

Cancer Medicine :: Prostate Cancer Treatment

Prostate Cancer


Treatment overview

In cancer care, different types of doctors often work together to create an overall treatment plan that combines different type of treatments. This is called a multidisciplinary team.


Descriptions of the most common treatment options for prostate cancer are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health.

It is important to discuss the goals and possible side effects of treatment with your doctor before treatment begins, including the likelihood that the treatment will work, the possible side effects(including urinary, bowel, sexual, and hormone-related side effects), and the patient’s preferences. Men should talk with their doctor about how the various treatments affect recurrence, survival, and quality of life. In addition, the success of any treatment often depends on the skill and expertise of the physician or surgeon, so it is important to find doctors who have experience treating prostate cancer.

Active surveillance for early-stage cancer

If a prostate cancer is in an early stage, growing slowly, and treating the cancer would cause more discomfort than the disease, a doctor may recommend active surveillance. During active surveillance, the cancer is monitored closely with periodic PSA tests, DRE tests, and watching for symptoms. Treatment would begin only if the tumor shows signs of becoming more aggressive or spreading, causes pain, or blocks the urinary tract. This approach may be used for much older patients, those with other serious or life-threatening illnesses, those who wish to delay active treatment because of possible side effects, or for patients with tumors that have a low risk of growing and spreading (small tumor size, low Gleason score, low PSA level). However, real caution must be taken not to make errors of judgment about the disease. In other words, doctors must collect as much information as possible about the patient’s other illnesses and life expectancy, so they don’t miss the chance to detect an early, aggressive prostate cancer. For this reason, many doctors recommend a repeat biopsy shortly after diagnosis to confirm that the cancer is in an early stage and growing slowly before considering active surveillance for an otherwise healthy man. New information is becoming available all the time, and it is important for men to discuss these issues with their doctor to make the best decisions about treatment.


Surgery is the removal of the tumor and surrounding tissue during an operation. It is used to try to cure cancer before it has spread outside the prostate. A surgical oncologist is a doctor who specializes in treating cancer using surgery. For prostate cancer, a urologist or urologic oncologist is the surgical oncologist involved in treatment. The type of surgery depends on the stage of the disease, the man’s general health, and other factors. Surgical options include:

Radical (open) prostatectomy. A radical prostatectomy is the surgical removal of the whole prostate and seminal vesicles; lymph nodes in the pelvic area may also be removed. This operation has the risk of interfering with sexual function. Nerve-sparing surgery, when possible, increases the chance that a man can maintain his sexual function after surgery by avoiding surgical damage to the nerves that allow erections and orgasm to occur. Orgasm can occur even if some nerves are cut since these are two separate processes. Urinary incontinence (inability to control urine flow) is also a possible side effect of prostatectomy. To help resume normal sexual function, men can receive drugs, penile implants, or injections. Sometimes, another surgery can fix urinary incontinence.

Robotic or laparoscopic prostatectomy. This type of surgery is possibly much less invasive than an open radical prostatectomy and may shorten recovery time. A camera and instruments are inserted through small, keyhole incisions in the patient’s abdomen. The surgeon then directs the robotic instruments to remove the prostate gland and surrounding tissue. In general, robotic prostatectomy has less bleeding and less pain, but sexual and urinary side effects can be similar to an open radical prostatectomy. This procedure has not been available for as long as open radical prostatectomy, so longer-term follow-up information, including permanent cure rates, are not yet certain. Talk with your doctor about whether your treatment center offers this procedure and how it compares with the results of the conventional open radical prostatectomy.

Transurethral resection of the prostate (TURP). TURP is most often used to relieve symptoms of a urinary blockage, not to cure cancer. In this procedure, with the patient under a full anesthetic, a surgeon inserts a cystoscope (a narrow tube with a cutting device) into the urethra and into the prostate to remove prostate tissue. This is rarely used to treat prostate cancer.

Cryosurgery. Cryosurgery (also called cryotherapy or cryoablation) is the freezing of cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that contains the testicles. Cryosurgery may be useful for early-stage cancer and for men who cannot have a radical prostatectomy. However, it has not been compared with radical prostatectomy or radiation therapy, so doctors do not know if this would be a better treatment option. A common side effect of cryosurgery is impotence, so this approach is not recommended for men who desire to preserve their sexual function. Another side effect may be the development of fistulae (holes between the prostate and the bowel), although this appears to be much less common with newer cryosurgery techniques. 

Radiation therapy


External-beam radiation therapy. External-beam radiation therapy focuses a beam of radiation on the area with the cancer. Some cancer centers use conformal radiation therapy (CRT), in which computers help precisely map the location and shape of the cancer. CRT reduces radiation damage to healthy tissues and organs around the tumor by directing the radiation therapy beam from different directions to focus the dose on the tumor. External-beam radiation therapy is usually given with a high-energy x-ray beam. It can also be given with proton therapy (also called proton beam therapy), which uses protons rather than x-rays. At high energy, protons can destroy cancer cells. 

Intensity-modulated radiation therapy (IMRT). IMRT is a type of three-dimensional (3-D) CRT. CRT uses CT scans to form a 3-D picture of the prostate before treatment. With IMRT, high doses of radiation can be directed at the prostate without increasing the risk of damaging nearby organs.

Brachytherapy. Brachytherapy is the insertion of radioactive sources directly into the prostate. These sources (called seeds) give off radiation just around the area in which they are inserted and may be used for hours (high-dose rate) or for weeks (low-dose rate). Low-dose rate seeds are left in the prostate permanently, even after all the radioactive material has been used up. It is not usually used as the only treatment for a man with a high-risk cancer.

Radiation therapy may cause immediate side effects such as diarrhea or other problems with bowel function; increased urinary urge or frequency; fatigue; impotence (erectile dysfunction); and rectal discomfort, burning, or pain. Most of these side effects usually go away after treatment, but erectile dysfunction is usually permanent. Many side effects of radiation therapy may not show up until months or years after treatment.

Hormone therapy

Because prostate cancer growth is driven by male sex hormones called androgens, lowering levels of these hormones can help slow the growth of the cancer. Hormone treatment is also called androgen ablation or androgen-deprivation therapy. The most common androgen is testosterone. Testosterone levels in the body can be lowered either surgically, with surgical castration (removal of the testicles), or with drugs that turn off the function of the testicles (see below).

Hormone therapy is used to treat prostate cancer in different situations, including cancers that have come back after surgery and radiation therapy, or if it has spread throughout the body at any time.

Recent research has shown that hormone therapy can help lengthen lives when used with radiation therapy for a prostate cancer that is more likely to recur. For some men, hormone therapy will be used first to shrink a tumor before radiation therapy or surgery. In some men with prostate cancer that has spread locally, called locally advanced or high-risk prostate cancer, hormone therapy is given before, during, and after radiation therapy for three years. Hormone therapy should also be considered for men who have prostate cancer that has spread to the lymph nodes (found after radical prostatectomy) as adjuvant therapy (treatment that is given after the first treatment). It may also be given for up to three years for men with intermediate-risk or high-risk cancer. 


One important side effect of hormone therapy is the risk of developing metabolic syndrome. Metabolic syndrome is a set of conditions, such as obesity, high levels of blood cholesterol and high blood pressure that increases a person’s risk of heart disease, stroke, and diabetes. Currently, it is not certain how often this happens or exactly why it happens, but it is quite clear that patients who receive a surgical or medical castration (even a temporary medical castration) with hormone therapy have an increased risk of developing metabolic syndrome. The risks and benefits of castration should be carefully discussed with your doctor. For men with metastatic prostate cancer, especially if it is advanced and causing symptoms, most doctors believe that the benefits of castration far outweigh the risks of metabolic syndrome.

Types of hormone therapy

Bilateral orchiectomy. Bilateral orchiectomy is the surgical removal of both testicles. Even though this is surgery, it is called a hormone treatment because it removes the main source of testosterone production, the testicles. This surgery is permanent and cannot be reversed.

LHRH agonists. LHRH stands for luteinizing hormone-releasing hormone. LHRH agonists are drugs that reduce the body's production of testosterone by interfering with hormonal control mechanisms within the brain, which control the functioning of the testicles.

LHRH antagonist. This type of drug, also called a gonadotropin-releasing hormone (GnRH) antagonist, stops the testicles from producing testosterone by inhibiting LHRH. The FDA has approved one drug, degarelix (Firmagon), given by injection, to treat advanced prostate cancer. One side effect of this drug is that it may cause a severe allergic reaction.

Anti-androgens. While LHRH agonists lower testosterone levels in the blood, anti-androgens block testosterone from binding to so-called “androgen receptors,” chemical structures in the cancer cells that allow testosterone and other male hormones to enter the cells.

Combined androgen blockade. Sometimes, LHRH agonists are used in combination with peripheral-blocking drugs, such as anti-androgens, to more completely block male hormones. Many doctors feel that this combined approach is the safest way to start hormone treatment, as this prevents a possible flare-up or increase in activity of the prostate cancer cells that sometimes happens because of a temporary surge in testosterone production by the testicles (in response to the LHRH agonists). Some, but not all, research has shown about a six months difference in long-term survival from the use of combined androgen blockade; therefore, some doctors prefer to give combined drug treatment while others may give the combination early in the treatment to prevent the flare-up. 

CYP-17 inhibitors. CYP-17 inhibitors are a type of hormone therapy that prevents androgen from being made by the body. Abiraterone (Zytiga) is a CYP-17 inhibitor that has been approved by the FDA as a treatment for castration-resistant prostate cancer that has spread when chemotherapy with docetaxel (Docefrez, Taxotere) has not worked (see Metastatic prostate cancer, below). Research studies have shown that abiraterone increased survival for men with this type of cancer.

Hormone therapy may cause significant side effects. Side effects generally go away after hormone treatment is finished, except in men who have had an orchiectomy. Patients may experience impotence, loss of libido (sexual desire), hot flashes, gynecomastia (enlarged breasts), and osteoporosis (weakening bones). Although testosterone levels may recover after stopping hormone therapy, some men who have taken LHRH agonists for many years may continue to have hormonal effects, even if the drugs are no longer given.

Palliative/supportive care




Recurrent prostate cancer

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. Treatments that help prevent a recurrence include androgen deprivation therapy and radiation therapy (see above). 


If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Also, an increasing PSA level may be a sign of prostate cancer recurrence even if no tumor can be found.

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. The choice of treatment plan is based on the cancer’s stage and may include the therapies described above (such as surgery, radiation therapy, and hormone therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.


Metastatic (advanced) prostate cancer

If cancer has spread to another location in the body, it is called metastatic cancer. The standard treatment for metastatic prostate cancer is hormone therapy (see above). Generally, prostate cancer will develop the ability to grow without using male sex hormones. This is called castration-resistant prostate cancer.


Your health care team may recommend a treatment plan that includes vaccine therapy with sipuleucel-T (Provenge), chemotherapy with docetaxel, or clinical trials. These treatment options are discussed in more detail below. If you have pain, radiation therapy may also be recommended.

Vaccine therapy. Sipuleucel-T (Provenge) is a form of immunotherapy (also called biologic therapy) which is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to bolster, target, or restore immune system function. 

In 2010, the FDA approved sipuleucel-T for men with castration-resistant metastatic prostate cancer with few or no symptoms, because in research studies it increased survival by about four months compared to placebo (inactive treatment). Sipuleucel-T is adapted for each patient. Before treatment, blood is removed from the patient in a process called leukapheresis. Special immune cells are separated from the patient’s blood, modified in the laboratory, and then put back in the patient. At this point, the patient’s immune system may recognize and kill the prostate cancer cells. It is difficult to find out if this treatment is working to treat the cancer for a specific patient, because it has not been shown to shrink the cancer, lower the PSA level, or keep the cancer from worsening.


Chemotherapy for prostate cancer is given intravenously (injected into a vein), and it may help patients with advanced or hormone-refractory prostate cancer. There are several standard drugs used for prostate cancer. The first drug used is often docetaxel given with a steroid called prednisone (multiple brand names). This combination has been shown to help men with advanced prostate cancer live longer than another chemotherapy, mitoxantrone (Novantrone), which is most useful for controlling pain from the cancer.

The FDA has approved the drugs mitoxantrone, docetaxel, and cabazitaxel (Jevtana) for use in men with prostate cancer in specific situations, such as prostate cancer that is resistant to hormone therapy. Cabazitaxel is similar to docetaxel, but research studies have shown that it can be effective for prostate cancer that is resistant to docetaxel. The side effects are similar to docetaxel and include low white blood cell counts, increased risk of infections, allergic reactions, nausea, vomiting, diarrhea, and kidney and liver problems.



Supportive care will also be important to help relieve symptoms and side effects. A few drugs can help treat the symptoms of advanced cancer to enhance the quality of the patient’s life.


Bone-modifying drugs. Hormone therapy for prostate cancer or prostate cancer that has spread to the bones can weaken a patient’s bones and lead to bone pain and an increased risk of fractures (breaks). The following bone-modifying drugs may be used to strengthen bone and reduce pain and fractures for men with prostate cancer.

Zoledronic acid (Zometa). Given by injection, zoledronic acid reduces the level of calcium in the blood and causes fewer bone complications (such as pain, fracture, and need for surgery) from metastases. A high calcium level is called hypercalcemia and is sometimes found in men with advanced prostate cancer.



Hormone therapy. Some types of hormone therapy may be used to treat advanced cancer. Recent research has looked at the use of the drug abiraterone along with hormone therapy. Abiraterone blocks the production of testosterone, which means that this drug combined with hormone therapy may be more effective to stop prostate cancer growth.  In addition, the drug enzalutamide (XTANDI Capsules) was recently approved for men with metastatic castration-resistant prostate cancer who previously received docetaxel. 


If treatment fails




Clinical Trials

Doctors and scientists are always looking for better ways to treat patients with prostate cancer. To make scientific advances, doctors create research studies involving people, called clinical trials.


There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating prostate cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future men with prostate cancer.




Side Effects


Common side effects from each treatment option for prostate cancer are described in detail within the Treatment section.  Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.




After Treatment



Latest Research


Finding causes of prostate cancer. Researchers continue to explore the link between nutrition and lifestyle factors in the development of prostate cancer.

Early detection. Researchers are developing a better PSA test, either a more specific and precise test or another test altogether. Researchers are also looking at a urine test to find a substance called prostate cancer gene 3 (PCA3) to help find prostate cancer. Because PCA3 is made by the body in larger amounts when a man has prostate cancer, doctors could use the test to decide if a man needs a prostate biopsy. With improved testing, more healthy men could be screened for prostate cancer, so more prostate cancers can be found and treated early.

Improved surgical techniques. Better techniques for nerve-sparing surgery can improve the likelihood that men who need radical prostatectomy keep their urinary continence and sexual function after surgery.


High-intensity focused ultrasound (HIFU). This procedure, which is still being researched in the United States, uses transrectal ultrasound to heat and destroy cancer cells.

Tests that evaluate the success of treatment. Circulating tumor cells (cells that have broken free of the tumor) can be used to monitor the effectiveness of treatment; this test uses a patient’s blood sample to collect the circulating tumor cells.

Improved therapy for advanced prostate cancer. Researchers are exploring different treatment options for advanced prostate cancer through a series of clinical trials including special targeted drugs, chemotherapy, hormone therapy, and immunotherapy options are being tested in clinical trials.

