Early-Stage Prostate Cancer Treatment

What are the first steps in prostate cancer treatment?

In terms of prostate cancer treatment, active surveillance refers to watching the cancer's progression carefully (for instance, with endoscopy procedures using the tool shown) and avoiding harsh treatments as long as is medically safe.
In terms of prostate cancer treatment, active surveillance refers to watching the cancer's progression carefully (for instance, with endoscopy procedures using the tool shown) and avoiding harsh treatments as long as is medically safe.

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.

Many prostate cancer treatments come with side effects, like incontinence or impotence, so it’s in the patient’s interest to put off invasive treatments as long as is medically safe.

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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Medically Reviewed on 1/8/2020
References
Ahlering, T., et al. "Unintended consequences of decreased PSA-based prostate cancer screening." World J Urol 37.3 March 2019: 489-496.

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.
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