Treatment Options for Prostate Cancer

You have been diagnosed with prostate cancer. What now?

The treatment choice depends on a lot of things: your age, your general health, your PSA, the grade of the cancer, its stage, how much cancer is in the prostate, and what else is in your medical history.

Many patients come in looking for the right answer, convinced that if they read enough they will find it. What they find instead is a great many opinions mixed in with facts and study results. What I tell patients is to find the answer that is right for them. The treatment of a 50-year-old man with high-grade cancer should not look like the treatment of a 78-year-old man with a small volume of low-grade cancer. Every treatment on this page is reasonable for some patients and wrong for others.

First, understand your grade

You will hear a Gleason score, and you may also hear a Grade Group. Grade Groups came into use to fix a confusing system, and they run from 1 to 5:

This matters more than it sounds like it should. Under the old system a Gleason 6 came across as a middling score on a scale of 10, which frightened people badly and unnecessarily. Grade Group 1 is the lowest there is, and it behaves that way.

Staging

Beyond the biopsy, imaging tells us whether the cancer has stayed in the prostate. MRI of the prostate is standard. For men with higher risk disease, PSMA PET has largely replaced older bone scans and CT. It is a good deal more sensitive, and it sometimes finds disease that would have been missed, which changes the plan.

Genomic tests on the biopsy tissue, such as Decipher, Prolaris, or Oncotype, can help when the decision is close. Men with high risk or metastatic disease, or a strong family history, should be offered germline genetic testing. It affects treatment choices, and it affects their relatives.

Does it need treating at all?

This is the first decision, and for many men it is the most important one.

Active surveillance is now the standard recommendation for most low risk prostate cancer, rather than one option among several. It means watching the cancer closely with periodic PSA, MRI and repeat biopsy, and keeping full curative treatment in reserve for use if the cancer starts to progress. The intent is still to cure if cure becomes necessary. You are not giving anything up.

This is the single biggest change in prostate cancer care in my career. It broke the link between finding a small cancer and having an operation you did not need, and that was the strongest argument against PSA screening in the first place.

Roughly half of men on surveillance will go on to treatment within ten to fifteen years. [verify current figure] The rest never need it.

Watchful waiting is a different thing, and the two get confused constantly. Watchful waiting means no curative treatment is planned at all, and we treat only if symptoms appear. It suits men whose life expectancy is short enough that the cancer is unlikely to be what harms them. Active surveillance watches with the intent to cure. Watchful waiting watches with the intent to keep you comfortable. Make sure you know which one you are being offered.

Surgery

Radical prostatectomy removes the entire prostate and surrounding tissue, sometimes including the seminal vesicles and lymph nodes.

Nearly all of it is now done robotically, usually through several small incisions, most commonly with the da Vinci system. When I first wrote this, robotic surgery was still displacing open surgery. That transition is finished. Open retropubic prostatectomy is still performed and still perfectly legitimate, but it has become uncommon.

The risks of any approach are the same ones: bleeding, urinary incontinence, erectile dysfunction, and injury to nearby structures. There is still little good evidence that any one technique lowers the risk of incontinence or erectile dysfunction. What matters far more than the tool is that your surgeon does a lot of these and is comfortable with the technique. Ask how many. It is a fair question and a good surgeon will not mind being asked.

Radiation

Radiation uses high-energy x-rays to kill cancer cells, and it is delivered two ways.

External beam aims radiation from outside, usually with markers placed in the prostate to target it accurately. The notable change here is schedule. Where treatment once meant eight or nine weeks of daily visits, hypofractionated regimens now deliver it in far fewer sessions, and SBRT can complete treatment in about five. Outcomes have held up, and for a man who is still working the difference is enormous.

Brachytherapy places radioactive seeds directly in the prostate.

For more aggressive cancers, radiation is often combined with hormonal therapy. Proton beam therapy remains available and remains unproven as better or safer than standard approaches for prostate cancer.

Focal therapy

Cryotherapy freezes prostate tissue; HIFU uses focused ultrasound to heat and destroy it. Both are now generally used as focal therapy, meaning we treat the part of the prostate that has cancer rather than the whole gland. That is possible mainly because MRI can show us where the cancer is.

Focal therapy is reasonable for carefully selected men whose disease is confined to one area. It is not a substitute for surgery or radiation in higher risk or multifocal disease, and the long term data are still thinner than for the established treatments. A real option, but a narrow one.

Treating advanced disease

Prostate cancer grows in response to testosterone, so blocking or removing testosterone causes many cancer cells to regress or die. For years that was essentially the whole of treatment for metastatic disease. Testosterone can be lowered by stopping its production or blocking its receptor, and modern medication has replaced surgical removal of the testicles.

What has changed is that we no longer wait. For metastatic disease, hormonal therapy is now combined up front with a second agent such as abiraterone, enzalutamide, apalutamide or darolutamide, and in some cases with chemotherapy as well. Treating harder and earlier has produced real survival gains.

Beyond that, several newer options apply to specific situations: PARP inhibitors for men carrying BRCA or related mutations, which is where germline testing pays off, and Lutetium-177 PSMA therapy for PSMA-positive disease after other treatments have failed. Chemotherapy still has an important role. Sipuleucel-T remains available for asymptomatic metastatic castration-resistant disease, though it now sits among many more choices than it did.

What I would tell you

Take the time to understand your grade and your stage before you look at any treatment. Those two facts decide which options are even relevant to you. Get a second opinion if you want one. No good physician will be offended.

And if you are told you have low-risk prostate cancer, ask specifically about active surveillance. It is the standard of care for that situation, and it is worth understanding properly before you agree to anything more.