Even the Best Prostate Cancer Treatments Have Side Effects

One of the most common treatments for prostate cancer is active surveillance. This involves close monitoring of a man who has lower-risk, low-grade cancer cells present in his prostate to see if they worsen or change over time, while holding off on more drastic intervention.

"Nowadays, the vast majority of men—particularly those that have small amounts of grade 1 prostate cancer—are managed very successfully with active surveillance," said Petar Bajic, M.D., a urologist affiliated with the Cleveland Clinic. "That means keeping a close eye on things to catch them early if they look like it's going to progress to a more aggressive type of cancer."

Urologists are quick to point out that active surveillance isn't the same as doing nothing. In fact, you'll probably see more of your doctor than you did before, because you'll be going in for frequent prostate-specific antigen (PSA) tests, biopsies and other screenings.

While active surveillance is clearly the least traumatic type of treatment, nonetheless, the attendant biopsies aren't a lot of fun.

"Unfortunately, the biopsy is uncomfortable," said Jayram Krishnan, D.O., a surgical urology specialist whose practice is affiliated with the Cleveland Clinic. "I give guys Valium before they get their biopsy. They don't really want to take a day off, so I give them Valium before the procedure, so that calms their nerves down so they're more comfortable."

Apart from pain afterward, other possible side effects of the frequent biopsies that come with active surveillance include:

• Blood in the urine
• Blood in the semen for up to a week
• Discomfort for a day or two

Ablative procedures include any intervention that aims to kill off just the cancerous cells, attacking only the cancerous lesions on the prostate rather than the whole gland.

While these procedures aren't rare, neither are they the most common. But they are growing in popularity because men who are legitimate candidates for ablation have a shot at keeping their prostate mostly intact, which is always a plus.

"Basically [ablation] is just destroying tissue," said Aditya Bagrodia, M.D., a urologic oncologist at the University of California San Diego Health. "It could mean that it's cutting off the blood supply and then it infarcts, like your cancer has a 'heart attack' instead of your heart having a heart attack. It could be that it freezes it to subdermal temperatures to where the cells can't live anymore, or heating it or introducing energy."

While most ablation techniques are considered minimally invasive, they nevertheless involve some type of procedure to get the device that's used to remove cancerous cells near enough to your prostate to do its job, which can cause side effects.

The most common types of focal therapy are high-intensity focused ultrasound (HIFU), cryotherapy, focal laser ablation and radiofrequency ablation.

According to a review of focal therapy procedures published in Frontiers in Surgery, the most common complications include (in order of frequency):

• Infections, including urinary tract infections (UTIs) and epididymo-orchitis
• Hematuria, or blood in the urine
• Urinary retention
• Urethral sloughing
• Urinary incontinence
• Erectile dysfunction (ED)
• Ejaculatory dysfunction
• Recto-urethral fistula

While focal therapy is promising and growing in popularity, the two most common types of prostate cancer treatment remain radiation therapy and prostatectomy.

The two major types of radiation therapy are external beam radiation—which involves going into a machine, similar to one used for a CAT scan, to receive nonpainful, focused radiation bursts—and brachytherapy, which is the insertion of radioactive "seeds" into strategic spots near the tumor to slowly deliver radiation.

Both types of radiation therapy frequently cause irritation to the surrounding structures, which can produce side effects.

Urinary symptoms are especially common and, according to the Mayo Clinic, can include:

• Frequent urge to urinate
• Difficulty starting the flow
• Blood in the urine
• Urinary leakage
• Not being able to empty the bladder completely

Other potential symptoms of both types of radiation therapy for prostate cancer are:

• Erectile dysfunction
• Abdominal cramping
• Diarrhea
• Painful bowel movements
• Blood in the stool
• Rectal bleeding
• More frequent bowel movements

And with brachytherapy, since the radioactive seeds are usually placed in the prostate via a long needle inserted through the perineum, you may well experience some aching and soreness there for a couple of days. The perineum is the area between the anus and the scrotum.

Keep in mind that in addition to the side effects you notice while you're actively undergoing treatment, radiation therapy can have long-term effects, too.

"Generally, these are temporary and just occur during treatment," Bajic said. "However, after many, many years, the farther a man goes down the road from radiation, the more likely he might experience some issues related to damage to the tissues from the radiation. Sometimes men can even develop severe bleeding issues from the bladder called radiation cystitis, which sometimes can be challenging to deal with. It can also cause scar tissue in the urethra or the prostate that might require procedures to open up."

While the term "prostate surgery" may be frightening, the modern-day prostatectomy is fine-tuned at this point.

But, we're talking about surgery, so there are bound to be side effects, especially if the surrounding lymph nodes are removed, as well, which is often indicated if the cancer has spread or looks like it might.

"This is about a two- to four-hour surgery in which the prostate is removed, as well as the surrounding lymph nodes," Bajic said. "The lymph nodes are sort of the sewer system for the organs. They collect fluid and cells as they leave the organs, so if there is prostate cancer that escapes, it might be in the surrounding lymph nodes."

What's truly comforting to men concerned about the surgery's potential side effects is how much the possibility of error has been removed from the equation. Not only is the treatment minimally invasive, but much of the trauma to surrounding tissue and other damage doesn't happen as often anymore.

"Broadly, 99 percent of prostatectomies in the U.S. are done robotically," Bagrodia said. "There's been some tremendous improvement in multimodal pain management, optimized anesthesia and early recovery, so we can get patients in and out. Generally, with that type of approach, Tylenol or ibuprofen are going to be perfectly adequate for pain control, and you're walking the day of [surgery], eating and drinking the day of. That's very different from what a prostatectomy looked like 30 years ago."

Both Bagrodia's team at UC San Diego Health and Bajic's at the Cleveland Clinic offer most otherwise healthy men the option to go home the day of the surgery.

Still, surgery isn't always so easy on the body, so there are potential side effects, including urinary and erectile problems.

Urinary problems

A prostatectomy includes pulling the bladder down and connecting it to the urethra where the prostate once was. Sometimes this can cause damage to the valve at the base of the bladder and lead to:

• Stress incontinence, or leaking urine when you sneeze, laugh, cough or exercise
• Overflow incontinence, or trouble emptying the bladder
• Urge incontinence, or a frequent need to urinate
• Continuous incontinence, or, in rare cases, the loss of all ability to control urine flow

Most of these urinary problems resolve after a few weeks—months at most—following surgery, according to the American Cancer Society.

Erectile problems

While surgeons have made tremendous advances in techniques for sparing the nerves and blood vessels that control the physical response of the man's erection, these tiny nerves and blood vessels are extremely delicate, and any trauma to the area can cause damage.

"There are some studies that show that up to 80 percent of men don't go back to quite where they were before surgery, particularly related to hardness," Bajic said. "But the vast majority of men will have sufficient and excellent response to medication and things like that, or perhaps not even need a medication and still be able to get good erections."

Most studies find that within one to two years after surgery, most men with intact nerves show substantial improvement in erectile function, even if they have issues immediately after surgery.

However, it's important to keep in mind that after surgery, at best you can only get back to the baseline erectile function you had before surgery. If you already have diabetes or vascular problems, you will be facing those same problems after surgery.

These days, every kind of prostate cancer treatment is miles ahead of where it used to be even a generation ago. This means doctors know what they're doing with regard to minimizing the worst side effects.

Consult closely with your medical team about both short- and long-term side effects as you discuss which type of procedure might be best for you, and rest assured that your healthcare providers and modern medicine have your back during prostate cancer treatment.