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Prostate cancer


Managing and treating prostate cancer


There are different options for managing and treating prostate cancer, and more than one treatment may be suitable for you. Your specialists will let you know your options. The treatment recommended by your doctors will depend on the stage and grade of the prostate cancer as well as your general health, age and preferences.

Prostate cancer is typically slow growing, even in its most aggressive form, giving you time to make decisions about your options.

Management and treatment options by stage

Localised (early)
  • active surveillance
  • surgery and/or radiation therapy
  • watchful waiting.
Locally advanced
  • surgery and/or radiation therapy
  • androgen deprivation therapy (ADT) may also be suggested
  • watchful waiting.
Advanced (metastatic)
  • usually androgen deprivation therapy (ADT)
  • sometimes chemotherapy or radiation therapy
  • watchful waiting may be an option
  • newer treatments as part of a clinical trial.

 

Monitoring prostate cancer

Choosing active surveillance or watchful waiting avoids treatment side effects, but you may feel anxious about not having active treatment. Talk to your doctors about ways to manage any worries or call 13 11 20 cancer support.

Active surveillance

This is a way of closely monitoring low-risk prostate cancer that isn’t causing any symptoms or problems. The aim is to avoid unnecessary treatment, while looking for changes that mean treatment should start.

Active surveillance may be suggested for prostate cancers with a PSA level under 10 ng/mL, stage T1–2, and Gleason 6 or less (Grade Group 1 and some Grade Group 2). About 70% of Australians with low-risk prostate cancer choose active surveillance. It usually involves:

  • PSA tests every 3–6 months
  • a digital rectal examination every six months
  • repeat mpMRI scans and biopsies as advised by your urologist.

Ask your doctor how often you need check-ups. If results show the cancer is growing faster or more aggressively, your specialist may suggest starting active treatment.

Watchful waiting

Watchful waiting is another way of monitoring prostate cancer. This approach may be suggested if you are older and the cancer is unlikely to cause a problem in your lifetime. It may be an alternative to active treatment if the cancer is advanced at diagnosis. It can also be an option if you have other health problems that would make it hard to handle treatments such as surgery.

The aim of watchful waiting is to maintain quality of life rather than to treat the cancer. If the cancer spreads or causes symptoms, you will have treatment to relieve symptoms or slow the growth of the cancer, rather than to cure it.

Watchful waiting usually involves fewer tests than active surveillance. You will have regular PSA tests and you probably won’t need to have a biopsy. 

Surgery

The main type of surgery for localised and locally advanced prostate cancer is a radical prostatectomy. This involves removing the prostate, part of the urethra and the seminal vesicles. After the prostate is removed, the urethra will be rejoined to the bladder and the vas deferens will be sealed.

Some people are able to have nerve-sparing surgery, which aims to avoid damaging the nerves that control erections. Nerve-sparing radical prostatectomy is more suitable for lower-grade cancers and is only possible if the cancer is not in or close to these nerves. It works best for those who had strong erections before diagnosis. Problems with erections are common even if nerve-sparing surgery is performed.

Cancer cells can spread from the prostate to nearby lymph nodes. For intermediate-risk or high-risk prostate cancer, nearby lymph nodes may also be removed (pelvic lymph node dissection). 

How the surgery is done

Different surgical methods may be used to remove the prostate:

  • open radical prostatectomy – usually done through one long cut in the lower abdomen
  • laparoscopic radical prostatectomy (keyhole surgery) – small surgical instruments and a camera are inserted through several small cuts in the abdomen
  • robotic-assisted radical prostatectomy – laparoscopic surgery performed with help from a robotic system.

Talk to your surgeon about the methods available to you, and the advantages and disadvantages of each option. There may be extra costs involved for some procedures and they are not all available at every hospital.

You may want to consider getting a second opinion. The surgeon’s experience and skill are 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. Current evidence suggests that the different approaches have a similar risk of side effects and no difference in long-term outcomes.

What to expect after surgery

  • Recovery time – whichever surgical method is used, a radical prostatectomy is major surgery and you will need time to recover. You can expect to return to your usual activities within about six weeks. Usually you can start driving again in a couple of weeks, but heavy lifting should be avoided for six weeks.
  • Pain and discomfort – it’s common to have pain after the surgery, so you may need pain relief for a few days.
  • Having a catheter – after a radical prostatectomy you will have a thin, flexible tube (catheter) in your bladder to drain your urine into a bag. The catheter will be removed after 1–2 weeks once the wound has healed.

Side effects of prostate cancer surgery

You may experience some or all of the following side effects:

  • Nerve damage – the nerves needed for erections and the muscle that controls the flow of urine 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. Sometimes the nerves will need to be removed to try to ensure all cancer is removed.
  • Loss of bladder control – you can expect to have some light dribbling or trouble controlling your bladder for some weeks to months, which can be managed by using continence pads. Bladder control usually improves in a few weeks and will continue to improve for up to a year after the surgery. In the long term, some people will continue to have some light dribbling. Some people may consider having an operation to fix urinary incontinence. In rare cases, people have no control over their bladder.
  • Changes in erections (impotence) – problems getting and keeping erections after prostate surgery are common. Erections may improve over months to a few years. It’s more likely you won’t get strong erections again if they were already difficult before the operation. 
  • Changes in ejaculation – during a radical prostatectomy, the vas deferens are sealed and the prostate and seminal vesicles are removed. This means semen is no longer ejaculated during orgasm (a dry orgasm). Your orgasm may feel different – it may be uncomfortable or, rarely, painful. Some people may leak a small amount of urine during orgasm, which is not harmful.
  • Infertility – a radical prostatectomy will cause infertility, so you won't be able to conceive a child without medical assistance. If you wish to have children, talk to your doctor before treatment. 
  • Changes in penis size – you may notice that your penis gradually becomes a little shorter after surgery. Talk to your doctor about whether vacuum erection devices and prescription medicines may help.

 

Your guide to best cancer care

A lot can happen in a hurry when you’re diagnosed with cancer. The guide to best cancer care for prostate cancer can help you make sense of what should happen. It will help you with what questions to ask your health professionals to make sure you receive the best care at every step.

Read the guide

Radiation therapy

Radiation therapy uses a controlled dose of radiation to kill or damage cancer cells so they cannot grow, multiply or spread. Radiation therapy may be used: 

  • for localised or locally advanced prostate cancer – it has similar rates of success to surgery in controlling prostate cancer that has spread to the lymph nodes
  • if you are not well enough for surgery or are older
  • after a radical prostatectomy for locally advanced disease, if there are signs of cancer left behind or the cancer has returned where the prostate used to be
  • for prostate cancer that has spread to other parts of the body.

There are two main ways of delivering radiation therapy – from outside the body (external beam radiation therapy) or inside the body (brachytherapy). You may have one of these or a combination of both. In intermediate and high-risk prostate cancer, radiation therapy is often combined with androgen deprivation therapy.

External beam radiation therapy (EBRT)

In EBRT, a machine precisely directs radiation beams from outside the body to the prostate. Each treatment session takes about 15 minutes, and you will not see or feel the radiation.

There are different types of EBRT. Your radiation oncologist will talk to you about the most suitable type for your situation. Usually, EBRT for prostate cancer is delivered every weekday for 4–9 weeks. Some newer forms of EBRT are delivered in 5–7 treatments over two weeks.

EBRT does not make you radioactive and there is no danger to the people around you. Most people feel well enough to continue working, driving, exercising or doing their normal activities throughout treatment.

Internal radiation therapy (brachytherapy)

Brachytherapy is a type of targeted internal radiation therapy where the radiation source is placed inside the body. Giving doses of radiation directly into the prostate may help to limit the radiation dose to nearby tissues such as the bladder.

There are two different types of brachytherapy – permanent or temporary. Permanent brachytherapy (seeds) is most suitable for people with few urinary symptoms, and small tumours with a low PSA level (less than 10) and a low to intermediate Gleason score or Grade Group. Temporary brachytherapy may be offered to people with a higher PSA level and a higher Gleason score or Grade Group. It is often given with a short course of EBRT.

If you already have significant urinary symptoms or a large prostate, brachytherapy is not suitable.

If you have permanent brachytherapy your body may give off some radiation for a short time. Your treatment team will explain the precautions to you. You will be advised to use a condom during sexual activity for the first few weeks after treatment in case a seed comes out during sex (though this is rare).

If you have temporary brachytherapy, you will not be radioactive once the wires are removed after treatment, and there is no risk to other people and no special precautions are needed during sex. 

Side effects of radiation therapy

The side effects you experience will vary depending on the type and dose of radiation, and the areas treated. Most side effects are temporary and tend to improve gradually in the weeks after treatment ends. Short-term side effects may include fatigue, urinary problems, bowel changes and ejaculation changes.

Some side effects may not show up until many months or years after treatment. These are known as late effects and may include infertility, urinary problems, bowel changes and erection problems.

To help prevent bowel side effects, the radiation oncologist may suggest a spacer to move the bowel away from the prostate. Before the treatment course begins, a temporary gel or balloon is injected into the space between the prostate and bowel. This procedure is usually done as a day procedure under a light anaesthetic. The cost is not subsidised by Medicare. Ask your doctors what you will have to pay and the benefits for your situation.

 

Androgen deprivation therapy (ADT)

Prostate cancer needs testosterone to grow. Reducing how much testosterone your body makes may slow the cancer’s growth or shrink the cancer 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 for locally advanced cancer may be used after a radical prostatectomy or with radiation therapy. It may also be given to help control advanced prostate cancer. 

Types of ADT

There are different types of ADT:

  • ADT injections (most common form of ADT) – involves injecting medicine to block the production of testosterone and can help slow the cancer’s growth for years. The injections can be given by your GP or specialist. How often you have injections depends on the drug – they may be given monthly, every three months or every six months. ADT injections may also be used before, during and after radiation therapy to increase the chance of getting rid of the cancer, and are sometimes combined with chemotherapy.
  • Intermittent ADT – occasionally ADT injections are given in cycles and continue until your PSA level is low. Injections can be restarted if your PSA rises again. This is known as intermittent ADT. In some cases, this can reduce side effects. It is not suitable for everyone.
  • Anti-androgen tablets – often called hormone tablets, anti-androgen tablets may be given in combination with ADT injections.
  • Removing the testicle (orchidectomy) – this surgery is not a common way to lower testosterone production. If you have advanced prostate cancer, you may choose surgery over regular ADT injections or tablets. It is possible to have a silicone prosthesis put into the scrotum to keep its shape. Removing only the inner part of the testicles also lowers testosterone and does not need a prosthesis.

Side effects of ADT

ADT may cause side effects because of the lower levels of testosterone in the body. Side effects may include: 

  • tiredness that doesn’t go away with rest (fatigue)
  • reduced sex drive (low libido)
  • erection problems
  • shrinking of the testicles and penis
  • loss of muscle strength
  • hot flushes and sweating
  • weight gain, especially around the middle
  • breast swelling and tenderness
  • genital shrinkage
  • mood swings
  • depression
  • trouble with thinking and memory
  • loss of bone density (osteoporosis) – calcium and vitamin D supplements and regular exercise help reduce this risk
  • higher risk of diabetes, high cholesterol and heart disease – your doctor will assess these risks with you.

For ways to manage side effects, talk to your treatment team or visit the Prostate Cancer Foundation of Australia for more information and support.

 

Advanced prostate cancer treatment

If the cancer has only spread to the nearby lymph nodes in the pelvis, you may have a combination of EBRT and ADT to try to remove the cancer. If prostate cancer has spread to other parts of the body, treatment usually aims to relieve symptoms or keep the cancer under control for years. ADT is the main treatment. Other treatments may include:

Chemotherapy

Chemotherapy uses drugs to kill cancer cells or slow their growth. If the prostate cancer continues to spread despite using ADT, chemotherapy may be suitable. It may also be offered as part of initial treatment in combination with ADT.

Generally, chemotherapy is given through a drip (infusion) into a vein (intravenously). For prostate cancer, chemotherapy is usually given once every three weeks for 4–6 months and you do not need to stay overnight in hospital.

Other drug therapies

Newer drug therapies may be used to treat advanced prostate cancer that has stopped responding to ADT. These drugs (e.g. abiraterone, enzalutamide, apalutamide, darolutamide) are hormone therapy tablets that can be combined with ADT to help prolong life and reduce symptoms. They are usually taken daily.

Other drug therapies include drugs that target specific features of cancer cells. These are known as targeted therapy. Clinical trials are testing whether targeted therapy drugs will benefit people with gene changes linked to prostate cancer.

Radiation therapy 

You may be offered radiation therapy to slow the growth of the cancer. Radiation therapy may be given to the sites where the cancer has spread, such as the lymph nodes or bones. You may also have radiation therapy to the prostate if you have not previously had any treatment.

Transurethral resection of the prostate (TURP)

This surgical procedure is used to relieve blockages in the urinary tract. It helps with symptoms of more advanced prostate cancer, such as the need to pass urine more often and a slow flow of urine.

If you have localised cancer, TURP may be used before radiation therapy to relieve symptoms of urinary blockage. TURP is also used to treat benign prostate hyperplasia.

You will be given a general or spinal anaesthetic. A thin tube-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 stay in hospital for a couple of days. Side effects may include blood in urine or problems urinating for a few days.

Bone therapies

If the prostate cancer has spread to the bones (bone metastases), your doctor may suggest treatments to manage the effect of the cancer on the bones. Drugs can be used to prevent or minimise bone pain and reduce the risk of fractures and pressure on the spinal cord.

Radiation therapy can also be used to control bone pain, to prevent fractures or help them heal, and to treat cancer in the spine that is causing pressure on spinal nerves (spinal cord compression).

Clinical trials

Clinical trials are testing new treatments for people with prostate cancer that has come back or not responded to treatment. These include a type of radiation therapy called focal brachytherapy and a type of radionuclide therapy known as lutetium PSMA, as well as new drugs.

Ask your doctor about recent developments and whether a clinical trial may be an option for you.

Palliative treatment

Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It may help at any stage of advanced cancer.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment may include:

  • radiation therapy to control pain if the cancer has spread to the bones
  • pain medicines (analgesics)
  • radionuclide therapy to control pain and improve quality of life. This involves swallowing or being injected with radioactive material (e.g. samarium, radium, strontium) which spreads through the body and targets cancer cells. It delivers high doses of radiation to kill cancer cells with minimal damage to normal tissues.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, practical, cultural, social and spiritual needs. The team also provides support to families and carers.

Understanding Prostate Cancer

Download our Understanding Prostate Cancer booklet to learn more.

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Expert content reviewers:

A/Prof Ian Vela, Urologic Oncologist, Princess Alexandra Hospital, Queensland University of Technology, and Urocology, QLD; A/Prof Arun Azad, Medical Oncologist, Urological Cancers, Peter MacCallum Cancer Centre, VIC; A/Prof Nicholas Brook, Consultant Urological Surgeon, Royal Adelaide Hospital and A/Prof Surgery, The University of Adelaide, SA; Peter Greaves, Consumer; Graham Henry, Consumer; Clin Prof Nat Lenzo, Nuclear Physician and Specialist in Internal Medicine, Group Clinical Director, GenesisCare Theranostics, and Notre Dame University Australia, WA; Henry McGregor, Men’s Health Physiotherapist, Adelaide Men’s Health Physio, SA; Jessica Medd, Senior Clinical Psychologist, Department of Urology, Concord Repatriation General Hospital, NSW; Dr Tom Shakespeare, Director, Radiation Oncology, Coffs Harbour, Port Macquarie and Lismore Public Hospitals, NSW; A/Prof David Smith, Senior Research Fellow, Daffodil Centre, Cancer Council NSW; Allison Turner, Prostate Cancer Specialist Nurse (PCFA), Canberra Region Cancer Centre, Canberra Hospital, ACT; Maria Veale, 13 11 20 Consultant, Cancer Council QLD; Michael Walkden, Consumer; Prof Scott Williams, Radiation Oncology Lead, Urology Tumour Stream, Peter MacCallum Cancer Centre, and Professor of Oncology, Sir Peter MacCallum Department of Oncology, The University of Melbourne, VIC.

Page last updated:

The information on this webpage was adapted from Understanding Prostate Cancer - A guide for people with cancer, their families and friends (2022 edition). This webpage was last updated in May 2022.

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