Prostate Cancer

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Treating Prostate Cancer TOPICS

Initial treatment of prostate cancer by stage

The stage of your cancer is one of the most important factors in choosing the best way to treat it. The section “How is prostate cancer staged?” explains how prostate cancer is staged, based on the extent of the cancer (using T, N, and M categories) and the PSA level and Gleason score at the time of diagnosis.

But keep in mind that other factors, such as your age, overall health, and life expectancy should also be taken into account when looking at treatment options.

In fact, many doctors determine a man’s possible treatment options based not just on the stage, but on the risk of cancer coming back (recurrence) after the initial treatment and on a man’s life expectancy.

You might want to ask your doctor what factors he or she is considering when discussing your treatment options. Some doctors could recommend options that are different from those listed here.

Stage I

These prostate cancers are small (T1 or T2a) and have not grown out of the prostate. They have low Gleason scores (6 or less) and low PSA levels (less than 10). They usually grow very slowly and may never cause any symptoms or other health problems.

For men without any prostate cancer symptoms who are elderly and/or have other serious health problems that may limit their lifespan, active surveillance is often recommended. For men who wish to start treatment, radiation therapy (external beam or brachytherapy) or radical prostatectomy may be options.

Men who are younger and healthy may consider active surveillance (knowing that they may need to be treated later on), radical prostatectomy, or radiation therapy (external beam or brachytherapy).

Stage II

Stage II cancers have not yet grown outside of the prostate, but are larger, have higher Gleason scores, and/or have higher PSA levels than stage I tumors. Compared with stage I prostate cancers, stage II cancers that are not treated with surgery or radiation are more likely to eventually spread beyond the prostate and cause symptoms.

As with stage I cancers, active surveillance is often a good option for men whose cancer is not causing any symptoms and who are elderly and/or have other serious health problems. Radical prostatectomy and radiation therapy (external beam or brachytherapy) may also be appropriate options.

Treatment options for men who are younger and otherwise healthy might include:

  • Radical prostatectomy (often with removal of the pelvic lymph nodes). This may be followed by external beam radiation if your cancer is found to have spread beyond the prostate at the time of surgery, or if the PSA level is still detectable a few months after surgery.
  • External beam radiation only*
  • Brachytherapy only*
  • Brachytherapy and external beam radiation combined*
  • Taking part in a clinical trial of newer treatments

*All of the radiation options may be combined with several months of hormone therapy if there is a greater chance of recurrence based on PSA level and/or Gleason score.

Stage III

Stage III cancers have grown outside of the prostate but have not reached the bladder or rectum (T3). They have not spread to lymph nodes or distant organs. These cancers are more likely to come back after treatment than earlier stage tumors.

Treatment options at this stage may include:

  • External beam radiation plus hormone therapy
  • External beam radiation plus brachytherapy, possibly with a short course of hormone therapy
  • Radical prostatectomy in selected cases (often with removal of the pelvic lymph nodes). This may be followed by radiation therapy.

Men who have other medical problems may be given less aggressive treatment such as hormone therapy (by itself) or even active surveillance.

Taking part in a clinical trial of newer treatments is also an option for many men with stage III prostate cancer.

Stage IV

Stage IV cancers have already spread to nearby areas such as the bladder or rectum (T4), to nearby lymph nodes, or to distant organs such as the bones. A small portion of T4 cancers may be curable using some of the same treatments for stage III cancers above. But most stage IV cancers can’t be cured with standard treatment.

Initial treatment options may include:

  • Hormone therapy
  • External beam radiation plus hormone therapy (in selected cases)
  • Surgery (TURP) to relieve symptoms such as bleeding or urinary obstruction
  • Treatments aimed at bone metastases, such as denosumab (Xgeva), a bisphosphonate like zoledronic acid (Zometa), external radiation aimed at bones, or a radiopharmaceutical such as strontium-89, samarium-153 or radium-223
  • Active surveillance (for those who have another serious illness)
  • Taking part in a clinical trial of newer treatments

Treatment of stage IV prostate cancer may also include treatments to help prevent or relieve symptoms such as pain.

The options listed above are for the initial treatment of prostate cancer at different stages. But if these treatments aren’t working (the cancer continues to grow and spread) or if the cancer comes back, other treatments might be used (see “Prostate cancer that remains or recurs after treatment”).

Last Medical Review: 12/22/2014
Last Revised: 03/12/2015