Patient education: Prostate cancer treatment; stage I to III cancer (Beyond the Basics)
- Eric A Klein, MD
Eric A Klein, MD
- Chairman, Glickman Urological and Kidney Institute
- Professor of Surgery
- Cleveland Clinic
- Section Editors
- Nicholas Vogelzang, MD
Nicholas Vogelzang, MD
- Section Editor — Prostate Cancer
- Professor of Medicine
- University of Nevada School of Medicine
- US Oncology Research
- W Robert Lee, MD, MS, MEd
W Robert Lee, MD, MS, MEd
- Section Editor — Prostate Cancer
- Professor of Radiation Oncology
- Duke University Medical Center
- Jerome P Richie, MD, FACS
Jerome P Richie, MD, FACS
- Section Editor — Cancer of the Urethra, Penis, and Ureter; Urologic Surgery; Prostate Cancer
- Elliott Carr Cutler Professor of Surgery
- Harvard Medical School
Prostate cancer is a cancer of the prostate gland. The prostate is an organ that forms a ring around the urethra, near its connection to the bladder (figure 1). The urethra is the tube that carries urine from the bladder to the outside of the body.
Over the last 20 years, more men are being diagnosed with prostate cancer at an early stage, when the cancer is highly curable. A separate article discusses screening tests for prostate cancer. (See "Patient education: Prostate cancer screening (Beyond the Basics)".)
This article discusses the symptoms, diagnosis, and treatment of stage I to III prostate cancer. Treatment of advanced prostate cancer is discussed separately. (See "Patient education: Treatment for advanced prostate cancer (Beyond the Basics)".)
More detailed information about early-stage prostate cancer, written for healthcare providers, is available by subscription. (See 'Professional level information' below.)
PROSTATE CANCER SYMPTOMS
Prostate cancer is usually found before symptoms develop. However, early symptoms of prostate cancer may include a need to rush to the bathroom frequently or a slow urine stream. These symptoms are usually related to a large prostate gland (called BPH or benign prostatic hyperplasia). Other much less common symptoms include blood in the urine or semen, and erectile dysfunction. (See "Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)".)
In many cases, your doctor or nurse may suspect that you have prostate cancer if you have an abnormal blood test (PSA [prostate-specific antigen]) or an abnormal rectal examination. To be certain about the diagnosis, you will need to have a prostate biopsy.
A prostate biopsy is used to establish the diagnosis of prostate cancer and is usually performed in a doctor's office. You will be given a course of antibiotics to take before and after the biopsy to reduce the risk of infection from the procedure.
The biopsy is done after you are given local anesthesia (a shot or gel in the rectum). Most men feel mild to moderate pain during the procedure. The entire procedure usually takes about 15 minutes.
After the procedure, you will probably feel soreness in your rectum or the area around the rectum (called the perineum). You may have some bleeding from your rectum, in your urine (for several days), or in your semen (for up to several months). In addition, there is a small risk of infection in the prostate or in the bloodstream that may require antibiotics.
The tissue taken during the biopsy will be examined by a pathologist using a microscope. The results are usually available within one week. Advances in molecular biology are leading to the development of tests that can be carried out on the prostate biopsy and may provide additional information that is useful to men considering active surveillance.
Gleason grade group — If cancer is found in the prostate biopsy, the amount of cancer and the aggressiveness of the tumor will be determined. The Gleason grade depends on how the tumor looks under the microscope. The higher the Gleason grade, the more likely the tumor is to behave aggressively (grow faster). The Gleason grades from different areas are combined to form the Gleason grade group (grade group 1 to 5).
Prostate cancer stage — Once prostate cancer is diagnosed, the next step is to determine its stage. Staging is a system used to describe the size, aggressiveness, and spread of a cancer. A cancer's stage helps to guide treatment and can help predict the chance of curing the cancer.
A prostate cancer's stage is based upon:
●How far the tumor extends in the prostate and surrounding tissue
●The likelihood that the cancer has spread to the nearby lymph nodes
●Signs of cancer in other organs (liver, bone)
In addition, the PSA (prostate-specific antigen) level and the Gleason grade are used to gauge how aggressive the tumor is and what treatment options are available.
In general, lower-stage cancers are less aggressive and less likely to come back after treatment compared with higher-stage cancers. Stage I and II prostate cancer are referred to as localized prostate cancer, stage III as locally advanced prostate cancer, and stage IV as advanced or metastatic prostate cancer.
Further testing — Other imaging tests, such as magnetic resonance imaging (MRI), ultrasound, or bone scan, may be done before treatment begins to determine whether the cancer has spread beyond the prostate. Newer tests, such as a scan based upon the PSMA (prostate-specific membrane antigen), are becoming available and may have a role in determining whether the cancer has spread.
STAGE I TO II (LOCALIZED) PROSTATE CANCER TREATMENT
Localized prostate cancer is cancer that has not spread to the lymph nodes or distant organs. There are three standard ways to treat localized prostate cancer:
●Surgery to remove the prostate gland (called radical prostatectomy)
●Radiation therapy (RT; external beam or brachytherapy), sometimes combined with androgen deprivation therapy (ADT)
●Active surveillance, also called "watchful waiting" (in which treatment is deferred until there is evidence of increased risk of progression)
In addition, other forms of therapy, such as cryotherapy and high-intensity focused ultrasound, are being developed. These approaches can target the specific area in the prostate gland that contains the tumor. Long-term data with these techniques are not available, and they have not been adequately compared with standard treatment approaches, but they may be suitable for some men after a consideration of all of the potential risks and benefits.
The best treatment depends upon your age and health, your preferences, and the stage of your cancer. (See 'Which treatment is right for me?' below.)
Radical prostatectomy — Radical prostatectomy (also called prostatectomy) is a surgery done to remove the prostate gland and then reconnect the urethra and bladder (figure 1).
The most common complications of prostatectomy are:
●Urinary incontinence (leakage of urine)
●Erectile dysfunction (difficulty having an erection)
There are two ways to perform prostatectomy: open and robotic.
●Open prostatectomy requires an up-and-down incision (cut) that is three to four inches (7.5 to 10 cm) long, beginning from the top of the pubic bone.
●Robotic prostatectomy is done through several small incisions. Small instruments and a camera are placed through the incisions. The surgeon operates while looking at a monitor, which displays what is seen through the camera.
The likelihood of curing your cancer and minimizing postsurgery complications depends on the skill and experience of the surgeon, not whether the surgery is done open or with a robot. In experienced hands, issues like needing a blood transfusion, pain, time in the hospital, and return to full activity (about three weeks) are similar with both approaches. Asking about your surgeon's experience is important in getting a good result.
Talk to your surgeon about the potential risks and benefits of the different types of prostatectomy to determine which is right for you.
Radiation therapy (RT) — Two forms of RT are used to treat prostate cancer: external beam RT and brachytherapy. These are sometimes used together.
External beam radiation — External beam RT, which is also often referred to as intensity-modulated RT, uses a machine that moves around you, directing X-rays at the pelvis. External beam RT is typically done daily, five days per week, for four to eight weeks. Each treatment takes just a few minutes, and you can usually continue your normal activities during treatment. External beam RT is sometimes used in combination with ADT. (See 'Androgen deprivation therapy (ADT)' below.)
Possible side effects of external beam RT include needing to run to the bathroom frequently to urinate, bladder pain, erectile dysfunction, and swelling and pain in the rectum (called proctitis). These symptoms are usually temporary.
Brachytherapy — In brachytherapy, a doctor places a radioactive source directly into the prostate gland. There are two types of brachytherapy, both of which are done under anesthesia.
●One type of brachytherapy, called low dose rate brachytherapy, involves placing rice-sized seeds, which emit radiation, into the prostate. The seeds gradually lose their radioactivity over time and are not removed. This is done as an outpatient procedure and does not require a hospital stay.
●High dose rate brachytherapy, which is used less frequently, involves temporarily implanting a radioactive source into the prostate gland, then removing it after one or two days. This treatment requires that you stay in the hospital for the one to two day period and is usually combined with external beam RT.
Men who undergo brachytherapy usually develop inflammation and swelling of the prostate gland, which can lead to urinary urgency and frequency (needing to rush to the bathroom to urinate frequently), burning with urination, and occasionally, retention of urine (being unable to empty the bladder completely, which requires temporary use of a catheter). Some men also experience erectile dysfunction. Less commonly, some men have bowel urgency and frequency, rectal bleeding, and rectal ulcers. These problems usually resolve within a few weeks to months.
Active surveillance — Some men choose to delay prostate cancer treatment, a strategy called active surveillance. During active surveillance, you may require one or more additional prostate biopsies, and you will be monitored carefully for signs of cancer growth with an exam and blood tests every three to six months. Your doctor may recommend that you begin treatment (surgery or RT) if the cancer begins to grow. Using this approach, you may be able to avoid or postpone treatment for long periods of time. Active surveillance may be a reasonable option if your cancer is very small and unlikely to grow quickly.
The ProtecT clinical trial compared radical prostatectomy, RT, and active surveillance in men with early-stage, predominantly low-risk prostate cancer. With a median follow-up of 10 years, there was no difference in the incidence of death due to prostate cancer, although more men in active surveillance eventually developed metastatic disease .
Active surveillance is not generally recommended if you have a high-grade tumor or if your tumor has other features that suggest it is likely to behave aggressively, making it hard to cure later. Active surveillance is controversial for patients under age 50 years because of the long-term need for frequent monitoring and biopsies.
Androgen deprivation therapy (ADT) — Male hormones (androgens, the most common of which is testosterone) fuel the growth of prostate cancer. Treatments that decrease the body's levels of androgens (called androgen deprivation therapy or ADT) decrease the size and slow the growth of prostate cancer. ADT can be done by taking medications that interfere with androgens or by having surgery to remove the testicles (called an orchiectomy).
●Medication therapy – This may involve periodic injections that provide sustained delivery of medication, or a device implanted under the skin.
●Removal of the testicles – This may be necessary in select situations in which testosterone levels must be reduced rapidly. It may also be more cost-effective than medicines. If you have your testicles removed, you can have artificial (prosthetic) testicles implanted to preserve a normal appearance.
ADT is not needed for men with small tumors that are unlikely to grow quickly. ADT might be recommended in addition to external beam RT for men with intermediate- and high-risk prostate cancer.
Side effects of ADT — The side effects of ADT are related to the lowered levels of male hormones and include:
●Decreased libido (sex drive) and difficulties with erection (erectile dysfunction)
●Enlargement of the breasts (called gynecomastia) (see "Patient education: Gynecomastia (breast enlargement in men) (Beyond the Basics)")
●Loss of muscle and increase in body fat
●Thinning and weakening of the bones (called osteoporosis), which can increase the risk of bone fractures (see "Patient education: Osteoporosis prevention and treatment (Beyond the Basics)")
●An increased risk of developing type 2 diabetes
●Loss of muscle mass
Many of these side effects are serious, and they might seem frightening. Not all men have these side effects. In addition, it is important to balance the risk of side effects with the risk of not using ADT, which could allow your cancer to grow or spread. In addition, there are ways to prevent or treat many of these side effects.
STAGE III (LOCALLY ADVANCED) PROSTATE CANCER TREATMENT
Locally advanced prostate cancer has spread outside the prostate gland to areas such as the seminal vesicles (figure 1). There is no one "best" treatment for locally advanced prostate cancer. Treatment often includes a combination of two approaches:
●Radiation therapy (RT) with androgen deprivation therapy (ADT)
Radiation therapy (RT) — Radiation therapy involves the use of X-rays to destroy cancer cells. There are two forms of RT used to treat prostate cancer: external beam RT (see 'External beam radiation' above) and brachytherapy (see 'Brachytherapy' above).
Most men who have RT for locally advanced prostate cancer are also given ADT (see 'Androgen deprivation therapy (ADT)' below). Having both treatments helps to control the cancer and improves the chance of survival. Most experts recommend treatment with ADT for at least two years after the RT is completed.
Surgery — Radical prostatectomy is a surgery that completely removes the prostate gland (see 'Radical prostatectomy' above), and it has become more popular in recent years for stage III disease. After surgery, some men are treated with adjuvant or preventative RT.
Androgen deprivation therapy (ADT) — ADT starves the cancer cells and causes the prostate gland to shrink. In men with locally advanced prostate cancer, ADT is usually given in combination with RT. (See 'Androgen deprivation therapy (ADT)' above.)
TREATMENT OF RISING PSA
After treatment for localized prostate cancer, experts advise follow-up testing to monitor for signs that the cancer has returned. This follow-up testing usually includes a blood test called PSA (prostate-specific antigen). The PSA test is very sensitive, meaning that the PSA may begin to rise well before you can see or feel that the cancer has returned. Many men with a rising PSA will not have any sign that the cancer has come back for many years (even 15 or more). Thus, not all men with a rising PSA need immediate treatment.
However, in some men with a rising PSA, treatment is recommended to reduce the chance that the cancer will continue to grow or spread. Talk to your doctor or nurse to discuss your options.
The best treatment for a rising PSA depends upon what treatment you had before:
●Men who had radiation therapy (RT) initially are usually advised to have a prostate biopsy and imaging studies. If those tests show cancer has not grown beyond the prostate, surgery (called salvage prostatectomy) or cryotherapy is advised. Cryotherapy is a treatment that freezes the tissue to destroy cancer cells.
●Men who initially had prostate surgery are usually treated with RT. In some cases, androgen deprivation therapy (ADT) may be given as well, particularly if there is thought to be a high risk of further recurrence.
●Men who cannot have RT, surgery, or cryotherapy can be treated with ADT.
WHICH TREATMENT IS RIGHT FOR ME?
For men with early-stage (localized) prostate cancer, the decision between radiation therapy (RT) and surgery is largely a matter of preference. The choice also depends on the risk that the cancer will grow quickly or come back after treatment.
The potential risks and complications of surgery, RT, and active surveillance are unique. The following table lists the advantages and disadvantages of each type of treatment (table 1).
Localized (stage I to II) prostate cancer — Men who have small tumors that are unlikely to grow quickly have the option to have treatment (with surgery or radiation) or delay treatment (active surveillance). Men who are older or who have other serious illnesses might prefer active surveillance to surgery or radiation.
Men who have moderate to large tumors or any size of tumor that could behave aggressively, making it hard to cure later, are usually encouraged to have treatment (surgery or radiation). Some men who have RT will also need androgen deprivation therapy (ADT).
Locally advanced (stage III) prostate cancer — There is no single best treatment for men with locally advanced prostate cancer. Most experts recommend a combination of either ADT plus RT or surgery plus adjuvant RT.
Advanced prostate cancer — Treatment for advanced (stage IV) prostate cancer is discussed separately. (See "Patient education: Treatment for advanced prostate cancer (Beyond the Basics)".)
Progress in treating prostate cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials or read about clinical trials at:
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Prostate cancer (The Basics)
Patient education: Prostate cancer screening (PSA tests) (The Basics)
Patient education: Hydronephrosis in adults (The Basics)
Patient education: Choosing treatment for low-risk localized prostate cancer (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Prostate cancer screening (Beyond the Basics)
Patient education: Treatment for advanced prostate cancer (Beyond the Basics)
Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)
Patient education: Sexual problems in men (Beyond the Basics)
Patient education: Gynecomastia (breast enlargement in men) (Beyond the Basics)
Patient education: Osteoporosis prevention and treatment (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Active surveillance for men with low-risk, clinically localized prostate cancer
Brachytherapy for localized prostate cancer
Chemoprevention strategies in prostate cancer
Clinical presentation and diagnosis of prostate cancer
Cryotherapy and other ablative techniques for the initial treatment of prostate cancer
Prostate cancer: Risk stratification and choice of initial treatment
External beam radiation therapy for localized prostate cancer
Follow-up surveillance during and after treatment for prostate cancer
Interpretation of prostate biopsy
Side effects of androgen deprivation therapy
Measurement of prostate-specific antigen
Investigational approaches for the treatment of advanced prostate cancer
Initial approach to low- and very low-risk clinically localized prostate cancer
Radical prostatectomy for localized prostate cancer
Rising serum PSA after radiation therapy for localized prostate cancer: Salvage local therapy
Rising serum PSA after treatment for localized prostate cancer: Systemic therapy
Rising serum PSA following local therapy for prostate cancer: Definition, natural history, and risk stratification
Rising serum PSA following local therapy for prostate cancer: Diagnostic evaluation
Rising or persistently elevated serum PSA following radical prostatectomy for prostate cancer: Management
Initial management of regionally localized intermediate-, high-, and very high-risk prostate cancer
The following organizations also provide reliable health information.
●National Cancer Institute
●American Society of Clinical Oncology
●National Comprehensive Cancer Network
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.