Management and treatment of prostate cancer

Thursday 1 March, 2018

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On this page: Active surveillance | Watchful waiting | Surgery | Radiation therapy | Androgen deprivation therapy (ADT) | Advanced prostate cancer treatment | Palliative treatment | Key points


There are different options for managing and treating prostate cancer. For some men, immediate treatment is not necessary or may not be appropriate. Your treating specialist will let you know your options based on the stage and grade of the prostate cancer, as well as your general health, age and preferences.

Stage Management of treatment options
Localised Active surveillance, surgery or radiation therapy are usually offered. Watchful waiting may be an option.
Locally advanced Active surveillance is not recommended and you will be offered surgery and/or radiation therapy. Androgen deprivation therapy (ADT) may also be suggested.
Advanced/metastatic (at diagnosis) Usually offered androgen deprivation therapy (ADT), sometimes chemotherapy or radiation therapy. Watchful waiting may be an option. Newer treatments may be available as part of a clinical trial.

Active surveillance

Active surveillance is a way of monitoring prostate cancer that isn't causing any symptoms or problems. It may be suggested if the cancer is small (low volume) and slow-growing (low grade), and is unlikely to spread or cause symptoms (low risk or, in some cases, intermediate risk). This is indicated by a PSA no higher than 20, stage T1–2, and Grade Group score 1 (Gleason 6 or less). About half of all Australian men with low-risk prostate cancer choose active surveillance.

Typically, active surveillance involves PSA tests every 3–6 months, digital rectal examination every six months, mpMRI scans, and biopsies at 12 months and three years. If the cancer shows signs of faster or more aggressive growth, you can start treatment with the aim of curing the cancer.

Watchful waiting

Watchful waiting is another way of monitoring prostate cancer. This involves regular PSA tests and clinic check-ups. The monitoring process is less strict than for active surveillance, and further biopsies are usually not required. Treatment can be considered if the cancer spreads and/or causes symptoms. The aim of treatment will be to treat symptoms that may be causing problems, rather than cure the prostate cancer.

Watchful waiting may be suitable for older men where the cancer is unlikely to cause a problem in their lifetime. Some men choose watchful waiting instead of immediate cancer treatment if the cancer is already advanced. It can also be an option for men with other health problems that would make it hard to handle treatments such as surgery or radiation therapy.

Choosing active surveillance or watchful waiting avoids treatment side effects, but some men have ongoing anxiety about the cancer. Before deciding not to have treatment, think about ways to manage any worries. Talk to your doctors, or call Cancer Council 13 11 20.

Tony's story

"I had been going to my GP for several years. He did regular blood tests to monitor my PSA and when he saw it rising, he referred me to a specialist.

"The specialist diagnosed me with prostate cancer and recommended I have radiation therapy treatment. I got a second opinion from a surgeon who offered to do a radical prostatectomy. I didn't want to have radiation – a couple of friends recommended surgery and I decided I wanted to get the cancer out.

"I suffered from incontinence after my operation. My surgeon gave me some exercises to improve my continence, but they weren't effective.

"Some friends recommended I see a physiotherapist who specialises in pelvic floor exercises, and I started to see her about 12 weeks after the operation.

"The physio gave me some exercises to do. They're straightforward – you can even sit and watch TV when you do them – but they've seemed to work. I've been doing them for over a year and my continence has improved at least 90%. On reflection, I wish I had seen the physio before my operation or very soon afterwards.

"I'm in a prostate cancer support group run by the hospital. I joined after finishing treatment, but I'd recommend that men join a group as early as possible after diagnosis.

"It's great information, and it's good to be with other people who have been through the same experience and can talk about it.

"It's magic to get help and support from other people. I've gone every month since joining and it's been of great benefit to me."

Tell your cancer story.

Surgery

Your doctor may suggest a radical prostatectomy if you have early prostate cancer and are fit enough for surgery. This operation aims to remove the cancer completely by removing the prostate, part of the urethra, and the seminal vesicles. For more aggressive cancer, nearby lymph glands may also be removed (pelvic lymph node dissection). After the prostate is removed, the urethra will be rejoined to the bladder and the vas deferens will be sealed.

For general information about surgery for cancer, see Understanding Surgery or call Cancer Council 13 11 20. The Prostate Cancer Foundation of Australia also has many useful resources, including Understanding Surgery for Prostate Cancer. Visit prostate.org.au or call 1800 22 00 99.

Radical prostatectomy to remove the prostate

Radical prostatectomy to remove the prostate

Types of radical prostatectomy

Radical prostatectomy may be performed using different surgical techniques. There may be extra costs involved for some options and they are not all available at every hospital.

Open radical prostatectomy

This is usually done through a cut in the lower abdomen.

Laparoscopic radical prostatectomy

Sometimes the prostate can be removed via keyhole surgery (also called laparoscopic surgery). Small surgical instruments are inserted through several small cuts in the abdomen, and the surgeon performs the procedure by moving the instruments while watching a screen.

Robotic-assisted radical prostatectomy

Laparoscopic surgery can be performed using a robotic device, which allows the surgeon to see a three-dimensional picture and to use more advanced instruments than those used for conventional laparoscopic surgery. This is called robotic-assisted laparoscopic radical prostatectomy or RARP.

Nerve-sparing radical prostatectomy

This involves removing the prostate and seminal vesicles and trying to preserve the nerves that control erections. This procedure is more suitable for lower grade cancers and is only possible if the cancer is not in or close to these nerves. It is best performed on younger men who have good erectile function. Problems with erections are common even if nerve-sparing surgery is performed, but these can be managed.

Making decisions about surgery

Talk to your surgeon about what types of surgery are available to you. Ask about the advantages and disadvantages of each option, and if you will have any out-of-pocket costs.

The surgeon's experience is more important than the type of surgery offered. Compared to open surgery, both standard laparoscopic surgery and robotic-assisted surgery usually mean a shorter hospital stay, less bleeding, a smaller scar and a faster recovery. However, there is currently no good, long-term evidence that one approach causes fewer ongoing side effects or better cancer outcomes.

Whichever surgical approach is used, a radical prostatectomy is major surgery and requires time to recover.

Side effects of prostate cancer surgery

You can expect to return to usual activities 4–6 weeks after surgery for prostate cancer. Most men can start driving again within a couple of weeks, but heavy lifting should be avoided for six weeks. You may experience some or all of the following side effects:

Nerve damage

The nerves needed for erections and the sphincter muscle required for bladder control are both close to the prostate. It may be very difficult to avoid these during surgery, and any damage can cause problems with erections and bladder control.

Loss of bladder control

You may have some trouble controlling your bladder after a radical prostatectomy. This condition is known as urinary incontinence. It usually improves a few months to a year after the surgery. A small number of men (about 5%) may be left with ongoing incontinence, which could need a further operation to fix. In rare cases, the incontinence may be permanent.

There are various ways to manage these problems, so it is worth seeing a continence physiotherapist or continence nurse before the surgery, or soon afterwards. In particular, pelvic floor exercises can help improve bladder control.

Erection problems (impotence)

Many men experience problems getting and keeping erections after prostate surgery. It may take some months to a few years for erections to improve. Some men may not get strong erections again. Oral medicines, vacuum erection devices, injection therapy or implants may help if you have ongoing problems with erections.

Infertility

During a prostatectomy, the tubes from the testicles (vas deferens) are sealed and the prostate and seminal vesicles are removed, so semen is no longer ejaculated during orgasm. This is known as a dry orgasm and results in infertility. If having children is important to you, talk to your doctor before treatment about sperm banking or other options.

Penile shortening

In some men, the penis gradually becomes shorter after surgery. Regularly using a vacuum erection device can help maintain penis length. You can see a psychologist or counsellor for assistance coming to terms with any changes to the appearance of your penis.

Radiation therapy

Radiation therapy (also known as radiotherapy) is one of the treatments offered to men with early prostate cancer. It is generally offered as an alternative to surgery and has similar rates of success. It may also be offered if you are not well enough for surgery. Sometimes radiation therapy is used after a prostatectomy for locally advanced or more aggressive cancers, or if there are signs that not all of the cancer has been removed by surgery.

Radiation therapy can be delivered externally using external beam radiation therapy, or internally using brachytherapy. Most men who have radiation therapy as their initial treatment for more advanced prostate cancer will receive androgen deprivation therapy (ADT) beforehand and/or afterwards.

External beam radiation therapy (EBRT)

External beam radiation therapy (EBRT) uses targeted radiation to kill cancer cells or injure them so they cannot multiply. The radiation is usually in the form of x-ray beams.

Treatment is planned to ensure there is as little damage as possible to the normal tissue and organs surrounding the prostate. The planning sometimes involves inserting small pieces of gold (marker seeds) into the prostate to allow more accurate targeting of the radiation. This is called image-guided radiation therapy (IGRT).

Usually, EBRT for prostate cancer is given every weekday for up to eight weeks, often in combination with temporary androgen deprivation therapy (ADT).

Each EBRT treatment session takes about 15 minutes. You will lie on the treatment table under the radiation machine. The machine does not touch you but may rotate around you. You will not see or feel the radiation. EBRT does not make you radioactive and there is no danger to the people around you.

Proton therapy for prostate cancer

A special type of EBRT uses protons rather than x-rays. This is known as proton therapy and is useful when the cancer is near sensitive areas, such as the brainstem and spinal cord. It is not yet available in Australia, but has been used in the US to treat prostate cancer. At this stage, there is no evidence that proton therapy provides better outcomes for prostate cancer than standard radiation therapy with x-rays.

Side effects of EBRT

You may experience some of the following side effects. Most will be temporary and there are ways to manage them.

Erection problems (impotence)

EBRT can damage the nerves that control erections. This can make it hard to get and keep an erection, especially in men who already had trouble with erections because of their age. ADT can make the problem worse. This side effect does not always occur immediately, but may develop over time and be ongoing.

Changes in ejaculation

Some men notice pain on ejaculation or find that they ejaculate less or not at all (dry orgasm) after radiation therapy. The discomfort usually eases over time, but dry orgasms may be a permanent side effect.

Infertility

Radiation therapy to the prostate usually results in infertility. If you wish to have children, speak to your doctor before treatment about sperm banking or other options.

Skin irritation

Skin in the area treated may become red and sore (like mild sunburn) during or soon after treatment. These reactions fade with time. Ask your treatment team for advice.

Tiredness

You may become very tired because your body is coping with the effects of radiation on normal cells. Fatigue may build up slowly during treatment and should go away afterwards, but can last up to six months. Talk to your radiation oncologist or call Cancer Council 13 11 20 to find out about programs that can help improve fatigue after cancer treatment.

Urinary problems

You may experience a burning sensation when urinating, or an increased urgency to urinate. These side effects usually go away after treatment, but your doctor can prescribe medicine to reduce any discomfort. Radiation is unlikely to cause incontinence, but it can damage the lining of the bladder. In rare cases, this can lead to ongoing bleeding (radiation cystitis), which can be difficult to control. Let your doctor know of any problems with urinating or bleeding.

Bowel problems

It is common to have a feeling of being unable to completely empty the bowel and/or to develop haemorrhoids. Less commonly, men may bleed when passing a bowel motion. This is caused by damage to the fine blood vessels in the lower bowel. Tell your doctor if you have any bleeding from the rectum. Some men may also have diarrhoea or difficulty holding onto their bowel motions. These side effects usually go away in time.

Brachytherapy

Brachytherapy is a type of targeted internal radiation therapy where the radiation source is placed directly within the prostate. This allows doses of radiation to be given directly inside of the prostate, and limits the effects on nearby tissues such as the rectum and bladder.

Brachytherapy can be given by inserting permanent "seeds" that are radioactive for a few months, or through temporary needle implants. Brachytherapy is not suitable for men who already have significant urinary symptoms, or a very small or very large prostate gland.

Permanent brachytherapy

This treatment is most suitable for men with a small to mediumsized prostate, few urinary symptoms, and small tumours with a low PSA level (less than 10) and a low/intermediate Grade Group or Gleason score. It can sometimes be an expensive treatment option, so check what costs are involved before making a decision.

Permanent brachytherapy involves putting radioactive seeds, about the size of an uncooked grain of rice, into the prostate. It is also called low-dose-rate (LDR) brachytherapy. The seeds are inserted under a general anaesthetic through the skin between the scrotum and anus using needles. They are guided into place with the help of an ultrasound. There is no incision, only some small puncture holes that heal very quickly, allowing for a faster recovery than EBRT or surgery. The procedure takes only 1–2 hours and you can usually go home the same day.

The seeds slowly release radiation to kill cancer cells, and lose their radioactivity after about three months. They are not removed from the prostate.

The level of radiation that comes from the seeds is low, but you will need to take care around pregnant women and young children for several weeks – your treatment team will explain the precautions to you. Although very uncommon, it is possible that a seed may dislodge during sexual activity. For this reason, you will be advised to use a condom or avoid sexual activity for three months. This way if a seed comes out, the condom will catch it.

More information about radiation therapy

To find out more about radiation therapy, see Understanding Radiation Therapy or call Cancer Council 13 11 20. The Prostate Cancer Foundation of Australia have a resource called Understanding Brachytherapy for Prostate Cancer - visit prostate.org.au or call 1800 22 00 99. You can also visit targetingcancer.com.au for more information and videos explaining radiation therapy.

Temporary brachytherapy

Also known as high-dose-rate (HDR) brachytherapy, temporary brachytherapy may be offered to men with higher PSA levels and Grade Group scores who are at risk of locally advanced cancer. It is often given with a short course of EBRT.

In temporary brachytherapy, the radiation is delivered through hollow needles that are inserted into the prostate, usually under general anaesthetic. These needle implants stay in place for several hours. During this time, you will have three brachytherapy sessions. For each session, radioactive wires will be inserted into the needles to deliver a high dose of radiation for about a minute. Once the wires are removed after each session, you will not be radioactive and there is no risk to other people. You will need to stay in hospital overnight for this treatment, and the needle implants will be removed before you go home.

Side effects of brachytherapy

The side effects of brachytherapy usually start 1–2 weeks after treatment and start to resolve within a couple of months. They may include pain when urinating, blood in the urine, poor urine flow and bladder irritation. Permanent radioactive seeds have the lowest chance of causing erection problems compared with other treatments. Erection problems and changes in ejaculation (such as pain or dry orgasm) sometimes occur after temporary needle implants.

Talk to your doctor and/or treatment team about ways to manage these side effects.

Derek's story

"I didn't have any symptoms, but I had a few high PSA results so my GP referred me to a urologist. The urologist suggested we keep an eye on it. After 12 months, my PSA was still rising so he arranged a biopsy. It was three days after my 60th birthday when the biopsy results came back and I was told I had prostate cancer. It was bloody frightening.

"The urologist explained he could do radical surgery, either open surgery or keyhole, and told me to go away and have a think. About a month later, I'd made up my mind – let's take this out, get rid of it – but I was deadset lucky he was such a great urologist. He said, "Wait a minute here – I might be doing myself out of a job, but you're 60, you're fit and healthy, and there are other options." And then he referred me to two specialists – one in external beam radiation therapy and the other in brachytherapy.

"As soon as we met with the brachytherapy specialist, my wife and I looked at each other and more or less knew this was our guy. It was just a feeling – when he described the treatment, we felt confident.

"Because it was hard to tell from the scans if the cancer had spread, I also had external beam radiation therapy a few months after the brachytherapy, just to mop up any cancer cells that might still be there.

"I read a lot about all the negative side effects you might get from radiation therapy, but I've had no long-term side effects and I wonder now what all the fuss was about.

"I have my PSA tested every six months and it's stayed low. I don't even think about the cancer now, but luck certainly played a part. For me the hardest part was the initial shock of the diagnosis."

Tell your cancer story.

Androgen deprivation therapy (ADT)

Prostate cancer needs testosterone to grow. Slowing the production of testosterone may slow the growth of the cancer or shrink it temporarily. Testosterone is an androgen (male sex hormone), so this treatment is called androgen deprivation therapy (ADT). It is also known as hormone therapy.

ADT injections

The most common form of ADT involves injections of drugs that block the body's production of testosterone. They are usually given monthly, four-monthly or six-monthly. These injections will not cure the cancer but may slow its growth for years.

ADT injections are often used before, during and after radiation therapy. They are the main treatment for advanced prostate cancer, often combined with chemotherapy.

Intermittent ADT

Occasionally ADT injections may be given in cycles, with treatment continuing until your PSA level is low, and then stopped for a period of time. It can then be restarted if your PSA rises again. This is known as intermittent ADT. In some cases, this can reduce side effects without affecting long-term prostate cancer outcomes. However, it is not suitable for all men.

Anti-androgen tablets

Often just called hormone tablets, anti-androgen tablets are taken by mouth. While ADT injections work by blocking the body's production of testosterone, anti-androgen tablets stop the testosterone reaching the cancer cells. Anti-androgen tablets are sometimes used on their own. More often, they are used with ADT injections. This combination is known as a complete or combined androgen blockade.

Surgical approach

Removing all or part of the testicles permanently reduces testosterone levels. This surgical approach is no longer commonly used, but some men with advanced prostate cancer may still prefer it over regular injections or tablets.

The removal of both testicles is called a bilateral orchidectomy. Some men have a silicone prosthesis put into the scrotum after surgery to keep its shape. The removal of only the inner part of the testicles (subcapsular orchidectomy) does not need a prosthesis.

Side effects of ADT

ADT may cause a range of side effects because of the reduced testosterone levels in the body. These can include:

  • fatigue
  • reduced sex drive (libido)
  • erection problems
  • loss of muscle strength, weight gain
  • hot flushes, breast growth and tenderness
  • mood swings, depression, trouble with thinking and memory
  • loss of bone density (osteoporosis) – your doctor may monitor
  • your bone mineral density, calcium and vitamin D levels
  • increased risk of other problems such as obesity, diabetes and
  • heart disease – your doctor will assess these risks with you and it may be helpful to seek advice from a dietitian.

Although the side effects of ADT can be significant, your treatment team can help you minimise the impact. To read more about this treatment, see Understanding Hormone Therapy for Prostate Cancer, available from the Prostate Cancer Foundation of Australia. Visit prostate.org.au or call 1800 22 00 99.

Advanced prostate cancer treatment

ADT (see above) is the main treatment for advanced prostate cancer, when disease has spread beyond the prostate. In this case, the treatment will not cure the cancer but can keep it under control for months and even years. It may also reduce or eliminate the symptoms of cancer (temporary remission) and help with symptoms such as pain caused by the cancer spreading.

Chemotherapy (see below) and external beam radiation therapy are also standard treatment options for advanced prostate cancer. These may be offered in combination with ADT.

Chemotherapy

Chemotherapy is the use of drugs to kill or slow the growth of cancer cells. If the prostate cancer continues to advance and spread to other parts of your body despite using ADT, chemotherapy may be suitable. Chemotherapy may also be offered as your first treatment in combination with ADT.

Generally, chemotherapy is given through a drip (infusion) into a vein (intravenously). It is usually given once every three weeks and you do not need to stay overnight in hospital.

To find out more about chemotherapy, see Understanding Chemotherapy, or call Cancer Council 13 11 20.

Side effects of chemotherapy may include fatigue; hair loss; changes in blood counts increasing the risk of bleeding or infections; numbness or tingling in the hands or feet (peripheral neuropathy); changes in nails; and rare side effects, such as allergic reactions or blockages of the tear ducts. Fortunately, improved medicines have greatly reduced the impact of chemotherapy on quality of life.

Transurethral resection of the prostate (TURP)

TURP is a surgical procedure to relieve blockages in the urinary tract. It helps with symptoms of more advanced prostate cancer, such as frequent urination, but does not cure the cancer. TURP is also used to treat benign prostate hyperplasia.

You will be given a general or a spinal anaesthetic. A small telescope-like instrument is passed through the opening of the penis and up the urethra to remove the blockage. The surgery takes about an hour, and you will usually need to stay in hospital for a couple of days.

Bone therapies

If you have prostate cancer that has spread to the bones, your doctor may suggest treatments to manage the impact on the bones. Drugs can be used to prevent or minimise bone pain and can reduce the risk of fractures and compression on the spinal cord. Radiation therapy can also be used to reduce bone pain, or to prevent or assist in the repair of fractures or spinal cord compression.

Other therapies

Newer drug therapies may be used to treat men with advanced prostate cancer that has stopped responding to ADT. This is known as second-line treatment. These drugs, such as abiraterone and enzalutamide, are hormone tablets that can be combined with ADT to help prolong life and reduce symptoms. Clinical trials are investigating whether these newer drugs should be given when ADT is started for advanced prostate cancer (first-line treatment).

Palliative treatment

Palliative treatment aims to improve quality of life by reducing cancer symptoms without trying to cure the disease. It can be used for symptom control at different stages of cancer, not just at the end of life. Palliative treatment is particularly important for people with advanced cancer. It can assist with managing symptoms such as pain, and slow the spread of the cancer.

Palliative radiation therapy may be used to treat pain, such as bone pain if the cancer has spread to the bones (bone metastases). Pain-relieving medicines (analgesics) are also often used.

Call Cancer Council 13 11 20 for free copies of Living with Advanced Cancer, Understanding Palliative Care or Overcoming Cancer Pain, or visit your local Cancer Council website.

Key points

  • Your options for managing and treating prostate cancer depend on the cancer stage and grade, as well as your health, age and preferences.
  • For some men, immediate treatment is not necessary or may not be appropriate.
  • Active surveillance is a way of monitoring prostate cancer that isn't causing any symptoms or is classified as low risk. Treatment can be considered if the cancer begins to cause problems.
  • Watchful waiting is another way of monitoring low-risk prostate cancer that is not causing symptoms.
  • The main surgery for early prostate cancer is known as a radical prostatectomy. The prostate, part of the urethra and the glands that store semen (seminal vesicles) are removed.
  • Radiation therapy may be given externally (external beam radiation therapy or EBRT) or internally (brachytherapy).
  • Side effects of surgery and radiation therapy include nerve damage, erection problems, infertility and incontinence.
  • Androgen deprivation therapy (ADT) is used to slow the growth of prostate cancer. It can be done through injections, tablets or surgery. ADT is often combined with radiation therapy.
  • Treatment for advanced prostate cancer may include chemotherapy, ADT, bone therapies and newer drugs.
  • A transurethral resection of the prostate (TURP) is an operation that may be used to remove blockages in the urinary tract.

Reviewed by: A/Prof Declan Murphy, Urologist and Director of Genitourinary Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC; Gregory Bock, Acting Coordinator of Nursing, WA Cancer & Palliative Care Network, Department of Health, WA; A/Prof Martin Borg, Radiation Oncologist, Adelaide Radiotherapy Centre, SA; Carmen Heathcote, 13 11 20 Consultant, Cancer Council Queensland; Dr Michael Lowy, Sexual Health Physician, Sydney Men's Health, NSW; Dr David Millar, Sexual Health Physician, Perth Men's Health, WA; Jennifer Siemsen, Clinical Nurse Consultant – Cancer Care, WP Holman Clinic, Launceston General Hospital, TAS; A/Prof David Smith, Senior Research Fellow and Cancer Epidemiologist, Cancer Council NSW; Dr Ben Tran, Medical Oncologist, Peter MacCallum Cancer Centre, Melbourne, VIC; Derek Wells, Consumer.  

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