What is prostate cancer ?

Prostate cancer is the most common cancer among men (after skin cancer), but it can often be treated successfully ¹⁾.

Other than skin cancer, prostate cancer is the most common cancer in American men. The American Cancer Society’s estimates for prostate cancer in the United States for 2017 are:

• About 161,360 new cases of prostate cancer
• About 26,730 deaths from prostate cancer

Prostate cancer is the third leading cause of cancer death in American men, behind lung cancer and colorectal cancer. About 1 man in 39 will die of prostate cancer.

Prostate cancer can be a serious disease, but most men diagnosed with prostate cancer do not die from it. In fact, more than 2.9 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today.

Prostate cancer begins when cells in the prostate gland start to grow uncontrollably. The prostate is a gland found only in males. It makes some of the fluid that is part of semen.

The prostate is below the bladder and immediately in front of the rectum, just above the pelvic floor. In men, the prostate gland can be felt by digital palpation during a rectal examination.The size of the prostate changes with age. In younger men, it is about the size of a walnut, but it can be much larger in older men.

Just behind the prostate are glands called seminal vesicles that make most of the fluid for semen. The urethra, which is the tube that carries urine and semen out of the body through the penis, goes through the center of the prostate.

Figure 1. Normal prostate gland

Prostate cancer types

Almost all prostate cancers are adenocarcinomas ²⁾. These cancers develop from the gland cells (the cells that make the prostate fluid that is added to the semen).

Other types of prostate cancer include:

• Sarcomas
• Small cell carcinomas
• Neuroendocrine tumors (other than small cell carcinomas)
• Transitional cell carcinomas

These other types of prostate cancer are rare. If you have prostate cancer it is almost certain to be an adenocarcinoma ³⁾.

Some prostate cancers can grow and spread quickly, but most grow slowly. In fact, autopsy studies show that many older men (and even some younger men) who died of other causes also had prostate cancer that never affected them during their lives. In many cases neither they nor their doctors even knew they had it.

Possible pre-cancerous conditions of the prostate

Some research suggests that prostate cancer starts out as a pre-cancerous condition, although this is not yet known for sure ⁴⁾. These conditions are sometimes found when a man has a prostate biopsy (removal of small pieces of the prostate to look for cancer).

Prostatic intraepithelial neoplasia (PIN)

In prostatic intraepithelial neoplasia, there are changes in how the prostate gland cells look under a microscope, but the abnormal cells don’t look like they are growing into other parts of the prostate (like cancer cells would) ⁵⁾. Based on how abnormal the patterns of cells look, they are classified as:

• Low-grade prostatic intraepithelial neoplasia: the patterns of prostate cells appear almost normal
• High-grade prostatic intraepithelial neoplasia: the patterns of cells look more abnormal

Prostatic intraepithelial neoplasia begins to appear in the prostates of some men as early as in their 20s.

Many men begin to develop low-grade prostatic intraepithelial neoplasia when they are younger but don’t necessarily develop prostate cancer. The possible link between low-grade prostatic intraepithelial neoplasia and prostate cancer is still unclear.

If high-grade prostatic intraepithelial neoplasia is found in your prostate biopsy sample, there is about a 20% chance that you also have cancer in another area of your prostate.

Proliferative inflammatory atrophy (PIA)

In proliferative inflammatory atrophy, the prostate cells look smaller than normal and there are signs of inflammation in the area ⁶⁾. Proliferative inflammatory atrophy is not cancer, but researchers believe that proliferative inflammatory atrophy may sometimes lead to high-grade prostatic intraepithelial neoplasia, or perhaps to prostate cancer directly.

Prostate cancer causes

About 1 man in 7 will be diagnosed with prostate cancer during his lifetime.

Prostate cancer develops mainly in older men. About 6 cases in 10 are diagnosed in men aged 65 or older, and it is rare before age 40. The average age at the time of diagnosis is about 66.

Prostate Cancer Risk Factors

A risk factor is anything that affects your chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person’s age or family history, can’t be changed.

But having a risk factor, or even several, does not mean that you will get the disease. Many people with one or more risk factors never get cancer, while others who get cancer may have had few or no known risk factors.

Researchers have found several factors that might affect a man’s risk of getting prostate cancer.

Age

Prostate cancer is rare in men younger than 40, but the chance of having prostate cancer rises rapidly after age 50. About 6 in 10 prostate cancers are found in men older than 65.

Race/ethnicity

Prostate cancer occurs more often in African-American men and Caribbean men of African ancestry than in men of other races. African-American men are also more than twice as likely to die of prostate cancer than white men. Prostate cancer occurs less often in Asian-American and Hispanic/Latino men than in non-Hispanic whites. The reasons for these racial and ethnic differences are not clear.

Geography

Prostate cancer is most common in North America, northwestern Europe, Australia, and on Caribbean islands. It is less common in Asia, Africa, Central America, and South America.

The reasons for this are not clear. More intensive screening in some developed countries probably accounts for at least part of this difference, but other factors such as lifestyle differences (diet, etc.) are likely to be important as well. For example, Asian Americans have a lower risk of prostate cancer than white Americans, but their risk is higher than that of men of similar backgrounds living in Asia.

Family history

Prostate cancer seems to run in some families, which suggests that in some cases there may be an inherited or genetic factor. Still, most prostate cancers occur in men without a family history of it.

Having a father or brother with prostate cancer more than doubles a man’s risk of developing this disease. The risk is higher for men who have a brother with the disease than for those who have a father with it. The risk is much higher for men with several affected relatives, particularly if their relatives were young when the cancer was found.

Gene changes

Several inherited gene changes (mutations) seem to raise prostate cancer risk, but they probably account for only a small percentage of cases overall. For example:

• Inherited mutations of the BRCA1 or BRCA2 genes raise the risk of breast and ovarian cancers in some families. Mutations in these genes (especially in BRCA2) may also increase prostate cancer risk in some men.
• Men with Lynch syndrome (also known as hereditary non-polyposis colorectal cancer, or HNPCC), a condition caused by inherited gene changes, have an increased risk for a number of cancers, including prostate cancer.

Other inherited gene changes can also raise a man’s risk of prostate cancer.

Factors with less clear effect on prostate cancer risk

Diet

The exact role of diet in prostate cancer is not clear, but several factors have been studied.

Men who eat a lot of red meat or high-fat dairy products appear to have a slightly higher chance of getting prostate cancer. These men also tend to eat fewer fruits and vegetables. Doctors aren’t sure which of these factors is responsible for raising the risk.

Some studies have suggested that men who consume a lot of calcium (through food or supplements) may have a higher risk of developing prostate cancer. Dairy foods (which are often high in calcium) might also increase risk. But most studies have not found such a link with the levels of calcium found in the average diet, and it’s important to note that calcium has other important health benefits.

Obesity

Being obese (very overweight) does not seem to increase the overall risk of getting prostate cancer.

Some studies have found that obese men have a lower risk of getting a low-grade (less dangerous) form of the disease, but a higher risk of getting more aggressive prostate cancer. The reasons for this are not clear.

Some studies have also found that obese men may be at greater risk for having more advanced prostate cancer and of dying from prostate cancer, but not all studies have found this.

Smoking

Most studies have not found a link between smoking and getting prostate cancer. Some research has linked smoking to a possible small increased risk of dying from prostate cancer, but this finding needs to be confirmed by other studies.

Chemical exposures

There is some evidence that firefighters can be exposed to chemicals that may increase their risk of prostate cancer.

A few studies have suggested a possible link between exposure to Agent Orange, a chemical used widely during the Vietnam War, and prostate cancer, although not all studies have found such a link. The Institute of Medicine considers there to be “limited/suggestive evidence” of a link between Agent Orange exposure and prostate cancer.

Inflammation of the prostate

Some studies have suggested that prostatitis (inflammation of the prostate gland) may be linked to an increased risk of prostate cancer, but other studies have not found such a link. Inflammation is often seen in samples of prostate tissue that also contain cancer. The link between the two is not yet clear, and is an active area of research.

Sexually transmitted infections

Researchers have looked to see if sexually transmitted infections (like gonorrhea or chlamydia) might increase the risk of prostate cancer, because they can lead to inflammation of the prostate. So far, studies have not agreed, and no firm conclusions have been reached.
Vasectomy

Some studies have suggested that men who have a vasectomy (minor surgery to make men infertile) have a slightly increased risk for prostate cancer, but other studies have not found this. Research on this possible link is still being done.

Can Prostate Cancer Be Prevented ?

There is no sure way to prevent prostate cancer. Many risk factors such as age, race, and family history can’t be controlled. But there are some things you can do that might lower your risk for this disease.

Body weight, physical activity, and diet

The effects of body weight, physical activity, and diet on prostate cancer risk are not clear, but there are things you can do that might lower your risk.

Some studies have found that men who are overweight may have a slightly lower risk of prostate cancer overall, but a higher risk of prostate cancers that are likely to be fatal.

Studies have found that men who are regularly physically active have a slightly lower risk of prostate cancer. Vigorous activity may have a greater effect, especially on the risk of advanced prostate cancer.

Several studies have suggested that diets high in certain vegetables (including tomatoes, cruciferous vegetables, soy, beans, and other legumes) or fish may be linked with a lower risk of prostate cancer, especially more advanced cancers. Examples of cruciferous vegetables include cabbage, broccoli, and cauliflower.

Although not all studies agree, several have found a higher risk of prostate cancer in men whose diets are high in calcium. There may also be an increased risk from consuming dairy foods.

For now, the best advice about diet and activity to possibly reduce the risk of prostate cancer is to:

• Eat at least 2½ cups of a wide variety of vegetables and fruits each day.
• Be physically active.
• Stay at a healthy weight.

It may also be sensible to limit calcium supplements and to not get too much calcium in the diet. This does not mean that men who are being treated for prostate cancer should not take calcium supplements if their doctor recommends them.

Vitamin, mineral, and other supplements

Vitamin E and selenium: Some earlier studies suggested that taking vitamin E or selenium supplements might lower prostate cancer risk.

But in a large study known as the Selenium and Vitamin E Cancer Prevention Trial (SELECT), neither vitamin E nor selenium supplements were found to lower prostate cancer risk. In fact, men in the study taking the vitamin E supplements were later found to have a slightly higher risk of prostate cancer. For selenium supplements, the risk of prostate cancer was unchanged in men who had lower selenium levels at the start of the study. Men who had higher baseline levels, though, had an increased risk of high-grade (fast-growing) prostate cancer.

Soy and isoflavones: Several studies are now looking at the possible effects of soy proteins (called isoflavones) on prostate cancer risk. The results of these studies are not yet available.

Taking any supplements can have both risks and benefits. Before starting vitamins or other supplements, talk with your doctor.

Medicines

Some drugs might help reduce the risk of prostate cancer.

5-alpha reductase inhibitors

5-alpha reductase is an enzyme in the body that changes testosterone into dihydrotestosterone (DHT), the main hormone that causes the prostate to grow. Drugs called 5-alpha reductase inhibitors, such as finasteride (Proscar) and dutasteride (Avodart), block this enzyme from making DHT. These drugs are used to treat benign prostatic hyperplasia (BPH), a non-cancerous growth of the prostate.

Large studies of both of these drugs have been done to see if they might also be useful in lowering prostate cancer risk. In these studies, men taking either drug were less likely to develop prostate cancer after several years than men getting an inactive placebo.

When the results were looked at more closely, the men who took these drugs had fewer low-grade prostate cancers, but slightly more higher-grade prostate cancers, which are more likely to grow and spread. Long term, though, this didn’t seem to affect death rates – both groups of men had similar survival.

These drugs can cause sexual side effects such as lowered sexual desire and erectile dysfunction (impotence). But they can help with urinary problems from BPH such as trouble urinating and leaking urine (incontinence).

Although these drugs are safe, they aren’t approved by the FDA to help prevent prostate cancer. Right now, it isn’t clear that taking one of these drugs just to lower prostate cancer risk is very helpful. Still, men who want to know more about these drugs should discuss them with their doctors.

Aspirin

Some research suggests that men who take aspirin daily for a long time might have a lower risk of getting and dying from prostate cancer. But more research is needed to show if the possible benefits outweigh the risks. Long-term aspirin use can have side effects, including an increased risk of bleeding in the digestive tract. While aspirin can also have other health benefits, at this time most doctors don’t recommend taking it solely to try to lower prostate cancer risk.

Other drugs

Other drugs and dietary supplements that might help lower prostate cancer risk are now being tested in clinical trials. But so far, no drug or supplement has been found to be helpful in studies large enough for experts to recommend them.

Signs and symptoms of prostate cancer

Early prostate cancer usually causes no symptoms. More advanced prostate cancers sometimes cause symptoms, such as:

• Problems urinating (such as pain, difficulty starting or stopping the stream, or dribbling), including a slow or weak urinary stream or the need to urinate more often, especially at night
• Pain with ejaculation
• Blood in the urine or semen
• Trouble getting an erection (erectile dysfunction)
• Pain in the hips, back (spine), chest (ribs), or other areas from cancer that has spread to bones
• Weakness or numbness in the legs or feet, or even loss of bladder or bowel control from cancer pressing on the spinal cord

Most of these problems are more likely to be caused by something other than prostate cancer. For example, trouble urinating is much more often caused by benign prostatic hyperplasia, a non-cancerous growth of the prostate. Still, it’s important to tell your health care provider if you have any of these symptoms so that the cause can be found and treated, if needed.

Can Prostate Cancer Be Found Early ?

Screening is testing to find cancer in people before they have symptoms. For some types of cancer, screening can help find cancers at an early stage, when they are likely to be easier to treat.

Prostate cancer can often be found before symptoms start by testing the amount of prostate-specific antigen (PSA) in a man’s blood. Another way to find prostate cancer is the digital rectal exam, in which the doctor puts a gloved, lubricated finger into the rectum to feel the prostate gland.

If the results of either one of these tests are abnormal, further testing is often done to see if a man has cancer. If prostate cancer is found as a result of screening with the PSA test or digital rectal exam, it will probably be at an earlier, more treatable stage than if no screening were done.

There is no question that screening can help find many prostate cancers early, but there are still questions about whether the benefits of screening outweigh the risks for most men. There are clearly both pros and cons to the prostate cancer screening tests in use today.

At this time, the American Cancer Society recommends that men thinking about getting screened for prostate cancer should make informed decisions based on available information, discussion with their doctor, and their own views on the possible benefits, risks, and limits of prostate cancer screening.

American Cancer Society Recommendations for Prostate Cancer Early Detection

The American Cancer Society recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer ⁷⁾. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information. The discussion about screening should take place at:

• Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
• Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65).
• Age 40 for men at even higher risk (those with more than one first-degree relative who had prostate cancer at an early age).

After this discussion, men who want to be screened should be tested with the prostate-specific antigen (PSA) blood test. The digital rectal exam may also be done as a part of screening.

If, after this discussion, a man is unable to decide if testing is right for him, the screening decision can be made by the health care provider, who should take into account the man’s general health preferences and values.

If no prostate cancer is found as a result of screening, the time between future screenings depends on the results of the PSA blood test:

• Men who choose to be tested who have a PSA of less than 2.5 ng/mL may only need to be retested every 2 years.
• Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher.

Because prostate cancer often grows slowly, men without symptoms of prostate cancer who do not have a 10-year life expectancy should not be offered testing since they are not likely to benefit. Overall health status, and not age alone, is important when making decisions about screening.

Even after a decision about testing has been made, the discussion about the pros and cons of testing should be repeated as new information about the benefits and risks of testing becomes available. Further discussions are also needed to take into account changes in a man’s health, values, and preferences.

What Tests Can Detect Prostate Cancer Early ?

The tests discussed below are used to look for warning signs of prostate cancer. But these early detection tests can’t tell for sure if you have cancer. If the result of one of these tests is abnormal, you will probably need a prostate biopsy to determine if you have cancer.

Prostate-specific antigen (PSA) blood test

Prostate-specific antigen (PSA) is a substance made by cells in the prostate gland (both normal cells and cancer cells). PSA is mostly found in semen, but a small amount is also found in the blood.

• Most men without prostate cancer have PSA levels under 4 nanograms per milliliter (ng/mL) of blood. The chance of having prostate cancer goes up as the PSA level goes up.

• When prostate cancer develops, the PSA level usually goes above 4. Still, a level below 4 does not guarantee that a man doesn’t have cancer. About 15% of men with a PSA below 4 will have prostate cancer on a biopsy.

• Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer. If the PSA is more than 10, the chance of having prostate cancer is over 50%.

If your PSA level is high, your doctor may advise either waiting a while and repeating the test, or getting a prostate biopsy to find out if you have cancer. When considering whether to do a prostate biopsy to look for cancer, not all doctors use the same PSA cutoff point. Some may advise it if the PSA is 4 or higher, while others might recommend it starting at a lower level, such as 2.5 or 3. Other factors, such as your age, race, and family history, may affect this decision.

Factors that might affect PSA levels

A number of factors other than prostate cancer can also raise PSA levels:

• An enlarged prostate: Conditions such as benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate that affects many men as they grow older, can raise PSA levels.
• Older age: PSA levels normally go up slowly as you get older, even if you have no prostate abnormality.
• Prostatitis: This term refers to infection or inflammation of the prostate gland, which can raise PSA levels.
• Ejaculation: This can make the PSA go up for a short time, and then go down again. This is why some doctors suggest that men abstain from ejaculation for a day or two before testing.
• Riding a bicycle: Some studies have suggested that cycling may raise PSA levels (possibly because the seat puts pressure on the prostate), although not all studies have found this.
• Certain urologic procedures: Some procedures done in a doctor’s office that affect the prostate, such as a prostate biopsy or cystoscopy, can result in higher PSA levels for a short time. Some studies have suggested that a digital rectal exam (DRE) might raise PSA levels slightly, although other studies have not found this. Still, if both a PSA test and a DRE are being done during a doctor visit, some doctors advise having the blood drawn for the PSA before having the digital rectal exam, just in case.
• Certain medicines: Taking male hormones like testosterone (or other medicines that raise testosterone levels) may cause a rise in PSA.

Some things might cause PSA levels to go down (even if a man has prostate cancer):

• 5-alpha reductase inhibitors: Certain drugs used to treat BPH or urinary symptoms, such as finasteride (Proscar or Propecia) or dutasteride (Avodart), may lower PSA levels. These drugs can also affect prostate cancer risk (discussed in Can Prostate Cancer Be Prevented?). Tell your doctor if you are taking these medicines because they may lower PSA levels, so the doctor might need to adjust the reading.
• Herbal mixtures: Some mixtures that are sold as dietary supplements may also mask a high PSA level. This is why it’s important to let your doctor know if you are taking any type of supplement, even ones that are not necessarily meant for prostate health. Saw palmetto (an herb used by some men to treat BPH) does not seem to affect PSA.
• Obesity: Obese (very overweight) men tend to have lower PSA levels.
• Aspirin: Some research has suggested that men taking aspirin regularly may have lower PSA levels. This effect may be greater in non-smokers. More research is needed to confirm this finding. If you take aspirin regularly (for example, to help prevent heart disease), talk to your doctor before you stop taking it for any reason.
• Statins: Some studies have linked the long-term use of cholesterol-lowering drugs known as statins, such as atorvastatin (Lipitor), rosuvastatin (Crestor), and simvastatin (Zocor), with lower PSA levels.
• Thiazide diuretics: Thiazide diuretics, such as hydrochlorothiazide, are a type of water pill often used to treat high blood pressure. Taking a thiazide diuretic for years is linked to lower PSA levels.

For men not known to have prostate cancer, it’s not always clear if lowering the PSA is helpful. In some cases the factor that lowers the PSA may also lower a man’s risk of prostate cancer. But in other cases, it might lower the PSA level without affecting a man’s risk of cancer. This could actually be harmful, if it were to lower the PSA from an abnormal level to a normal one, as it might result in not detecting a cancer. This is why it’s important to talk to your doctor about anything that might affect your PSA level.

Special types of PSA tests

Some doctors might consider using different types of PSA tests (discussed below) to help decide if you need a prostate biopsy, but not all doctors agree on how to use these other PSA tests. If your PSA test result isn’t normal, ask your doctor to discuss your cancer risk and your need for further tests.

Percent-free PSA: PSA occurs in 2 major forms in the blood. One form is attached to blood proteins, while the other circulates free (unattached). The percent-free PSA (fPSA) is the ratio of how much PSA circulates free compared to the total PSA level. The percentage of free PSA is lower in men who have prostate cancer than in men who do not.

This test is sometimes used to help decide if you should have a prostate biopsy if your PSA results are in the borderline range (like between 4 and 10). A lower percent-free PSA means that your chance of having prostate cancer is higher and you should probably have a biopsy.

Many doctors recommend biopsies for men whose percent-free PSA is 10% or less, and advise that men consider a biopsy if it is between 10% and 25%. Using these cutoffs detects most cancers and helps some men avoid unnecessary prostate biopsies. This test is widely used, but not all doctors agree that 25% is the best cutoff point to decide on a biopsy, and the cutoff may change depending on the overall PSA level.

Complexed PSA: This test directly measures the amount of PSA that is attached to other proteins (the portion of PSA that is not “free”). This test could be done instead of checking the total and free PSA, and it could give the same amount of information as the other tests done separately. This test is being studied to see if it provides the same level of accuracy.

Tests that combine different types of PSA: Some newer tests, such as the prostate health index (phi) and the 4Kscore test, combine the results of different types of PSA to get an overall score that reflects the chance a man has prostate cancer. These tests might be useful in men with a slightly elevated PSA, to help determine if they should have a prostate biopsy. Some tests might be used to help determine if a man who has already had a prostate biopsy that didn’t find cancer should have another biopsy.

PSA velocity: The PSA velocity is not a separate test. It is a measure of how fast the PSA rises over time. Normally, PSA levels go up slowly with age. Some research has found that these levels go up faster if a man has cancer, but studies have not shown that the PSA velocity is more helpful than the PSA level itself in finding prostate cancer. For this reason, the ACS guidelines do not recommend using the PSA velocity as part of screening for prostate cancer.

PSA density: PSA levels are higher in men with larger prostate glands. The PSA density (PSAD) is sometimes used for men with large prostate glands to try to adjust for this. The doctor measures the volume (size) of the prostate gland with transrectal ultrasound (discussed in If Prostate Cancer Screening Test Results Aren’t Normal) and divides the PSA number by the prostate volume. A higher PSA density indicates a greater likelihood of cancer. PSA density has not been shown to be as useful as the percent-free PSA test.

Age-specific PSA ranges: PSA levels are normally higher in older men than in younger men, even when there is no cancer. A PSA result within the borderline range might be very worrisome in a 50-year-old man but cause less concern in an 80-year-old man. For this reason, some doctors have suggested comparing PSA results with results from other men of the same age.

But because the usefulness of age-specific PSA ranges is not well proven, most doctors and professional organizations (as well as the makers of the PSA tests) do not recommend their use at this time.

Digital rectal exam (DRE)

For a digital rectal exam, the doctor inserts a gloved, lubricated finger into the rectum to feel for any bumps or hard areas on the prostate that might be cancer. As shown in the picture below, the prostate is just in front of the rectum. Prostate cancers often begin in the back part of the gland, which might be felt during a rectal exam. This exam can be uncomfortable (especially for men who have hemorrhoids), but it usually isn’t painful and only takes a short time.

Prostate cancer diagnosis

Most prostate cancers are first found during screening with a prostate-specific antigen (PSA) blood test or a digital rectal exam. Early prostate cancers usually don’t cause symptoms, but more advanced cancers are sometimes first found because of symptoms they cause.

If cancer is suspected based on results of screening tests or symptoms, tests will be needed to confirm the diagnosis. The actual diagnosis of prostate cancer can only be made with a prostate biopsy.

Medical history and physical exam

If your doctor suspects you might have prostate cancer, he or she will ask you about any symptoms you are having, such as any urinary or sexual problems, and how long you have had them. You might also be asked about possible risk factors, including your family history.

Your doctor will also examine you. This might include a digital rectal exam, during which the doctor’s gloved, lubricated finger is inserted into your rectum to feel for any bumps or hard areas on the prostate that might be cancer. If you do have cancer, the digital rectal exam can sometimes help tell if it’s only on one side of the prostate, if it’s on both sides, or if it’s likely to have spread beyond the prostate to nearby tissues.

Your doctor may also examine other areas of your body. He or she might then order some tests.

PSA blood test

The prostate-specific antigen (PSA) blood test is used mainly to screen for prostate cancer in men without symptoms (see Prostate Cancer Prevention and Early Detection). It’s also one of the first tests done in men who have symptoms that might be caused by prostate cancer.

Most men without prostate cancer have PSA levels under 4 nanograms per milliliter (ng/mL) of blood ⁸⁾. The chance of having prostate cancer goes up as the PSA level goes up.

When prostate cancer develops, the PSA level usually goes above 4. Still, a level below 4 does not guarantee that a man doesn’t have cancer ⁹⁾. About 15% of men with a PSA below 4 will have prostate cancer on a biopsy ¹⁰⁾.

Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer ¹¹⁾. If the PSA is more than 10, the chance of having prostate cancer is over 50% ¹²⁾.

When considering whether to do a prostate biopsy to look for cancer, not all doctors use the same PSA cutoff point. Some may advise it if the PSA is 4 or higher, while others might recommend it starting at a lower level, such as 2.5 or 3. Other factors, such as your age, race, and family history, may affect this decision.

The PSA test can also be useful if you have already been diagnosed with prostate cancer.

• In men just diagnosed with prostate cancer, the PSA test can be used together with physical exam results and tumor grade (determined on the biopsy, described further on) to help decide if other tests (such as CT scans or bone scans) are needed.

• The PSA test is a part of staging (determining the stage of your cancer) and can help tell if your cancer is likely to still be confined to the prostate gland. If your PSA level is very high, your cancer is more likely to have spread beyond the prostate. This may affect your treatment options, since some forms of therapy (such as surgery and radiation) are not likely to be helpful if the cancer has spread to the lymph nodes, bones, or other organs.

• PSA tests are also an important part of monitoring prostate cancer during and after treatment.

Transrectal ultrasound (TRUS)

For this test, a small probe about the width of a finger is lubricated and placed in your rectum. The probe gives off sound waves that enter the prostate and create echoes. The probe picks up the echoes, and a computer turns them into a black and white image of the prostate.

The procedure often takes less than 10 minutes and is done in a doctor’s office or outpatient clinic. You will feel some pressure when the probe is inserted, but it is usually not painful. The area may be numbed before the procedure.

Transrectal ultrasound is often used to look at the prostate when a man has a high PSA level or has an abnormal digital rectal exam result. It is also used during a prostate biopsy to guide the needles into the correct area of the prostate.

Transrectal ultrasound is useful in other situations as well. It can be used to measure the size of the prostate gland, which can help determine the PSA density and may also affect which treatment options a man has. Transrectal ultrasound is also used as a guide during some forms of treatment such as brachytherapy (internal radiation therapy) or cryotherapy.

Prostate biopsy

If certain symptoms or the results of tests such as a PSA blood test or digital rectal exam suggest that you might have prostate cancer, your doctor will do a prostate biopsy.

A biopsy is a procedure in which small samples of the prostate are removed and then looked at under a microscope. A core needle biopsy is the main method used to diagnose prostate cancer. It is usually done by a urologist, a surgeon who treats cancers of the genital and urinary tract, which includes the prostate gland.

Using transrectal ultrasound to “see” the prostate gland, the doctor quickly inserts a thin, hollow needle through the wall of the rectum and into the prostate. When the needle is pulled out it removes a small cylinder (core) of prostate tissue. This is repeated several times. Most urologists will take about 12 core samples from different parts of the prostate.

Though the procedure sounds painful, each biopsy usually causes only a brief uncomfortable sensation because it is done with a special spring-loaded biopsy instrument. The device inserts and removes the needle in a fraction of a second. Most doctors who do the biopsy will numb the area first by injecting a local anesthetic alongside the prostate. You might want to ask your doctor if he or she plans to do this.

The biopsy itself takes about 10 minutes and is usually done in the doctor’s office. You will likely be given antibiotics to take before the biopsy and possibly for a day or 2 after to reduce the risk of infection.

For a few days after the procedure, you may feel some soreness in the area and will probably notice blood in your urine. You may also have some light bleeding from your rectum, especially if you have hemorrhoids. Many men notice blood in their semen or have rust colored semen, which can last for several weeks after the biopsy, depending on how often you ejaculate.

Your biopsy samples will be sent to a lab, where they will be looked at a microscope to see if they contain cancer cells. If cancer is seen, it will also be assigned a grade (see the next section). Getting the results (in the form of a pathology report) usually takes at least 1 to 3 days, but it can sometimes take longer.

Even when taking many samples, biopsies can still sometimes miss a cancer if none of the biopsy needles pass through it. This is known as a false-negative result. If your doctor still strongly suspects you have prostate cancer (because your PSA level is very high, for example) a repeat biopsy might be needed to help be sure.

Grade (Gleason score) of prostate cancer

Prostate cancers are graded according to the Gleason system. This system assigns a Gleason grade based on how much the cancer looks like normal prostate tissue.

• If the cancer looks a lot like normal prostate tissue, a grade of 1 is assigned.
• If the cancer looks very abnormal, it is given a grade of 5.
• Grades 2 through 4 have features in between these extremes.

Most cancers are grade 3 or higher, and grades 1 and 2 are not often used.

Since prostate cancers often have areas with different grades, a grade is assigned to the 2 areas that make up most of the cancer. These 2 grades are added to yield the Gleason score (also called the Gleason sum).

There are some exceptions to this rule. If the highest grade takes up most (95% or more) of the biopsy sample, the grade for that area is counted twice as the Gleason score. Also, if 3 grades are present in a biopsy core, the highest grade is always included in the Gleason score, even if most of the core is taken up by areas of cancer with lower grades.

The Gleason score can be between 2 and 10, but most are at least a 6. The higher the Gleason score, the more likely it is that the cancer will grow and spread quickly.

Aside from the Gleason score, the grade of the cancer is sometimes expressed using other terms:

• Cancers with a Gleason score of 6 or less may be called well-differentiated or low-grade.
• Cancers with a Gleason score of 7 may be called moderately-differentiated or intermediate-grade.
• Cancers with Gleason scores of 8 to 10 may be called poorly-differentiated or high-grade.

Recently, doctors have also begun to use Grade Groups, which are thought to be a more accurate way to divide up the Gleason scores.

Along with the grade of the cancer (if it is present), the pathology report often contains other information about the cancer, such as:

• The number of biopsy core samples that contain cancer (for example, “7 out of 12”)
• The percentage of cancer in each of the cores
• Whether the cancer is on one side (left or right) of the prostate or both sides (bilateral)

Suspicious results

Sometimes when the prostate cells are seen, they don’t look like cancer, but they’re not quite normal, either. These results are often reported as suspicious.

Prostatic intraepithelial neoplasia (PIN): In prostatic intraepithelial neoplasia, there are changes in how the prostate cells look, but the abnormal cells don’t look like they’ve grown into other parts of the prostate (like cancer cells would). PIN is often divided into 2 groups:

• Low-grade PIN: the patterns of prostate cells appear almost normal
• High-grade PIN: the patterns of cells look more abnormal

Many men begin to develop low-grade prostatic intraepithelial neoplasia at an early age but don’t necessarily develop prostate cancer. The importance of low-grade prostatic intraepithelial neoplasia in relation to prostate cancer is still unclear. If low-grade prostatic intraepithelial neoplasia is reported on a prostate biopsy, the follow-up for patients is usually the same as if nothing abnormal was seen.

If high-grade prostatic intraepithelial neoplasia is found on a biopsy, there is about a 20% chance that cancer may already be present somewhere else in the prostate gland. This is why doctors often watch men with high-grade prostatic intraepithelial neoplasia carefully and may advise a repeat prostate biopsy, especially if the original biopsy did not take samples from all parts of the prostate.

Atypical small acinar proliferation: This is sometimes just called atypia. In atypical small acinar proliferation, the cells look like they might be cancerous when viewed under the microscope, but there are too few of them to be sure. If atypical small acinar proliferation is found, there’s a high chance that cancer is also present in the prostate, which is why many doctors recommend getting a repeat biopsy within a few months.

Proliferative inflammatory atrophy: In proliferative inflammatory atrophy, the prostate cells look smaller than normal, and there are signs of inflammation in the area. Proliferative inflammatory atrophy is not cancer, but researchers believe that proliferative inflammatory atrophy may sometimes lead to high-grade PIN or to prostate cancer directly.

Imaging tests to look for prostate cancer spread

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body.

If you are found to have prostate cancer, your doctor will use your digital rectal exam results, prostate-specific antigen (PSA) level, and Gleason score from the biopsy results to figure out how likely it is that the cancer has spread outside your prostate. This information is used to decide if any imaging tests need to be done to look for possible cancer spread. Men with a normal digital rectal exam result, a low PSA, and a low Gleason score may not need any other tests because the chance that the cancer has spread is so low.

The imaging tests used most often to look for prostate cancer spread include:

Bone scan

If prostate cancer spreads to distant sites, it often goes to the bones first. A bone scan can help show whether cancer has reached the bones.

For this test, you are injected with a small amount of low-level radioactive material, which settles in damaged areas of bone throughout the body. A special camera detects the radioactivity and creates a picture of your skeleton.

A bone scan may suggest cancer in the bone, but to make an accurate diagnosis, other tests such as plain x-rays, CT or MRI scans, or even a bone biopsy might be needed.

Computed tomography (CT) scan

A CT scan uses x-rays to make detailed, cross-sectional images of your body. This test isn’t often needed for newly diagnosed prostate cancer if the cancer is likely to be confined to the prostate based on other findings (DRE result, PSA level, and Gleason score). Still, it can sometimes help tell if prostate cancer has spread into nearby lymph nodes. If your prostate cancer has come back after treatment, the CT scan can often tell if it is growing into other organs or structures in your pelvis.

CT scans are not as useful as magnetic resonance imaging (MRI) for looking at the prostate gland itself.

Magnetic resonance imaging (MRI)

Like CT scans, MRI scans show detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. A contrast material called gadolinium may be injected into a vein before the scan to better see details.

MRI scans can give a very clear picture of the prostate and show if the cancer has spread outside the prostate into the seminal vesicles or other nearby structures. This can be very important in determining your treatment options. But like CT scans, MRI scans aren’t usually needed for newly diagnosed prostate cancers that are likely to be confined to the prostate based on other factors.

To improve the accuracy of the MRI, you might have a probe, called an endorectal coil, placed inside your rectum for the scan. This can be uncomfortable. If needed, medicine to make you feel sleepy (sedation) can be given before the scan.

Lymph node biopsy

In a lymph node biopsy, also known as lymph node dissection or lymphadenectomy, one or more lymph nodes are removed to see if they have cancer cells. This isn’t done very often for prostate cancer, but can be used to find out if the cancer has spread from the prostate to nearby lymph nodes.

Biopsy during surgery to treat prostate cancer

The surgeon may remove lymph nodes in the pelvis during the same operation as the removal of the prostate, which is known as a radical prostatectomy.

If there is more than a very small chance that the cancer might have spread (based on factors such as a high PSA level or a high Gleason score), the surgeon may remove some lymph nodes before removing the prostate gland.

Sometimes the nodes will be looked at right away, while you are still under anesthesia, to help the surgeon decide whether to continue with the radical prostatectomy. This is called a frozen section exam because the tissue sample is frozen before thin slices are taken to check under a microscope. If the nodes contain cancer cells, the operation might be stopped (leaving the prostate in place). This could happen if the surgeon feels that removing the prostate would be unlikely to cure the cancer, but would still probably result in serious complications or side effects.

More often (especially if the chance of cancer spread is low), a frozen section exam is not done. Instead the lymph nodes and the prostate are removed and are then sent to the lab to be looked at. The lab results are usually available several days after surgery.

Lymph node biopsy as a separate procedure

A lymph node biopsy is rarely done as a separate procedure. It’s sometimes used when a radical prostatectomy isn’t planned (such as for some men who choose treatment with radiation therapy), but when it’s still important to know if the lymph nodes contain cancer.

Laparoscopic biopsy: A laparoscope is a long, slender tube with a small video camera on the end that is inserted into the abdomen through a small cut. It lets the surgeon see inside the abdomen and pelvis without needing to make a large cut (incision). Other small incisions are made to insert long instruments to remove the lymph nodes around the prostate gland, which are then sent to the lab.

Because there are no large incisions, most people recover fully in only 1 or 2 days, and the operation leaves very small scars.

Fine needle aspiration (FNA): If your lymph nodes appear enlarged on an imaging test (such as a CT or MRI scan) a doctor may take a sample of cells from an enlarged node by using a technique called fine needle aspiration.

To do this, the doctor uses a CT scan image to guide a long, hollow needle through the skin in the lower abdomen and into the enlarged node. The skin is numbed with local anesthesia before inserting the needle. A syringe attached to the needle lets the doctor take a small tissue sample from the node, which is then sent to the lab to look for cancer cells.

You will be able to return home a few hours after the procedure.

Prostate cancer stages

Prostate cancer staging can be complex. If you have any questions about your stage, please ask your someone on your cancer care team to explain it to you in a way you understand.

The stage (extent) of a prostate cancer is one of the most important factors in choosing treatment options and predicting a man’s outlook for survival (prognosis).

The stage is based on:

• The prostate biopsy results (including the Gleason score)
• The blood PSA level at the time of diagnosis
• The results of any other exams or tests that were done to find out how far the cancer has spread

These tests are described in Tests for Prostate Cancer.

The AJCC TNM staging system

A staging system is a standard way for the cancer care team to describe how far a cancer has spread. The most widely used staging system for prostate cancer is the American Joint Committee on Cancer (AJCC) TNM system.

The TNM system for prostate cancer is based on 5 key pieces of information:

1. The extent of the main (primary) tumor (T category)
2. Whether the cancer has spread to nearby lymph nodes (N category)
3. Whether the cancer has spread (metastasized) to other parts of the body (M category)
4. The PSA level at the time of diagnosis
5. The Gleason score, based on the prostate biopsy (or surgery)

There are 2 types of staging for prostate cancer:

• The clinical stage is your doctor’s best estimate of the extent of your disease, based on the results of the physical exam (including DRE), lab tests, prostate biopsy, and any imaging tests you have had.

• If you have surgery, your doctors can also determine the pathologic stage, which is based on results above, plus the results of the surgery. This means that if you have surgery, the stage of your cancer might actually change afterward (if cancer was found in a place it wasn’t suspected, for example). Pathologic staging is likely to be more accurate than clinical staging, as it gives your doctor a firsthand impression of the extent of your disease.

Both types of staging use the same categories (but the T1 category is only used for clinical staging).

T categories (clinical)

There are 4 categories for describing the local extent of a prostate tumor, ranging from T1 to T4. Most of these have subcategories as well.

T1: Your doctor can’t feel the tumor or see it with imaging such transrectal ultrasound.

T1a: Cancer is found incidentally (by accident) during a transurethral resection of the prostate (TURP) that was done for benign prostatic hyperplasia (BPH), a non-cancerous growth of the prostate. Cancer is in no more than 5% of the tissue removed.
T1b: Cancer is found during a TURP but is in more than 5% of the tissue removed.
T1c: Cancer is found by needle biopsy that was done because of an increased PSA.

T2: Your doctor can feel the cancer with a digital rectal exam (DRE) or see it with imaging such as transrectal ultrasound, but it still appears to be confined to the prostate.

T2a: The cancer is in one half or less of only one side (left or right) of your prostate.
T2b: The cancer is in more than half of only one side (left or right) of your prostate.
T2c: The cancer is in both sides of your prostate.

T3: The cancer has grown outside your prostate and may have grown into the seminal vesicles.

T3a: The cancer extends outside the prostate but not to the seminal vesicles.
T3b: The cancer has spread to the seminal vesicles.

T4: The cancer has grown into tissues next to your prostate (other than the seminal vesicles), such as the urethral sphincter (a muscle that helps control urination), the rectum, the bladder, and/or the wall of the pelvis.

N categories

N categories describe whether the cancer has spread to nearby (regional) lymph nodes.

NX: Nearby lymph nodes were not assessed.

N0: The cancer has not spread to any nearby lymph nodes.

N1: The cancer has spread to one or more nearby lymph nodes.

M categories

M categories describe whether the cancer has spread to distant parts of the body. The most common sites of prostate cancer spread are to the bones and to distant lymph nodes, although it can also spread to other organs, such as the lungs and liver.

M0: The cancer has not spread beyond nearby lymph nodes.

M1: The cancer has spread beyond nearby lymph nodes.

M1a: The cancer has spread to distant (outside of the pelvis) lymph nodes.
M1b: The cancer has spread to the bones.
M1c: The cancer has spread to other organs such as lungs, liver, or brain (with or without spread to the bones).

Stage grouping

Once the T, N, and M categories have been determined, this information is combined (along with the Gleason score and PSA level if they are available) to get the overall stage of the cancer. The stage is expressed in Roman numerals from I (the least advanced) to IV (the most advanced). The stage helps determine treatment options and a man’s outlook for survival (prognosis).

Table 1. Prostate cancer stages

Stage	Stage grouping	Stage description
I	T1, N0, M0 Gleason score 6 or less PSA less than 10	The doctor can’t feel the tumor or see it with an imaging test such as transrectal ultrasound (it was either found during a transurethral resection or was diagnosed by needle biopsy done for a high PSA) [T1]. The cancer is still within the prostate and has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Gleason score is 6 or less and the PSA level is less than 10.
	OR
	T2a, N0, M0 Gleason score 6 or less PSA less than 10	The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in one half or less of only one side (left or right) of the prostate [T2a]. The cancer is still within the prostate and has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Gleason score is 6 or less and the PSA level is less than 10.
IIA	T1, N0, M0 Gleason score of 7 PSA less than 20	The doctor can’t feel the tumor or see it with imaging such as transrectal ultrasound (it was either found during a transurethral resection or was diagnosed by needle biopsy done for a high PSA level) [T1]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor has a Gleason score of 7. The PSA level is less than 20.
	OR
	T1, N0, M0 Gleason score of 6 or less PSA at least 10 but less than 20	The doctor can’t feel the tumor or see it with imaging such as transrectal ultrasound (it was either found during a transurethral resection or was diagnosed by needle biopsy done for a high PSA) [T1]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor has a Gleason score of 6 or less. The PSA level is at least 10 but less than 20.
	OR
	T2a or T2b, N0, M0 Gleason score of 7 or less PSA less than 20	The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in only one side of the prostate [T2a or T2b]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. It has a Gleason score of 7 or less. The PSA level is less than 20.
IIB	T2c, N0, M0 Any Gleason score Any PSA	The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in both sides of the prostate [T2c]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor can have any Gleason score and the PSA can be any value.
	OR
	T1 or T2, N0, M0 Any Gleason score PSA of 20 or more	The cancer has not yet spread outside the prostate. It may (or may not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound [T1 or T2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor can have any Gleason score. The PSA level is at least 20.
	OR
	T1 or T2, N0, M0 Gleason score of 8 or higher Any PSA	The cancer has not yet spread outside the prostate. It may (or may not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound [T1 or T2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Gleason score is 8 or higher. The PSA can be any value.
III:	T3, N0, M0 Any Gleason score Any PSA	The cancer has grown outside the prostate and may have spread to the seminal vesicles [T3], but it has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor can have any Gleason score and the PSA can be any value.
IV	T4, N0, M0 Any Gleason score Any PSA	The cancer has grown into tissues next to the prostate (other than the seminal vesicles), such as the urethral sphincter (muscle that helps control urination), rectum, bladder, and/or the wall of the pelvis [T4]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor can have any Gleason score and the PSA can be any value.
	OR
	Any T, N1, M0 Any Gleason score Any PSA	The tumor may or may not be growing into tissues near the prostate [any T]. The cancer has spread to nearby lymph nodes [N1] but has not spread elsewhere in the body [M0]. The tumor can have any Gleason score and the PSA can be any value.
	OR
	Any T, any N, M1 Any Gleason score Any PSA	The cancer may or may not be growing into tissues near the prostate [any T] and may or may not have spread to nearby lymph nodes [any N]. It has spread to other, more distant sites in the body [M1]. The tumor can have any Gleason score and the PSA can be any value.

[Source: American Cancer Society ¹³⁾]

Prostate cancer survival rate

Survival rates tell you what percentage of people with the same type and stage of cancer are still alive a certain amount of time (usually 5 years) after they were diagnosed. They can’t tell you how long you will live, but they may help give you a better understanding of how likely it is that your treatment will be successful. Some men want to know the survival rates for their cancer, and some don’t. If you don’t want to know, you don’t have to.

What is a 5-year survival rate ?

Statistics on the outlook for a certain type and stage of cancer are often given as 5-year survival rates, but many people live longer – often much longer – than 5 years. The 5-year survival rate is the percentage of people who live at least 5 years after being diagnosed with cancer. For example, a 5-year survival rate of 90% means that an estimated 90 out of 100 people who have that cancer are still alive 5 years after being diagnosed. Keep in mind, however, that many of these people live much longer than 5 years after diagnosis.

Relative survival rates are a more accurate way to estimate the effect of cancer on survival. These rates compare men with prostate cancer to men in the overall population. For example, if the 5-year relative survival rate for a specific stage of prostate cancer is 90%, it means that men who have that cancer are, on average, about 90% as likely as men who don’t have that cancer to live for at least 5 years after being diagnosed.

But remember, all survival rates are estimates – your outlook can vary based on a number of factors specific to you.

Cancer survival rates don’t tell the whole story

Survival rates are often based on previous outcomes of large numbers of men who had the disease, but they can’t predict what will happen in any particular man’s case. There are a number of limitations to remember:

The numbers below are among the most current available. But to get 5-year survival rates, doctors have to look at men who were treated at least 5 years ago. As treatments are improving over time, men who are now being diagnosed with prostate cancer may have a better outlook than these statistics show.
These statistics are based on the stage of the cancer when it was first diagnosed. They don’t apply to cancers that later come back or spread.
The outlook for men with prostate cancer varies by the stage (extent) of the cancer – in general, the survival rates are higher for men with earlier stage cancers. But many other factors can affect a man’s outlook, such as age and overall health, and how well the cancer responds to treatment. The outlook for each man is specific to his circumstances.

Your doctor can tell you how these numbers may apply to you, as he or she is familiar with your particular situation.

Survival rates for prostate cancer

According to the most recent data, when including all stages of prostate cancer ¹⁴⁾:

• The 5-year relative survival rate is 99%
• The 10-year relative survival rate is 98%
• The 15-year relative survival rate is 96%

Keep in mind that just as 5-year survival rates are based on men diagnosed and first treated more than 5 years ago, 10-year survival rates are based on men diagnosed more than 10 years ago (and 15-year survival rates are based on men diagnosed at least 15 years ago).

Prostate cancer survival rates by stage

The National Cancer Institute maintains a large national database on survival statistics for different types of cancer, known as the SEER database. The SEER database does not group cancers by American Joint Committee on Cancer stage, but instead groups cancers into local, regional, and distant stages.

• Local stage means that there is no sign that the cancer has spread outside of the prostate. This corresponds to American Joint Committee on Cancer stages I and II. About 4 out of 5 prostate cancers are found in this early stage. The relative 5-year survival rate for local stage prostate cancer is nearly 100%.

• Regional stage means the cancer has spread from the prostate to nearby areas. This includes stage III cancers and the stage IV cancers that haven’t spread to distant parts of the body, such as T4 tumors and cancers that have spread to nearby lymph nodes (N1). The relative 5-year survival rate for regional stage prostate cancer is nearly 100%.

• Distant stage includes the rest of the stage IV cancers – cancers that have spread to distant lymph nodes, bones, or other organs (M1). The relative 5-year survival rate for distant stage prostate cancer is about 29%.

Remember, these survival rates are only estimates – they can’t predict what will happen to any one man. We understand that these statistics can be confusing and may lead you to have more questions. Talk with your doctor to better understand your situation.

Which treatments are used for prostate cancer ?

Depending on each case, treatment options for men with prostate cancer might include ¹⁵⁾:

• Watchful waiting or active surveillance
• Surgery
• Radiation therapy
• Cryotherapy (cryosurgery)
• Hormone therapy
• Chemotherapy
• Vaccine treatment
• Bone-directed treatment

These treatments are generally used one at a time, although in some cases they may be combined.

Making treatment decisions

It’s important to discuss all of your treatment options, including their goals and possible side effects, with your doctors to help make the decision that best fits your needs. Some important things to consider include:

• The stage and grade of your cancer
• Your age and expected life span
• Any other serious health conditions you have
• Your feelings (and your doctor’s opinion) about the need to treat the cancer right away
• The likelihood that treatment will cure your cancer (or help in some other way)
• Your feelings about the possible side effects from each treatment

You may feel that you must make a decision quickly, but it’s important to give yourself time to absorb the information you have just learned. It’s also very important to ask questions if there is anything you’re not sure about.

Watchful Waiting or Active Surveillance for Prostate Cancer

Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) might never need treatment for their prostate cancer. Instead, their doctors may recommend approaches known as watchful waiting or active surveillance. Other terms sometimes used include observation or expectant management.

Some doctors use the terms active surveillance and watchful waiting to mean the same thing. For other doctors these terms mean something slightly different:

• Active surveillance is often used to mean monitoring the cancer closely. Usually this approach includes a doctor visit with a prostate-specific antigen (PSA) blood test and digital rectal exam about every 6 months. Prostate biopsies may be done every year as well. If your test results change, your doctor would then talk to you about treatment options.
• Watchful waiting (observation) is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a man’s symptoms to decide if treatment is needed.

Not all doctors agree with these definitions or use them exactly this way. In fact, some doctors prefer to no longer use the term watchful waiting. They feel it implies that nothing is being done, when in fact a man is still being closely monitored.

No matter which term your doctor uses, it’s very important for you to understand exactly what he or she means when they refer to it.

When might these approaches be an option ?

One of these approaches might be recommended if your cancer:

• Isn’t causing any symptoms
• Is expected to grow slowly (based on Gleason score)
• Is small
• Is just in the prostate

These approaches are not likely to be a good option if you have a fast-growing cancer (for example, a high Gleason score) or if the cancer is likely to have spread outside the prostate (based on PSA levels). Men who are young and healthy are less likely to be offered active surveillance, out of concern that the cancer might become a problem over the next 20 or 30 years.

Watchful waiting and active surveillance are reasonable options for some men with slow-growing cancers because it is not known whether treating the cancer with surgery or radiation will actually help them live longer. These treatments have definite risks and side effects that may outweigh the possible benefits for some men. Some men are not comfortable with this approach, and are willing to accept the possible side effects of active treatments to try to remove or destroy the cancer.

In active surveillance, only men whose cancer is growing (and therefore have a more serious form of cancer) are treated. This lets men with less serious cancer avoid the side effects of a treatment that might not have helped them live longer. A possible downside of this approach is that it might give the cancer a chance to grow and spread. This might limit your treatment options, and could possibly affect the chances of the cancer being treated successfully.

Not all experts agree how often testing should be done during active surveillance. There is also debate about when is the best time to start treatment if things change.

Comparing watchful waiting or active surveillance with active treatment

A few large studies have compared watchful waiting (where men were treated only if they developed symptoms from their cancer) and surgery for early stage prostate cancer, but the evidence from these studies has been mixed. Some have found that men who have surgery might live longer, while others have not found a difference in survival.

So far, no large studies have compared active surveillance to treatments such as surgery or radiation therapy. Some early studies of men who are good candidates for active surveillance have shown that only about a third of the men need to go on to treatment with radiation or surgery.

Surgery for Prostate Cancer

Surgery is a common choice to try to cure prostate cancer if it is not thought to have spread outside the prostate gland.

The main type of surgery for prostate cancer is a radical prostatectomy. In this operation, the surgeon removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. A radical prostatectomy can be done in different ways.

Open approaches to radical prostatectomy

In the more traditional approach to doing a prostatectomy, the surgeon operates through a single long skin incision (cut) to remove the prostate and nearby tissues. This type of surgery, sometimes referred to as an open approach, is now done less often than in the past.

There are 2 main ways to do this operation.

Radical retropubic prostatectomy

For this operation, the surgeon makes an incision (cut) in your lower abdomen, from the belly button down to the pubic bone. You will either be under general anesthesia (asleep) or be given spinal or epidural anesthesia (numbing the lower half of the body) along with sedation during the surgery.

If there is a reasonable chance the cancer might have spread to nearby lymph nodes (based on your PSA level, prostate biopsy results, and other factors), the surgeon may also remove some of these lymph nodes at this time (known as a lymph node biopsy). The nodes are usually sent to the lab to see if they have cancer cells in them (it can take a few days to get results), but in some cases the nodes may be looked at during the surgery. If this is done and cancer cells are found in any of the nodes, the surgeon might not continue with the surgery. This is because it’s unlikely that the cancer can be cured with surgery, and removing the prostate could lead to serious side effects.

After the surgery, while you are still under anesthesia, a catheter (thin, flexible tube) will be put in your penis to help drain your bladder. The catheter will usually stay in place for 1 to 2 weeks while you heal. You will be able to urinate on your own after the catheter is removed.

You will probably stay in the hospital for a few days after the surgery, and your activities will be limited for several weeks. The possible side effects of prostatectomy are described below.

Radical perineal prostatectomy

In this operation, the surgeon makes the cut (incision) in the skin between the anus and scrotum (the perineum), as shown in the picture above. This approach is used less often because it’s more likely to lead to erection problems and because the nearby lymph nodes can’t be removed. But it is often a shorter operation and might be an option if you aren’t concerned about erections and you don’t need lymph nodes removed. It also might be used if you have other medical conditions that make retropubic surgery difficult for you. It can be just as curative as the retropubic approach if done correctly. The perineal operation usually takes less time than the retropubic operation, and may result in less pain and an easier recovery afterward.

After the surgery, while you are still under anesthesia, a catheter will be put in your penis to help drain your bladder. The catheter usually stays in place for 1 to 2 weeks while you are healing. You will be able to urinate on your own after the catheter is removed.

You will probably stay in the hospital for a few days after the surgery, and your activities will be limited for several weeks. The possible side effects of prostatectomy are described below.

Laparoscopic approaches to radical prostatectomy

Laparoscopic approaches use several smaller incisions and special long surgical tools to remove the prostate. The surgeon either holds the tools directly, or uses a control panel to precisely move robotic arms that hold the tools. This approach to prostatectomy has become more common in recent years.

If you’re thinking about treatment with laparoscopic surgery, it’s important to understand what is known and what is not yet known about this approach. The most important factors are likely to be the skill and experience of your surgeon. If you decide that laparoscopic surgery is the right treatment for you, be sure to find a surgeon with a lot of experience.

Laparoscopic radical prostatectomy

For a laparoscopic radical prostatectomy (LRP), the surgeon inserts special long instruments through several small incisions to remove the prostate. One of the instruments has a small video camera on the end, which lets the surgeon see inside the body.

Laparoscopic prostatectomy has some advantages over open radical prostatectomy, including less blood loss and pain, shorter hospital stays (usually no more than a day), and faster recovery times (although the catheter will need to remain in the bladder for about the same amount of time).

In experienced hands, LRP appears to be as good as open radical prostatectomy, but we do not yet have long-term results from procedures done in the United States.

The rates of major side effects from LRP, such as erection problems and trouble holding urine (incontinence) seem to be about the same as for open prostatectomy. Recovery of bladder control may be delayed slightly with this approach.

Robotic-assisted laparoscopic radical prostatectomy

In this approach, also known as robotic prostatectomy, the laparoscopic surgery is done using a robotic interface (called the da Vinci system). The surgeon sits at a control panel in the operating room and moves robotic arms to operate through several small incisions in the patient’s abdomen.

Robotic prostatectomy has advantages over the open approach in terms of less pain, blood loss, and recovery time. But in terms of the side effects men are most concerned about, such as urinary or erection problems (described below), there doesn’t seem to be a difference between robotic prostatectomy and other approaches.

For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. Still, the most important factor in the success of either type of laparoscopic surgery is the surgeon’s experience and skill.
Risks and side effects of any type of radical prostatectomy

There are possible risks and side effects with any type of surgery for prostate cancer.

Risks of prostate surgery

The risks with any type of radical prostatectomy are much like those with any major surgery. Problems during or shortly after the operation can include:

• Reactions to anesthesia
• Bleeding from the surgery
• Blood clots in the legs or lungs
• Damage to nearby organs
• Infections at the surgery site.

Rarely, part of the intestine might be injured during surgery, which could lead to infections in the abdomen and might require more surgery to correct. Injuries to the intestines are more common with laparoscopic and robotic surgeries than with the open approach.

If lymph nodes are removed, a collection of lymph fluid (called a lymphocele) can form and may need to be drained.

In extremely rare cases, people die because of complications of this operation. Your risk depends, in part, on your overall health, your age, and the skill of your surgical team.

Side effects of prostate surgery

The major possible side effects of radical prostatectomy are urinary incontinence (being unable to control urine) and erectile dysfunction (impotence; problems getting or keeping erections). These side effects can also occur with other forms of prostate cancer treatment.

Urinary incontinence: You may not be able to control your urine or have leakage or dribbling. There are different levels of incontinence. Being incontinent can affect you not only physically but emotionally and socially as well. There are 3 major types of incontinence:

Men with stress incontinence might leak urine when they cough, laugh, sneeze, or exercise. Stress incontinence is the most common type after prostate surgery. It’s usually caused by problems with the valve that keeps urine in the bladder (the bladder sphincter). Prostate cancer treatments can damage the muscles that form this valve or the nerves that keep the muscles working.

Men with overflow incontinence have trouble emptying their bladder. They take a long time to urinate and have a dribbling stream with little force. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by scar tissue.

Men with urge incontinence have a sudden need to urinate. This happens when the bladder becomes too sensitive to stretching as it fills with urine.

Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence.

After surgery for prostate cancer, normal bladder control usually returns within several weeks or months. This recovery usually occurs slowly over time.

Doctors can’t predict for sure how any man will be affected after surgery. In general, older men tend to have more incontinence problems than younger men. Large cancer centers, where prostate surgery is done often and surgeons have a lot of experience, generally report fewer problems with incontinence.

Incontinence can be treated. Even if your incontinence can’t be corrected completely, it can still be helped.

Erectile dysfunction (impotence): This means you can’t get an erection sufficient for sexual penetration.

Erections are controlled by 2 tiny bundles of nerves that run on either side of the prostate. If you can have erections before surgery, the surgeon will try not to injure these nerves during the prostatectomy. This is known as a nerve-sparing approach. But if the cancer is growing into or very close to the nerves, the surgeon will need to remove them.

If both nerves are removed, you won’t be able to have spontaneous erections, but you might still be able to have erections using some of the aids described below. If the nerves on only one side are removed, you might still have erections, but the chance is lower than if neither were removed. If neither nerve bundle is removed you might have normal erections at some point after surgery.

Your ability to have an erection after surgery depends on your age, your ability to get an erection before the operation, and whether the nerves were cut. All men can expect some decrease in the ability to have an erection, but the younger you are, the more likely it is that you will keep this ability.

Surgeons who do many radical prostatectomies tend to report lower impotence rates than doctors who do the surgery less often. A wide range of impotency rates have been reported in the medical literature, but each man’s situation is different, so the best way to get an idea of your chances for recovering erections is to ask your doctor about his or her success rates and what the outcome is likely to be in your case.

If your ability to have erections does return after surgery, it often occurs slowly. In fact, it can take from a few months up to 2 years. During the first few months, you will probably not be able to have a spontaneous erection, so you may need to use medicines or other treatments.

Most doctors feel that regaining potency is helped along by trying to get an erection as soon as possible once the body has had a chance to heal (usually several weeks after the operation). Some doctors call this penile rehabilitation. Medicines (see below) may be helpful at this time. Be sure to talk to your doctor about your situation.

There are several options for treating erectile dysfunction:

• Phosphodiesterase-5 (PDE5) inhibitors such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are pills that can help with erections. These drugs won’t work if both nerves that control erections have been damaged or removed. Common side effects of these drugs are headache, flushing (skin becomes red and feels warm), upset stomach, light sensitivity, and runny or stuffy nose. Rarely, these drugs can cause vision problems, possibly even blindness. Some other drugs such as nitrates, which are drugs used to treat heart disease, can cause problems if you are taking a PDE5 inhibitor, so be sure your doctor knows what medicines you take.
• Alprostadil is a man-made version of prostaglandin E1, a substance naturally made in the body that can produce erections. It can be injected almost painlessly into the base of the penis 5 to 10 minutes before intercourse or placed into the tip of the penis as a suppository. You can even increase the dosage to prolong the erection. You might have side effects, such as pain, dizziness, and prolonged erection, but they are not usually serious.
• Vacuum devices are another option to create an erection. These mechanical pumps are placed over the penis. The air is sucked out of the pump, which draws blood into the penis to produce an erection. The erection is maintained after the pump is removed by a strong rubber band placed at the base of the penis. The band is removed after sex.
• Penile implants might restore your ability to have erections if other methods don’t help. An operation is needed to put them inside the penis. There are several types of penile implants, including those using silicone rods or inflatable devices.

Changes in orgasm: After surgery, the sensation of orgasm should still be pleasurable, but there is no ejaculation of semen – the orgasm is “dry.” This is because the glands that made most of the fluid for semen (the seminal vesicles and prostate) were removed during the prostatectomy, and the pathways used by sperm (the vas deferens) were cut. In some men, orgasm becomes less intense or goes away completely. Less often, men report pain with orgasm.

Loss of fertility: Radical prostatectomy cuts the vas deferens, which are the pathways between the testicles (where sperm are made) and the urethra (through which sperm leave the body). Your testicles will still make sperm, but they can’t leave the body as a part of the ejaculate. This means that a man can no longer father a child the natural way. Often, this is not an issue, as men with prostate cancer tend to be older. But if it is a concern for you, you might want to ask your doctor about “banking” your sperm before the operation. To learn more, see Fertility and Men With Cancer.

Lymphedema: This is a rare but possible complication of removing many of the lymph nodes around the prostate. Lymph nodes normally provide a way for fluid to return to the heart from all areas of the body. When nodes are removed, fluid can collect in the legs or genital region over time, causing swelling and pain. Lymphedema can usually be treated with physical therapy, although it may not go away completely. You can learn more on our lymphedema page.

Change in penis length: A possible effect of surgery is a small decrease in penis length. This is probably due to a shortening of the urethra when a portion of it is removed along with the prostate.

Inguinal hernia: A prostatectomy increases a man’s chances of developing an inguinal (groin) hernia in the future.

Transurethral resection of the prostate (TURP)

This operation is more often used to treat men with non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). But it is also sometimes used in men with advanced prostate cancer to help relieve symptoms, such as urination problems. (It is not used to try to cure the cancer.)

During this operation, the surgeon removes the inner part of the prostate gland that surrounds the urethra (the tube through which urine exits the bladder). The skin is not cut with this surgery. An instrument called a resectoscope is passed through the tip of the penis into the urethra to the level of the prostate. Once it is in place, either electricity is passed through a wire to heat it or a laser is used to cut or vaporize the tissue. Spinal anesthesia (which numbs the lower half of your body) or general anesthesia (where you are asleep) is used.

The operation usually takes about an hour. After surgery, a catheter (thin, flexible tube) is inserted through the penis and into the bladder. It remains in place for about a day to help urine drain while the prostate heals. You can usually leave the hospital after 1 to 2 days and return to normal activities in 1 to 2 weeks.

You will probably have some blood in your urine after surgery. Other possible side effects from TURP include infection and any risks that come with the type of anesthesia used.

Radiation Therapy for Prostate Cancer

Radiation therapy uses high-energy rays or particles to kill cancer cells.

Radiation may be used:

• As the first treatment for cancer that is still just in the prostate gland and is low grade. Cure rates for men with these types of cancers are about the same as those for men treated with radical prostatectomy.
• As part of the first treatment (along with hormone therapy) for cancers that have grown outside the prostate gland and into nearby tissues.
• If the cancer is not removed completely or comes back (recurs) in the area of the prostate after surgery.
• If the cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.

Types of radiation therapy

The 2 main types of radiation therapy used for prostate cancer are:

• External beam radiation
• Brachytherapy (internal radiation)

External beam radiation therapy (EBRT)

In EBRT, beams of radiation are focused on the prostate gland from a machine outside the body. This type of radiation can be used to try to cure earlier stage cancers, or to help relieve symptoms such as bone pain if the cancer has spread to a specific area of bone.

Before treatments start, your radiation team will take careful measurements to find the correct angles for aiming the radiation beams and the proper dose of radiation. This planning session, called simulation, usually includes getting imaging tests such as CT or MRI scans. You might be fitted with a plastic mold resembling a body cast to keep you in the same position for each treatment so that the radiation can be aimed more accurately.

You will usually be treated 5 days a week in an outpatient center for at least several weeks, depending on why the radiation is being given. Each treatment is much like getting an x-ray. The radiation is stronger than that used for an x-ray, but the procedure is painless. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — takes longer.

Newer EBRT techniques focus the radiation more precisely on the tumor. This let doctors give higher doses of radiation to the tumor while reducing the radiation exposure to nearby healthy tissues.

Three-dimensional conformal radiation therapy (3D-CRT)

3D-CRT uses special computers to precisely map the location of your prostate. Radiation beams are then shaped and aimed at the prostate from several directions, which makes it less likely to damage normal tissues.

Intensity modulated radiation therapy (IMRT)

IMRT, an advanced form of 3D therapy, is the most common type of EBRT for prostate cancer. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the prostate from several angles, the intensity (strength) of the beams can be adjusted to limit the doses reaching nearby normal tissues. This lets doctors deliver an even higher dose to the cancer.

Some newer radiation machines have imaging scanners built into them. This advance, known as image guided radiation therapy (IGRT), lets the doctor take pictures of the prostate and make minor adjustments in aiming just before giving the radiation. This may help deliver the radiation even more precisely, which might result in fewer side effects, although more research is needed to prove this.

Another approach is to place tiny implants into the prostate that send out radio waves to tell the radiation therapy machines where to aim. This lets the machine adjust for movement (like during breathing) and may allow less radiation to go to normal tissues. In theory, this could lower side effects. So far, though, no study has shown side effects to be lower with this approach than with other forms of IMRT. The machines that use this are known as Calypso®.

A variation of IMRT is called volumetric modulated arc therapy (VMAT). It uses a machine that delivers radiation quickly as it rotates once around the body. This allows each treatment to be given over just a few minutes. Although this can be more convenient for the patient, it hasn’t yet been shown to be more effective than regular IMRT.

Stereotactic body radiation therapy (SBRT)

This technique uses advanced image guided techniques to deliver large doses of radiation to a certain precise area, such as the prostate. Because there are large doses of radiation in each dose, the entire course of treatment is given over just a few days.

SBRT is often known by the names of the machines that deliver the radiation, such as Gamma Knife®, X-Knife®, CyberKnife®, and Clinac®.

The main advantage of SBRT over IMRT is that the treatment takes less time (days instead of weeks). The side effects, though, are not better. In fact, some research has shown that some side effects might actually be worse with SBRT than with IMRT.

Proton beam radiation therapy

Proton beam therapy focuses beams of protons instead of x-rays on the cancer. Unlike x-rays, which release energy both before and after they hit their target, protons cause little damage to tissues they pass through and release their energy only after traveling a certain distance. This means that proton beam radiation can, in theory, deliver more radiation to the prostate while doing less damage to nearby normal tissues. Proton beam radiation can be aimed with techniques similar to 3D-CRT and IMRT.

Although in theory proton beam therapy might be more effective than using x-rays, so far studies have not shown if this is true. Right now, proton beam therapy is not widely available. The machines needed to make protons are very expensive, and they aren’t available in many centers in the United States. Proton beam radiation might not be covered by all insurance companies at this time.

Possible side effects of EBRT

Some of the side effects from EBRT are the same as those from surgery, while others are different.

Bowel problems: Radiation can irritate the rectum and cause a condition called radiation proctitis. This can lead to diarrhea, sometimes with blood in the stool, and rectal leakage. Most of these problems go away over time, but in rare cases normal bowel function does not return. To help lessen bowel problems, you may be told to follow a special diet during radiation therapy to help limit bowel movement during treatment. Sometimes a balloon-like device is put in the rectum during each treatment to keep the bowel as still as possible while treatment is given.

Urinary problems: Radiation can irritate the bladder and lead to a condition called radiation cystitis. You might need to urinate more often, have a burning sensation while you urinate, and/or find blood in your urine. Urinary problems usually improve over time, but in some men they never go away.

Some men develop urinary incontinence after treatment, which means they can’t control their urine or have leakage or dribbling. As described in the surgery section, there are different levels and types of incontinence. Overall, this side effect occurs less often than after surgery. The risk is low at first, but it goes up each year for several years after treatment.

Rarely, the tube that carries urine from the bladder out of the body (the urethra) may become very narrow or even close off, which is known as a urethral stricture. This might require further treatment to open it up again.

Erection problems, including impotence: After a few years, the impotence rate after radiation is about the same as that after surgery. Problems with erections usually do not occur right after radiation therapy but slowly develop over time. This is different from surgery, where impotence occurs immediately and may get better over time.

As with surgery, the older you are, the more likely it is you will have problems with erections. Erection problems can often be helped by treatments such as those listed in the surgery section, including medicines.

Feeling tired: Radiation therapy can cause fatigue that might not go away until a few weeks or months after treatment stops.

Lymphedema: The lymph nodes normally provide a way for fluid to return to the heart from all areas of the body. If the lymph nodes around the prostate are damaged by radiation, fluid may collect in the legs or genital region over time, causing swelling and pain. Lymphedema can usually be treated with physical therapy, although it may not go away completely.

Brachytherapy (internal radiation therapy)

Brachytherapy (also called seed implantation or interstitial radiation therapy) uses small radioactive pellets, or “seeds,” each about the size of a grain of rice. These pellets are placed directly into your prostate.

• Brachytherapy alone is generally used only in men with early-stage prostate cancer that is relatively slow growing (low-grade).
• Brachytherapy combined with external radiation is sometimes an option for men who have a higher risk of the cancer growing outside the prostate.

The use of brachytherapy is also limited by some other factors. For men who have had a transurethral resection of the prostate (TURP) or for those who already have urinary problems, the risk of urinary side effects may be higher. Brachytherapy might not work as well in men with large prostate glands because it might not be possible to place the seeds into all of the correct locations. One way to get around this may be to get a few months of hormone therapy beforehand to shrink the prostate.

Imaging tests such as transrectal ultrasound, CT scans, or MRI are used to help guide the placement of the radioactive pellets. Special computer programs calculate the exact dose of radiation needed.

There are 2 types of prostate brachytherapy. Both are done in an operating room. You will get either spinal anesthesia (where the lower half of your body is numbed) or general anesthesia (where you are asleep), and you might need to stay in the hospital overnight.

Permanent (low dose rate, or LDR) brachytherapy

In this approach, pellets (seeds) of radioactive material (such as iodine-125 or palladium-103) are placed inside thin needles, which are inserted through the skin in the area between the scrotum and anus and into the prostate. The pellets are left in place as the needles are removed and give off low doses of radiation for weeks or months. Radiation from the seeds travels a very short distance, so the seeds can give off a large amount of radiation in a very small area. This limits the amount of damage to nearby healthy tissues.

Usually, around 100 seeds are placed, but this depends on the size of the prostate. Because the seeds are so small, they seldom cause discomfort, and are simply left in place after their radioactive material is used up.

You may also get external beam radiation along with brachytherapy, especially if there is a higher risk that your cancer has spread outside the prostate (for example, if you have a higher Gleason score).

Temporary (high dose rate, or HDR) brachytherapy

This technique is done less often. It uses higher doses of radiation that are left in place for a short time. Hollow needles are placed through the skin between the scrotum and anus and into the prostate. Soft nylon tubes (catheters) are placed in these needles. The needles are then removed but the catheters stay in place. Radioactive iridium-192 or cesium-137 is then placed in the catheters, usually for 5 to 15 minutes. Generally, about 3 brief treatments are given over 2 days, and the radioactive substance is removed each time. After the last treatment the catheters are removed. For about a week after treatment, you may have some pain or swelling in the area between your scrotum and rectum, and your urine may be reddish-brown.

These treatments are usually combined with external beam radiation given at a lower dose than if used by itself. The advantage of this approach is that most of the radiation is concentrated in the prostate itself, sparing nearby normal tissues.

Possible risks and side effects of brachytherapy

Radiation precautions: If you get permanent (LDR) brachytherapy, the seeds will give off small amounts of radiation for several weeks or months. Even though the radiation doesn’t travel far, your doctor may advise you to stay away from pregnant women and small children during this time. If you plan on traveling, you might want to get a doctor’s note regarding your treatment, as low levels of radiation can sometimes be picked up by detection systems at airports.

There’s also a small risk that some of the seeds might move (migrate). You may be asked to strain your urine for the first week or so to catch any seeds that might come out. You may be asked to take other precautions as well, such as wearing a condom during sex. Be sure to follow any instructions your doctor gives you. There have also been reports of the seeds moving through the bloodstream to other parts of the body, such as the lungs. As far as doctors can tell, this is uncommon and doesn’t seem to cause any ill effects.

These precautions aren’t needed after HDR brachytherapy, because the radiation doesn’t stay in the body after treatment.

Bowel problems: Brachytherapy can sometimes irritate the rectum and cause a condition called radiation proctitis. Bowel problems such as rectal pain, burning, and/or diarrhea (sometimes with bleeding) can occur, but serious long-term problems are uncommon.

Urinary problems: Severe urinary incontinence (trouble controlling urine) is not a common side effect. But some men have problems with frequent urination or other symptoms due to irritation of the urethra, the tube that drains urine from the bladder. This tends to be worse in the weeks after treatment and gets better over time. Rarely, the urethra may actually close off (known as a urethral stricture) and need to be opened with a catheter or surgery.

Erection problems: Some studies have found rates of erection problems to be lower after brachytherapy, but other studies have found that the rates were no lower than with external beam radiation or surgery. The younger you are and the better your sexual function before treatment, the more likely you will be to regain function after treatment.

Erection problems can often be helped by treatments such as those listed in the surgery section, including medicines.

Cryotherapy for Prostate Cancer

Cryotherapy (also called cryosurgery or cryoablation) is the use of very cold temperatures to freeze and kill prostate cancer cells. Despite it sometimes being called cryosurgery, it is not actually a type of surgery.

Cryotherapy is sometimes used to treat early-stage prostate cancer. Most doctors do not use cryotherapy as the first treatment for prostate cancer, but it is sometimes an option if the cancer has come back after radiation therapy. As with brachytherapy, this may not be a good option for men with large prostate glands.

How is cryotherapy done ?

This type of procedure requires spinal or epidural anesthesia (the lower half of your body is numbed) or general anesthesia (you are asleep).

The doctor uses transrectal ultrasound (TRUS) to guide several hollow probes (needles) through the skin between the anus and scrotum and into the prostate. Very cold gases are then passed through the needles to freeze and destroy the prostate. To be sure the prostate is destroyed without too much damage to nearby tissues, the doctor carefully watches the ultrasound during the procedure. Warm saltwater is circulated through a catheter in the urethra during the procedure to keep it from freezing. The catheter is left in place for several weeks afterward to allow the bladder to empty while you recover.

After the procedure, you might need to stay in the hospital overnight, but many patients leave the same day.

Cryotherapy is less invasive than surgery, so there is usually less blood loss, a shorter hospital stay, shorter recovery period, and less pain. But compared with surgery or radiation therapy, doctors know much less about the long-term effectiveness of cryotherapy. Cryotherapy doesn’t appear to be as good as radiation for more advanced prostate tumors.

Possible side effects of cryotherapy

Side effects from cryotherapy tend to be worse if it is done in men who have already had radiation therapy, as opposed to men who have it as the first form of treatment.

Most men have blood in their urine for a day or two after the procedure, as well as soreness in the area where the needles were placed. Swelling of the penis or scrotum is also common.

Freezing might also affect the bladder and rectum, which can lead to pain, burning sensations, and the need to empty the bladder and bowels often. Most men recover normal bowel and bladder function over time.

Freezing often damages the nerves near the prostate that control erections. Erectile dysfunction is more common after cryotherapy than after radical prostatectomy.

Urinary incontinence (having problems controlling urine) is rare in men who have cryotherapy as their first treatment for prostate cancer, but it is more common in men who have already had radiation therapy.

After cryotherapy, less than 1% of men develop a fistula (an abnormal connection) between the rectum and bladder. This rare but serious problem can allow urine to leak into the rectum and often requires surgery to repair.

Hormone Therapy for Prostate Cancer

Hormone therapy is also called androgen deprivation therapy (ADT) or androgen suppression therapy. The goal is to reduce levels of male hormones, called androgens, in the body, or to stop them from affecting prostate cancer cells.

Androgens stimulate prostate cancer cells to grow. The main androgens in the body are testosterone and dihydrotestosterone (DHT). Most of the androgens are made by the testicles, but the adrenal glands (glands that sit above your kidneys) also make a small amount. Lowering androgen levels or stopping them from getting into prostate cancer cells often makes prostate cancers shrink or grow more slowly for a time. But hormone therapy alone does not cure prostate cancer.

Hormone therapy may be used:

• If the cancer has spread too far to be cured by surgery or radiation, or if you can’t have these treatments for some other reason
• If the cancer remains or comes back after treatment with surgery or radiation therapy
• Along with radiation therapy as initial treatment if you are at higher risk of the cancer coming back after treatment (based on a high Gleason score, high
• PSA level, and/or growth of the cancer outside the prostate)
• Before radiation to try to shrink the cancer to make treatment more effective

Types of hormone therapy

Several types of hormone therapy can be used to treat prostate cancer.

Treatments to lower androgen levels

Orchiectomy (surgical castration)

Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where most of the androgens (testosterone and DHT) are made. This causes most prostate cancers to stop growing or shrink for a time.

This is done as an outpatient procedure. It is probably the least expensive and simplest form of hormone therapy. But unlike some of the other treatments, it is permanent, and many men have trouble accepting the removal of their testicles.

Some men having this surgery are concerned about how it will look afterward. If wanted, artificial testicles that look much like normal ones can be inserted into the scrotum.

LHRH agonists

Luteinizing hormone-releasing hormone (LHRH) agonists (also called LHRH analogs or GnRH agonists) are drugs that lower the amount of testosterone made by the testicles. Treatment with these drugs is sometimes called chemical castration or medical castration because they lower androgen levels just as well as orchiectomy.

Even though LHRH agonists cost more than orchiectomy and require more frequent doctor visits, most men choose this method. With these drugs, the testicles remain in place, but they will shrink over time, and they may even become too small to feel.

LHRH agonists are injected or placed as small implants under the skin. Depending on the drug used, they are given anywhere from once a month up to once a year. The LHRH agonists available in the United States include:

• Leuprolide (Lupron, Eligard)
• Goserelin (Zoladex)
• Triptorelin (Trelstar)
• Histrelin (Vantas)

When LHRH agonists are first given, testosterone levels go up briefly before falling to very low levels. This effect is called flare and results from the complex way in which these drugs work. Men whose cancer has spread to the bones may have bone pain. If the cancer has spread to the spine, even a short-term increase in tumor growth as a result of the flare could press on the spinal cord and cause pain or paralysis. Flare can be avoided by giving drugs called anti-androgens (discussed below) for a few weeks when starting treatment with LHRH agonists.

LHRH antagonist

Degarelix (Firmagon) is an LHRH antagonist. It works like the LHRH agonists, but it lowers testosterone levels more quickly and doesn’t cause tumor flare like the LHRH agonists do. Treatment with this drug can also be considered a form of medical castration.

This drug is used to treat advanced prostate cancer. It is given as a monthly injection under the skin. The most common side effects are problems at the injection site (pain, redness, and swelling) and increased levels of liver enzymes on lab tests. Other side effects are discussed in detail below.

CYP17 inhibitor

LHRH agonists and antagonists can stop the testicles from making androgens, but other cells in the body, including prostate cancer cells themselves, can still make small amounts, which can fuel cancer growth. Abiraterone (Zytiga) blocks an enzyme called CYP17, which helps stop these cells from making androgens.

Abiraterone can be used in men with advanced castrate-resistant prostate cancer (cancer that is still growing despite low testosterone levels from an LHRH agonist, LHRH antagonist, or orchiectomy).

This drug is taken as pills every day. It doesn’t stop the testicles from making testosterone, so men who haven’t had an orchiectomy need to continue treatment with an LHRH agonist or antagonist. Because abiraterone also lowers the level of some other hormones in the body, prednisone (a cortisone-like drug) needs to be taken during treatment as well to avoid certain side effects.

Drugs that stop androgens from working

Anti-androgens

Androgens have to bind to a protein in the prostate cell called an androgen receptor to work. Anti-androgens are drugs that bind to these receptors so the androgens can’t.

Drugs of this type include:

• Flutamide (Eulexin)
• Bicalutamide (Casodex)
• Nilutamide (Nilandron)

They are taken daily as pills.

Anti-androgens are not often used by themselves in the United States. An anti-androgen may be added to treatment if orchiectomy or an LHRH agonist or antagonist is no longer working by itself. An anti-androgen is also sometimes given for a few weeks when an LHRH agonist is first started to prevent a tumor flare.

An anti-androgen can also be combined with orchiectomy or an LHRH agonist as first-line hormone therapy. This is called combined androgen blockade (CAB). There is still some debate as to whether CAB is more effective in this setting than using orchiectomy or an LHRH agonist alone. If there is a benefit, it appears to be small.

In some men, if an anti-androgen is no longer working, simply stopping the anti-androgen can cause the cancer to stop growing for a short time. Doctors call this the anti-androgen withdrawal effect, although they are not sure why it happens.

Enzalutamide (Xtandi) is a newer type of anti-androgen. Normally when androgens bind to their receptor, the receptor sends a signal to the cell’s control center, telling it to grow and divide. Enzalutamide blocks this signal. It is taken as pills each day.

Enzalutamide can often be helpful in men with castrate-resistant prostate cancer. In most studies of this drug, men were also treated with an LHRH agonist, so it isn’t clear how helpful this drug would be in men with non-castrate levels of testosterone.

Other androgen-suppressing drugs

Estrogens (female hormones) were once the main alternative to orchiectomy for men with advanced prostate cancer. Because of their possible side effects (including blood clots and breast enlargement), estrogens have been replaced by other types of hormone therapy. Still, estrogens may be tried if other hormone treatments are no longer working.

Ketoconazole (Nizoral), first used for treating fungal infections, blocks production of certain hormones, including androgens, much like abiraterone. It’s most often used to treat men just diagnosed with advanced prostate cancer who have a lot of cancer in the body, as it offers a quick way to lower testosterone levels. It can also be tried if other forms of hormone therapy are no longer working.

Ketoconazole also can block the production of cortisol, an important steroid hormone in the body, so men treated with this drug often need to take a corticosteroid (such as prednisone or hydrocortisone).

Possible side effects of hormone therapy

Orchiectomy and LHRH agonists and antagonists can all cause similar side effects from lower levels of hormones such as testosterone. These side effects can include:

• Reduced or absent sexual desire
• Erectile dysfunction (impotence)
• Shrinkage of testicles and penis
• Hot flashes, which may get better or go away with time
• Breast tenderness and growth of breast tissue
• Osteoporosis (bone thinning), which can lead to broken bones
• Anemia (low red blood cell counts)
• Decreased mental sharpness
• Loss of muscle mass
• Weight gain
• Fatigue
• Increased cholesterol levels
• Depression

Some research has suggested that the risk of high blood pressure, diabetes, strokes, heart attacks, and even death from heart disease is higher in men treated with hormone therapy, although not all studies have found this.

Anti-androgens have similar side effects. The major difference from LHRH agonists and antagonists and orchiectomy is that anti-androgens may have fewer sexual side effects. When these drugs are used alone, sexual desire and erections can often be maintained. When these drugs are given to men already being treated with LHRH agonists, diarrhea is the major side effect. Nausea, liver problems, and tiredness can also occur.

Abiraterone can cause joint or muscle pain, high blood pressure, fluid buildup in the body, hot flashes, upset stomach, and diarrhea.

Enzalutamide can cause diarrhea, fatigue, and worsening of hot flashes. This drug can also cause some nervous system side effects, including dizziness and, rarely, seizures. Men taking this drug are more likely to fall, which may lead to injuries.

Many side effects of hormone therapy can be prevented or treated. For example:

• Hot flashes can often be helped by treatment with certain antidepressants or other drugs.
• Brief radiation treatment to the breasts can help prevent their enlargement, but this is not effective once breast enlargement has occurred.
• Several drugs can help prevent and treat osteoporosis.
• Depression can be treated with antidepressants and/or counseling.
• Exercise can help reduce many side effects, including fatigue, weight gain, and the loss of bone and muscle mass.

There is growing concern that hormone therapy for prostate cancer may lead to problems thinking, concentrating, and/or with memory, but this has not been studied thoroughly. Still, hormone therapy does seem to lead to memory problems in some men. These problems are rarely severe, and most often affect only some types of memory. More studies are being done to look at this issue.

Current issues in hormone therapy

There are many issues around hormone therapy that not all doctors agree on, such as the best time to start and stop it and the best way to give it. Studies are now looking at these issues. A few of them are discussed here.

Treating early-stage cancer: Some doctors have used hormone therapy instead of watchful waiting or active surveillance in men with early stage prostate cancer who do not want surgery or radiation. Studies have not found that these men live any longer than those who don’t get any treatment until the cancer progresses or symptoms develop. Because of this, hormone treatment is not usually advised for early-stage prostate cancer.

Early versus delayed treatment: For men who need (or will eventually need) hormone therapy, such as men whose PSA levels are rising after surgery or radiation or men with advanced prostate cancer who don’t yet have symptoms, it’s not always clear when it is best to start hormone treatment. Some doctors think that hormone therapy works better if it’s started as soon as possible, even if a man feels well and is not having any symptoms. Some studies have shown that hormone treatment may slow the disease down and perhaps even help men live longer.

But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the side effects of hormone therapy and the chance that the cancer could become resistant to therapy sooner, treatment shouldn’t be started until a man has symptoms from the cancer. This issue is being studied.

Intermittent versus continuous hormone therapy: Most prostate cancers treated with hormone therapy become resistant to this treatment over a period of months or years. Some doctors believe that constant androgen suppression might not be needed, so they advise intermittent (on-again, off-again) treatment. The hope is that giving men a break from androgen suppression will also give them a break from side effects like decreased energy, sexual problems, and hot flashes.

In one form of intermittent hormone therapy, treatment is stopped once the PSA drops to a very low level. If the PSA level begins to rise, the drugs are started again. Another form of intermittent therapy uses hormone therapy for fixed periods of time – for example, 6 months on followed by 6 months off.

At this time, it isn’t clear how this approach compares to continuous hormone therapy Some studies have found that continuous therapy might help men live longer, but other studies have not found such a difference.

Combined androgen blockade (CAB): Some doctors treat patients with both androgen deprivation (orchiectomy or an LHRH agonist or antagonist) plus an anti-androgen. Some studies have suggested this may be more helpful than androgen deprivation alone, but others have not. Most doctors are not convinced there’s enough evidence that this combined therapy is better than starting with one drug alone when treating prostate cancer that has spread to other parts of the body.

Triple androgen blockade (TAB): Some doctors have suggested taking combined therapy one step further, by adding a drug called a 5-alpha reductase inhibitor – either finasteride (Proscar) or dutasteride (Avodart) – to the combined androgen blockade. There is very little evidence to support the use of this triple androgen blockade at this time.

Castrate-resistant versus hormone-refractory prostate cancer: Both these terms are sometimes used to describe prostate cancers that are no longer responding to hormones, although there is a difference between the two.

Castrate-resistant means the cancer is still growing even when the testosterone levels are as low as what would be expected if the testicles were removed (called castrate levels). Levels this low could be from an orchiectomy, an LHRH agonist, or an LHRH antagonist. Some men might be uncomfortable with this term, but it’s specifically meant to refer to these cancers, some of which might still be helped by other forms of hormone therapy, such as the drugs abiraterone and enzalutamide. Cancers that still respond to some type of hormone therapy are not completely hormone-refractory.

Hormone-refractory refers to prostate cancer that is no longer helped by any type of hormone therapy, including the newer medicines.

Chemotherapy for Prostate Cancer

Chemotherapy (chemo) uses anti-cancer drugs injected into a vein or given by mouth. These drugs enter the bloodstream and go throughout the body, making this treatment potentially useful for cancers that have spread (metastasized) to distant organs.

Chemo is sometimes used if prostate cancer has spread outside the prostate gland and hormone therapy isn’t working. Recent research has also shown that chemo might be helpful if given along with hormone therapy.

Chemo is not a standard treatment for early prostate cancer, but some studies are looking to see if it could be helpful if given for a short time after surgery.

Chemo drugs used to treat prostate cancer

For prostate cancer, chemo drugs are typically used one at a time. Some of the chemo drugs used to treat prostate cancer include:

• Docetaxel (Taxotere)
• Cabazitaxel (Jevtana)
• Mitoxantrone (Novantrone)
• Estramustine (Emcyt)

In most cases, the first chemo drug given is docetaxel, combined with the steroid drug prednisone. If this drug does not work (or stops working), cabazitaxel is often the next chemo drug tried (although there may be other treatment options as well).

Both of these drugs have been shown to help men live longer, on average, than older chemo drugs. They may slow the cancer’s growth and also reduce symptoms, resulting in a better quality of life. Still, chemo is very unlikely to cure prostate cancer.

Doctors give chemo in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Each cycle typically lasts for a few weeks.

Possible side effects of chemotherapy

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells can also be affected by chemo, which can lead to side effects.

The side effects of chemo depend on the type and dose of drugs given and how long they are taken. Some common side effects can include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea
• Increased chance of infections (from having too few white blood cells)
• Easy bruising or bleeding (from having too few blood platelets)
• Fatigue (from having too few red blood cells)

These side effects usually go away once treatment is finished. There is help for many of these side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting.

Along with the risks above, some side effects are seen more often with certain chemo drugs. For example:

• Docetaxel and cabazitaxel sometimes cause severe allergic reactions. Medicines are given before each treatment to help prevent this. These drugs can also damage nerves (known as peripheral neuropathy), which can cause numbness, tingling, or burning sensations in the hands or feet.
• Mitoxantrone can, very rarely, cause leukemia several years later.
• Estramustine carries an increased risk of blood clots.

If you notice any side effects while getting chemo report them to your medical team so that they can be treated promptly. In some cases, the doses of the chemo drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

Vaccine Treatment for Prostate Cancer

Sipuleucel-T (Provenge) is a cancer vaccine. Unlike traditional vaccines, which boost the body’s immune system to help prevent infections, this vaccine boosts the immune system to help it attack prostate cancer cells.

The vaccine is used to treat advanced prostate cancer that’s no longer responding to hormone therapy but is causing few or no symptoms.

This vaccine is made specifically for each man. To make it, white blood cells (cells of the immune system) are removed from your blood over a few hours while you are hooked up to a special machine. The cells are then sent to a lab, where they are exposed to a protein from prostate cancer cells called prostatic acid phosphatase (PAP). The cells are then sent back to the doctor’s office or hospital, where they are given back to you by infusion into a vein (IV). This process is repeated 2 more times, 2 weeks apart, so that you get 3 doses of cells. The cells help your other immune system cells attack the prostate cancer.

The vaccine hasn’t been shown to stop prostate cancer from growing, but it seems to help men live an average of several months longer. As with hormone therapy and chemotherapy, this type of treatment has not been shown to cure prostate cancer.

Studies are now being done to see if this vaccine can help men with less advanced prostate cancer.

Possible side effects of vaccine treatment

Side effects from the vaccine tend to be milder than those from hormone therapy or chemotherapy. Common side effects can include fever, chills, fatigue, back and joint pain, nausea, and headache. These most often start during the cell infusions and last no more than a couple of days. A few men may have more severe symptoms, including problems breathing and high blood pressure, which usually get better after treatment.

Preventing and Treating Prostate Cancer Spread to Bones

If prostate cancer spreads to other parts of the body, it nearly always goes to the bones first. Bone metastasis can be painful and can cause other problems, such as fractures (breaks) or high blood calcium levels, which can be dangerous or even life threatening.

If the cancer has grown outside the prostate, preventing or slowing the spread of the cancer to the bones is a major goal of treatment. If the cancer has already reached the bones, controlling or relieving pain and other complications is also a very important part of treatment.

Treatments such as hormone therapy, chemotherapy, and vaccines may help with this, but other treatments more specifically target bone metastasis and the problems it may cause.

Bisphosphonates

Bisphosphonates are drugs that work by slowing down bone cells called osteoclasts. These cells normally break down the hard mineral structure of bones to help keep them healthy. Osteoclasts often become overactive when prostate cancer spreads to the bones, which can cause problems. Bisphosphonates can be used:

• To help relieve pain and high calcium levels caused by cancer that has spread to the bones
• To help slow the growth of cancer that has spread to the bones and help delay or prevent fractures
• To help strengthen bones in men who are getting hormone therapy

Zoledronic acid (Zometa) is the most commonly used bisphosphonate for prostate cancer. This drug is given as an intravenous (IV) injection, usually once every 3 or 4 weeks. Men given this drug are advised to take a supplement containing calcium and vitamin D to prevent problems with low calcium levels.

Some doctors use other bisphosphonates to treat prostate cancer that has spread to bone.

Bisphosphonates can have side effects, including flu-like symptoms and bone or joint pain. They can also cause kidney problems, so patients with poor kidney function might not be able to be treated with these medicines.

A rare but very serious side effect of these drugs is osteonecrosis of the jaw. With this condition, part of the jaw bone loses its blood supply and dies. This can lead to tooth loss and infections of the jaw bone that are hard to treat. Some people develop osteonecrosis of the jaw when dental work is done during treatment. Many cancer doctors advise men to have a dental checkup and have any tooth or jaw problems treated before they start taking a bisphosphonate. Maintaining good oral hygiene by flossing and brushing, making sure that dentures fit properly, and having regular dental checkups may also help prevent osteonecrosis of the jaw.

Denosumab

Denosumab (Xgeva, Prolia) is another drug that can help when prostate cancer spreads to bone. Like the bisphosphonates, denosumab also blocks bone cells called osteoclasts, but it does so in a different way. This drug can be used:

• To help prevent or delay problems like fractures in men whose cancer has already spread to the bones. It may be helpful even if zoledronic acid is no longer working.
• To help slow the spread of the cancer to the bones in men with no obvious cancer spread but with rising PSA levels despite hormone therapy

This drug is injected under the skin every 4 weeks. Men given this drug are often advised to take a supplement containing calcium and vitamin D to prevent problems with low calcium levels.

Common side effects include nausea, diarrhea, and feeling weak or tired. Like the bisphosphonates, denosumab can also cause osteonecrosis of the jaw, so doctors recommend taking the same precautions (such as having teeth and jaw problems treated before starting the drug).

Corticosteroids

Some studies suggest that corticosteroid drugs (such as prednisone and dexamethasone) can help relieve bone pain in some men. They also can help lower PSA levels.

External radiation therapy

Radiation therapy can help reduce bone pain, especially if the pain is limited to one or only a few areas of bone. Radiation can be aimed at tumors on the spine, which can help relieve pressure on the spinal cord in some cases. Radiation therapy may also help relieve other symptoms by shrinking tumors in other parts of the body.

Radiopharmaceuticals

Radiopharmaceuticals are drugs that contain radioactive elements. They are injected into a vein and settle in areas of damaged bones (like those containing cancer spread). Once there, they give off radiation that kills cancer cells. These drugs can be used to treat prostate cancer that has spread to many bones. Unlike external beam radiation, these drugs can reach all the affected bones at the same time.

The radiopharmaceuticals that can be used to treat prostate cancer spread to bone include:

• Strontium-89 (Metastron)
• Samarium-153 (Quadramet)
• Radium-223 (Xofigo)

All of these drugs can help relieve pain caused by bone metastases. Radium-223 has also been shown to help men who have prostate cancer spread only to their bones (as opposed to spread to other organs such as the lungs) to live longer. For these men, radium-223 may be an early part of treatment.

The major side effect of these drugs is a decrease in blood cell counts, which could increase risks for infections or bleeding, especially if your counts are already low. Other side effects have also been seen, so ask your doctor what you can expect.

Pain medicines

When properly prescribed, pain medicines are very effective. Pain medicines work best when they’re taken on a regular schedule. They don’t work as well if they’re only used when the pain becomes severe.

If you have bone pain from prostate cancer, it’s very important that it’s treated. This can help you feel better and let you focus on the things that are most important to you. Don’t hesitate to discuss pain, other symptoms, or any quality of life concerns with your cancer care team. Pain and most other symptoms of prostate cancer can often be treated.

Initial Treatment of Prostate Cancer, by Stage

The stage of your cancer is one of the most important factors in choosing the best way to treat it. Prostate cancer is staged based on the extent of the cancer (using T, N, and M categories) and the PSA level and Gleason score at the time of diagnosis.

But other factors, such as your age, overall health, life expectancy, and personal preferences should also be taken into account when looking at treatment options. In fact, many doctors determine a man’s possible treatment options based not just on the stage, but on the risk of cancer coming back (recurrence) after the initial treatment and on the man’s life expectancy.

You might want to ask your doctor what factors he or she is considering when discussing your treatment options. Some doctors might recommend options that are different from those listed here.

Prostate Cancer Stage I

These prostate cancers are small (T1 or T2a) and have not grown outside the prostate. They have low Gleason scores (6 or less) and low PSA levels (less than 10). They usually grow very slowly and may never cause any symptoms or other health problems.

For men without any prostate cancer symptoms who are elderly and/or have other serious health problems that may limit their lifespan, watchful waiting or active surveillance is often recommended. For men who wish to start treatment, radiation therapy (external beam or brachytherapy) or radical prostatectomy may be options.

Men who are younger and healthy may consider active surveillance (knowing that they may need to be treated later on), radical prostatectomy, or radiation therapy (external beam or brachytherapy).

Prostate Cancer Stage II

Stage II cancers have not yet grown outside of the prostate, but are larger, have higher Gleason scores, and/or have higher PSA levels than stage I cancers. Stage II cancers that are not treated with surgery or radiation are more likely than stage I cancers to eventually spread beyond the prostate and cause symptoms.

As with stage I cancers, active surveillance is often a good option for men whose cancer is not causing any symptoms and who are elderly and/or have other serious health problems. Radical prostatectomy and radiation therapy (external beam or brachytherapy) may also be appropriate options.

Treatment options for men who are younger and otherwise healthy might include:

• Radical prostatectomy (often with removal of the pelvic lymph nodes). This may be followed by external beam radiation if your cancer is found to have spread beyond the prostate at the time of surgery, or if the PSA level is still detectable a few months after surgery.
• External beam radiation only*
• Brachytherapy only*
• Brachytherapy and external beam radiation combined*
• Taking part in a clinical trial of newer treatments

*All of the radiation options may be combined with several months of hormone therapy if there is a greater chance of cancer recurrence based on PSA level and/or Gleason score.

Prostate Cancer Stage III

Stage III cancers have grown outside the prostate but have not reached the bladder or rectum (T3). They have not spread to lymph nodes or distant organs. These cancers are more likely to come back after treatment than earlier stage tumors.

Treatment options at this stage may include:

• External beam radiation plus hormone therapy
• Radiation (external beam plus brachytherapy), possibly with a short course of hormone therapy
• Radical prostatectomy in selected cases (often with removal of the pelvic lymph nodes). This may be followed by radiation therapy.

Men who are older or who have other medical problems may choose less aggressive treatment such as hormone therapy (by itself) or even active surveillance.

Taking part in a clinical trial of newer treatments is also an option for many men with stage III prostate cancer.

Prostate Cancer Stage IV

Stage IV cancers have already spread to nearby areas such as the bladder or rectum (T4), to nearby lymph nodes, or to distant organs such as the bones. A small portion of T4 cancers may be curable using some of the same treatments for stage III cancers. Most stage IV cancers can’t be cured, but are treatable. The goals of treatment are to keep the cancer under control for as long as possible and to improve a man’s quality of life.

Initial treatment options may include:

• Hormone therapy, possibly along with chemotherapy
• External beam radiation (sometimes along with brachytherapy), plus hormone therapy
• Radical prostatectomy in some men whose cancer has not spread to the lymph nodes or other parts of the body. This might be followed by external radiation therapy.
• Surgery (TURP) to relieve symptoms such as bleeding or urinary obstruction
• Treatments aimed at bone metastases, such as denosumab (Xgeva), a bisphosphonate like zoledronic acid (Zometa), external radiation aimed at bones, or a radiopharmaceutical such as strontium-89, samarium-153 or radium-223
• Active surveillance (for those who are older or have other serious health issues and do not have major symptoms from the cancer)
• Taking part in a clinical trial of newer treatments

Treatment of stage IV prostate cancer may also include treatments to help prevent or relieve symptoms such as pain.

The options above are for the initial treatment of prostate cancer at different stages. But if these treatments aren’t working (the cancer continues to grow and spread) or if the cancer comes back, other treatments might be used.

Treating Prostate Cancer That Doesn’t Go Away or Comes Back After Treatment

If your prostate-specific antigen (PSA) blood level shows that your prostate cancer has not been cured or has come back (recurred) after the initial treatment, further treatment can often still be helpful. Follow-up treatment will depend on where the cancer is thought to be and what treatment(s) you’ve already had. Imaging tests such as CT, MRI, or bone scans may be done to get a better idea about where the cancer is.

Cancer that is still thought to be in or around the prostate

If the cancer is still thought to be just in the area of the prostate, a second attempt to cure the cancer might be possible.

After surgery: If you’ve had a radical prostatectomy, radiation therapy might be an option, sometimes along with hormone therapy.

After radiation therapy: If your first treatment was radiation, treatment options might include cryotherapy or radical prostatectomy, but when these treatments are done after radiation, they carry a higher risk for side effects such as incontinence. Having radiation therapy again is usually not an option because of the increased potential for serious side effects, although in some cases brachytherapy may be an option as a second treatment after external radiation.

Sometimes it might not be clear exactly where the remaining cancer is in the body. If the only sign of cancer recurrence is a rising PSA level (as opposed to the cancer being seen on imaging tests), another option for some men might be active surveillance instead of active treatment. Prostate cancer often grows slowly, so even if it does come back, it might not cause problems for many years, at which time further treatment could then be considered.

In a Johns Hopkins University study of men whose PSA level began to rise after surgery for prostate cancer, there was an average of about 10 years before there were signs the cancer had spread to distant parts of the body. Of course, these signs appeared earlier in some men and later in others.

Factors such as how quickly the PSA is going up and the original Gleason score of the cancer can help predict how soon the cancer might show up in distant parts of the body and cause problems. If the PSA is going up very quickly, some doctors might recommend that you start treatment even before the cancer can be seen on tests or causes symptoms.

Observation might be a more appealing option to certain groups of men, such as those who are older and in whom the PSA level is rising slowly. Still, not all men might be comfortable with this approach.

Cancer that clearly has spread

If the cancer has spread outside the prostate, it will most likely go to nearby lymph nodes first, and then to bones. Much less often the cancer will spread to the liver or other organs.

When prostate cancer has spread to other parts of the body (including the bones), hormone therapy is probably the most effective treatment. But it isn’t likely to cure the cancer, and at some point it might stop working. Usually the first treatment is a luteinizing hormone-releasing hormone (LHRH) agonist or antagonist (or orchiectomy). If this stops working, an anti-androgen drug may be added. Another option might be to get chemotherapy along with the hormone therapy. Other treatments aimed at bone metastases might be used as well.

Castrate-resistant and hormone-refractory prostate cancer

Hormone therapy is often very effective at shrinking or slowing the growth of prostate cancer that has spread, but it usually becomes less effective over time. Doctors use different terms to describe cancers that are no longer responding to hormones.

• Castrate-resistant prostate cancer (CRPC) is cancer that is still growing despite the fact that hormone therapy (an orchiectomy or an LHRH agonist or antagonist) is keeping the testosterone level in the body as low as what would be expected if the testicles were removed (called castrate levels). The cancer might still respond to other forms of hormone therapy, though.
• Hormone-refractory prostate cancer (HRPC) is cancer that is no longer helped by any form of hormone therapy.

Men whose prostate cancer is still growing despite initial hormone therapy now have many more treatment options than they had even a few years ago.

If an anti-androgen drug was not part of the initial hormone therapy, it is often added at this time. If a man is already getting an anti-androgen but the cancer is still growing, stopping the anti-androgen (while continuing other hormone treatments) seems to help sometimes.

Other forms of hormone therapy may also be helpful for a while, especially if the cancer is causing few or no symptoms. These include abiraterone (Zytiga), enzalutamide (Xtandi), ketoconazole, estrogens (female hormones), and corticosteroids.

The prostate cancer vaccine sipuleucel-T (Provenge) is another option for men whose cancer is causing few or no symptoms. This might not lower PSA levels, but it can often help men live longer.

For cancers that are no longer responding to initial hormone therapy and are causing symptoms, several options might be available. Chemotherapy with the drug docetaxel (Taxotere) is often the first choice because it has been shown to help men live longer, as well as to reduce pain. If docetaxel doesn’t work or stops working, other chemo drugs, such as cabazitaxel (Jevtana), may help. Another option may be a different type of hormone therapy, such as abiraterone or enzalutamide (if they haven’t been tried yet).

Bisphosphonates or denosumab can often help if the cancer has spread to the bones. These drugs can reduce pain and even slow cancer growth in many men. Other medicines and methods can also help keep pain and other symptoms under control. External radiation therapy can help treat bone pain if it’s only in a few spots. Radiopharmaceutical drugs can often reduce pain if it’s more widespread, and may also slow the growth of the cancer.

If you are having pain from prostate cancer, make sure your doctor and entire health care team know about it.

Several promising new medicines are now being tested against prostate cancer, including vaccines, monoclonal antibodies, and other new types of drugs. Because the ability to treat hormone-refractory prostate cancer is still not good enough, men are encouraged to explore new options by taking part in clinical trials.