a "TURP," is a surgical procedure performed when the tube from the bladder to the penis (urethra) is blocked by prostate enlargement. In general, TURP is done for benign prostatic hyperplasia and is not meant as definitive treatment for prostate cancer. During a TURP, a small instrument (cystoscope) is placed into the penis and the blocking prostate is cut away by cautery.
Surgical removal of the testicles In metastatic disease, where cancer has spread beyond the prostate, removal of the testicles (called orchiectomy) may be done to decrease testosterone levels and control cancer growth. (See hormonal therapy, below).
Complications of surgery The most common significant complications of surgery are erectile dysfunction and loss of urinary control. Reported rates of both complications vary widely.
Erectile dysfunction Although penile sensation and the ability to achieve orgasm usually remain intact, erection and ejaculation are often impaired. Medications such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) may restore some degree of potency. For men struggling with erections after a prostatectomy, taking medication on a scheduled basis may result in a similar self-reported rate and quality of erections as taking medication as needed. There may also be similar rates of serious unwanted side effects for both types of medication usage. For most men with organ-confined disease, a more limited "nerve-sparing" technique may help reduce urinary incontinence and impotence.
Urinary incontinence Radical prostatectomy, transurethral resection of the prostate (TURP), and radiation therapy are the main causes of stress incontinence in men, with radical prostatectomy being the top cause. In most cases, the incontinence resolves within 12 months with conservative treatment. Multiple factors, such as injury of the urethral sphincter or nervous bundles can play a role, causing mostly stress incontinence. Stress urinary incontinence happens when the urethral sphincter (the muscular sphincter that closes the bladder) fails to properly close, leading to leakage of urine in situations where the abdominal pressure is higher than usual, such as when laughing, sneezing, or coughing.
Conservative treatment, such as pelvic floor muscle training (Kegel exercise) has been prescribed to improve urinary continence, the evidence for efficacy in men after radical prostatectomy has come into question. According to information from the Men After Prostate Surgery (MAPS) randomized control trial, pelvic floor muscle training was not shown to be therapeutic or cost effective in improving urinary continence.
Other therapies include the use of penile clamps, transurethral bulking agents, and catheters, however, the most commonly used surgical therapies performed are the placement of a urethral sling or artificial urinary sphincter. For people with moderate to severe stress urinary incontinence after prostate surgery, artificial urinary sphincter is the treatment of choice, after all the other conservative measures fail.
Radiation therapy