Prostate cancer - Treating prostate cancer

Staging of prostate cancer

Doctors will use the results of your prostate examination, biopsy and scans to identify the "stage" of your prostate cancer (how far the cancer has spread). The stage of the cancer will determine which types of treatments will be necessary.

A widely used method of staging is a number staging system. The stages are:

• Stage 1 – the cancer is very small and completely within the prostate gland
• Stage 2 – the cancer is within the prostate gland, but is larger
• Stage 3 – the cancer has spread from the prostate and may have grown into the tubes that carry semen
• Stage 4 – the cancer has spread into the lymph nodes or another part of the body, including the bladder, rectum or bones; about 20-30% of cases are diagnosed at this stage 

If prostate cancer is diagnosed at an early stage, the chances of survival are generally good. About 90% of men diagnosed at stages 1 or 2 will live at least five more years and 65-90% will live for at least 10 more years.

If you are diagnosed with stage 3 prostate cancer, you have a 70-80% of chance of living for at least five more years.

However, if you are diagnosed when your prostate cancer has reached stage 4, there is only a 30% chance you will live for at least five more years.

Want to know more?

• Cancer Research UK: the stages of prostate cancer

Watchful waiting

Watchful waiting is often recommended for older men when it is unlikely that the cancer will affect your natural life span.

If the cancer is in its early stages and not causing symptoms, you may decide to delay treatment, and wait to see if any symptoms of progressive cancer develop. If this happens, pain medication and hormone medication (see below) to control prostate cancer are usually used.

Watchful waiting may also be recommended for people with a higher risk of prostate cancer if:

• your general health means you are unable to receive any form of treatment
• your life expectancy means you will die with the cancer rather than from it

In this case, hormone treatment may be started if there are symptoms caused by the prostate cancer.

Active surveillance

Active surveillance aims to avoid unnecessary treatment of harmless cancers, while still providing timely treatment for men who need it.

When they are diagnosed, we know that around half to two-thirds of men with low-risk prostate cancer do not need treatment. Surveillance is a safe strategy that provides a period of observation to gather extra information over time to see whether the disease is changing.

Active surveillance involves you having regular PSA tests and often several biopsies to ensure any signs of progression are found as early as possible. Sometimes, MRI scans may also be carried out. If these tests reveal the cancer is changing or progressing, you can then make a decision about further treatment.

About one in three men who undergo surveillance will later have treatment. This does not mean they made the wrong initial decision. Good evidence shows that active surveillance is safe over an average of six years. Men undergoing active surveillance will have delayed any treatment-related side effects, and those who eventually need treatment will be reassured that it was necessary.

Radical prostatectomy

A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer.

Like any operation, this surgery carries some risks, and there may be some side effects. These are outlined below.

• Some men have problems with urinary incontinence. This can range from leaking small drips of urine, to leaking larger amounts. However, for most men, this usually clears up within three to six months of the operation. About two in every 10 men have long-term problems requiring the use of pads.
• Some men have problems getting an erection (erectile dysfunction). For some men, this improves with time, but around half of men will have long-term problems.
• In extremely rare cases, problems arising after surgery can be fatal. For example, one in 1,000 men under 65 years old and one in 200 men over 65 will die following a radical prostatectomy.

For many men, having a radical prostatectomy will get rid of the cancer cells. However, for around one in three men, the cancer cells may not be fully removed, and the cancer cells may return some time after the operation.

Studies have shown that radiotherapy after prostate removal surgery may increase the chances of a cure, although research is still being carried out into when it should be used after surgery.

After a radical prostatectomy, you will no longer ejaculate during sex. This means that you will not be able to have a child through sexual intercourse. You may want to ask your doctors about storing a sperm sample before the operation, so it can be used later for in vitro fertilisation (IVF).

Want to know more?

• Macmillan: surgery for early prostate cancer

Radiotherapy

Radiotherapy involves using radiation to kill cancerous cells. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer. Radiotherapy can also be used to slow the progression of metastatic prostate cancer and relieve symptoms.

Radiotherapy is normally given as an outpatient at a hospital near you. It is done in short sessions for five days a week, for four to eight weeks. There are short-term and long-term side effects associated with radiotherapy.

You may receive hormone therapy before undergoing radiotherapy to increase the chance of successful treatment. Hormone therapy may also be recommended after radiotherapy to reduce the chances of cancerous cells returning.

Short-term effects of radiotherapy can include:

• discomfort around the rectum and anus (the opening through which stools pass out of your body)
• diarrhoea 
• loss of pubic hair
• tiredness
• cystitis – an inflammation of the bladder lining, which can cause you to urinate frequently; urination may be painful.

Possible long-term side effects can include:

• an inability to obtain an erection – this affects about one- to two-thirds of men
• urinary incontinence – this affects about one or two in every 10 men
• back passage problems (diarrhoea, bleeding, discomfort) – these affect between five and 20 in every 100 men

As with radical prostatectomy, there is a one-in-three chance the cancer will return. In these cases, medication is usually used to control the cancer instead of surgery. This is because there is a higher risk of complications from surgery in men who have previously had radiotherapy.

Some hospitals now offer new minimally invasive treatments if radiotherapy fails to work, sometimes as part of a clinical trial. These new treatments are called high-intensity focused ultrasound (HIFU) and cryotherapy. These treatments have fewer side effects, but the long-term outcomes are not yet known.

Want to know more?

• Macmillan: radiotherapy for early prostate cancer

Brachytherapy

Brachytherapy is a form of radiotherapy where the radiation dose is delivered inside the prostate gland. It is also known as internal or interstitial radiotherapy.

The radiation can be delivered using a number of tiny radioactive seeds that are surgically implanted into the tumour. This is called low dose-rate brachytherapy.

The radiation can also be delivered through hollow, thin needles placed inside the prostate. This is calld high dose-rate brachytherapy.

This method has the advantage of delivering a high dose of radiation to the prostate, while minimising damage to other tissues. However, the risk of sexual dysfunction and urinary problems is the same as with radiotherapy, although the risk of bowel problems is slightly lower.

Want to know more?

• Cancer Research UK: internal radiotherapy (brachytherapy) for prostate cancer

Hormone therapy

Hormone therapy is often used in combination with radiotherapy. For example, you may receive hormone therapy before undergoing radiotherapy to increase the chance of a successful treatment. Hormone therapy may also be recommended after radiotherapy to reduce the chances of cancerous cells returning.

Hormone therapy alone should not normally be used to treat localised prostate cancer in men who are fit and willing to receive surgery or radiotherapy. This is because it does not cure the cancer on its own. Hormone therapy can be used to slow the progression of advanced prostate cancer and relieve symptoms.

Hormones control the growth of cells in the prostate. In particular, prostate cancer needs the hormone testosterone to grow. The purpose of hormone therapy is to block the effects of testosterone, either by stopping its production or by stopping your body being able to use testosterone.

Hormone therapy can be given as:

• injections to stop your body making testosterone, called luteinising hormone-releasing hormone (LHRH) agonists
• tablets to block the effects or reduce the production of testosterone, called anti-androgen treatment
• combined LHRH and anti-androgen treatment

The main side effects of hormone treatment are caused by their effects on testosterone. They usually go away when treatment stops. They include loss of sex drive and erectile dysfunction (this is more common with LHRH agonists than anti-androgens).

Other possible side effects include:

• hot flushes
• sweating
• weight gain
• swelling and tenderness of the breasts

An alternative to hormone therapy is to surgically remove the testicles, called orchidectomy. The operation does not cure prostate cancer, but by removing the testosterone, it controls the growth of the cancer and its symptoms. However, many men prefer to have hormone treatment to block the effects of testosterone.

Want to know more?

• Cancer Research UK: hormone therapy for prostate cancer

Trans-urethral resection of the prostate (TURP)

During TURP, a thin metal wire with a loop at the end is inserted into your urethra (the tube that carries urine from your bladder to your penis) and pieces of the prostate are removed.

This is carried out under general anaesthetic or a spinal anaesthetic (epidural).

This is done to relieve pressure from the urethra to treat any problematic symptoms you may have with urination. It does not cure the cancer.

Read more information about transurethral resection of the prostate (TURP).

High intensity focused ultrasound (HIFU)

HIFU is sometimes used to treat men with localised prostate cancer that has not spread beyond their prostate.

An ultrasound probe inserted into the rectum releases high-frequency sound waves through the wall of the rectum. These sound waves kill cancer cells in the prostate gland by heating them to a high temperature.

The risk of side effects from HIFU is usually lower than other treatments.

However, possible effects can include impotence (in five to 10 in every 100 men) or urinary incontinence (in less than one in every 100 men). Back passage problems are rare.

Fistulas (an abnormal channel between the urinary system and rectum) are also rare, affecting less than one in every 500 men. This is because the treatment targets the cancer area only and not the whole prostate.

However, HIFU treatment is still going through clinical trials for prostate cancer. In some cases, doctors can carry out HIFU treatment outside of clinical trials. HIFU is not widely available and its long-term effectiveness has not yet been conclusively proven.

Want to know more?

• Cancer Research UK: high intensity focused ultrasound (HIFU) for prostate cancer

Cryotherapy

Cryotherapy is a method of killing cancer cells by freezing them. It is sometimes used to treat men with localised prostate cancer that has not spread beyond their prostate gland.

Tiny probes called cryoneedles are inserted into the prostate gland through the wall of the rectum. They freeze the prostate gland and kill the cancer cells, but some normal cells also die.

The aim is to kill cancer cells while causing as little damage as possible to healthy cells. The side effects of cryotherapy can include:

• erectile dysfunction – this can affect between two and nine in every 10 men
• incontinence – this affects less than one in 20 men

It is rare for cryotherapy to cause rectal problems or fistulas.

Cryotherapy is still undergoing clinical trials for prostate cancer. In some cases, doctors can carry out cryotherapy treatment outside of clinical trials. It is not widely available and its long-term effectiveness has not yet been conclusively proven.

Treating advanced prostate cancer

If the cancer has reached an advanced stage, it is no longer possible to cure it. However, it may be possible to slow its progression, prolong your life and relieve symptoms.

Treatment options include:

• radiotherapy
• hormone treatment
• chemotherapy

If the cancer has spread to your bones, medicines called bisphosphonates may be used. Bisphosphonates help reduce bone pain and bone loss.

Chemotherapy

Chemotherapy is mainly used to treat prostate cancer that has spread to other parts of the body (metastatic prostate cancer) and which is not responding to hormone therapy.

Chemotherapy destroys cancer cells by interfering with the way they multiply. Chemotherapy does not cure prostate cancer, but can keep it under control and reduce symptoms (such as pain) so everyday life is less affected.

The main side effects of chemotherapy are caused by their effects on healthy cells, such as immune cells. They include infections, tiredness, hair loss, sore mouth, loss of appetite, nausea and vomiting. Many of these side effects can be prevented or controlled with other medicines, which your doctor can prescribe for you.

Steroids

Steroid tablets are used when hormone therapy no longer works because the cancer is resistant to it. This is called hormone-refractory cancer.

Steroids can be used to try to shrink the tumour and stop it from growing. The most effective steroid treatment is dexamethasone.

Other medical treatments

There are a number of new medications that could be used if hormones and chemotherapy fail. Your medical team can tell you if these are suitable and available for you.

NICE has recently issued guidance on medications called abiraterone and enzalutamide. Both abiraterone and enzalutamide may be used to treat men with metastatic prostate cancer that no longer responds to the chemotherapy drug docetaxel.

Read the NICE guidelines on:

• enzalutamide for metastatic hormone-relapsed prostate cancer previously treated with docetaxel
• abiraterone for castration-resistant metastatic prostate cancer previously treated with a docetaxel-containing regimen

Deciding against treatment

As many of the treatments above have unpleasant side effects that can affect your quality of life, you may decide against treatment. This make be especially true if you are at an age when you feel that treating the cancer is unlikely to significantly extend your life expectancy.

This is entirely your decision, and your MDT will respect it.

If you decide not to have treatment, your GP and hospital team will still give you support and pain relief. This is called palliative care. Support is also available for your family and friends.

Want to know more?

• End of life care