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Prostate Cancer: Treatment

Jessica Evert, MD, edited by Benjamin McDonald, MD

As with other cancers, treatments for prostate cancer may involve surgery, radiation therapy or forms of chemotherapy. The exact treatment approach that will be recommended for a given patient is determined by many factors including the stage of the cancer (whether it has metastasized or not), and the patient's age and general health. In some cases more than one treatment approach may be useful, and options can be offered to the patient, along with likely side-effects. In selecting among treatment approaches, become well informed about the pros and cons associated with each treatment type before committing. It may prove helpful to seek a second opinion if you find your choices confusing. Another doctor may be able to provide you with more information which can lead to a better decision on your part.

Surgery is a commonly recommended treatment approach for prostate cancer. What follows are descriptions of the more common surgical procedures doctors use to treat prostate cancer:

  • Radical Prostatectomy. During this procedure the entire prostate gland and sometimes a small amount of surrounding tissue is removed. The aim of this surgery is to remove all cancer cells leaving the patient cancer free. Doctors make an incision into the patient's body, either through the lower belly area, or through the perineal area (between the scrotum and the anus). In addition to removing the prostate gland, it is common for doctors to also take lymph nodes for further biopsy (if the lymph nodes do not contain cancer it means that the cancer has probably not spread beyond the prostate and that the surgery alone should resolve the cancer). The operation can last anywhere from one to four hours and the patient will commonly need to remain in the hospital for roughly three days. During the surgery a thin tube called a catheter is inserted through the penis and into the bladder to allow urine drainage while the patient recovers. This catheter will remain in for one to three weeks after surgery. Once the catheter is removed the patient should be able to urinate on his own again. Most patients can return to work within three to five weeks.

    The most common side effects of prostatectomy are the inability to control bladder function (incontinence) and the inability to have or sustain an erection (impotence). For anywhere from three months to a year after surgery it is unlikely that the patient will be able to get an erection, but after that period some men do regain potency. Reports show that around 75% of men experience some measure of erectile dysfunction after successful treatment (Potosky, 2000).  Medications like Viagra can be helpful in this context. If you are able to achieve an erection again, any orgasm (sensation of pleasure from sexual activity) will be dry because you will not be able to produce semen.

  • Transurethral Resection of the Prostate. Rather than aiming at producing a cure, transurethral resection of the prostate is performed to reduce some of the symptoms of prostate cancer prior to other treatment. During this operation you will be asleep and a doctor will insert a special instrument with a tiny loop of wire on the end of it through the penis to the prostate gland. The wire is heated and used to cut out a portion of the prostate. The benefit of this procedure is that it is short (usually around an hour) and there is no incision. After the procedure a catheter is inserted into the penis to allow for urine drainage. The catheter commonly stays in for two or three days. After the catheter is removed you should be able to urinate on your own again. You will most likely stay in the hospital for one or two days and return to work in about a week. It is common to see a small amount of blood in the urine after surgery.
  • Cryosurgery. This is another surgical approach used to treat prostate cancer that has not spread beyond the prostate. During this procedure the doctor will make a small incision in the perineal area between the anus and the scrotum. They then insert a probe through the incision into the prostate gland which is used to freeze (and thereby kill) adjacent cancer cells. You will (of course) be anesthetized during the procedure. The benefits of cryosurgery are that it is much less invasive than conventional surgeries, meaning that recovery times are shorter and surgery-associated pain is less. Cryosurgery is not without side effects, however. The freezing process can damage healthy prostate and surrounding tissues, potentially causing impotence (inability to have an erection), incontinence (loss of bladder control), pain in the bowels, frequent need to urinate, and a burning sensation during urination. The incidence of such unwelcome side effects is about the same as with conventional surgeries.

Radiation therapy is an alternative to surgical approaches for prostate cancer. In radiation therapy radiation is directed at the cancerous prostate tissues. Radiation can be applied externally using a beam source, or internally, via the implantation of small radioactive 'seeds' or pellets in or near the affected tissues. Radiation therapy is just as successful at curing the cancer as is surgery when the prostate tumor is intact and metastasis has not yet occurred. When the cancer has spread beyond the prostate, radiation therapy is used more to shrink the tumor and/or alleviate pain and other symptoms of the cancer.

There are significant side effects to radiation therapy, including frequent urination, pain while urinating, blood in the urine, and fatigue. Patients may also experience diarrhea, blood in their stool, and incontinence (stool leakage). Patient's elimination functions do tend to start working properly after therapy is completed, but occasionally, bowel function is not regained. Impotency (inability to have or sustain an erection) is also a common side effect of radiation therapy. Unlike with surgery where impotency onset is swift, impotency associated with radiation therapy takes time to develop.

Hormone therapy is also used to treat prostate cancer. Higher levels of male sex hormones (androgens) cause prostate cancer cells to grow and reproduce rapidly. Hormone treatments work by reducing the level of male hormones in a patient's body, or by blocking the effect of available male hormones.   While hormone treatments can reduce the growth of prostate cancers, they cannot cure these cancers. They are most commonly prescribed for men whose cancer has spread beyond the prostate or returned after a successful prior treatment.

There are multiple methods for administering hormone therapy:

  • Castration. Castration is the surgical removal of the testicles, the dangling glands responsible for producing male hormones as well as sperm. While removal of the testicles does effectively reduce male hormone levels, many men find the prospect of life without testicles to be troubling, and elect to go with alternative techniques.

  • LHRH Analog Medications. Medications known as LHRH (Leutinizing Hormone Releasing Hormone) analogs can be prescribed to reduce the level of androgens produced by the testicles. These drugs are administered as shots usually on a monthly basis.

  • Antiandrogen Medications. Medications known as antiandrogens reduce the effective level of male hormones available in the body by blocking their effect (rather than by reducing their total amount). Antiandrogens are taken daily in pill format.

As with other therapies, hormone therapy also has associated side-effects. In many cases, the therapy is only effective for a period of time as the body adapts to the presence of the medications and they become less effective. Even while it does prove useful in suppressing prostate cancer growth, hormone therapy can produce a variety of unwanted side-effects such as breast growth and tenderness, weakening of the bones, lower red blood cell counts, weight gain, fatigue, hot flashes, and loss of muscle mass.