Articles on Prostate Cancer
What are the first steps in prostate cancer treatment?
When a man receives a prostate cancer diagnosis, especially if testing shows the disease is in early stages, the doctor and patient often start with a “watch and wait” approach.
Prostate cancer is one of the most common cancers among men. As a result, there’s a large body of data that show what treatments are most effective at any given stage of the disease. If prostate cancer is detected early and appears to be slow-growing, invasive procedures, chemotherapy, radiation and other approaches can sometimes do more harm than good.
As long as your doctor is monitoring your early-stage prostate cancer and has signed off, you can also try diets and doctor-approved, non-invasive alternative therapy to improve prostate cancer symptoms or general health. Beware, however; herbal remedies, homeopathy, and acupuncture, etc., have shown limited or no effect on prostate cancer and could interfere with your doctor’s prescribed treatment. The most effective complementary/alternative therapy is focused on symptom relief rather than curing the cancer itself.
Observation and active surveillance of prostate cancer
These two options are not the same. Both observation and active surveillance therapies share in common the decision up front to hold on treatment of the cancer and to follow the cancer periodically to determine if there is progression. Observation involves monitoring the course of the prostate cancer with the goal of treating the cancer with palliative care for the development of symptoms or changes in physical examination or PSA, that suggest that symptoms will develop soon. Observation treatment is not trying to cure the cancer, rather to treat symptoms of cancer progression. Thus, observation treatment is preferred for men with low-risk prostate cancer and with a life expectancy of less than 10 years.
Active surveillance involves actively monitoring the course of the prostate cancer with the intent to intervene, with the intention to cure if the cancer appears to be progressing. Active surveillance is preferred for men with very low risk prostate cancer and a life expectancy of < 20 years. Cancer progression may have occurred if a repeat biopsy shows a high Gleason score (Gleason 4 or 5) or if cancer is found in a greater number of the biopsies or a greater extent of the core compared to prior biopsy.
- The NCCN guidelines for prostate cancer (version 2.2017) note the following for active surveillance for prostate cancer:
- The PSA test should be obtained no more than every 6 months unless clinical changes support more frequent testing.
- A DRE should be performed no more than every 12 months unless clinical changes support more frequent examination.
- A repeat prostate biopsy should be done within 6 months if the initial biopsy removed less than 10 cores or the examination findings were not consistent with the biopsy results.
- A repeat biopsy should be considered as frequently as every year to assess for progression of the cancer.
- If one's life expectancy is less than 10 years, then repeat biopsy is not needed.
- If the PSA is rising and biopsy is negative, consider multiparametric MRI.
Active surveillance has advantages and disadvantages: From an advantage standpoint, it avoids unnecessary treatment and possible side effects of such treatments. Disadvantages of active surveillance include the risk of missed opportunity for cure, although the risk of this is very low if you are followed regularly, and the need for periodic prostate biopsies and the side effects of prostate biopsy.
Observation has advantages and disadvantages. From an advantage standpoint, observation avoids/delays the possible side effects of treatment. There is, however, the risk of troubles urinating (urinary retention) or bone fractures occurring before treatment is started.
As reported in the journal European Urology, Dr. Lu-Yao and colleagues performed a population-based cohort study that included 31,137 Medicare patients 65 years of age and older diagnosed with localized prostate cancer in 1992-2009 who initially received conservative management (no surgery, radiotherapy, cryotherapy, or androgen-deprivation therapy) who were followed until death or Dec. 31, 2009 (for prostate cancer specific mortality), and Dec. 31, 2011, for overall mortality and found that the 15-year outcomes with conservative management of newly diagnosed T1c Gleason 5-7 prostate cancer for men 65 years of age and older were excellent (15-year risk of prostate cancer specific mortality of 5.7%), whereas in men with T1c Gleason 8-10 prostate cancer there was a significant risk of prostatic cancer mortality (22%).
Complementary and alternative care approaches
In addition to standard types of prostate cancer treatments, there are other approaches that patients may choose during their treatment for their disease.
Some of these treatments are called complementary treatments and may help with control of symptoms or problems the patient may be experiencing. Examples of these include acupuncture for pain control, yoga and meditation for relaxation, as well as guided imagery, aromatherapy, and other techniques. Tell your doctors about all treatment approaches you are engaged in. These approaches usually will be of no harm to you, and may be very beneficial. Knowing what you are doing may help your doctor to better understand and coordinate your treatments and medications.
Herbal therapies have been demonstrated in the lab to affect prostate cancer cells, but in many cases, have not been proven to be clinically effective. PC-SPES is an herbal therapy that has been used in the past for prostate cancer, for example. It was associated with an increased risk of blood clots. Thus, prior to taking this or other herbal therapies, discuss these therapies with your doctor.
Be very careful about alternative treatments. The vast majority of medical professionals keep up-to-date on the latest advances, or are willing to research them for patients when asked. No truly effective treatments are being withheld from patients, though alternative care providers often say they are in an attempt to sell patients on their types of treatment. Such alternative therapies can do harm to patients, and can interfere with conventional treatment. Many alternative care providers prey on the desperation of cancer patients.
If an alternative care professional suggests nutritional supplements in addition to conventional therapy, tell all your doctors what you are taking. Some nutritional substances can interfere with the effectiveness of some conventional cancer treatments. Some "natural" substances can be toxic and can result in side effects or problems your regular doctor may not recognize unless they know what you are taking.
Prostate cancer patients, like all cancer patients, are frightened. Discuss your anxiety and concerns with your primary care doctor, urologist, and radiation and medical oncologists. They have many ways to help.
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American Cancer Society (ACS). <http://www.cancer.org/cancer/prostatecancer/index>.
American Urological Association. "Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline." 2017. <http://www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017)>.
Byrd, E.S., et al. AJCC Cancer Staging Manual, 7th Ed. New York, NY: Springer, 2009.
The James Buchanan Brady Urological Institute. Johns Hopkins Medicine.
Lu-Yao, G.L., P.C. Albertson, D.F. Moore, et al. "Fifteen-year outcomes following conservative management among men aged 65 years or older with localized prostate cancer." Eur Urol 68.5 (2015): 805-811.
Mottet, Nicolas, et al. "Updated Guidelines for Metastatic Hormone-Sensitive Prostate Cancer: Abiraterone Acetate Combined With Castration Is Another Standard." European Urology 73 (2018): 316-321.
National Comprehensive Cancer Network
"Prostate Cancer." Memorial Sloan Kettering Cancer Center.
Top Early Prostate Cancer Treatment Surveillance Related Articles
How Is Prostate Cancer Diagnosed?
Prostate cancer is largely a disease of men over 40, so it’s around this age doctors recommend the first prostate screening. The first exam is a blood test to determine if there are abnormal prostate specific antigen (PSA) levels in your blood – PSA is produced by the prostate. If the PSA is high, your doctor will perform a digital rectal exam, during which the doctor feels your prostate from inside your rectum with a gloved finger. Other diagnostic tests include an endoscopic biopsy of tumor tissue for analysis in a lab.
Prostate cancer is the most common cancer in men after skin cancer. Risk factors include age, family history, ethnicity, and diet. Prostate cancer is diagnosed by digital rectal exam, prostate specific antigen (PSA) test, and prostate biopsy.
Symptoms may include frequent need to urinate, incontinence, pain, blood in the urine, fatigue, and more. Prognosis and treatment depend on cancer staging. Watchful waiting, surgery, radiation, cryotherapy, and other management strategies are available. Research and clinical trials strive to find new and better treatments for prostate cancer.
Prostate Cancer Treatment: Chemotherapy, Bone-Targeted and Immune Therapy
Doctors may introduce chemotherapy and immune therapy if other measures fail to cure a case of prostate cancer. However, unlike with other forms of cancer, chemotherapy isn’t the first choice for early prostate cancer. Immune therapy uses the body's own immune system to attack the prostate tumor, while bone-targeted therapy aims to preserve bone and prevent metastasis.
Prostate Cancer Facts
Prostate cancer is a leading cause of cancer and cancer death in males; in some men, identifying it early may prevent or delay metastasis and death from prostate cancer. The prostate is a walnut-shaped gland that is a part of the male reproductive system that wraps around the male urethra at it exits the bladder. Prostate cancer is common in men over 50 years of age, with the risk of developing prostate cancer increases with aging.
Prostate Cancer Treatment: Focal Therapy and Other Experimental Treatments
Several new and experimental treatments for prostate cancer are under study, including treatments that use ultrasound, lasers, tissue-freezing gas, and new ways of administering radiation. These new methods are types of focal therapy, that is, treatment focused on the cancer cells in the prostate, rather than systemic therapy that administers medications or other treatments to the whole body with the aim of treating the prostate.
Prostate Cancer (Prostatic Cancer) Symptoms and Causes
Difficulty with urination – frequency, weak stream, trouble getting started, etc. – is usually the first sign of prostate cancer. But these and other early symptoms of prostatic cancer can also come from benign prostate conditions, so diagnostic testing is important, including PSA tests and digital rectal exam.
Prostate Cancer Treatment: Radiation, Brachytherapy and Radiopharmaceuticals
Radiation treatment for prostate cancer is a powerful tool at doctors’ disposal. Using radiation vs. surgery or other invasive treatments to kill cancer cells may still cause side effects, but ideally they are less severe. Radiation therapy can be performed via external beam therapy (EBRT) or the placement of radioactive seeds into the prostate (prostate brachytherapy) or using radioactive drugs (radiopharmaceuticals).
Prostate Cancer Treatment: Radical Prostatectomy Surgery
Radical prostatectomy, or surgical removal of the entire prostate gland, isn’t typically the first choice in prostate cancer treatment. Sometimes a radical approach is necessary to keep the cancer from metastasizing, however. Some cases are too severe or diagnosed too late for drugs or radiation to have much effect. In these cases, treatment teams may opt for a radical prostatectomy, despite potential side effects like impotence and incontinence.
Prostate Cancer Staging and Prognosis
The prognosis for prostate cancer, as with any cancer, depends on how advanced the cancer has become, according to established stage designations. The patient's PSA score at diagnosis, as well as their Gleason score (the grading system used to determine the aggressiveness of prostate cancer) determines the prognosis and final stage designation. Prostate cancer has a high survival rate in general, but your chances depend on the stage of the cancer.
Prostate Cancer Treatment: Hormonal Therapy
Prostate cancer is highly sensitive to, and dependent on, the level of the male hormone testosterone, which drives the growth of prostate cancer cells. Testosterone belongs to a family of hormones called androgens, and today front-line hormonal therapy for advanced and metastatic prostate cancer is called androgen deprivation therapy (ADT).