Prostate cancer, like all cancers, can be an overwhelming diagnosis. Patients and caregivers are expected to make important treatment choices while dealing with the emotional shock and stress of the diagnosis. Fortunately, prostate cancer grows very slowly, providing plenty of time to decide. Patients need to educate themselves so they can discuss their treatment options with their medical team and make the best decisions. Even doctors may be unaware of the latest treatment options, which is not surprising when considering the explosive rate of new medical developments.

The proper way of staging prostate cancer has been elevated almost to an art form. Of the various treatments listed below, some are appropriate for one stage and inappropriate for another. So, while this article won’t address the issue of staging, the question of whether a specific treatment is “stage-appropriate” always remains important.

1. Active surveillance

Active surveillance is defined as close monitoring with the implementation of delayed therapy only in the men whose prostate cancer shows significant progression. Experts have learned that prostate cancer may never progress. Ten years ago, surgery was considered the “Gold Standard.” Now you rarely encounter the “Gold Standard” argument. What led to this change? In 2012, the New England Journal of Medicine published a study by Dr. Timothy Wilt comparing the long-term outcome of surgery versus observation. Between 1994 and 2002, 731 men volunteered to undergo either surgery or observation. The average PSA of the men in the study was 7.8. The study found no difference in prostate cancer mortality with either option. The only men who benefited by immediate treatment were those whose PSA was over 10. Even in this group with more advanced disease, the 10-year mortality rate was relatively small—12.8 percent in the observation group and 5.5 percent in the surgery group.

Even before Dr. Wilt’s report was published, active surveillance had been gaining mainstream acceptance in the medical community. Multiple, independently-published studies have consistently reached the same conclusion that active surveillance rather than immediate treatment is safe for appropriately selected men.

The reason to forgo immediate surgery (or radiation) is the frequent occurrence of permanent side effects. In a study of 475 men less than 20 percent of men described their sexual function as returning to normal after treatment. In another study of 785 men, three years after surgery or seed implantation, less than 20 percent of men who had surgery and less than 50 percent of the men who had seeds described their sexual function as returning to normal. Unfortunately, to many people these statistics are an abstraction. Nevertheless, the tragedy of unnecessarily destroying a man’s sexual identity cannot be calculated. These side effects must be discussed and weighed carefully before embarking on treatment.

2. Immunotherapy

Provenge is an FDA-approved treatment for prostate cancer that activates a component of the immune system called the dendritic cells, enabling the immune system to better home in on the cancer. Provenge is a highly personalized therapy because dendritic cells are filtered from the blood of each patient, processed in the laboratory and then reinfused into that same patient. Provenge was FDA approved in 2010 after two separate Phase III trials showed that Provenge-treated men lived 20 percent longer than men treated with a placebo. Provenge’s side effects tend to be very modest, with transient fevers or chills occurring in a minority of men on the day of infusion.

3. Radioactive seed implantation (Brachytherapy)

Brachytherapy is the insertion of radioactive seeds directly into the prostate. There are two variations on seed implant methodology — permanent and temporary. Brachytherapy with permanent seeds is an outpatient procedure. Temporary, high-dose-rate (HDR) brachytherapy requires an overnight stay in the hospital. Seed implants deliver the highest dose of radiation, which appears to result in better cure rates compared to other types of radiation. Not everyone is a candidate for seed implantation. Men with preexisting urinary problems or who have very large prostate glands are more prone to develop urinary irritation.

4. Surgery

All types of radiation have a slight cure-rate advantage over surgery because only radiation can provide a treatment margin beyond the outside edge of the gland. Surgery, especially when extracapsular disease is present, may leave cancer behind, an unfortunate situation called “a positive margin.”

The best surgeons average a 10 percent rate of leaving cancer behind. Studies show that many urologists, even at reputable centers, leave cancer behind up to 50 percent of the time. One advantage of prostate removal is to gain a better understanding of the size and grade of the cancer. Surgery also simplifies PSA monitoring after treatment, since unlike radiation, there is no residual prostate gland to produce PSA.

Unfortunately, after prostate surgery only 5-15 percent of men describe their sexual function as unchanged. And erectile dysfunction isn’t the only way to ruin intimacy. Dr. John P. Mulhall, author of the excellent book, Saving Your Sex Life: A Guide for Men with Prostate Cancer, has coined the term “climacturia” to describe the distressing news that, after surgery, some men ejaculate urine rather than sperm.

Why is surgery still offered as an option? The primary reason is the excitement about the supposed advantages of robotic surgery. But can the robotic approach claim any advantage over older surgical methods? Studies show that the postoperative surgery scars are smaller, the hospital stay is shorter, and serious bleeding less frequent. However, studies clearly show that robotic surgery causes impotence and incontinence just as frequently as older surgical methods.

5. Focal cryotherapy

Focal cryotherapy is defined as the destruction of a section of the prostate gland by freezing. To be considered for focal cryotherapy the patient must have unilateral prostate cancer, that is, cancer in only one lobe. The known tumor site is treated, but the other lobe and surrounding structures are spared, improving the odds that sexual potency and urinary continence will be preserved. The procedure involves strategically placing hollow cryoprobes into the prostate as an outpatient. Subzero argon gas is circulated, creating a lethal ice ball at the tip of the probe. The combination of aggressive freezing at targeted locations within the prostate, while maintaining the integrity of the urethra, external sphincter, and contralateral lobe, including the neurovascular bundle, is the premise of focal cryoablation. The results of focal cryotherapy show long-term stable PSA levels in 75 to 85 percent of carefully selected men.

6. Stereotactic body radiation therapy

Stereotactic body radiation therapy (SBRT) consists of very high doses of radiation. It uses several beams of various intensities aimed at different angles to precisely target the prostate. SBRT delivers a much larger dose of radiation per patient visit than other types of beam radiation. Treatment can be completed in a week or two. Preliminary studies indicate that cure rates are similar with or without hormone therapy and the side effects are like other types of radiation. Early side effects tend to dissipate 3 months after treatment. The most common early side effects are increased frequency of urination. The risk of erectile dysfunction is roughly 50 percent, very similar to other types of radiation. SBRT is likely to become mainstream treatment option due to its greater convenience and reduced cost.

7. Intensity modulated radiation therapy and proton therapy

External beam radiation with photons (IMRT) or protons requires about two months of daily doctor visits. During each visit, radiation is beamed at the prostate for a few minutes. Proton therapy and IMRT are very similar, assuming that proton treatment is being given at a state-of-the-art proton center. Patients should be aware that some of the older proton centers have outdated targeting systems. The newer proton centers deliver the beam in a fashion identical to modern IMRT. Unlike the photon beam radiation of IMRT, protons are purported to come to an abrupt stop at their target point within the body. The proton centers therefore claim that photons expose a smaller volume of healthy tissue outside the target area to radiation compared to IMRT. Whether this theory translates into a meaningful difference in clinical outcome is yet to be established.

8. Hormone therapy

Hormone therapy treatment works by blocking the activity of testosterone. Hormone therapy has been proven to prolong life in men with serious types of prostate cancer. Despite its effectiveness, a variety of side effects can occur including weight gain, loss of libido, and fatigue. To reduce side effects, hormone therapy is often given in a cyclical, intermittent pattern; studies show that men who are responding well can stop hormone therapy and take “treatment holidays.” The management of the potential side effects of hormone therapy requires special training in diet, physical fitness, bone integrity, and sexual health to limit the risk of lingering damage after treatment is completed.

Two new hormonal agents have been FDA approve since 2011 — Zytiga and Xtandi. Both agents have increased anticancer efficacy compared to older hormonal medications. Initially their use was restricted to very advanced cases. More recently studies have shown they have a meaningful role for the treatment of earlier-stage disease.  

9. Chemotherapy

There are two chemotherapy drugs available for prostate cancer, Jevtana and Taxotere. The treatment is via an intravenous infusion administered in the doctor’s office every three weeks. Historically, chemotherapy has been held in reserve and used as a last-ditch effort, that is, after the cancer has become resistant to hormone therapy. New studies, however, show that these drugs have a much bigger survival advantage if they are utilized before the development of resistance to first-line hormonal therapy. The potential side effects of these chemotherapy are fatigue, hair loss, and low blood counts, which can sometimes be associated with infections.

10. Smart radiation: Xofigo

Xofigo is an isotope of Radium. Studies show that when Xofigo is injected into the bloodstream, the Radium homes in and concentrates on cancerous spots in the bone. The standard protocol is one injection administered every month for 6 months. Side effects tend to be very mild; patients occasionally have some transient nausea or diarrhea.

New treatments for prostate cancer are being developed a rapid pace. As such, the doctors who care for men with prostate cancer may not always fully informed about the latest developments. Selecting treatment is a high stakes proposition, especially since some types of treatment can have irreversible side effects such as loss of sexual and urinary function. Patients and caregivers need to take the time to learn about all the options so they can make the best possible decisions for themselves.