Prostate cancer treatment; stage I to III cancer

Prostate cancer treatment; stage I to III cancer

Author
Eric A Klein, MD
Section Editors
Nicholas Vogelzang, MD
W Robert Lee, MD, MS, MEd
Jerome P Richie, MD, FACS
Deputy Editor
Michael E Ross, MD

Disclosures

INTRODUCTION — Prostate cancer is a cancer of the prostate gland, an organ that forms a ring around the urethra, near its connection to the bladder (figure 1). The urethra is the tube that carries urine from the bladder to the outside of the body.

Over the last 15 years, more men are being diagnosed with prostate cancer at an early stage, when the cancer is highly curable. A separate article discusses screening tests for prostate cancer. (See “Patient information: Prostate cancer screening”.)

This article discusses symptoms, diagnosis, and treatment of stage I to III prostate cancer. Treatment of advanced prostate cancer is discussed separately. (See “Patient information: Treatment for advanced prostate cancer”.) More detailed information about early-stage prostate cancer is available by subscription. (See “Overview of treatment for clinically localized prostate cancer”.)

PROSTATE CANCER SYMPTOMS — Prostate cancer is usually found before symptoms develop. However, early symptoms of prostate cancer may include:

A need to rush to the bathroom frequently or a slow urine stream. These symptoms are usually related to an enlarged prostate (called BPH), not prostate cancer. (See “Patient information: Benign prostatic hyperplasia (BPH)”.)
Erectile dysfunction (difficulty having an erection). Erectile dysfunction is more commonly caused by problems other than prostate cancer. (See “Patient information: Sexual problems in men”.)
Blood in the urine or semen
PROSTATE CANCER DIAGNOSIS — Your doctor or nurse may suspect that you have prostate cancer if you have an abnormal blood test (PSA, or prostate-specific antigen) or an abnormal rectal examination. To be certain about the diagnosis, you will need to have a prostate biopsy. (See “Clinical presentation, diagnosis, and staging of prostate cancer”.)

Prostate biopsy — Prostate biopsy is usually performed in a doctor’s office. You will be given a course of antibiotics to take before and after the biopsy to reduce the risk of infection from the procedure.

The biopsy is done after you are given local anesthesia (a shot or gel in the rectum). Most men feel mild to moderate pain during the procedure. The entire procedure usually takes about 15 minutes.

After the procedure, you will probably feel soreness in your rectum or the area around the rectum (called the perineum). You may have some bleeding from your rectum, in your urine (for several days), or in your semen (for up to several months).

The tissue taken during the biopsy will be examined by a pathologist using a microscope. The results are usually available within one week.

Gleason grade — If cancer is found in the prostate biopsy, the amount of cancer and aggressiveness of the tumor will be determined. The Gleason grade depends on how the tumor looks under the microscope. The higher the Gleason grade, the more likely the tumor is to behave aggressively (grow faster).

Prostate cancer stage — Once prostate cancer is diagnosed, the next step is to determine its stage. Staging is a system used to describe the size, aggressiveness, and spread of a cancer. A cancer’s stage helps to guide treatment and can help predict the chance of curing the cancer.

A prostate cancer’s stage is based upon:

How far the tumor extends in the prostate and surrounding tissue
Possible spread of the cancer to the nearby lymph nodes
Signs of cancer in other organs (liver, bone)
In addition, the PSA (prostate-specific antigen) level and the Gleason grade are used to gauge how aggressive the tumor is and what treatment options are available.

In general, lower-stage cancers are less aggressive and less likely to come back after treatment compared with higher-stage cancers. Stage I and II prostate cancer are referred to as localized prostate cancer, stage III is locally advanced, and stage IV is referred to as advanced or metastatic prostate cancer.

Further testing — Other tests, such as MRI, ultrasound, or bone scan, may be done before treatment begins to determine whether the cancer has spread beyond the prostate.

STAGE I TO II (LOCALIZED) PROSTATE CANCER TREATMENT — Localized prostate cancer is cancer that has not spread to the lymph nodes or distant organs. There are three standard ways to treat localized prostate cancer:

Surgery to remove the prostate gland (called radical prostatectomy)
Radiation therapy (external beam or brachytherapy), sometimes combined with androgen deprivation therapy
Active surveillance, also called “watch and wait”
The best treatment depends upon your age and health, your preferences, and the stage of your cancer. (See ‘Which treatment is right for me?’ below.)

Radical prostatectomy — Radical prostatectomy (also called prostatectomy) is a surgery done to remove the prostate gland and then reconnect the urethra and bladder (figure 1). (See “Radical prostatectomy for localized prostate cancer”.)

The most common complications of prostatectomy are:

Urinary incontinence (leakage of urine)
Erectile dysfunction (ED, difficulty having an erection)
There are two ways to perform prostatectomy: open and robotic.

Open prostatectomy requires an up-and-down incision (cut) that is three to four inches (7.5 to 10 cm) long, beginning from the top of the pubic bone.
Robotic prostatectomy is done through several small incisions. Small instruments and a camera are placed through the incisions. The surgeon operates while looking at a monitor, which displays what is seen through the camera.
The likelihood of curing your cancer and having as few postsurgery complications as possible depends on the skill and experience of the surgeon, not whether the surgery is done open or with a robot. In experienced hands, issues like needing a blood transfusion, pain, time in the hospital, and return to full activity (about three weeks) are similar with both approaches. Asking about your surgeon’s experience is important in getting a good result.

Talk to your surgeon about the potential risks and benefits of all types of prostatectomies to determine which is right for you.

Radiation therapy (RT) — Two forms of RT are used to treat prostate cancer: external beam RT and brachytherapy. These are sometimes used together.

External beam radiation — External beam RT (EBRT) uses a machine that moves around you, directing X-rays at the pelvis. EBRT is typically done daily five days per week, for five to eight weeks. Each treatment takes just a few minutes, and you can usually continue your normal activities during treatment. EBRT is sometimes used in combination with androgen deprivation therapy (see ‘Androgen deprivation therapy’ below).

Possible side effects of EBRT include needing to run to the bathroom frequently to urinate, bladder pain, erectile dysfunction, and swelling and pain in the rectum (called proctitis). These symptoms are usually temporary. (See “External beam radiation therapy for localized (clinical T1, T2) prostate cancer”.)

Brachytherapy — In brachytherapy, a doctor places a radioactive source directly into the prostate gland. There are two types of brachytherapy, both of which are done under anesthesia. (See “Brachytherapy for localized prostate cancer”.)

One type of brachytherapy, called low-dose rate, involves placing rice-size seeds, which emit radiation, into the prostate. The seeds gradually lose their radioactivity over time and are not removed.
The second type of brachytherapy, called high-dose rate, involves temporarily implanting a radioactive source into the prostate gland, then removing it after one or two days. This treatment is done while you stay in the hospital and is usually combined with EBRT.
Men who undergo brachytherapy usually develop inflammation and swelling of the prostate gland, which can lead to urinary urgency and frequency (needing to rush to the bathroom to urinate frequently), burning with urination, and occasionally retention of urine (being unable to empty the bladder completely, which requires temporary use of a catheter). Less commonly, some men experience bowel urgency and frequency, rectal bleeding, and rectal ulcers. These problems usually resolve within a few weeks to months.

Active surveillance — Some men choose to delay prostate cancer treatment, a strategy called active surveillance. During active surveillance, you may require one or more additional prostate biopsies, and you will be monitored carefully for signs of cancer growth with an exam and blood tests every three to six months. Your doctor may recommend that you begin treatment (surgery or radiation therapy) if the cancer begins to grow. Using this approach, you may be able to avoid or postpone treatment for long periods of time. Active surveillance may be a reasonable option if your cancer is very small and unlikely to grow quickly.

Active surveillance is not generally recommended if you have a high-grade tumor or if your tumor has other features that make it likely to behave aggressively, making it hard to cure later. (See “Active surveillance for men with early prostate cancer”.)

Androgen deprivation therapy (ADT) — Male hormones (androgens, the most common of which is testosterone) fuel the growth of prostate cancer. Treatments that decrease the body’s levels of androgens (called androgen deprivation therapy, or ADT) decrease the size and slow the growth of prostate cancer. ADT can be done by taking medicines that interfere with androgens or by having surgery to remove the testicles (called an orchiectomy).

ADT is not needed for men with small tumors that are unlikely to grow quickly. ADT might be recommended, in addition to external beam radiation therapy (EBRT), for men with intermediate and high-risk prostate cancer.

Side effects of ADT — The side effects of ADT are related to the lowered levels of male hormones and include:

Decreased libido (sex drive) and difficulties with erection (erectile dysfunction)
Hot flashes
Enlargement of the breasts (called gynecomastia) (see “Patient information: Gynecomastia (breast enlargement in men)”)
Loss of muscle and increase in body fat
Thinning and weakening of the bones (called osteoporosis), which can increase the risk of bone fractures (see “Patient information: Osteoporosis prevention and treatment”)
An increased risk of developing type 2 diabetes
Loss of muscle mass
Many of these side effects are serious, and they might seem frightening. Not all men have these side effects. In addition, it is important to balance the risk of side effects with the risk of not using androgen deprivation, which could allow your cancer to grow or spread. In addition, there are ways to prevent or treat many of these side effects. (See “Managing the side effects of androgen deprivation therapy”.)

STAGE III (LOCALLY ADVANCED) PROSTATE CANCER TREATMENT — Locally advanced prostate cancer has spread outside the prostate gland, to areas such as the seminal vesicles (figure 1). There is no one “best” treatment for locally advanced prostate cancer. Treatment often includes a combination of two approaches:

Radiation therapy with ADT
Radical prostatectomy
(See “Clinical stage T3 prostate cancer”.)

Radiation therapy — Radiation therapy involves the use of X-rays to destroy cancer cells. There are two forms of radiation therapy used to treat prostate cancer: external beam radiation therapy (EBRT) (see ‘External beam radiation’ above) and brachytherapy (see ‘Brachytherapy’ above).

Most men who have radiation therapy for locally advanced prostate cancer are also given androgen deprivation therapy (ADT) (see ‘Androgen deprivation therapy’ below). Having both treatments helps to control the cancer and improves the chance of survival. Most experts recommend treatment with ADT for at least two years after the radiation therapy is completed.

Surgery — Radical prostatectomy is a surgery that completely removes the prostate gland (see ‘Radical prostatectomy’ above) and has become more popular in recent years for stage III disease. After surgery, some men are treated with adjuvant radiotherapy.

Androgen deprivation therapy — Androgen deprivation therapy starves the cancer cells and causes the prostate gland to shrink. In men with locally advanced prostate cancer, ADT is usually given in combination with radiation therapy. (See ‘Androgen deprivation therapy (ADT)’ above.)

TREATMENT OF RISING PSA — After treatment for localized prostate cancer, experts advise follow-up testing to monitor for signs that the cancer has returned. This follow-up testing usually includes a blood test called PSA (prostate-specific antigen). The PSA test is very sensitive, meaning that the PSA may begin to rise well before you can see or feel that the cancer has returned. Many men with a rising PSA will not have any sign that the cancer has come back for many years (even 15 or more). Thus, not all men with a rising PSA need immediate treatment.

However, in some men with a rising PSA, treatment is recommended to reduce the chance that the cancer will continue to grow or spread. Talk to your doctor or nurse to discuss your options. (See “Rising serum PSA after treatment for localized prostate cancer: Systemic therapy”.)

The best treatment for a rising PSA depends upon what treatment you had before.

Men who had radiation therapy initially are usually advised to have a prostate biopsy and imaging studies. If those tests show cancer has not grown beyond the prostate, surgery (salvage prostatectomy) or cryotherapy is advised. Cryotherapy is a treatment that freezes the tissue to destroy cancer cells. (See “Rising serum PSA after radiation therapy for localized prostate cancer: Salvage local therapy”.)
Men who initially had prostate surgery are usually treated with radiation therapy. (See “Rising serum PSA following radical prostatectomy for prostate cancer: Salvage radiation therapy”.)
Men who cannot have radiation therapy, surgery, or cryotherapy can be treated with androgen deprivation therapy. (See “Rising serum PSA after treatment for localized prostate cancer: Systemic therapy”.)
WHICH TREATMENT IS RIGHT FOR ME? — For men with early-stage (localized) prostate cancer, the decision between radiation therapy (RT) and surgery is largely a matter of preference. The choice also depends on the risk that the cancer will grow quickly or come back after treatment.

The potential risks and complications of surgery, radiation therapy, and active surveillance are unique. The following tables list the advantages and disadvantages of each type of treatment (table 1 and table 2).

Localized (stage I to II) prostate cancer — Men who have small tumors that are unlikely to grow quickly have the option to have treatment (with surgery or radiation) or delay treatment (active surveillance). Men who are older or who have other serious illnesses might prefer active surveillance to surgery or radiation.

Men who have moderate to large tumors or any size of tumor that could behave aggressively, making it hard to cure later, are usually encouraged to have treatment (surgery or radiation). Some men who have radiation therapy will also need androgen deprivation therapy.

Locally advanced (stage III) prostate cancer — There is no single best treatment for men with locally advanced prostate cancer. Most experts recommend a combination of either androgen deprivation therapy plus radiation therapy or surgery plus adjuvant radiotherapy.

Advanced prostate cancer — Treatment for advanced (stage IV) prostate cancer is discussed separately. (See “Patient information: Treatment for advanced prostate cancer”.)

CLINICAL TRIALS — Progress in treating prostate cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials or read about clinical trials at:

www.cancer.gov/clinicaltrials/learning/
file://clinicaltrials.gov/
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Prostate cancer screening
Patient information: Treatment for advanced prostate cancer
Patient information: Benign prostatic hyperplasia (BPH)
Patient information: Sexual problems in men
Patient information: Gynecomastia (breast enlargement in men)
Patient information: Osteoporosis prevention and treatment

Professional Level Information:

Active surveillance for men with early prostate cancer
Brachytherapy for localized prostate cancer
Chemoprevention strategies in prostate cancer
Chemotherapy in castrate-resistant prostate cancer
Clinical presentation, diagnosis, and staging of prostate cancer
Cryotherapy for prostate cancer
Early stage prostate cancer: Predicting the pathologic extent of disease and clinical outcome
Evaluation of regional lymph nodes in men with prostate cancer
External beam radiation therapy for localized (clinical T1, T2) prostate cancer
Follow-up surveillance after treatment for prostate cancer
Interpretation of prostate biopsy
Management of prostate cancer patients with positive regional lymph nodes
Managing the side effects of androgen deprivation therapy
Measurement of prostate specific antigen
Novel and emerging treatment techniques in advanced prostate cancer
Overview of treatment for clinically localized prostate cancer
Radiation therapy for clinically localized prostate cancer: General principles
Radical prostatectomy for localized prostate cancer
Rising serum PSA after radiation therapy for localized prostate cancer: Salvage local therapy
Rising serum PSA after treatment for localized prostate cancer: Systemic therapy
Rising serum PSA following local therapy for prostate cancer: Definition, natural history, and risk stratification
Rising serum PSA following local therapy for prostate cancer: Diagnostic evaluation
Rising serum PSA following radical prostatectomy for prostate cancer: Salvage radiation therapy
Clinical stage T3 prostate cancer

The following organizations also provide reliable health information.

National Cancer Institute
1-800-4-CANCER
(www.cancer.gov/cancertopics/types/prostate)

National Comprehensive Cancer Network
(file://www.nccn.org/index.asp)

National Library of Medicine
(www.nlm.nih.gov/medlineplus/prostatecancer.html)

Patient support — There are a number of online forums where you can find information and support from other people with similar conditions.

About.com Cancer Forum
(file://cancer.about.com/forum)

REFERENCES
Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 2007; 177:2106.
Koch MO. Focal prostate therapy. J Urol 2008; 179:2091.
Loblaw DA, Virgo KS, Nam R, et al. Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol 2007; 25:1596.