Prostate Cancer

The prostate

The prostate is a gland found only in men. As shown in the picture below, the prostate is just below the bladder and in front of the rectum. It is about the size of a walnut. The tube that carries urine (the urethra) runs through the prostate. The prostate contains cells that make some of the fluid (semen) that protects and nourishes the sperm.
The prostate begins to develop before birth and keeps on growing until a man reaches adulthood. Male hormones (called androgens) cause this growth. If male hormone levels are low, the prostate gland will not grow to full size. In older men, though, the part of the prostate around the urethra may keep on growing. This causes BPH (benign prostatic hyperplasia) which can result in problems passing urine. BPH is a problem that must be treated, but it is not cancer.

Prostate cancer

There are several cell types in the prostate, but nearly all prostate cancers start in the gland cells. This kind of cancer is known as adenocarcinoma. The rest of the information here refers only to prostate adenocarcinoma.
Most of the time, prostate cancer grows slowly. Autopsy studies show that many older men (and even younger men) who died of other diseases also had prostate cancer that never caused a problem during their lives. These studies showed that as many as 7 to 9 out of 10 men had prostate cancer by age 80. But neither they nor their doctors even knew they had it.

Pre-cancerous changes of the prostate

Some doctors believe that prostate cancer begins with very small changes in the size and shape of the prostate gland cells. These changes are known as PIN (prostatic intraepithelial neoplasia). Almost half of all men have PIN by the time they reach 50. In PIN, there are changes in how the prostate gland cells look under the microscope, but the cells are basically still in place -- they don't look like they've gone into other parts of the prostate (like cancer cells would). These changes can be either low-grade (almost normal) or high-grade (abnormal).
If you have had a prostate biopsy that showed high-grade PIN, there is a greater chance that there are cancer cells in your prostate. For this reason, you will be watched carefully and may need another biopsy.

What Causes Prostate Cancer?

Prostate cancer is caused by changes in the DNA of a prostate cancer cell. DNA makes up our genes, which control how cells behave. DNA is inherited from our parents. A small percentage (about 5% to 10%) of prostate cancers is linked to these inherited changes. Prostate cancer may also be linked to higher levels of certain hormones. High levels of male hormones (androgens) may play a part in prostate cancer risk in some men. Some researchers have noted that men with high levels of a hormone called IGF-1 are more likely to get prostate cancer, too. But others have not found such a link. More research is needed in this area.

While we do not yet know exactly what causes prostate cancer, we do know that certain risk factors are linked to the disease. A risk factor is anything that increases a person's chance of getting a disease. Different cancers have different risk factors. Some risk factors, such as smoking, can be controlled. Others, like a person's age or family history, can't be changed.

But risk factors don't tell us everything. Many people with one or more risk factors never get cancer, while others with this disease may have had no known risk factors. For some of these factors, the link to prostate cancer risk is not yet clear.

Risk factors for prostate cancer.

Age:

Age is the strongest risk factor for prostate cancer. The chance of getting prostate cancer goes up quickly after a man reaches age 50. Almost 2 out of every 3 prostate cancers are found in men over the age of 65.

Race:

For unknown reasons, prostate cancer is more common among African-American men than among men of other races. African-American men are also more likely to have a more advanced disease when it is found and are more likely to die of the disease. Prostate cancer occurs less often in Asian-American and Hispanic/Latino men than in non-Hispanic whites. The reasons for these racial and ethnic differences are not clear.

Nationality:

Prostate cancer is most common in North America, northwestern Europe, and a few other places. It is less common in Asia, Africa, Central and South America. The reasons for this are not clear. More testing in some developed countries likely accounts for at least part of this difference, but other factors are likely to be important, too.

Family history:

Prostate cancer seems to run in some families. Men with close family members (father or brother) who have had prostate cancer are more likely to get it themselves, especially if their relatives were young when they got the disease.

Genes:

Scientists have found several inherited genes that seem to raise prostate cancer risk, but they probably account for only a small number of cases overall. Genetic testing for most of these genes is not yet available, and more study is needed in this area.

Diet:

The exact role of diet in prostate cancer is not clear, but several different factors have been studied. Men who eat a lot of red meat or high-fat dairy products seem to have a greater chance of getting prostate cancer. These men also tend to eat fewer fruits and vegetables. Doctors are not sure which of these factors causes the risk to go up.

Obesity:

Most studies have not found that being obese (having a high amount of extra body fat) is linked with a higher risk of getting prostate cancer. Some, but not all, studies have found that obese men may be at greater risk for having more advanced prostate cancer and of dying from prostate cancer.

Exercise:

Exercise has not been shown to reduce prostate cancer risk in most studies. But some studies have found that high levels of physical activity, particularly in older men, may lower the risk of advanced prostate cancer. More research in this area is needed.

Infection and inflammation of the prostate:

Some studies have suggested that prostatitis (inflammation of the prostate gland) may be linked to an increased risk of prostate cancer, but other studies have not found such a link. Some researchers have also looked at whether sexually transmitted infections might increase the risk of prostate cancer. So far, studies have not agreed, and no firm conclusions have been reached.

Can Prostate Cancer Be Prevented?

Because we don't know the exact cause of prostate cancer, it is not possible to prevent most cases of the disease. But some cases might be prevented.

Diet

While the results of research studies are not yet clear, you may be able to reduce your risk of prostate cancer by changing the way you eat. The ACS suggests eating less red meat and fat and eating more vegetables, fruits, and whole grains. Eat 5 or more servings of fruits and vegetables each day. These guidelines give you a healthy way to eat that may help lower your risk for some types of cancer, as well as other diseases.
Tomatoes, pink grapefruit, and watermelon are rich in substances called lycopenes. Lycopenes help prevent damage to DNA and may help lower prostate cancer risk. Research on this is still going on.
Some studies suggest that taking vitamin E daily may lower the risk of prostate cancer. But others have found that vitamin E has no impact on cancer risk and might raise the risk for some kinds of heart disease. Selenium, a mineral, may also lower risk. A large study is going on now to see if vitamin E or selenium lowers prostate cancer risk.
On the other hand, vitamin A (beta-carotene) supplements may actually increase prostate cancer risk. Before starting any vitamins or other supplements, you should talk with your doctor.

Medicine

A study of the drug finasteride (Proscar) found that men taking the drug were less likely to get prostate cancer than men taking a placebo ( "sugar pill"). The drug can cause side effects such as lower sex drive and trouble getting an erection. On the other hand, it seems to help with urinary problems. At this time it's not clear whether taking finasteride to lower the risk of prostate cancer is a good idea or not. The results of the study will become clearer over the next few years. And other drugs that may help prevent prostate cancer are now being tested in clinical trials.

How Is Prostate Cancer Found?

Prostate cancer can often be found early by testing the amount of PSA (prostate-specific antigen) in your blood. Another way prostate cancer is found early is when the doctor does a digital rectal exam (DRE). Because the prostate gland lies just in front of the rectum, during the DRE the doctor can feel if there are any bumps or hard places on the prostate. These might be cancer. If you have had routine yearly exams and either one of these test results becomes abnormal, any cancer you might have has probably been found at an early, more treatable stage.
Since about 1990 it has become more common for men to have tests to find prostate cancer early. The prostate cancer death rate has dropped, too. But we do not yet know if this drop is the direct result of the tests.
These tests are not perfect, though. Uncertain or false test results could cause confusion and anxiety. There is no question that the PSA test can help spot prostate cancer. But it can't tell how dangerous the cancer is. The problem is that some prostate cancers are slow-growing and may never cause problems. But because of a high PSA level, many men will be found to have prostate cancer that would never have led to their deaths. Often these men are being treated with either surgery or radiation, either because their doctor can't be sure how fast the cancer might spread or because they are uncomfortable not having treatment. Doctors and patients are still struggling to decide who should get treatment and who can be followed without treatment.
Until more is known, you should talk to your doctor about whether or not you want to be tested. Things to take into account are your age and your health. If you are young and you get prostate cancer, it will probably shorten your life if it is not caught early. But if you are older or in poor health, then prostate cancer may never become a major problem because it often grows so slowly.

The PSA blood test

PSA (prostate-specific antigen) is a substance made by the prostate gland. Although PSA is mostly found in semen, a small amount is also found in the blood. Most healthy men have levels under 4 ng/mL (nanograms per milliliter) of blood. The chance of having prostate cancer goes up as the PSA level goes up. If your level is between 4 and 10, you have about a 1 in 4 chance of having prostate cancer. If it is above 10, your chance is over 50%. But some men with a PSA below 4 can also have prostate cancer.
Factors other than cancer can also cause the PSA level to go up, including:

• BPH (benign prostatic hyperplasia), a non-cancerous swelling of the prostate that many men get as they grow older.
• Age: PSA levels go up slowly as you get older, even if you have no prostate changes.
• Prostatitis: an infection or inflammation of the prostate gland
• Ejaculation can cause the PSA to go up for a short time, and then go down again.

There are a number of new types of PSA tests that might help to show whether or not you need more testing. Not all doctors agree on how to use these new PSA tests. You should talk to your doctor about your cancer risk and any tests that you are having.

Use of the PSA blood test after prostate cancer diagnosis

Although the PSA test is used mainly to find prostate cancer early, it has other uses, too.

• In men diagnosed with prostate cancer, it can be used along with other results to help decide which types of testing or treatment might be helpful.

• A very high PSA level might mean that the cancer has spread beyond the prostate. This also helps determine treatment because some forms of treatment are not as helpful for cancer that has spread to the lymph nodes or other organs.

• The PSA test can also be used to help show if treatment is working, how well it is working, or whether the cancer has come back after treatment.

• If you choose a "watchful waiting" approach to treatment, the PSA level can be used to help decide whether the cancer is growing and whether active treatment should be considered.

If prostate cancer has come back (recurred) after treatment, or if it has spread outside of the prostate (metastatic disease), the actual PSA number may not be as important as whether it changes. The PSA number does not predict whether or not a person will have symptoms or how long he will live. Many people have very high PSA values and feel just fine. Other people have low values and have symptoms. With advanced disease, it also may be more important to look at the way the PSA level is changing rather than the actual number.

DRE (digital rectal exam)

To do the DRE, the doctor puts a gloved, lubricated finger into the rectum to feel for any irregular or firm areas that might be cancer. The prostate gland is next to the rectum, and most cancers begin in the part of the gland that can be reached by rectal exam. While it is uncomfortable, the exam isn't painful and takes only a short time.
The DRE is less effective than the PSA blood test in finding prostate cancer, but it can sometimes find cancers in men with normal PSA levels. For this reason, ACS guidelines recommend that when prostate cancer screening is done, both the DRE and the PSA should be used. The DRE is also used once a man is known to have prostate cancer. It can help tell whether the cancer has spread beyond his prostate gland. It can also be used to find cancer that has come back after treatment.

Transrectal ultrasound (TRUS)

Transrectal ultrasound (TRUS) uses sound waves to make an image of the prostate on a video screen. For this test, a small probe is placed in the rectum. It gives off sound waves, which enter the prostate and create echoes that are picked up by the probe. A computer turns the pattern of echoes into a black and white picture of the prostate.
The test takes only a few minutes. You will feel some pressure when the TRUS probe is placed in your rectum, but it is usually not painful. TRUS is most commonly used during a prostate biopsy to guide the biopsy needles into the right area of the prostate.

If cancer is suspected

Signs that may be prostate cancer

Early prostate cancer often causes no symptoms. It may be found by a PSA test or DRE. Problems with urinating could be a sign of advanced prostate cancer. But more often this problem is caused by a less serious disease known as BPH (benign prostatic hyperplasia).
Symptoms of advanced prostate cancer could include the following:

• trouble having or keeping an erection (impotence)
• blood in the urine
• pain in the spine, hips, ribs, or other bones
• weakness or numbness in the legs or feet
• loss of bladder or bowel control

Once again, other diseases also can cause these symptoms.
If certain symptoms or the results of early tests suggest you might have prostate cancer, your doctor will do a prostate biopsy to find out whether the disease is present.

The prostate biopsy

A biopsy is the only way to know for sure if you have prostate cancer. During a biopsy, tissue from your prostate is removed so it can be sent to the lab to see if it contains cancer cells. A core needle biopsy is type used most often. Here is how it's done:
A small probe is placed in the rectum. The probe gives off sound waves which make a picture of the prostate on a video screen. This technique is called TRUS (transrectal ultrasound). Guided by TRUS, the doctor places a thin needle through the wall of the rectum into the prostate gland. When the needle is pulled out, it takes out a piece of tissue, usually about ½ inch long and 1/16 inch across. Some doctors do the biopsy through the skin between the rectum and the scrotum.
Although the test sounds painful, it usually causes little discomfort because it is done very quickly. The doctor can numb the area ahead of time. You might want to ask your doctor about numbing the area. Several samples are often taken from different parts of the prostate. Ask your doctor how many samples will be taken.
The biopsy takes about 15 minutes and is usually done in the doctor's office. You will likely be given antibiotics to take ahead of time and afterwards to reduce the chance of infection. For a few days afterwards you may notice some soreness, blood in your urine, or light bleeding from the rectum. Some men also have blood in their semen for a month or 2 after the biopsy.
Cancer may only be present in a small area of the prostate. Because of this, sometimes the biopsy will miss the cancer even when it is there. This is known as a "false negative." If your biopsy doesn't show cancer, but your doctor still strongly suspects cancer, a repeat biopsy may be needed.

Grading the prostate cancer

The biopsy sample will be sent to a lab. A doctor there will look for cancer cells in the sample. If cancer is present, the sample will be graded. Grading the cancer helps to predict how fast the cancer is likely to grow and spread.
Prostate cancers are graded on the basis of how closely the cells in the sample look like normal prostate cells. Those that look very different from normal cells are likely to mean a cancer that grows faster. The system used most often for grading prostate cancer is called the Gleason system.
Samples from 2 areas of the prostate are each graded from 1 to 5, and the number grades are added to give a Gleason score or sum of between 2 and 10. The lower the number, the more the cells in the sample look like normal prostate cells. A higher score means the cells look less normal and the cancer is likely to grow more quickly. Ask your doctor to explain the grade of your tumor because it is an important factor in making treatment decisions.
Sometimes the cells don't look like cancer but they don't look really normal either. In these cases, more biopsies may be done later.

Other things you may see on a biopsy report

The bopsy report tells you the grade of the cancer (if it is present), but it also often gives you other pieces of information that may give a better idea of the scope of the cancer. These can include:

• the number of biopsy samples that contain cancer (for example, "7 out of 12")
• the amount of cancer in each of the cores (given as a percentage)
• whether the cancer is on one side (left or right) of the prostate or both sides (bilateral)

How Is Prostate Cancer Treated?

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 provide some other measure of benefit)
• your feelings about the side effects common with each treatment

You may want to get a second opinion, especially if you have several 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 (expectant management)

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 an approach called watchful waiting (also called expectant management).
This approach involves closely watching the cancer (with PSA testing) without using treatment such as surgery or radiation therapy. It may be a good option if the cancer is not causing any symptoms, will probably grow slowly, and is small and contained in one place in the prostate. It is less often a choice if you are younger, healthy, and have a fast-growing cancer.
At this time, watchful waiting is a reasonable option for some men with slow-growing cancers because it is not known whether active treatment helps them to live longer. 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.
Watchful waiting does not mean your cancer will be ignored. Rather, your doctor will watch what is going on. You will most likely have a PSA blood test and DRE every 3 to 6 months, maybe with a yearly biopsy of the prostate. If you start to have symptoms or if your cancer begins to grow more quickly, you can think about active treatment. A possible downside of this approach is that there's a chance it could allow the cancer to become more advanced, which might limit your treatment options.

Surgery

The most common operations for prostate cancer are radical prostatectomy and transurethral resection of the prostate (TURP). Each is explained in more detail below.

Radical prostatectomy

This surgery is done to try to cure the cancer. It is done most often if it looks like the cancer has not spread outside the prostate. The entire prostate gland and some tissue around it are removed.

There are 2 main types of radical prostatectomy:

Radical retropubic prostatectomy:

This is the approach used by most surgeons. 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 need the nerve-sparing procedure or who have other medical problems that make the first approach harder.

These operations last from 1 1/2 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 for only a few years in the United States. The machines themselves are expensive, 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 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.

Side effects

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, 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. Stress incontinence is the most common type of incontinence after prostate surgery.

• 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 the operation. Doctors can't predict how any one man will function after 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 (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 to12 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 you will still 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 and Cancer: For the Man Who Has Cancer and His Partner. You can order it through our toll-free number or find it on our Web site.

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.

Radiation therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. 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 techniques allow doctors to be more accurate in treating the prostate gland while reducing the radiation exposure to nearby healthy tissues. These techniques appear 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 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 several 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 buildup 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 (catheters) in the prostate. A strong radioactive substance is placed in these catheters for 5 to 15 minutes and then taken out. 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 anesthesia is used during this procedure.

A catheter is also put in place (usually through the belly) so that when the prostate swells (it usually does after this treatment) urine does not stay trapped in the bladder. You will probably be in the hospital for a day. The catheter is removed a couple of weeks later. After the procedure, there will be some bruising and soreness of 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.

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 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 is not a substitute for treatments aimed at a cure.
Hormone therapy is often used in the following situations:

• 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.
• It may be used 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 to 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 (or agonists) are given as shots, either monthly or every 3, 4, 6, or 12 months. 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:

A newer drug, abarelix (Plenaxis) is an LHRH antagonist. It lowers testosterone more quickly and does not cause a flare. But a small number of men are allergic to this drug. For this reason it is only used for men who cannot take other forms of hormone therapy.
Abarelix is given only in certain doctors' offices. It is given as a shot every 2 weeks for the first month, then every 4 weeks. You will need to stay in the office for 30 minutes after the shot to make sure you do not have an allergic reaction.

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:

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. 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 (inability 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. 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. Symptoms such as drowsiness and itching may occur, but usually go away after you get used to the medicine. Constipation may be a 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. They may also slow the growth of the cancer cells 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

Sometimes 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.

What is the best treatment for me?

If you have prostate cancer, you will want to think about a lot of things before you choose a course of treatment. These things include your age, your overall health, your goals for treatment, and your feelings about side effects. Some men, for example, can't imagine living with side effects such as incontinence or impotence. Others are less concerned about these and more concerned about getting rid of the cancer.
If you are over 70 or have serious health problems, you might want to think of prostate cancer as a chronic disease. It will most likely not lead to your death. But it could cause symptoms you want to avoid. In this view, the goal is to relieve symptoms and avoid side effects of treatment. So you might decide to choose watchful waiting or hormone therapy. Of course, age itself is not the best basis on which to make your choice. Many men are in good mental and physical shape at age 70, while some younger men may not be as healthy.

If you are younger and otherwise healthy, you might be more willing to put up with the side effects of treatment if they offer you the best chance for cure. Most doctors now feel that external radiation, radical prostatectomy, and radioactive implants have the same cure rates for the earliest stage prostate cancers. But each man's situation is unique and is influenced by many factors.

These decisions are even harder for you if you try to make them alone. It is often helpful to discuss treatment options with more than one doctor. It's natural for surgical specialists, such as urologists, to recommend surgery, and for radiation oncologists to recommend radiation. You may want to consider getting more than one medical opinion, perhaps even from different types of doctors. Your primary care doctor can often help you sort out which treatment plan is best for you.

 

 

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