Treatment of Prostate Cancer

Prostate cancer is the second most common cancer affecting American males (skin cancer ranks first). Fortunately, prostate cancer can be successfully treated if diagnosed in its early stages. The treatment protocol for prostate cancer is typically determined by several factors in the diagnosis.

Prostate cancer overview

The prostate is a walnut-shaped gland that sits below the bladder and in front of the rectum. The prostate plays an important role in sexual reproduction, as it makes the fluid for semen, which transports sperm.

Prostate cancer may be diagnosed based on symptoms you are experiencing or with a prostate exam during your annual wellness checkup. Some men never experience any symptoms, while other men may display a few but not all symptoms.

Symptoms of prostate cancer may include problems such as frequent urination, difficulty in starting and stopping urination, ejaculatory problems, and continuous pain in the hips, pelvis or lower back. If you experience one or more of these symptoms, you should see your primary care physician as soon as possible.

If you are older than 40, you should have your physician perform an annual prostate exam. This includes a physical examination, or digital rectal exam (DRE), of your prostate and a blood test to check your prostate-specific antigen (PSA) levels—elevated levels may indicate prostate cancer, but not always.

If your doctor suspects you may have prostate cancer, you will be referred to a urologist who specializes in male sexual oncology. If the urologist determines you have prostate cancer, the grade and stage of your cancer will be determined based on its aggressiveness and whether it has spread to other parts of your body.

Once the grade and stage determinations are made, your urologist will discuss effective treatments.

Surgery for prostate cancer

If the prostate cancer is confined to your prostate, your urologist will probably recommend surgical removal of the prostate, or radical prostatectomy. During the surgery, which may be done laparoscopically (small incisions done robotically) or by the open method (a large incision from your lower abdomen down to your pubic bone), your prostate and surrounding tissue, including the seminal vesicles, are removed.

Both types of surgeries require a hospital stay of two to three days. A catheter will be inserted into your urethra after the surgery, and you will have to use it for up to two weeks after surgery.

After your prostate removal, you will not be able to resume all your normal activities, such as lifting heavy objects and strenuous exercise, for four to six weeks on average.

Immediate prostate cancer surgery side effects include:

• Postsurgical bleeding
• Deep vein thrombosis (DVT) or pulmonary embolisms
• Adjacent organ damage
• Surgical site infections

Possible long-term or permanent prostate cancer surgery side effects are urinary incontinence and erectile dysfunction (ED).

Radiation for prostate cancer

If you have low-grade prostate cancer confined to your prostate, radiation therapy is your first line of treatment. It may also be used in combination with hormone therapy if your prostate cancer has spread regionally.

Radiation therapy may be used if you had prostate surgery that did not remove all the cancerous cells, or if you experience a recurrence of prostate cancer.

There are two types of radiation therapy for prostate cancer: internal radiation therapy and external beam radiation therapy (EBRT). You may receive both internal radiation therapy and EBRT if the prostate cancer has spread to your seminal vesicles, nearby organs and/or adjacent lymph nodes.

EBRT can be administered in several ways. The most common is with intensity modulation. This therapy consists of a computerized machine moving around you and targeting radiation beams at your prostate from different angles.

Side effects from EBRT include:

• Damage to healthy tissues near your prostate
• Damage to bowel function (that may or may not resolve with time)
• Frequent and painful urination that may include bloody urine (leading to permanent urinary incontinence in some men)
• Fatigue
• Swelling and pain in the lymph nodes around the prostate
• Impotence or difficulty getting and maintaining an erection

If you undergo internal radiation therapy (also known as interstitial radiation therapy or seed planting), small radioactive pellets will be put directly into your prostate. This type of therapy is usually given to men with slow-growing stage I prostate cancer.

Internal radiation therapy is performed in the hospital under a local or general anesthesia. If general anesthesia is used, you may be admitted to the hospital overnight.

There are two types of internal radiation therapy: permanent and temporary. Permanent therapy involves a low-dose rate, or LDR. Radioactive pellets—about 100, on average—are inserted into your prostate where they deliver low doses of radiation for several weeks or several months. This method is very safe for healthy tissues around the prostate.

Temporary therapy involves a high-dose rate, or HDR. In this infrequently used treatment, high doses of radiation are delivered to the prostate for short intervals of five to 15 minutes. With this treatment, you'll likely have up to four sessions over a two-day period.

If you have LDR therapy, you should use precautions and be aware of the risks and side effects.

First, you are radioactive, so you will need to keep a safe distance from children and women who are pregnant. Radiation may set off security system alarms (at airports, courthouses, schools and so on), so you should get your doctor to write a note about the treatment you are receiving.

Some of the radiation pellets may migrate, so you may have to strain your urine for a short time. If you have sex, you should wear a condom as a precaution.

Side effects of both LDR and HDR therapies may include short-term bowel irritation, urinary issues and difficulties getting or maintaining an erection.

Chemotherapy for prostate cancer

If you have an advanced stage (stage IV), where the cancer has spread (metastasized) from your prostate to adjacent organs, nearby lymph nodes and/or seminal vesicles (regional spread), or to your bones, lungs, liver and/or brain (distant spread), then chemotherapy is the recommended treatment.

Chemotherapy drugs can be delivered orally or intravenously, and are administered through your bloodstream so they travel throughout your body to eradicate cancer cells.

Your urologist will assemble a team with a palliative physician, a cancer educator and a cancer contact person at their office.

Before you begin chemotherapy, the cancer educator will let you know which drug or drugs will be used to treat your prostate cancer. The cancer educator will give you comprehensive information on possible side effects (common and rare) of the drugs, nutritional guidance and an explanation of the items you will need on hand before chemotherapy to help with possible side effects.

The palliative physician will work to manage any pain you are experiencing because of the cancer and ensure you have prescription medications to manage side effects of chemotherapy. Before you begin chemotherapy, be sure to ask about the possible benefits of getting a prescription for "magic mouthwash" to help with mouth sores.

Several different chemotherapy drugs are used to treat prostate cancer: estramustine (Emcyt), cabazitaxel (Jevtana), mitoxantrone (Novantrone) and docetaxel (Taxotere).

Intravenous docetaxel combined with oral prednisone is usually the first line of defense in treating stage IV prostate cancer. The chemotherapy schedule will have several cycles that consist of two or three weeks of treatment and one week with no treatment.

Chemotherapy is distributed at local infusion centers. Each treatment can last several hours, so be sure to bring something to eat and drink to prevent your blood sugar from dropping too low.

You will get regular bloodwork as part of your chemotherapy treatment so the cancer team can monitor you for neutropenia, or a low count of white blood cells that help fight off infections. Neutropenia is common with chemotherapy, so you will likely develop it, which means you might need a regular infusion of a drug that promotes white blood cell production.

In addition to a lower white blood cell count, docetaxel's other common side effects include hair loss, fatigue, nausea, fluid retention (stomach and ankles), mouth sores and weakness.

Once prostate cancer has metastasized, treatment, even with docetaxel, may be unsuccessful. In some cases, chemotherapy may be successful, but you could suffer health damage from chemotherapy and chances of prostate cancer recurrence may be higher.

Hormone therapy for prostate cancer

You may receive hormone therapy, also known as androgen suppression therapy:

• If your prostate cancer has spread too much for surgical or radiation treatment
• If your prostate cancer recurs after surgery or radiation
• In conjunction with radiation, if there is a strong possibility of recurrence
• Before radiation to reduce the amount of cancer for a better outcome

Hormone therapy lowers male hormone levels to shrink cancer cells or slow their growth. The most effective way to reduce your hormone levels is to have one or both testicles surgically removed (orchiectomy). However, if you are like most men, you will probably opt for a drug.

Luteinizing hormone-releasing hormone (LHRH) agonists accomplish the same effects as an orchiectomy, except you keep your testicles. However, over time, this hormone therapy will shrink your testicles, perhaps to the point that you can no longer feel them.

Another type of hormone therapy, known as luteinizing hormone-releasing hormone antagonists, may be used if you have advanced prostate cancer. Like orchiectomies and LHRH, this hormone therapy is a form of medical castration.

In addition to testicle shrinkage, you may experience other side effects with hormone therapy for your prostate cancer:

• Diminished or no sexual desire
• Anemia
• Loss of cognitive function
• Impotence
• Osteoporosis
• Development of breasts
• Hot flashes
• Fatigue
• Depression
• Weight gain

Other hormone therapies for prostate cancer target male hormone production in the adrenal glands and the cancer cells themselves to keep them from growing into tumors.

Whether or when to use hormone therapy as a treatment for prostate cancer is a subject of debate in the medical profession. You should discuss all treatment options with your urologist before treatment begins.

Outlook after prostate cancer

If your prostate cancer was diagnosed and treated in its early stages, then your outlook is excellent for being cured. If the cancer was localized or regional, the five-year relative survival rate is nearly 100 percent. However, you are at a higher risk for recurrence, so it's important to have regular screening done to ensure the cancer has not returned.

If you had an advanced stage of prostate cancer, the outlook is not quite as promising. In cases of prostate cancer where distant spread has happened, it is not unusual for all treatments to fail because there is too much cancer throughout your body. If treatment is somewhat successful, your five-year relative survival rate is about one-third of that for men with localized or regional prostate cancer.

Recovery from prostate cancer

Your recovery time from prostate cancer will depend on the type of treatment you received. If your prostate cancer resolves, as it does with many men, then you will want to do everything you can to keep it from recurring.

You should be regularly screened by your primary care physician to make sure your PSA levels are at or below normal. You should adopt a diet that is mostly plant-based (with dairy products limited or eliminated) and develop a regular exercise program.

Your biggest challenges in recovering from prostate cancer may be the changes in your sex life. There are common complications with prostate cancer treatments that may make sex more difficult or less interesting.

Your urologist and a professional cancer counselor can be invaluable in helping you and your partner meet or overcome these challenges in a way that strengthens your relationship.