Prostate Cancer – Treatment

Different doctors are usually involved in the treatment of prostate cancer (urologist, radiation oncologist, medical oncologist). These specialists discuss prostate cancer cases in so call tumor boards.
Several factors will be considered for each patient’s individual treatment plan:

  • size of the tumor
  • whether it is limited to the prostate or has already spread
  • aggressiveness of the tumor
  • age and general life expectancy of the patient
  • other diseases and tumor associated symptoms

Several different treatment forms can be applied either alone or in combination to optimally address the individual patient’s situation. The main forms of treatment are:

Surgery is usually carried out if the cancer hasn’t spread (metastasized). In some select cases surgery can relieve symptoms. It consists of the removal of the prostate gland, together with the seminal vesicles and neighboring lymph nodes. Unfortunately, there is a probability of between 30 to 70% that the patient will suffer from impotence and/or incontinence as a result. Both side effects can be transient or permanent.

Radiation therapy / Brachytherapy
With respect to chances of recovery, an equivalent alternative to surgery is radiation therapy. As surgery it can also be applied to relief tumor related symptoms like pain.
Two treatment methods are available: (1) irradiation from outside the body (percutaneous radiotherapy), usually in conjunction with hormone therapy.
(2) irradiation using so-called seeds or loaded tubes (brachytherapy). Seeds are small radioactive elements positioned directly into the tumor by puncture needles using ultrasound guidance. These seeds release radioactivity for up to a few weeks and won’t need to be removed. Alternatively several tubes can be inserted into the prostate which can then be loaded with radioactive material. Both ways the tumor is destroyed from the inside.
Possible side effects depend on the type of radiotherapy and the applied dose. They may include damage to the rectal mucous membrane or bladder. In addition, incontinence and impotence can occur.

Hormone therapy
Hormone therapy is mainly applied to men with far advanced prostate cancer or in combination with other forms of treatment. In hormone sensitive tumors, hormone therapy can block tumor growth or even shrink the tumor volume. This relies on the fact that without testosterone, tumor growth is retarded or, over time, even halted. In this case, you will receive hormone-suppressing medications in the form of a depot injection or a pill. Possible immediate side effects include hot flashes and reduced libido or potency.

Chemotherapy is usually applied to men with advanced or metastasized prostate cancer that need therapy and no longer respond to hormone therapy. Chemotherapy retards the growth of the tumor in the case of metastasis. As chemotherapy affects not just tumor cells but also other rapidly growing cells and tissues in the body, chemotherapy can cause nausea, loss of appetite and vomiting, as well as temporary hair loss.

Active surveillance
Active surveillance is increasingly recommended to patients with a cancer in early stage and slow growth behaviour (usually so called “low risk” cancers). With active surveillance the patient will be checked every 3-6 month for changes of the tumor by digital rectal examination and PSA testing. In addition to that an annual prostate biopsy is performed to control the Gleason score of the tumor. If the patient’s Gleason score or PSA level rises or the patients develops other symptoms, the physician will suggest treatment measures as described above. By choosing active surveillance the patient can delay the side effects of a potentially necessary treatment.

Watchful waiting
In contrast to active surveillance, watchful waiting is an approach to delay treatment for patients who have no curative treatment options due to age or other diseases etc. Watchful waiting does not follow a systematic monitoring schedule and palliative treatment will usually only be recommended when the patient starts to suffer from tumor related symptoms.