The Froedtert & MCW Cancer Network offers a range of treatment options for prostate cancer. As you consider treatment for your prostate cancer, consider the quality of life factors that are important to you and discuss them with your doctor. Treatment risks include bladder incontinence, bowel problems (diarrhea, frequent stools, loss of control of bowel movements, rectal bleeding) and loss of sexual function — the ability to get and maintain an erection.
When considering treatment options, keep in mind that prostate tumors usually grow slowly. Most patients live a long time with their disease, so while cancer control is critical, preserving physical function is an important part of creating a treatment plan. Discuss the pros and cons of treatment for your individual situation to ensure you are making an informed decision.
For some men, “watchful waiting” provides the greatest chance of achieving the best overall health. Others benefit from several different therapies, provided individually or in combination with other therapies.
Types of Prostate Cancer Treatments
Although it is ideal to find prostate cancer early when you may have more treatment options, there are many effective treatments for men diagnosed with advanced or metastatic prostate cancer (cancer that has spread beyond the prostate gland). These include:
- Radiation therapy
- Hormonal therapy
- Targeted therapies
- Chemotherapy
- Immunotherapy
- Clinical trials
While these treatments currently do not cure metastatic prostate cancer, they can prolong survival, help control symptoms and improve quality of life.
Active Surveillance and Watchful Waiting
Active surveillance or watchful waiting may be appropriate for men who are older or men with very slow-growing prostate cancer.
In active surveillance, instead of treating the cancer, men are monitored with PSA blood tests every six months, a digital rectal exam every year and periodic imaging tests. The type and the extent of tests depend on each man’s medical situation.
Watchful waiting is similar to active surveillance but with less intensive tests and monitoring.
Some men will never need treatment for their prostate cancer. If tests reveal the cancer is growing, we can consider treatment at that time.
Radiation Therapy
There are several types of radiation therapy to consider depending on the stage of the prostate cancer and if it has spread beyond the prostate gland.
Internal Radiation Therapy — Brachytherapy
Men who have prostate cancer that has not spread beyond the prostate gland and that has a low risk of spreading can typically have brachytherapy. Some men with intermediate or high-risk prostate cancer can also have brachytherapy. Cure rates are similar to those achieved with surgery, although men with intermediate or high-risk prostate cancer may also need to have external beam radiation.
The risks for urinary and bowel incontinence are reduced with brachytherapy, as is the risk for decreased sexual function. Brachytherapy is given on an outpatient basis (no hospital stay needed), and there is less pain after the procedure when compared with surgery.
- Standard brachytherapy — Radioactive "seeds" are implanted in the prostate gland in an outpatient surgical procedure. The seeds give off radiation at a low dose-rate for several weeks and remain in the prostate gland permanently.
- High dose-rate brachytherapy — A number of tiny catheters (tubes) are placed into and around the tumor, and a high dose of radiation is delivered through the catheters to the tumor. The entire treatment takes days instead of weeks.
External Beam Radiation Therapy
In external beam radiation therapy, cancer cells are destroyed by radiation fields generated by a device outside the body. It can be very effective at controlling cancer, and it offers an excellent option to limit side effects. External beam radiation can also be given in combination with brachytherapy, drug therapy (usually hormonal) or both.
External beam radiation therapy is used in several different situations. It is often the primary treatment for cancers that have not spread beyond the prostate. It can also be given, if needed, after prostate surgery, or it may be used for patients who are not good candidates for surgery because of age or other health problems. In addition, external beam radiation therapy can be part of treatment for men whose cancer has moved beyond the prostate gland. External beam radiation can also help relieve the pain of bone metastases.
A key goal in external beam therapy is producing radiation fields that conform tightly to the tumor target. “Conformal” radiation allows physicians to deliver a higher dose of radiation to cancer cells, while sparing healthy tissue. The results are a greater ability to destroy cancer while avoiding damage to bowel, bladder and nerves that control sexual function.
There are several ways of delivering external beam radiation therapy.
Image-Guided Radiation Therapy (IGRT)
IGRT uses imaging techniques such as CT, PET or MRI to accurately locate a tumor during each radiation treatment.
- MR-linac combines a linear accelerator with built-in MRI to provide adaptive therapy. This allows radiation oncologists to adjust the radiation dose and target the tumor precisely in real time — even with breathing motion and day-to-day changes of the tumor’s size and position.
- Radixact™ is another form of adaptive radiation therapy. The radiation oncologist uses 3D volumetric CT imaging to verify the tumor’s position and adjust the radiation dose and target just before every treatment.
Intensity-Modulated Radiation Therapy (IMRT)
IMRT uses computers to plan the precise delivery of thousands of tiny, thin radiation beams, (rather than a single large radiation beam) to the tumor. The computer determines the best way to deliver treatment by adjusting the intensity of each radiation beam.
TomoTherapy
TomoTherapy® enables doctors to selectively destroy tumors in the prostate gland with higher doses of radiation while reducing exposure to surrounding structures, such as the rectum and bladder. It is an IMRT system that combines precise 3D imaging from computerized tomography (CT) scanning with highly targeted radiation beams. The CT images, along with computerized radiation dose calculations, are used to determine the radiation dose that will best conform to the tumor shape.
TomoTherapy can reduce the length of time patients spend in treatment. A typical course consists of five 20 to 25 minute treatments per week for eight weeks. If a tumor returns after treatment, some patients can be treated again with TomoTherapy because of the precise nature of technology. The system enables such finely tuned dose delivery that even areas previously treated with radiation can be treated again.
Focal Therapy
Focal therapy, also known as prostate cancer ablation or partial gland ablation, is a treatment for certain men diagnosed with small tumors — ideally, tumors located in only one area of the prostate. Focal therapy may also be the right treatment for men who cannot have or do not want standard treatments (surgery or radiation therapy) and for men whose cancer comes back within the prostate gland after radiation therapy. When used appropriately, focal therapy has the potential to eliminate cancer, while avoiding urinary incontinence and long-term erectile dysfunction.
Focal therapy is not for all men diagnosed with prostate cancer.
The care team follows strict patient selection criteria before offering focal therapy. To make sure focal therapy is the best choice, you will receive an MRI scan and an MRI-guided biopsy of the prostate gland. There should not be any evidence of the cancer having spread outside the prostate. Your doctor will talk with you about individual risks and benefits before you choose focal therapy.
For men with newly diagnosed prostate cancer, it is important to know that there is not enough long-term data to show that cancer control after focal therapy is as effective as radiation therapy or surgery.
However, for patients with prostate cancer that comes back after previous radiation to the prostate (recurrence), prostate ablations are considered a standard of care. Focal therapies can be repeated, if appropriate, or you may need a different type of treatment.
Types of Focal Therapy
There are several types of focal therapy for prostate cancer. Using real-time image guidance, the doctor treats small tumors in the prostate with cold, heat or electrical fields to destroy cancer, while preserving healthy prostate tissue. Focal therapy may use one of several energy sources:
- Cryotherapy applies cold to freeze prostate tumors.
- High-intensity focused ultrasound (HIFU) uses ultrasound beams to heat and destroy tumors.
- Laser ablation uses heat generated by lasers to destroy tumors.
- Irreversible electroporation (IRE) surrounds tumors with strong electrical fields that create holes in cancer cell walls. This causes cancer cells to die.
Focal therapy does not require a hospital stay. You can go home the same day after a period of recovery. You can usually resume daily routines in a few weeks.
Side Effects
Focal therapy side effects can include the following.
- Urinary tract infection (your doctor may prescribe antibiotics)
- Blood in the urine
- Discomfort from the temporary (three to 10 days) catheter
- Urinary retention
- Unable to urinate — serious condition requiring emergency treatment
- Numbness and swelling of the penis and scrotum (less common)
These issues usually happen within 30 days after focal therapy. Be sure to tell your doctor about any side effects.
After successful treatment, your doctor will monitor you very closely with PSA blood tests, MRI scans and periodic prostate tissue biopsies. If the cancer comes back (recurrence), it can be found and treated before it has a chance to progress.
Surgery
Treatment for prostate cancer sometimes requires surgery. Your doctors help you determine the best option for you.
Radical Prostatectomy
Removing the entire prostate gland is called a radical prostatectomy. A radical prostatectomy is different from a simple prostatectomy — surgery for an enlarged prostate gland or benign prostatic hyperplasia (BPH). BPH is not cancer. Learn more about BPH and its treatment.
A radical prostatectomy is a treatment for prostate cancer that remains within the prostate gland (localized) and has not spread. The surgeon removes the entire prostate gland, along with tissues surrounding the prostate and glands that produce fluid for semen, which are called seminal vesicles. Most prostatectomies are done using minimally invasive methods.
Open Radical Prostatectomy
In an open radical prostatectomy, the surgeon removes the prostate gland through a standard surgical incision, which is four or five inches long. This surgery can be done as a nerve-sparing procedure, which means the surgeon removes the prostate gland while sparing nerves that control a man's ability to have an erection.
Robotic-Assisted Prostatectomy
The robotic-assisted surgical system is a minimally invasive way to remove prostate tumors. The surgeon sits at a computer console in the operating room, controlling four computerized robotic arms. The arms hold slim tools and a camera to perform the surgery, while the surgeon views the surgical site on a computer screen. This can be a nerve-sparing procedure, which means the surgeon removes the prostate gland while sparing nerves that control a man's ability to have an erection. Learn more about robotic-assisted prostatectomy.
Hormone Therapy, Chemotherapy, Targeted Therapy, Immunotherapy
Hormone therapy, chemotherapy and targeted therapy can be offered to men with prostate cancers that have spread beyond the prostate gland (metastasized) or if cancer has come back after treatment. For some men, immunotherapy is an option. Your doctor may recommend one of these treatments combined with surgery or radiation therapy if your prostate tumor is very aggressive, even if it is contained within your prostate gland.
Hormone Therapy
Prostate cancer cells require male sex hormones (such as testosterone) to grow. Some drugs reduce the body’s natural testosterone production from normal to very low levels, which can “starve” prostate cancer cells. Other drugs block the action of male sex hormones.
Androgen deprivation therapy, also called ADT, is the backbone of medical therapy for men with prostate cancer. It is appropriate for men with localized prostate cancer in combination with radiation therapy, in combination with other medical therapies or as a stand-alone treatment. These drugs are usually pills or injections.
Androgen deprivation therapy has many side effects, including inability to get an erection, fatigue, weight gain, reduced muscle mass and hot flashes. Your team will follow you closely and continue to monitor your side effects to weigh the benefits and risks of treatment.
Chemotherapy
Chemotherapy drugs block the rapid division of cancer cells and have proven to be effective for many men with prostate cancer. The role of chemotherapy and its use in combination with other treatment continues to change. Chemotherapy has many side effects which can depend on the specific drug, how it is given and how often. Your team will monitor you closely to help you cope with side effects and continue to weigh the benefits and risks of your treatment.
Targeted Therapy
Targeted therapies are drugs that work by affecting certain mechanisms in cancer cells that help cancer cells grow. Using advanced molecular tests, pathologists can determine if there are abnormal changes in DNA and if a targeted therapy will work on these genetic changes.
Targeted therapies work differently than chemotherapy. While chemotherapy eliminates all quickly dividing cells — cancer and healthy cells — targeted therapies affect cells with a specific genetic abnormality.
Like all other treatments, targeted therapy can have side effects. Targeted therapy can raise blood pressure, or cause nausea, vomiting and diarrhea, skin issues and problems with metabolism. Be sure to let your care team know of your side effects so they can help you manage them.
Immunotherapy
Immunotherapy drugs help stimulate your immune system so it can better identify cancer cells and eliminate them. Immunotherapy is not usually used to treat prostate cancer. It may, however, be an effective option for some men with metastatic prostate cancer that is not responding to other treatments.
Theranostics
Theranostics combines diagnosis, treatment and monitoring of prostate cancer. It starts with an injection of an agent that carries a very low level of a radioactive element (called an isotope) into the bloodstream. Using positron emission tomography (PET) imaging, the doctor can see where the agent is collecting to make sure it will hit the target — prostate tumor cells.
Next, the doctor switches to a version of the agent that carries enough radiation to kill the cancer cells. Finally, imaging shows the treatment team where the treatment dose went to confirm the cancer cells have been eliminated.
Lutetium Lu 177 vipivotide tetraxetanis is an example of a theranostic. Also known as a radiopharmaceutical, it is available for some men who have advanced prostate cancer. This treatment can extend survival, delay progression of the cancer and shrink tumors. It’s given in up to six doses, either with an IV injection or via infusion, once every six weeks.
Many types of prostate cancer cells (and some healthy cells) have a biomarker called PSMA – prostate-specific membrane antigen – a type of protein on the outside of the cell. Lutetium Lu 177 is designed to treat PSMA-positive metastatic castration-resistant prostate cancer. Once it reaches the targeted cancer cell, the cell absorbs the treatment. Radiation is released inside the cell, damaging or destroying it. There is limited damage to healthy cells surrounding the cancer cell.
Side Effects
Side effects can include the following. Talk with your doctor about these side effects and ways to cope with them.
- Fatigue
- Dry mouth or eyes
- Nausea or vomiting
- Low red blood cell count
- Appetite loss
- Constipation or diarrhea
- Low blood platelet count
- Urinary tract infection
- Weight loss
- Pain in the abdomen
Vascular and Interventional Radiology
Men with prostate cancers that have spread to the bone (or other parts of the body) can be treated with minimally invasive vascular and interventional radiology (IR) procedures. These procedures can serve as a primary therapy for bone metastases or as a follow-up to external beam radiation or chemotherapy.
- Radiofrequency ablation (RFA): An interventional radiologist uses imaging technology to position a special probe at the tumor site. A high-frequency current passed through the probe destroys the tumor with heat.
- Cryoablation: In this procedure, one or more needle probes with super-cooled tips are used to destroy the tumor through freezing. Most bone tumors are treated with two freeze-thaw cycles.
Clinical Trials for Prostate Cancer
Patients with prostate cancer have access to a large number of clinical trials, some of which are only available through the Froedtert & MCW Cancer Network. Others are national, multicenter trials. The trials may study new combinations of therapies, new drugs, radiation therapy or focal therapies. Clinical trials are carefully evaluated and planned with patient safety in mind, and they have the potential to benefit patients.
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