Treatment options

Treatment options

Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health, called a multidisciplinary team. 

Treatment for prostate cancer depends on: 

• the stage of the disease 
• the location of the cancer 
• the severity of symptoms 
• your general health and wishes. 

Treatment may involve the following: 

Management options

For some people with prostate cancer, treatment may not be recommended straight away. 

Active surveillance

If you have low risk, localised prostate cancer, you might have ‘active surveillance’. This is because prostate cancer often grows slowly and, for some people, the side effects of treatment can outweigh the potential benefits. 

You will likely have regular blood tests to check your PSA level, regular digital rectal examinations, and mpMRI scans and biopsies. If the cancer starts to grow or there are signs that it is getting worse, you might start treatment. 

Watchful waiting

You might be monitored in case symptoms develop or change – this is called ‘watchful waiting’. This may be suggested if you are older and the cancer is unlikely to cause you a problem in your lifetime. It can also be an option if you have other health problems that would make it hard to handle treatments.^[7] 

You will likely have regular PSA tests. If symptoms develop, such as bone pain, you will be offered treatment to manage these symptoms. 

Surgery

If the tumour has not spread outside the prostate, you might have surgery to remove the prostate, part of the urethra and the seminal vesicles. This is called a radical prostatectomy. For intermediate-risk or high-risk prostate cancer, nearby lymph glands may also be removed (called pelvic lymph node dissection).^[7] 

There are 2 main types of radical prostatectomy: 

• Open – where an incision (cut) is made in your belly (retropubic area) or in the skin between the anus and the scrotum (perineum) and the prostate is removed through the cut; nearby lymph nodes may also be removed during radical retropubic prostatectomy 
• Laparoscopic (or ‘keyhole’) – where several small cuts are made in your belly and the prostate is removed using special surgical instruments; robotic-assisted surgery is a type of laparoscopic surgery where the surgeon is assisted by a special machine (robot). 

After surgery, a catheter will be inserted into your penis to help drain your bladder while you heal. This will stay in place for about 1 to 2 weeks, and you will be able to urinate normally after it is removed. 

Another type of surgery, called transurethral resection of the prostate (TURP), uses a piece of equipment called a resectoscope to remove some of the tissue in the prostate. The resectoscope is inserted in the penis and uses heat or a laser to remove tissue from the prostate. This type of surgery is not often used as the primary treatment for prostate cancer, but can be used to relieve symptoms, or for people who can’t have a radical prostatectomy.

Possible side effects of surgery for prostate cancer include: 

• urinary incontinence (where urine leaks out or you can’t control your urination) 
• erectile dysfunction or impotence 
• orgasms that are less intense 
• dry orgasms (where semen is no longer produced because the prostate and seminal vesicles have been removed) 
• shortening of the penis 
• lymphoedema. 

Some side effects get better over time, but others may be lifelong. 

Surgery for prostate cancer can also lead to infertility because of erectile dysfunction or because the sperm can no longer travel out of the penis, although other parts of semen might still be produced. Nerve-sparing surgery is a type of open surgery that aims to avoid damaging the nerves that control erections. However, problems with erections are common even if this surgery is performed.^[8] 

Radiation therapy

Radiation therapy can be used to treat early prostate cancer, or if surgery is not an option. This can be: 

• external beam radiation therapy – where a machine outside the body directs radiation towards the prostate gland; it includes intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT), stereotactic body radiation therapy (SBRT) and proton therapy^[8] 
• internal radiation therapy (brachytherapy) – where small radioactive ‘seeds’ are placed inside the prostate; some seeds give off low doses of radiation and are left in place permanently (i.e. not removed after the radiation has been used up), while others are held in place temporarily using catheters and give off higher doses of radiation for a shorter time. 

Some side effects of radiation therapy include:^[9] 

• urinary problems, including needing to urinate more frequently, a burning feeling when urinating, or a slower flow of urine 
• bowel problems, including passing smaller and more frequent motions, or feeling that you can’t completely empty your bowel 
• erectile dysfunction or impotence 
• dry orgasms 
• infertility. 
• fatigue 

Some side effects get better over time, but others may be lifelong. 

Radiopharmaceuticals

Radiopharmaceutical therapy uses radiation therapy delivered directly to specific cancer cells. This is done with radioactive substances targeting a specific protein called PSMA (prostate-specific membrane antigen) which is highly expressed in prostate cancer cells. Examples of radiation therapy by infusion include Lutetium Lu177 therapy. 

Hormone therapy

Some types of cancer, including prostate cancer, need certain hormones to grow. By reducing the levels of these hormones in the body, the cancer can slow its growth or even shrink. 

Prostate cancer cells use hormones called androgens – an example of an androgen hormone is testosterone. Hormone therapy for prostate cancer is also called androgen deprivation therapy (ADT), and there are several types: 

• surgical removal of one or both testicles (orchiectomy); because the testicles make androgens, this surgery is a type of hormone therapy because it results in reduced androgen levels 
• drugs that stop the testicles from making testosterone (called luteinising hormone-releasing hormone analogues) e.g. goserelin or leuprorelin 
• drugs that stop androgen production at different body sites (called androgen synthesis inhibitors) e.g. abiraterone or ketoconazole 
• drugs that block the androgen receptors on cancer cells so they can’t receive hormones (called antiandrogens) e.g. apalutamide, darolutamide, bicalutamide or enzalutamide. 

Some of the common side effects of hormone therapy can include: 

• erectile dysfunction 
• loss of sexual desire 
• hot flushes 
• growth of breast tissue 
• osteoporosis or weakened bones 
• Fatigue 
• Muscle weakness 
• Weight gain 

Chemotherapy

Chemotherapy can be used to treat advanced or metastatic prostate cancer^[10]. Some chemotherapy drugs that are used to treat prostate cancer include docetaxel and cabazitaxel,

Some of the side effects of chemotherapy include: 

• allergic reactions 
• weakened immune system (low white cell count - neutropaenia) 
• hair loss 
• changes in bowel habits, e.g. diarrhoea 
• fatigue 
• increased risk of blood clots. 

Immunotherapy

Immunotherapy works by stimulating the person’s own immune system to damage and kill the prostate cancer cells. Types of immunotherapies used in the treatment of prostate cancer include immune checkpoint inhibitors such as pembrolizumab and Sipuleucel-T. Sipuleucel-T is a drug that uses your own white blood cells to destroy prostate cancer cells. It can be offered to treat advanced cancer or cancer that has spread. 

Some of the common side effects of immunotherapy include:^[11] 

• fever 
• fatigue 
• rash 
• back and joint pain 
• nausea 
• headache. 

Targeted therapy

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells without harming normal cells^[12]. These types of medicines affect the way that cancer cells grow, divide, repair themselves or interact with other cells. 

Medicines used for targeted therapy of prostate cancer include rucaparib and olaprib, which are poly (ADP-ribose) polymerase (PARP) inhibitors. These block the pathway that tumour cells with a mutated BRCA gene use to repair damaged DNA, which often leads to the death of these cells. 

Some of the side effects of PARP inhibitors include: 

• nausea and vomiting 
• fatigue 
• shortness of breath 
• skin rash 
• a low number of red blood cells (anaemia). 
• Weakened immune system (neutropaenia) 
• Cryosurgery 

Prostate cancer can sometimes be treated with cryosurgery, which involves inserting long needles through the perineum into the prostate. Very cold gases are then passed through the needles, which freezes the prostate and destroys cancer cells. Warm liquid is also passed through a catheter in the penis to stop the urethra from freezing. 

Cryosurgery is not often used as the main treatment for prostate cancer, but it may be used after radiotherapy, or if the cancer has come back after other treatments. 

Side effects of cryotherapy can include: 

• urinary incontinence (where urine leaks out or you can’t control your urination) 
• erectile dysfunction 
• fistula (abnormal connection) between the bladder and the rectum. 

High-intensity-focused ultrasound therapy

Prostate cancer may be treated with high-intensity-focused ultrasound therapy. An endorectal probe is used to make high-energy sound waves (ultrasound) that create heat, destroying cancer cells.^[13] 

Follow-up

After treatment, you might need regular visits to the doctor for physical examinations, X-rays, scans and PSA tests to check whether the cancer has come back (recurred). 

You should let your doctor know if you notice any new symptoms between check-ups. 

Advanced and recurrent cancer

If prostate cancer spreads to other parts of the body, you will receive treatment to relieve symptoms and keep the cancer under control. This may include:^[14] 

• ADT 
• chemotherapy, other hormone therapy, immunotherapy or targeted therapy 
• radiation therapy 
• transurethral resection of the prostate (TURP). 

If prostate cancer spreads beyond the prostate, it usually spreads to the bones. This is called secondary cancer or metastasis. Cancer in the bones can be painful and might lead to bone fractures or other complications. 

Treatment to prevent prostate cancer from spreading to the bones, or to relieve symptoms associated with secondary cancer in the bones may include: 

• bisphosphonates, which can help strengthen bones, and is also used in people who have had hormone therapy 
• external beam radiation therapy, which can help relieve bone pain 
• monoclonal antibodies such as denosumab injected under the skin to help protect bones 
• corticosteroids, which can relieve pain and lower PSA levels 
• radiopharmaceuticals (medicines that contain radioactivity) such as radium-223, which are injected into the body and settle in areas of damaged bone, where they can destroy cancer cells 
• pain medications. 

Prostate cancer may recur (come back) after treatment. The cancer can recur in the prostate or somewhere else in the body, and is classified as local or distant (often called metastatic cancer). 

If prostate cancer has come back, the type of treatment you have may depend on how your primary cancer was treated. You might have the same treatment again, or a different treatment. 

Supportive Care

Supportive care forms an important component of managing advanced prostate cancer. The aim of supportive care is to improve the quality of life of patients, by either preventing or treating symptoms caused by the cancer or it’s treatment.  Supportive care includes physical, psychological, social, and spiritual support for patients and their families. Symptoms arising from prostate cancer and its treatment including pain, bowel and urinary problems and weight loss, can be managed in conjunction with a pain specialist or palliative care specialist to provide improved quality of life.