Prostate Cancer

Understanding treatment for prostate cancer and how it is delivered

Last modified: January 20, 2022

What are the treatment options for prostate cancer? Treatment options

The most common treatment options for prostate cancer include watchful waiting, active surveillance, surgery, radiation therapy and hormone therapy, however other treatments such as chemotherapy, cryotherapy and theranostics are also used. The type of treatment you receive will depend on several different considerations, such as the type of prostate cancer you have, its stage, your overall health and your treatment preferences. This page aims to give you a comprehensive overview of how prostate cancer treatment works.

Types of prostate cancer treatmentTypes of treatment

Watchful waiting for prostate cancerWatchful waiting

Watchful waiting is an option for men with small, early-stage prostate cancer which is slow-growing and isn’t causing symptoms. It is typically used for older people who are diagnosed with prostate cancer which isn’t expected to require treatment during their lifetime or for men with serious pre-existing health conditions. In some cases, it may also be offered as an alternative to active cancer treatments such as surgery or radiation therapy. Watchful waiting involves monitoring the prostate cancer through regular PSA tests, with treatment only occurring if the cancer progresses to help manage symptoms.

Active surveillance for prostate cancerActive surveillance

Active surveillance focuses on avoiding or delaying progression to active cancer treatment by monitoring the growth and spread of low-risk prostate cancer which isn’t causing symptoms. It typically involves additional tests to monitor the prostate cancer compared to watchful waiting, including PSA tests, digital rectal exams, MRI scans and biopsies. If the results show that your prostate cancer has begun growing and spreading, your doctor may recommend that you begin active treatment.

Surgery for prostate cancerSurgery

Surgery is the main treatment for prostate cancer that has not spread beyond the prostate. This commonly involves a radical prostatectomy (removal of the entire prostate, part of the urethra and seminal vesicles).

The three approaches for prostatectomy, performed under general anaesthesia, include:

Open prostatectomy

An open prostatectomy is a procedure where a long incision is made through the skin and abdominal wall or perineum to access your prostate.

Laparoscopic prostatectomy

A minimally invasive procedure that uses several small incisions to access the prostate. Laparoscopic procedures result in less postoperative pain and complications, shorter hospital stay and faster recovery compared to open prostatectomy.

Robotic-assisted prostatectomy

This procedure uses a robotic system to perform laparoscopic prostatectomy remotely, allowing greater precision in comparison to standard laparoscopic surgery.

During surgery, surrounding lymph nodes may also be removed in a procedure known as a pelvic lymph node dissection. They will then be analysed for the presence of prostate cancer under a microscope to detect if your cancer has spread from the prostate.

Radiation therapy for prostate cancer Radiation therapy

Radiation therapy treatment is often used in men with early prostate cancer that hasn’t spread, although it can also be used in combination with other treatments or if your cancer has returned. Radiation therapy may be combined with hormone therapy for high-risk prostate cancers and some unfavourable intermediate risk prostate cancers.

As you may have the option between surgery and radiation therapy treatment, it’s important to talk with your urologist and your radiation oncologist to help you weigh up the advantages and disadvantages of different treatment options and possible side effects like incontinence and erectile dysfunction, availability and cost to help you make an informed decision about the best treatment for you.

There are many different radiation therapy techniques that may be suitable for your prostate cancer.

External beam radiation therapy

External beam radiation therapy (EBRT) is used to treat prostate cancer by delivering highly targeted radiation therapy beams directly to your prostate cancer.

Types of EBRT which can be used for the treatment of prostate cancer include:

Image guided radiation therapy (IGRT) is used to ensure EBRT is delivered as accurately as possible to your prostate cancer. This involves the use of advanced imaging equipment and computer software such as MRI, CT and x-ray.

Ensuring your radiation therapy treatment is highly-accurate

As part of your external beam radiation therapy treatment, you may have Calypso® radiofrequency transponders surgically placed in your prostate tumours to track and adjust the radiation beams due to natural movements of the body, such as breathing. Fiducial markers (gold seeds) may also be used, which help to more accurately locate the prostate gland during your radiation therapy treatment.

If your treatment is being delivered using the Varian TrueBeam linear accelerator (radiation therapy machine), triggered imaging technology may be used. This helps identify that a tumour is being accurately and precisely targeted by radiation and is specifically used for prostate cancers. Using markers implanted in the prostate, radiation therapists can visualise your tumour throughout treatment using low dose x-ray images, which allow the machine to automatically detect the position of the markers.

Reducing your risk of side effects

Your doctor may talk to you about having a prostate spacer such as SpaceOAR Hydrogel implanted by a urologist ahead of your treatment. A prostate spacer is a gel-like substance that is implanted between the prostate and rectum to reduce side effects during radiation therapy treatment.

Stereotactic radiation therapy

Stereotactic radiation therapy is an advanced technique used to treat small tumours with well-defined edges and can be used for both primary and metastatic (advanced) prostate cancer. It is different to conventional radiation therapy for prostate cancer, where the whole prostate is generally treated. Stereotactic radiation therapy reduces the overall treatment time for prostate cancer to one and a half weeks, delivering high doses of radiation in less than 15 minutes, and monitors the patient’s prostate motion using small gold markers to ensure the radiation is delivered accurately.

Stereotactic radiation therapy can also be used to treat advanced prostate cancer where the disease has started to spread to other parts of the body. Traditionally patients would be treated with hormone therapy and chemotherapy, which are often associated with negative side effects. Icon Group’s TRANSFORM study, published in the International Journal of Cancer, found that stereotactic radiation therapy can delay progression to these treatments for more than two years.

Seed brachytherapy

Brachytherapy is a special form of internal radiation therapy where radioactive seeds are placed in the prostate to treat your cancer. Focal brachytherapy uses the same technique, however the radioactive seeds are placed into the tumour to directly target your cancer instead of the whole prostate, preserving the rest of the prostate gland and reducing side effects.

Hormone therapy for prostate cancerHormone therapy

As hormones can be a source of fuel for prostate cancer, hormone therapies can be used to block or lower your body’s natural hormones to stop your prostate cancer from growing or returning. Hormone therapy treatment for prostate cancer is also known as Androgen Deprivation Therapy (ADT) and is used to reduce the amount of testosterone in the body. It may be delivered before, during or after other treatments such as radiation therapy or chemotherapy and is commonly given as a tablet or injection.

Chemotherapy for prostate cancerChemotherapy

Chemotherapy uses a range of drugs to kill and slow the growth of prostate cancer cells. It may be used to treat prostate cancer which has spread beyond the prostate cancer, and for locally advanced or advanced prostate cancers which have not responded to hormone therapy treatment.

Learn more about chemotherapy and how it is delivered.

Chemotherapy treatment for prostate cancer takes place over several sessions, which is known as a cycle. Your care team will walk you through how many cycles you may need for your course of treatment, with most people completing chemotherapy in a period of three to six months.

Theranostics for prostate cancer

Theranostics is a personalised cancer treatment which combines diagnostic imaging to identify a person’s cancer cells and targeted therapy to treat their cancer with radioactive drugs. If standard treatments for advanced prostate cancer have not worked as well as expected or are unsuitable, a type of treatment known as Lutetium-177 Prostate Specific Membrane Antigen (Lu-177 PSMA) therapy may be considered.

PSMA is a type of protein found on the surface of prostate cancer cells – even cells have spread to other areas of the body. In Lu-177 PSMA therapy, a radioactive drug called a radiopharmaceutical is injected into the bloodstream. The drug attaches to the PSMA proteins on prostate cancer cells and delivers targeted radiation to injure or kill them.

Lu-177 PSMA therapy aims to relieve symptoms, maintain or improve quality of life, and potentially slow the growth and spread of cancer.

Treatment by stage of prostate cancerTreatment by stage

When you are diagnosed with prostate cancer, your oncologist will develop your treatment plan as part of a multidisciplinary team based on the stage of your cancer.

Common treatment options for each stage of prostate cancer include:

Localised prostate cancer (Stage I and II) 

Surgery to remove the prostate gland (radical prostatectomy), radiation therapy with or without hormone therapy and active surveillance are the most common treatment options for early-stage prostate cancer, alongside cryotherapy. Radiation therapy may involve external beam radiation therapy or brachytherapy. With recent advances in prostate cancer treatment, you may also have the option of focal brachytherapy treatment.

Locally advanced prostate cancer (Stage III) 

Locally advanced prostate cancer requires a combination of treatments, which usually begins with radiation therapy combined with hormone therapy or surgery. If you receive surgery, radiation therapy is often recommended as your second line of treatment.

Metastatic or advanced prostate cancer (Stage IV) 

Treatment for stage IV prostate cancer commonly includes hormone therapy, which may be delivered in combination with chemotherapy. If hormone therapy is no longer effective, further treatments may include chemotherapy, immunotherapy, or targeted therapy or theranostics. Clinical trials may also offer new treatment options for advanced prostate cancer patients.

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