This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

Some general comments about treatment

There is a lot for you to think about when choosing the best way to treat or manage your cancer. There may be more than one treatment to choose from. You may feel that you need to make a decision quickly. But give yourself time to take in all the information you have learned. Talk to your doctor. Look at the list of questions at the end of this article to get some ideas. Then add your own.

The treatment you choose for prostate cancer should take into account:

• your age and how long you can expect to live
• any other serious health problems you may have
• the stage and grade of your cancer
• your feelings (and your doctor's opinion) about the need to treat the cancer
• the chance that each type of treatment will cure your cancer (or help you on some other way)
• your feelings about the side effects common with each treatment

You may want to get a second opinion, especially if you have many treatments to choose from. Prostate cancer is a complex disease, and doctors may differ in their opinions about the best treatment options. Talking with doctors who specialize in different kinds of treatment may be helpful. You will want to weigh the benefits of each treatment against its drawbacks, side effects, and risks.

Watchful waiting and active surveillance

Because prostate cancer often grows very slowly, some men (especially those who are older or who have other major health problems) may never need treatment for their cancer. Instead, their doctor may suggest approaches called watchful waiting (also called expectant management) or active surveillance.

Until recently, watchful waiting meant waiting until the cancer was causing symptoms before starting any treatment. Now, it is more common to watch the patient closely with regular PSA tests, rectal exams, and ultrasounds to see if the cancer is growing. If the cancer does seem to be growing or getting worse, the doctor may suggest starting treatment. Some doctors still think of as watchful waiting, while others call it "active surveillance." Not every doctor means the same thing when they say "watchful waiting," so it is important to ask your doctor what he or she means if they use this term.

Right now, not all experts agree how often testing should occur for active surveillance. There is also debate about when is the best time to start treatment. Still, some early studies have shown that men who choose active surveillance and go on to be treated do just as well as those who decide to start treatment right away.

Either of these methods may be a good choice if the cancer is not causing any symptoms, is likely to grow slowly, and is small and contained in one place in the prostate. It is less often a choice if you are young, healthy, and have a cancer that is growing fast.

Some men choose watchful waiting because, in their view, the side effects of strong treatments outweigh the benefits. Others are willing to accept the possible side effects of active treatments in order to try to remove or destroy the cancer.

Surgery

Radical prostatectomy is surgery that is done to cure prostate cancer. It is used most often if it looks like the cancer has not spread outside of the gland. In this operation, the surgeon removes the whole prostate gland plus some of the tissue around it, including the seminal vesicles.

Types of radical prostatectomy

Radical retropubic prostatectomy: This approach is most common. The cut (incision) is made in the lower belly (abdomen), as shown in the picture below. You will either be in a deep sleep (under general anesthesia) or be given medicine to numb the lower half of the body (an epidural) along with drugs to make you sleepy (sedation).

Your doctor may first remove lymph nodes near the prostate and have them looked at under a microscope. If any of the nodes contain cancer, it means the cancer has spread. Since the cancer probably can't be cured by taking out the prostate, the doctor may stop the operation.

The nerves that control erections are very close to the prostate. During this operation, it is sometimes possible to avoid harming these nerves (called a nerve-sparing approach). This lowers, but does not do away with, the risk of impotence (being unable to have an erection) after surgery. If you were able to have erections before, the doctor will try not to injure these nerves. Of course, if the cancer is growing into them, the doctor will have to remove them. Even if the nerves have been spared, it takes at least a few months after surgery to have an erection. This is because the nerves have been handled during the operation and won't work properly for a while.

Radical perineal approach: In the perineal approach, the surgeon makes the cut (incision) in the skin between the anus and the scrotum, as shown in the picture below. Nerve-sparing operations are harder to do with the perineal approach, and lymph nodes cannot be removed. Still, the surgeon can remove some lymph nodes another way, if needed. Because this operation is often shorter, it might be used for men who don't want the nerve-sparing procedure and who don't need to have lymph nodes removed. It also might be used if you have other medical problems that make retropubic surgery hard to do.

Retropubic approach                 Perineal approach

Either of these operations lasts from 1½ to 4 hours. The perineal approach often takes less time than the retropubic approach. They are followed by an average hospital stay of 3 days. The average time away from work is 3 to 5 weeks.

In most cases, you will be able to donate your own blood before surgery. The blood can be given back to you during the operation, if needed. Usually a tube for draining urine (called a catheter) is put into the bladder through the penis after surgery, while you are still asleep. The catheter stays in for 1 to 3 weeks and allows you to pass urine easily while you are healing. You will be able to urinate on your own after the catheter is removed.

Laparoscopic radical prostatectomy (LRP): Both of the operations described above use an "open" approach in which the surgeon makes a long cut (incision) to remove the prostate. A newer method involves making several smaller cuts and using special long instruments to remove the prostate. It is called laparoscopic radical prostatectomy or LRP and is being used more and more in this country.

LRP has advantages over the open approach: less blood loss and pain, shorter hospital stays, and faster recovery time. Nerve-sparing is possible with LRP, and the side effects seem to be about the same as for open prostatectomy.

LRP has been used in the United States since 1999. It is done in community and university centers. Because it is still somewhat new, results of long-term studies are not in yet. If you are thinking about treatment with LRP, find out as much as you can about this approach. Also be sure to find a surgeon with a lot of experience doing LRP.

Robotic-assisted laparoscopic radical prostatectomy: An even newer approach is to do LRP remotely using a robotic interface. The surgeon sits at a panel near the operating table and controls robotic arms to do the operation through several small cuts (incisions) in the patient's belly (abdomen). For the patient, there is little difference between direct and remote (robotic) LRP, either during surgery or recovery.

Robotic LRP has been in use in the United States since 2003. The machines themselves cost a lot, and are found in only a few medical centers across the country. Still, this approach has become more popular in recent years. Again, the most important factors are likely to be the skill and experience of your surgeon.

Transurethral resection of the prostate (TURP): This procedure is done to relieve symptoms, such as trouble passing urine, in men who can't have other types of surgery. It is not done to cure the disease or to remove all the cancer. The same operation is used even more often to relieve symptoms of non-cancerous prostate swelling called BPH.

During this operation, a tool with a small loop of wire on the end is placed through the end of the penis into the urethra. The wire is heated and cuts out the part of the prostate that is pressing in on the urethra. No cut (incision) is needed for TURP. Either spinal anesthesia, where you are made numb from the waist down, or general anesthesia, which outs you into a deep sleep, is used.

The operation takes about an hour. You can usually leave the hospital after 1 to 2 days and go back to work in 1 to 2 weeks. After surgery you will need a tube for draining urine (called a catheter) for about 2 or 3 days. There may be some blood in your urine for a short time after surgery.

Risks and side effects of radical prostatectomy

There are possible risks and side effects with any type of surgery for prostate cancer.

Surgical risks: The risks with this surgery are like those of any major surgery. They can include problems from the drugs used during the operation (anesthesia), a small risk of heart attack, stroke, blood clots in the legs, infection, and bleeding. Your risk depends, in part, on your overall health, your age, and the skill of your doctors.

The main possible side effects of radical prostatectomy are lack of bladder control (incontinence) and not being able to get an erection (impotence). These side effects can also happen with other kinds of treatment but they are described here in more detail.

Urinary incontinence: Incontinence means you can't control your urine or you have trouble with leaking. There are different types of incontinence. Having this problem can affect you not only physically but emotionally and socially, too.

There are 3 types of incontinence:

• Stress incontinence is the most common type of incontinence after prostate surgery. Men with stress incontinence leak urine when they cough, laugh, sneeze, or exercise.

• Men with overflow incontinence take a long time to urinate and have a dribbling stream with little force.

• Men with urge incontinence have a sudden need to go to the bathroom and pass urine.

In rare cases, men lose all ability to control their urine. This is called continuous incontinence.

Normal bladder control returns for many men within several weeks or months after surgery. Doctors can't predict how any one man will do after prostate surgery.

Most large cancer centers, where this surgery is done more often and surgeons have more experience, report fewer problems with incontinence. If you have problems with incontinence, let your doctors know. Doctors who treat men with prostate cancer should know about incontinence, and should be able to suggest ways to help you. There are exercises (called Kegel exercises) you can learn that might help to strengthen your bladder. There are medicines or even surgery that might help. There are also products to help keep you dry and comfortable.

Impotence: Impotence means that a man can't get an erection strong enough to have sex. The nerves that allow men to get erections may be damaged during surgery, radiation treatment, or other treatments. During the first 3 to 12 months after surgery, you will probably not be able to get an erection without using medicine or some other treatment. Later, some men will be able to get an erection and some will still have trouble. Whether or not you will be able to get an erection depends on your age and the type of surgery that was done. The younger you are, the more likely it is that you will be able to get an erection. If you are able to get an erection the feeling of pleasure (orgasm) during sex will still be there. The orgasm will be "dry," though, since semen is not being made.

If you are concerned about erection problems, be sure and talk to your doctor. There are ways to help. There are medicines and even devices such as vacuum pumps and penile implants that could prove useful.

For more information to help you understand and cope with the sexual side effects of prostate cancer treatment, please see Sexuality for the Man with Cancer.

Sterility: A radical prostatectomy cuts the tubes between the testicles (where sperm are made) and the urethra. This means that a man can no longer father a child by natural means. Often this is not an issue as men with prostate cancer tend to be older. But if this is a concern for you, talk to your doctor about "banking" your sperm before the operation.

Lymphedema: A rare side effect of removing many of the lymph nodes around the prostate is lymphedema, which causes swelling and pain. Lymph nodes provide a way for fluid to return from all around the body to the heart. When the nodes are removed, fluid can collect in the legs or genital region. Lymphedema can often be treated with physical therapy, but it might not go away completely.

Change in penis length: Another possible side effect of surgery is a decrease in penis length. Doctors are not sure what causes this.

Radiation therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill cancer cells or shrink tumors. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly in the tumor (brachytherapy or internal radiation).

Radiation is sometimes used as the first treatment for low-grade cancer that has not spread outside the prostate gland, or has spread only to nearby tissue. It is also sometimes used if the cancer is not completely removed or comes back (recurs) in the area of the prostate after surgery. Cure rates for men treated with radiation seem to be about the same as for men having surgery. If the cancer is more advanced, radiation may be used to shrink the tumor and provide pain relief.

External beam radiation therapy (EBRT)

This treatment is much like getting a regular x-ray, but for a longer time. Each treatment lasts only a few minutes. Men usually have 5 treatments per week in an outpatient center over a period of 7 to 9 weeks. The treatment itself is quick and painless.

Today, standard EBRT is used much less often than in the past. Newer methods allow doctors to be more accurate in treating the prostate gland while reducing the radiation exposure to nearby healthy tissues. Some of these methods you may hear about are 3-dimensional conformal radiation therapy (3D-CRT), intensity modulated radiation therapy (IMRT), and conformal proton beam radiation therapy. These methods seem to offer better chances of increasing the success rate and reducing side effects. If you are having one of the newer methods, your doctor can tell you more about it.

Possible side effects of external beam radiation therapy

The possible side effects below relate to standard external radiation therapy, which is now used much less often than in the past. The risks of the newer treatment methods mentioned above are likely to be lower.

Bowel problems: During and after treatment with external beam radiation therapy, you may have diarrhea, sometimes with blood in the stool, rectal leakage, and an irritated large intestine. Most of these problems go away over time, but in rare cases normal bowel function does not return after treatment ends.

Bladder problems: You might find yourself needing to urinate more often, have burning while passing urine, and maybe see blood in your urine. Bladder problems last in about 1 out of 3 patients, with the most common problem being the need to urinate often.

Urinary incontinence: Incontinence means you can't control your urine or you have trouble with leaking. Although this side effect is less common than after surgery, the chance of incontinence goes up each year for several years after radiation treatment. For more information, see the above section on incontinence under the surgery side effects.

Impotence: Impotence means that a man can't get an erection strong enough to have sex. After a few years, the impotence rate after radiation is about the same as that of surgery. It usually does not happen right after radiation therapy, but slowly develops over a year or more. As with surgery, the older you are, the more likely it is you will become impotent. Impotence may be helped by treatments such as those listed in the surgery section above, including erectile dysfunction medicines.

Feeling tired: Radiation therapy may also cause severe tiredness called fatigue. It may not go away until a few months after treatment stops.

Lymphedema: Fluid build-up in the legs or genitals (described in the surgery section of this document) is possible if the lymph nodes receive radiation.

Brachytherapy (internal radiation)

Permanent or low dose brachytherapy uses small radioactive pellets (each about the size of a grain of rice) that are put into the prostate. Sometimes these pellets are referred to as "seeds." Because they are so small, they cause little discomfort and are often left in place after their radioactive material is used up.

Another form of brachytherapy is called temporary or high dose brachytherapy. In this type, needles are used to place soft tubes (called catheters) in the prostate. A strong radioactive substance is placed in these catheters for 5 to 15 minutes and then taken out. (The catheters are left in place.) You will stay in the hospital for this treatment. Usually 3 treatments are given over a couple of days. After the last treatment the catheters are removed. Often this treatment is combined with external radiation, given at a lower dose than it would be if used alone. For about a week after this treatment you may have some pain in the area between your scrotum and rectum, and your urine may be reddish-brown.

Possible risks and side effects of brachytherapy

If you have pellets that are left in place, they will give off small amounts of radiation for several weeks. Even though the radiation doesn't travel far, you may be told to stay away from pregnant women and small children during this time. You may be asked to be careful in other ways, too, such as wearing a condom during sex.

For about a week after the pellets are put in place, there may be some pain in the area and a red-brown color to the urine. There is also a small risk that some of the seeds might move to other parts of the body, but this is rare. Like external radiation treatment, this approach can have side effects such as problems with the bladder and bowel and impotence. Talk to your doctor if you have any problems. Often there are medicines or other methods to help.

Cryosurgery

Cryosurgery is sometimes used to treat prostate cancer by freezing the cells with cold metal probes. It is used only for prostate cancer that has not spread, but may not be a good option for men with large prostate glands. The probes are placed through cuts (incisions) between the anus and the scrotum. Cold gases are then passed through the probes, which creates ice balls that destroy the prostate gland. Some type of drug to make you numb and sleepy (anesthesia) is used during this procedure.

A catheter is also put into the bladder (usually through the lower belly) so that when the prostate swells (as it often does after this treatment) urine is not trapped in the bladder. The catheter is removed a couple of weeks later. After the procedure, there will be some bruising and soreness in the area where the probe was inserted. You may have some blood in the urine for the first few days. Short-term swelling of the penis and scrotum after cryosurgery is also common. You may need to stay in the hospital for a day, but many patients can leave the same day.

Possible side effects of cryosurgery

There are benefits and drawbacks to cryosurgery. Because it is less invasive than radical surgery, there is less loss of blood, a shorter hospital stay, shorter recovery time, and less pain. But freezing can damage nerves near the prostate and cause impotence and incontinence. These side effects may occur more often with cryosurgery than they do after radical prostatectomy. Freezing may also damage the bladder and intestines. This can cause pain, a burning sensation, and the need to empty the bladder and bowels often.

Compared to surgery or radiation treatment, doctors know much less about how well this method works in the long run. For this reason, most doctors do not include cryosurgery among the first options they recommend for treating prostate cancer.

Hormone therapy

The goal of hormone therapy (also called androgen deprivation) is to lower the levels of the male hormones (or androgens), such as testosterone. Androgens, which are made mostly in the testicles, cause prostate cancer cells to grow. Lowering androgen levels often makes prostate cancer shrink or grow more slowly. Hormone therapy can control, but will not cure the cancer. It does not take the place of treatments aimed at a cure.

Hormone therapy is often used in these cases:

• In men who do not have surgery or radiation as good treatment options.
• For men whose cancer has spread to other parts of the body or has come back after earlier treatment.
• Along with radiation in men who are at high risk of having the cancer return after treatment.
• Sometimes it is used before surgery or radiation to shrink the cancer.

While hormone therapy does not cure the cancer, it can provide relief from symptoms. Some doctors think that hormone therapy works better if it is started as early as possible after the cancer has reached an advanced stage. But not all doctors agree with this.

Because nearly all prostate cancers become resistant to hormone therapy over time, some doctors use an on-again, off-again approach (this is called intermittent therapy). The drugs are given for a while, then stopped, then started again. One advantage is that some men are able to avoid the side effects (impotence, loss of sex drive, etc.) for a time. Studies are now going on to see whether this new approach is better or worse than giving the drugs non-stop.

Types of hormone therapy

There are several types of hormone therapy. They involve either surgery or the use of drugs to lower the amount of testosterone or block the body's ability to use androgens.

Orchiectomy: Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where more than 90% of the androgens, mostly testosterone, are made. While this is a fairly simple procedure and is not as costly as some other options, it is permanent and many men have trouble accepting this operation. Most men who have this surgery lose the desire for sex and cannot have erections.

LHRH analogs (luteinizing hormone-releasing analogs): These drugs lower testosterone levels just as well as orchiectomy. LHRH analogs (also called LHRH agonists) are given as shots or as small pellets of medicine put under the skin. Depending on the drug used, they are given anywhere from every month, every 3 or 4 months, up to once a year. Even though this treatment costs more and means more doctor visits, most men choose this method over surgery to remove the testicles.

When LHRH analogs are the first given, the testosterone level goes up briefly before going down to low levels. This is called "flare." Men whose cancer has spread to the bones may have bone pain during this flare. To reduce flare, drugs called anti-androgens can be given for a few weeks before starting treatment with LHRH analogs.

LHRH antagonists: Abarelix (Plenaxis^®) was an LHRH antagonist drug. It lowered testosterone levels quickly and did not cause a flare. In 2005, the company making abarelix decided to take it off the market. Men already taking abarelix could keep on taking this drug, but no new patients could be started on it. It is no longer available.

Degarelix (Firmagon^®) is a new LHRH antagonist. It was approved for use by the FDA in 2008 to treat advanced prostate cancer. It is given as a monthly shot under the skin. Like abarelix, degarelix quickly lowers testosterone levels. The most common side effects are pain, redness, and swelling at the place where the shot was given and increased levels of liver enzymes on lab tests.

Anti-androgens: These drugs block the body's ability to use any androgens. Even after the testicles are removed or during LHRH treatment, the adrenal glands still make a small amount of androgens. Anti-androgens may be used along with orchiectomy or the LHRH analogs to provide combined androgen blockade (CAB), or total blocking of all androgens produced by the body. There is still debate about whether CAB is better than using the other treatments alone.

Other drugs to lower androgen levels: At one time estrogens (female hormones) were used to treat men with prostate cancer. Because of side effects, LHRH analogs and anti-androgens are now used more often. But estrogen or some other drugs, such as ketoconazole (Nizoral^®), may be used if other hormone treatments are no longer working.

Side effects of hormone therapy

Orchiectomy, LHRH analogs, and LHRH antagonists all cause side effects because of changes in the levels of hormones. These side effects can include:

• less sexual desire
• impotence (not being able to get an erection)
• hot flashes (these may get better or even go away with time)
• breast tenderness and growth of breast tissue
• bone thinning (osteoporosis) which can lead to broken bones
• low red blood cell counts (anemia)
• decreased mental sharpness
• loss of muscle mass
• weight gain
• extreme tiredness (fatigue)
• increased cholesterol
• depression

The risk of high blood pressure, diabetes, and heart attacks is also higher in men treated with hormone therapy.

Many side effects can be prevented or treated. For example, hot flashes can be helped by treatment with certain antidepressants. Brief radiation treatment to the breasts can help prevent their enlargement. There are drugs available to prevent and treat osteoporosis. Depression can be treated by antidepressants or counseling. Exercise can help reduce many side effects, including fatigue, weight gain, and the chance of loss of bone and muscle mass. If anemia occurs, it is often very mild and usually doesn't cause symptoms.

There is growing concern that hormone therapy for prostate cancer may lead to problems with thinking, concentration, or memory. But this link has not been studied well in men getting hormone therapy for prostate cancer. Different studies have shown changes in different types of memory. Some have even found that while some types of memory get worse, another type got better. Other studies found no effect at all. More studies are being done to look at this issue.

Debates about hormone therapy

Many issues about hormone therapy are not yet resolved, such as the best time to start and stop it and the best way to give it. Studies looking at these issues are now going on. If you are thinking about hormone therapy, ask your doctor to explain which treatments will be used and what side effects you might expect to have.

Chemotherapy (chemo)

Chemo is the use of drugs to treat cancer. The drugs are often injected into a vein (given IV). Some can be swallowed in pill form. Once the drugs enter the bloodstream, they spread throughout the body to reach and destroy the cancer cells.

Chemo is sometimes used if prostate cancer has spread outside of the prostate gland and hormone therapy isn't working. It is not a standard treatment for early prostate cancer, but some studies are looking to see if chemo could be helpful if given for a short time after surgery.

Like hormone therapy, chemo is unlikely to result in a cure. This treatment is not expected to destroy all the cancer cells, but it may slow the cancer's growth and reduce symptoms, resulting in a better quality of life.

There are many different chemo drugs. Often 2 or more are given at the same time for better effect.

Side effects of chemo

While chemo drugs kill cancer cells, they also damage some normal cells and this can lead to side effects. The side effects of chemo depend on the type of drugs, the amount taken, and the length of treatment. They could include:

• nausea and vomiting
• loss of appetite
• hair loss
• mouth sores

Because normal cells are also damaged, you may have low blood cell counts. This can cause:

• increased risk of infection (from a shortage of white blood cells)
• bleeding or bruising after minor cuts or injuries (from a shortage of blood platelets)
• tiredness (from low red blood cell counts)

Also, each drug may have its own unique side effects.

Most side effects go away once treatment is over. If you have problems with side effects, talk with your doctor or nurse about what can be done. There is help for many chemo side effects. For example, there are drugs to prevent or reduce nausea and vomiting. Other drugs can be given to boost blood cell counts.

Treating pain and other symptoms

Most of this article talks about ways to remove or destroy cancer cells or to slow their growth. But it is important to know that having a good quality of life is also an important goal. Be sure to talk to your doctor or nurse about pain or any symptoms that are bothering you. There are ways to treat these. And getting good treatment can help you feel better and allow you to focus on things that are important in your life.

Pain medicines

Pain medicines work very well. When the drugs are being used as directed to treat cancer pain, you do not need to worry about addiction or dependence. You may have symptoms like tiredness and itching, but these usually go away after you get used to the medicine. Constipation is the most common problem, but there are things you can do to prevent this. Side effects can often be managed by changing the dosage or by adding other medicines.

Bisphosphonates

This is a group of drugs that can help relieve bone pain caused by cancer that has spread to the bones. They may also slow the growth of the cancer and strengthen bones in men who are getting hormone treatment.

Bisphosphonates can cause side effects, such as flu-like symptoms and bone pain. Some men have had a very rare, but distressing side effect from these drugs. They have pain in the jaw and their doctors find that part of the jaw bone has died. This can lead to loss of teeth or infections of the jaw bone. Doctors don't know why some people develop these jaw problems or how to prevent them. So far, the only treatment has been to stop the bisphosphonate treatment. Some cancer doctors recommend that patients have a dental check-up and have any tooth or jaw problems treated before they start taking bisphosphonates.

Steroids

Steroids can relieve bone pain and increase appetite for some men.

Radiation therapy

While radiation therapy can be used as the main treatment for prostate cancer, it can also be used to treat bone pain caused by cancer that has spread to the bone.

Drugs called radiopharmaceuticals are also used for this purpose. This is a group of drugs that have radioactive elements. They are given into a vein. They settle in areas of bones that contain cancer and the radioactive part kills the cancer cells there. About 8 out of 10 prostate cancer patients with bone pain are helped by this treatment. The main side effect is a lowering of blood cell counts. This could increase your risk of getting an infection or bleeding easily.

Last Medical Review: 08/21/2009
Last Revised: 08/21/2009