Prostate cancer is the second most common cancer in men, with more than 1 million cases diagnosed in 2018. It often grows slowly so that most men die of other causes before it becomes clinically advanced and hard to treat.
As most prostate cancers are diagnosed in slow-growing stages, they usually do not require immediate treatment decisions.
For localized and locally advanced prostate cancers, surgery and radiation therapy are the main treatment options.
Both options have risks, including erectile dysfunction, urinary problems, and bowel complications.
Your doctor will use the results of your diagnostic tests to balance the treatment benefits against those side effects.
Here, we explore the suitability of different treatment options. We offer information to help you consider the best treatment for your specific disease.
Treatment options for prostate cancer
Early-stage prostate cancer is often slow-growing. Here, it is hard to balance treatment benefits against its side effects. Therefore, delaying treatment until there is evidence of cancer progression is one way to avoid unnecessary side effects.
In some cases, a doctor may recommend watchful waiting or active surveillance to avoid unnecessary treatments.
Doctors recommend watchful waiting for older men or those with other terminal illnesses. Men who have less than five years to live are unlikely to experience prostate cancer mediated changes in their natural lifespan.
Here, the doctor usually monitors prostate cancer without conducting routine tests. It is controversial to perform routine screening (PSA-test and scans) when prostate cancer is unlikely to negatively impact survival. Therefore, delaying detection and treatment until it shows a sign of disease progression can help maintain a man’s quality of life.
If prostate cancer causes pain and urinary tract symptoms, then hormone treatment may be recommended.
Alternatively, a doctor may recommend monitoring with routine screening (active surveillance). Active surveillance aims to limit treatment to men with progressive disease.
Unlike watchful waiting, you will get regular PSA tests, MRI scans, and biopsies to monitor the activity of your cancer.
Your doctor will help with treatment decisions when these tests reveal the disease is progressing. It is common to switch to watchful waiting if you experience changes in life expectancy.
This change in treatment method aims to eliminate the negative impact of tests and biopsies on quality of life. The effectiveness of these approaches is dependent on the reliability of information about coexisting illnesses.
Expect to undertake a repeat biopsy to confirm that prostate cancer is in an early and slow-growing stage.
Local treatments, including surgery and radiation therapy, remove cancer from the gland and surrounding tissues.
For localized or locally advanced prostate cancer, these methods may cure the disease. However, curative treatment is only beneficial to younger men who are likely to survive prostate progression.
Due to treatment side-effects, older men with shorter life expectancy rarely benefit from radical treatments.
Surgery to remove the prostate gland, sometimes with some surrounding lymph nodes is one of the surest ways to treat localized prostate cancer. It is only suitable for curing prostate cancer that has not spread to distant organs. The type of surgery you get will depend on the stage of cancer, your general health, and other clinical factors.
Contemporary surgical methods include highly invasive radical prostatectomy and robotic prostatectomy.
Depending on the disease stage some men will get transurethral resection of the prostate (TURP). This is considered a minimally invasive surgery, to relieve the urinary symptoms of prostate cancer.
Like any surgical procedure, these operations carry some risks. Impaired sexual function is the most common risk, with more than 50% of treated men developing long-term erectile dysfunction.
Surgeons may use nerve-sparing techniques, when possible, to reduce the damage to the nerves that control erection. Urinary incontinence is also a potential complication of prostate surgeries.
Before surgery, talk to your doctor about the risk of erectile dysfunction and urinary incontinence. Your doctor may recommend drugs, penile implants, or injections to fix erectile dysfunction.
Radiation therapy using high-energy rays to destroy cancer cells is an effective way to treat prostate cancer. It is suitable for a variety of cases;
(1) first treatment for low-grade localized prostate cancer
(2) part of a combination treatment with hormone therapy for diseases that have spread to nearby tissues
(3) to control advanced prostate cancer and relieve symptoms. Compared to surgery, men with low-grade localized experience similar cure rates after radiation therapy or radical prostatectomy.
There are two main types of radiation therapy for prostate cancer; internal radiation (brachytherapy) and external beam radiation.
In brachytherapy, you may get low or high dose radiation. Low-dose brachytherapy involves placing seeds containing radiation within the prostate gland. The seeds are kept in place for several months to kill prostate cancer cells. Conversely, a surgeon delivers high-dose radiation through a small tube inserted into the prostate.
However, external-beam radiation therapy remains the most common way of giving radiotherapy for low-grade prostate cancer. For external beam radiotherapy, intensity-modulated radiation therapy (IMRT) and stereotactic radiosurgery are typical.
Generally, the best radiotherapy for your disease will depend on the cancer stage.
In addition to short-term side effects like bowel irritation, tiredness, radiation therapy may cause erectile dysfunction. However, the rate of long-term side effects is lower following radiation therapy compared to surgical treatments.
Systemic treatments are required to target and destroy cancers anywhere in the body because surgery or radiation therapy alone is not useful for metastatic prostate cancer. Two main approaches are hormone treatment and chemotherapy.
The purpose of hormone therapy is to stop the production of androgens (testosterone). However, prostate cancer cells can become insensitive to androgen levels.
As a result, they can grow in low testosterone (castration-resistant prostate cancer). Steroid tablets like dexamethasone may be used to stop cancer growth when it is resistant to the hormone.
Chemotherapy involves killing cancer cells with anti-cancer drugs. The purpose of chemotherapy is to block the way cancer cells grow and multiply wherever they are in the body.
Docetaxel and Cabazitaxel are the most commonly used drugs for treating advanced prostate cancer. They can also be used alongside hormone therapy in advanced disease.
Systemic treatments for advanced prostate cancer are not curative. They slow the progression of the disease, allowing men to live with fewer symptoms.
Surgery is the primary treatment option for localized high-risk prostate cancers. After ten years of treatment, surgery reduces disease-specific mortality, overall mortality, risk of disease progression, and cancer metastasis.
Patients with a biopsy Gleason score ≤ 8, PSA less than 20 ng/ml, and tumor stage ≤ cT3a benefit most from surgical therapy.
What are the benefits of surgery?
The success rate for surgery to treat prostate cancer is very high when all the cancer is removed. Surgical treatment is generally safe, with most men making a full recovery within two months after surgery.
Further, surgery provides information about the exact genetics and state of cancer. Genetic analysis of surgically removed prostate tissue allows doctors to estimate prognosis and plan any complementary treatments.
What are the risks of surgery?
Prostate surgery is associated with risks. It is common for men to experience one or more side effects after prostate surgeries. Some side effects are short-lived, while others persist for many years after surgery.
Common side effects of prostate surgeries are:
- Urinary complications, including painful urination, difficulty urinating, urinary incontinence. Most prostate cancer patients treated with surgery will experience urinary incontinence. This usually improves after four weeks. In some men, surgery-related urinary incontinence persists for many years.
- Erectile dysfunction, difficulty with getting, and maintaining an erection is frequent. More than 10% of men treated with prostate surgery develop erectile dysfunction. An injury to the nerves that control erection increases the risk of developing long-term erectile problems.
- Retrograde ejaculation and infertility occur in more than 90% of cases. This side effect occurs because radical prostatectomy removes the seminal vesicles (semen producing glands).
- Lymphedema: Surgery can damage lymph nodes around the prostate gland, causing swelling and pain. Both can be improved with treatment.
Radiotherapy is the second common treatment option for localized high-risk prostate cancers. Significant clinical developments in recent decades have helped improve outcomes after radiotherapy.
Giberti et al. compared the effectiveness of radical prostatectomy and low-dose radiation brachytherapy. This randomized clinical trial demonstrated that both methods had similar rates of disease progression, mortality, and metastasis.
Similarly, high-dose brachytherapy offers effective treatment for men with locally advanced prostate cancer.
Regarding external-beam radiation therapy, nearly all men without distant metastases, and a long life expectancy experience a favorable outcome. Proton beam therapy, a form of external-beam radiation therapy has increased the survival rates of prostate cancer patients.
What are the benefits of radiation treatment?
Radiation therapy is an effective treatment for both low- and high-grade prostate cancer. It is an option for treating residual cancer after surgery or relapsed cancer.
What are the risks of radiation treatment?
However, like surgery, radiation therapies often cause side effects. In particular, radiation may cause severe damage to healthy cells and tissues near the prostate area.
These problems are different for each patient, depending on the radiation dose and your general health. Common side effects are detailed below.
- Erectile dysfunction
- Radiation therapy may cause you to experience erection problems, possibly impotence. After a few years, the erectile dysfunction rates in men treated with radiotherapy is similar to that after surgery. Radiation-induced erection problems usually develop over time. This delayed erectile problem is contrary to the presentation after surgery, where erection problems occur immediately and improve over time.
- Concerning different types of radiation therapy for prostate cancer, studies comparing rates of erection problems in brachytherapy and external beam radiation reported conflicting results.
- Some studies found that erection problems are lower after brachytherapy compared to external beam radiation. Other studies have found that rates were not different between ways of delivering radiotherapy.
- Urinary incontinence
- Severe urinary problems are not common in radiation therapy. Nevertheless, you may experience frequent urination and symptoms of the irritated urethra. Urinary issues tend to improve over time, with most men making a full recovery.
Other side effects
- Bowel side effects: Irritation to the rectum can cause radiation proctitis, leading to diarrhea and rectal leakage. Rarely, some men develop permanent bowel complications. Adhering to the pre-radiation diet prescribed by your doctor can limit bowel movement during treatment.
- Lymphedema: Damage to lymph nodes around the prostate gland can cause fluid to collect in the legs and genitalia over time. Lymphedema causes swelling and pain but can be treated with physical therapy.
- Tiredness: Radiation therapy can cause months of fatigue.
Technological developments in radiation therapy have made it more targeted, thereby reducing the risk of developing these side effects. Further, some men experience fewer side effects or none. Other men get more severe adverse reactions.
Is one treatment better than the other?
A personalized approach is the most effective way to treat prostate cancer. Thus, it is not a question of which method is better but rather which method is the most suitable for your specific disease.
There is no overall best between surgery and radiotherapy; both have advantages and disadvantages.
Your doctor may recommend surgery if you are healthy enough for a significant surgical procedure. It is also a good option if you have had previous radiation therapy to your pelvic region.
It is also better if you have an existing bowel disease, which can be exacerbated by radiation therapy. Your doctor may recommend radiation therapy if your health or other medical conditions make surgery risky.
Nonetheless, men who receive either treatment options have a low risk of prostate cancer death. A seminal study that compared active monitoring, radical prostatectomy, and radiotherapy found no significant difference among treatment options.
Surgery and radiotherapy reduced the rates of disease progression and metastases, by similar proportions, compared to active monitoring.
Things to consider
Though it is up to you and your doctor to decide the best treatment approach, you should consider several factors. Specifically, the best treatment for your prostate cancer is likely to be influenced by:
- Tumour grade
- Presence of metastasis
- Existing medical conditions and treatments
- Lifestyle changes
Remember that these factors also influence your prognosis, and initial treatment may affect future treatment decisions.
Non-invasive treatment options may be suitable for your specific circumstances. However, untreated early-stage prostate cancer may progress to advanced disease, spreading to your lymph nodes and bones.
This advanced stage of prostate cancer is not curable by current treatment methods. Men with advanced or metastatic prostate cancer have a poorer survival rate compared to those with localized disease.
Early treatment, especially with high-risk disease, is a key determinant of a favorable outcome.
Speak to your medical provider if you are concerned about the side effects of surgery or radiation treatments. Your healthcare provider may implement an alternative treatment option that is suitable for the stage of your cancer.