HEALTH CONDITION

Treatment

Treatment for prostate cancer will depend on your individual circumstances. For many men with prostate cancer, no treatment will be necessary.

When treatment is necessary, the aim is to cure or control the disease so it affects everyday life as little as possible and does not shorten life expectancy.

Sometimes, if the cancer has already spread, the aim is not to cure it but to prolong life and delay symptoms.

Your cancer care team

People with cancer should be cared for by a multidisciplinary team (MDT). This is a team of specialists who work together to provide the best care and treatment.

The team often consists of specialist cancer surgeons, oncologists (radiotherapy and chemotherapy specialists), radiologists, pathologists, radiographers and specialist nurses.

Other members may include physiotherapists, dietitians and occupational therapists. You may also have access to clinical psychology support.

When deciding what treatment is best for you, your doctors will consider:

  • the type and size of the cancer
  • what grade it is
  • your general health
  • whether the cancer has spread to other parts of your body

Good prostate cancer care

Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.

You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.

You should also be told about any clinical trials you may be eligible for.

If you have side effects from treatment, you should be referred to specialist services (such as continence services) to help stop or ease these side effects.

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.

If prostate cancer is diagnosed at an early stage, the chances of survival are generally good.

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Watchful waiting or active surveillance

Watchful waiting and active surveillance are different approaches to keeping an eye on the cancer and starting treatment only if it shows signs of getting worse or causing symptoms.

Watchful waiting

Watchful waiting is often recommended for older men when it's unlikely the cancer will affect their natural lifespan.

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, hormone medication to control prostate cancer is usually used.

Watchful waiting may also be recommended if your general health means you're unable to receive any form of treatment.

In either of these cases, you may just have hormone treatment to treat any 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.

Active surveillance involves having regular PSA tests, MRI scans and sometimes biopsies to ensure any signs of progression are found as early as possible.

If these tests reveal the cancer is changing or progressing, you can then make a decision about further treatment.

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.

Surgically removing the prostate gland (radical prostatectomy)

A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.

Like any operation, this surgery carries some risks.

A recent trial showed possible long-term side effects of radical prostatectomy may include an inability to get an erection and urinary incontinence.

Before having any treatment, 67% of men said they could get erections firm enough for intercourse.

When the men who had a radical prostatectomy were asked again after 6 months, this had decreased to 12%. When asked again after 6 years, it had slightly improved to 17%.

For urinary incontinence, 1% of men said they used absorbent pads before having any treatment.

When the men who had a radical prostatectomy were asked again after 6 months, this had increased to 46%. After 6 years, this had improved to 17%.

Out of the men who were actively monitored instead, 4% were using absorbent pads at 6 months and 8% after 6 years.

In extremely rare cases, problems arising after surgery can be fatal.

It’s possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.

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'll no longer ejaculate during sex. This means 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).

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Radiotherapy

Radiotherapy involves using radiation to kill cancerous cells.

This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.

Radiotherapy can also be used to slow the progression of prostate cancer that's spread and relieve symptoms.

You'll normally have radiotherapy as an outpatient in a hospital near you. It's done in short sessions for 5 days a week, usually for 4 weeks.

There are short- 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 your bottom
  • diarrhoea
  • loss of pubic hair
  • tiredness
  • inflammation of the bladder lining, which can cause painful peeing and needing to go more often (cystitis)

A recent trial showed that possible long-term side effects of radiotherapy can include an inability to get an erection.

Before having treatment, 67% of men said they could get erections firm enough for intercourse, decreasing to 22% after 6 months.

Although this improved over the next 6 months, it declined again to 27% when the men were asked again after 6 years.

Radiotherapy is also slightly more likely than other treatments to cause moderate-to-severe back passage problems, such as diarrhoea, bleeding and discomfort.

It’s possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.

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 brachytherapy, high-intensity focused ultrasound (HIFU) and cryotherapy.

These treatments have fewer side effects, but the long-term outcomes are not yet known. There's a higher risk of complications from surgery in men who have previously had radiotherapy.

If these treatments are not appropriate, medicine is usually used to control the cancer.

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Brachytherapy

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

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

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

The idea behind this method is to deliver a high dose of radiation to the prostate while minimising damage to other tissues.

But the risk of urinary problems is higher than with radiotherapy, although the risk of sexual dysfunction is the same. The risk of bowel problems is slightly lower.

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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 successful treatment.

It may also be recommended after radiotherapy to reduce the chances of cancerous cells returning.

Hormone therapy alone does not cure prostate cancer. It 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
  • tablets to block the effects or reduce the production of testosterone
  • a combination of the 2

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 the injections than with the tablets).

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 (orchidectomy). This does not cure prostate cancer, but by removing the testosterone, it controls the growth of the cancer and its symptoms.

Many men prefer to have hormone treatment to block the effects of testosterone.

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Trans-urethral resection of the prostate (TURP)

TURP is a procedure that can help relieve pressure from the tube that carries urine from your bladder out of your penis (urethra) to treat any problematic symptoms you may have with urination.

It does not cure the cancer.

During TURP, a thin metal wire with a loop at the end is inserted into your urethra and pieces of the prostate are removed.

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

Find out more about 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 bottom (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.

But possible effects can include erectile dysfunction (in 5 to 10 in every 100 men) or urinary incontinence (in less than 1 in every 100 men). Back passage problems are rare.

A fistula, where an abnormal channel forms between the urinary system and the rectum, is also rare, affecting less than 1 in every 500 men.

This is because the treatment targets the cancer area only and not the whole prostate.

But 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.

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Cryotherapy

Cryotherapy is a method of killing cancer cells by freezing them. It's 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
  • incontinence – this affects less than 1 in 20 men

It's rare for cryotherapy to cause a fistula or problems with the back passage.

Cryotherapy is still undergoing clinical trials for prostate cancer. In some cases, doctors can carry out cryotherapy treatment outside of clinical trials.

It's 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's no longer possible to cure it. But 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.

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Chemotherapy

Chemotherapy is often used to treat prostate cancer that's spread to other parts of the body (metastatic prostate cancer).

Chemotherapy destroys cancer cells by interfering with the way they multiply. It does not cure prostate cancer, but can keep it under control to help you live longer.

It also aims to reduce symptoms, such as pain, so everyday life is less affected.

The main side effects of chemotherapy come from how it affects healthy cells, such as immune cells.

They include:

  • infections
  • tiredness
  • hair loss
  • a sore mouth
  • loss of appetite
  • feeling sick (nausea)
  • being sick (vomiting)

Many of these side effects can be prevented or controlled with other medicines that your doctor can prescribe.

Steroids

Steroid tablets are used when hormone therapy no longer works because the cancer is resistant to it. This is called castration-resistant prostate cancer (CRPC).

Steroids can be used to try to shrink the tumour and stop it 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 issued guidance on medications called abiraterone, enzalutamide and radium-223 dichloride.

All of these may be used to treat men with metastatic prostate cancer that no longer responds to standard hormone therapy.

Read the NICE guidelines on:

Deciding against treatment

Some men may decide against treatment for prostate cancer, particularly if they're at an age where they feel treating the cancer is unlikely to significantly extend their life expectancy.

The decision is entirely yours and your care team 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.

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Page last reviewed: Sat Jun 2021 Next review due: Wed Feb 2020

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