What are the treatment options prostate cancer?

Treatment options which may be considered include: watchful waiting (no active treatment), surgery, radiotherapy, hormone treatment, and less commonly, chemotherapy. Often a combination of two or more of these treatments are used. The treatments used depend on:

• The cancer itself - its size and stage (whether it has spread), the grade of the cancer cells, the PSA level, AND
• The man with the cancer - your age, your general health, and personal preferences for treatment.

For example, certain types of prostate cancer are confined to the prostate, are slow growing and are unlikely to affect your life expectancy. Some types are more aggressive, more likely to spread and may cause serious illness and lead to death unless treated. The risks and possible side-effects of treatment are another consideration.

You should have a full discussion with a specialist who knows your case. They will be able to give the pros and cons, likely success rate, possible side effects, and other details about the various possible treatment options for your type of cancer.

You should also discuss with your specialist the aims of treatment. For example:

• Treatment may aim to cure the cancer. In particular, the earlier the stage of the cancer, the better the chance of a cure. (Doctors tend to use the word 'remission' rather than the word 'cured'. Remission means there is no evidence of cancer following treatment. If you are 'in remission', you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.)
• Treatment may aim to control the cancer. If a cure is not realistic, with treatment it is often possible limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.
• Treatment may aim to ease symptoms. Even if a cure is not possible, treatments may be used to reduce the size of a cancer which may ease symptoms such as pain. If a cancer is advanced then you may require treatments such as nutritional supplements, painkillers, or other techniques to help keep you free of pain or other symptoms.

Watchful waiting
In some cases it may be best not to have any active treatment but to see how the cancer develops. This is called 'watchful waiting'. Various factors are taken into account such as the stage of the cancer, your age, general health, the impact and potential side-effects if treatment were to be used, etc. Watchful waiting may be more appropriate for men where the cancer is not causing much in the way of symptoms, is slow growing, especially in older men. With a watchful waiting approach you will need regular check ups and the decision about treatment can be reviewed at any time.

Surgery
Removing the prostate can be curative if the cancer is in an early stage (confined to the prostate and not spread.) It is a major operation and so tends to be advised more often for younger men whose general health is good, especially if the cancer grade means the cancer is likely to spread in the future. Side-effects such as impotence may occur following surgery to remove the prostate.

Even if the cancer is advanced and a cure is not possible, surgery may still have a place to ease symptoms. For example, a blockage of the flow of urine may be eased by an operation.

Radiotherapy
Radiotherapy is a treatment which uses high energy beams of radiation which are focussed on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. (There is a separate leaflet which gives more details about radiotherapy.)

Radiotherapy may be used as an alternative to surgery, or may be used in addition to surgery. Two types of radiotherapy are used for prostate cancer, external and internal. Again, the type chosen depends on various factors such as the size, grade, and stage of cancer, etc. Some people have both types.

• External radiotherapy. This is where radiation is targeted on the prostate cancer from a machine. (This is common type of radiotherapy used for many types of cancer.)
• Internal radiotherapy (brachytherapy). This treatment involves inserting a small radioactive implant into the cancerous tumour, or next to the tumour. Sometimes radioactive 'seeds' are placed into the prostate gland. The 'seeds' are left in place permanently but lose their radioactivity over time. Sometimes a larger radioactive implant is inserted into the prostate for a short time and then removed.

Even if the cancer is advanced and a cure is not possible, radiotherapy may still have a place to ease symptoms. For example, radiotherapy may be used to shrink secondary tumours which have spread to bones and are causing pain.

Hormone treatment
Prostate cancer cells need the male hormone called testosterone to grow and multiply well. Testosterone is made in the testes and circulates in the bloodstream. Hormone treatments aim to stop you from making testosterone or to block the effect of testosterone on prostate cancer cells. Hormone treatments dont cure prostate cancer but may greatly slow down the growth of the cancer for a number of years.

The level of testosterone can be reduced by surgery or by drugs.

• Surgery. This involves removing the testes (orchidectomy). Without testes you no longer make testosterone.
• Drugs. Two groups of drugs are available:
  • Drugs which work on the pituitary gland. For example: goserelin, leuprorelin and triptorelin. (Your pituitary gland makes a hormone which circulates in the bloodstream to stimulate the testes to make testosterone. These drugs stop your pituitary from making this stimulating hormone.)
  • Drugs which block the action of testosterone (anti-androgen drugs). For example: flutamide, bicalutamide and cyproterone acetate.

Hormone treatments can cause side-effects such as erectile dysfunction (impotence) and other problems. Hormone treatment may be used in addition to surgery or radiotherapy. It may be used alone in cases where the cancer is more advanced.

Chemotherapy
Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stop them from multiplying. See separate leaflet called chemotherapy for more details. Chemotherapy is not used as much as the above treatments for prostate cancer.

What is the prognosis (outlook)?

The outlook for prostate cancer is very variable. Some prostate cancers are slow growing and do not affect life expectancy. On the other hand some are already spread to other parts of the body when they are diagnosed and can lead to death. The response to treatment is also variable. The specialist who knows your case can give more accurate information about your particular outlook, and how well your type and stage of cancer is likely to respond to treatment.

Screening for prostate cancer

Screening for prostate cancer is controversial. A routine blood test which shows a high PSA may indicate that you have prostate cancer. However, there are other causes of a high PSA. Also, many prostate cancers are slow growing and do not cause problems, particularly in older men. Some experts believe that if all men were screened then there may be many men found with a raised PSA level. Many men may then be investigated and treated unnecessarily with all the possible risks and side-effects of the investigations and treatment. Put simply, some people believe that screening for all men may do more harm than good.

Currently there is no national screening programme in the UK. However, you can decide for yourself if you would like a PSA test. It is best to discuss the pros and cons of the test with your GP. After counselling, if you decide that you would like the test, many GPs will do the test on request. There are other leaflets in this series which discuss the PSA screening test in more detail.

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