How are prostate cancer treatments compared?

Diana Meeks
Diana Meeks on behalf of Sigma Nursing
Family Practitioner

Prostate cancer treatment depends on several factors, chiefly how fast the cancer is growing and spreading. The benefits of immediate treatment will be weighed against potential long-term risks and side effects. If your prostate cancer is in an early stage, or you are elderly and otherwise not in good health, your doctor may recommend a strategy known as watchful waiting, or active surveillance, in which no treatments are immediately made.

Surgery may be used to freeze cancerous tissues or remove the prostate either in parts or entirely. Radiation, either internal or external, is a more likely option at this stage and is often combined with hormone therapy, in which prostate cancer cells are denied the male hormones that they feed off of. Chemotherapy drugs can be used as a treatment if the cancer cells don't respond to hormone therapy.

Consult your doctor and/or the appropriate specialists (urologists, radiologists, and oncologists) for your best options and don't be afraid to seek a second opinion. The good news is that choosing one type of treatment doesn't necessarily rule out other types of treatment, although certain types are usually reserved as an option of last resort.

There are a number of treatments for prostate cancer including surgery, radiation and cryotherapy. In this video, William Oh, MD, an oncologist at The Mount Sinai Medical Center, explains the available treatments.

Prostate cancer is treated using any of the following:

  • surgery
  • radiation
  • seed implant
  • active surveillance

Prostate cancer is a slow-moving cancer, and not all treatment plans are the same for all patients. In this video, Winston Wilfong, MD, of Coliseum Medical Centers, explains prostate cancer treatment.

There's a lot of misinformation around prostate cancer, says Simon Hall, MD, a urologist at The Mount Sinai Medical Center and director of the Deane Prostate Health and Research Center.

There are a number of treatment options for prostate cancer. These include:

  • Surgery
  • External beam radiation therapy
  • Brachytherapy, or placement of radioactive "seeds" into the prostate
  • Experimental options, including high-intensity focused ultrasound and cryotherapy
  • Active surveillance of prostate cancer

The right prostate cancer treatment for you is a personal choice. Doctors can help you make a choice that's consistent with your personal values and offer evidence about the risks and benefits. Some doctors recommend software that helps people make decisions about their prostate cancer treatment.

The various potential options for curative treatment for prostate cancer—external beam radiation therapy, brachytherapy (radioactive seed implantation) and surgery—have comparable cure rates. We try to help the patient choose what fits best with his situation. It’s not one size fits all. We try to present all the options and help the patient make a decision, but often there are competing options.

The treatment options for prostate cancer are contingent on the following factors:

  • the stage of the cancer, whether it affects only part of the prostate, the whole prostate, or has spread to other areas of the body;
  • the patient's overall state-of-health and age;
  • whether the cancer has just been diagnosed or whether it is a reoccurrence.
Debra Fulghum Bruce PhD
Healthcare Specialist

The best methods of treatment for prostate cancer include:

If the cancer is early and localized, surgery to remove the prostate (radical prostatectomy) or radiation therapy are the two most common treatments. With radical prostatectomy, the prostate is removed from above the pubic bone or between the scrotum and rectum. Possible side effects include incontinence, with leakage of urine, and impotence with erectile dysfunction. The latter occurs less often with surgery techniques that protect the nerves that supply the penis.

Radiation therapy is the other major treatment for early prostate cancer. This type of treatment takes 6 to 7 weeks by external beam radiation therapy, which is directed at the prostate to destroy cancer cells. Also possible is radiation therapy using radioactive implants. The risks include intestinal problems with rectal bleeding, diarrhea, and abdominal pain and other problems. From 25 to 80 percent of men develop impotence with erectile dysfunction after radiation therapy. Erection problems may develop months after the treatment is completed. Difficulty urinating, painful or frequent urination happen in some patients, yet this side effect is usually not permanent.

For more advanced prostate cancer, other treatments are available and have been found to be effective. Your urologist can guide you. Treatments available include hormone treatment with estrogens that stop the production of testosterone and therefore remove its effect on the prostate cancer cells.

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Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The stage of the cancer (whether it affects part of the prostate, involves the whole prostate or has spread to other places in the body).
  • The patient's age and health.
  • Whether the cancer has just been diagnosed or has recurred (come back).
  • The Gleason score and the level of PSA.

This answer is based on source information from the U.S National Institutes of Health.

Dr. Mark S. Litwin, MD

There is a variety of different treatments for prostate cancer. These include surgical approaches, radiation and medications. In many cases, doctors do what is called active surveillance in which we monitor the prostate cancer for signs that it might be progressing. The issue of treatment is then revisited if necessary.

The patient and his family will go through a specific process with the doctor following diagnosis. A urologist, radiation oncologist, medical oncologist or primary care doctor might be consulted to help the patient choose a best treatment, because it has to be customized. In other words, the treatment has to be personalized to the man’s individual situation.

A variety of treatments are available for prostate cancer. The choice of which option is best for you will depend upon the location and size of the tumor, whether the cancer has spread, side effects of treatment, and your personal preferences.

  • Radical prostatectomy involves removal of the entire prostate gland and some surrounding tissue. This procedure can be performed as an open surgery, laparoscopically (through a small incision in the skin and with use of a flexible lighted tube with a video camera attached and thin instruments), and laparoscopically with the aid of a robot (the surgical instruments are attached to a machine and controlled by a surgeon using a console). Side effects include bladder problems and sexual side effects.
  • External beam radiation therapy involves the use of computer imaging to map out the precise location of the cancer cells in order to target a high level of radiation only to that area. The treatment is painless and is given in a short dose (1 minute) five days a week for about eight weeks. Side effects include diarrhea, problems urinating, fatigue, and possibly sexual side effects.
  • Radioactive seeds implants are about the size of a grain of rice and are implanted directly into the tumor. They give off a small amount of radiation over a few months to kill cancer cells. Side effects include problems urinating, diarrhea, and other rectal problems.
  • Cryotherapy or cryosurgery involves inserting a small metal tool into the tumor and destroying the cancer cells by freezing them. Side effects include sexual and urinary side effects.
  • Chemotherapy uses chemicals to destroy cancer cells. Because of the side effects associated with chemotherapy (nausea, fatigue, killing of healthy cells, etc.), this therapy is usually reserved for men whose disease has spread to other parts of the body.
  • Watchful waiting means that no treatment is given, but your doctor will monitor you carefully to see if the tumor grows. This may be an option for men whose tumor is small and expected to grow slowly and in older men who may live their normal lifespan without having their cancer spread or cause other problems.
  • Hormone therapy is designed to stop your body from making testosterone, which can stimulate the growth of cancer cells. This can be used to shrink a tumor before using other therapies or can be used alone. Side effects can include sexual problems, hot flashes, weight gain, and bone thinning.

Once you receive a diagnosis of prostate cancer, you should go to the library or purchase one of the many books available to read up on it. The best examples include Dr. Patrick Walsh's book and the book published by the American Cancer Society.

After reading these books, you and your partner should be armed with questions that pertain to your particular situation. Then, in consulting your urologist, radiation oncologist or medical oncologist, you will be able to understand the pros and cons of the various approaches to this cancer. There is no one right answer for everyone.

The priorities to consider, in order of importance, include prostate cancer control, risk of urinary incontinence and urinary bother and finally the impact on sexual function after treatment. I would also talk to friends, family and local American Cancer Society Chapter to see if there are any resources in terms of psychological help/coping, dietary and lifestyle modifications, etc.

The standard treatment options of prostate cancer are:

  1. Active surveillance
  2. Radical prostatectomy (open or robotic) 
  3. Radiation (either brachytherapy seeds or external beam)   
  4. Cryotherapy 

In the near future, focal therapy may be a viable option.

Finding the "right" treatment for your prostate cancer isn't about looking at cancer cells under a microscope and then applying a treatment algorithm. It's about looking at you as a whole person—your family, job, likes/dislikes, habits, personality, culture—and then finding the treatment that will work best to maintain both your health and happiness.

Full disclosure and open communication are important when working with your doctor to treat your prostate cancer. That means frank discussion about sexual performance and habits, emotional well-being and other potentially sensitive topics. Remember that the patient-doctor relationship is highly confidential and having these conversation will lead to better care for you.

Dr. Mehmet Oz, MD
Cardiologist (Heart Specialist)

The treatment for prostate cancer depends on the stage the cancer is caught:

  • Stage 1: Watchful waiting; prostatectomy and/or radiation
  • Stage 2: Similar to stage 1, with cryosurgery and other options added
  • Stage 3: Some combo of surgery, radiation, cryosurgery and more
  • Stage 4: Similar to stage 3, with more extensive surgery

A number of studies have attempted to compare prostate cancer treatments, but they all have serious limitations—most importantly that the men receiving the various treatments are usually different. For example, men who receive surgery are usually younger and healthier, while those who are followed without treatment (watchful waiting) are usually older. Men who are treated with radiation are typically somewhere in between. In general, for men with well-to-moderately differentiated disease, treatment appears to offer little benefit over no treatment. But for a subset of younger men with more aggressive-appearing early disease, surgery may yet show a survival advantage.

To compare treatments, researchers must have a large group of men randomly assigned to alternative treatments, so that the treatment groups are similar. This way the differences in outcomes can be attributed more to the treatments than to the men receiving them. Such a study is in progress: the Prostate Cancer Intervention vs Observation Trial, which is a randomized trial comparing radical prostatectomy vs expectant management for the treatment of clinically localized prostate cancer.

In lieu of conclusive evidence to compare treatments, one method researchers have used to compare treatment options is decision analysis, which combines the available evidence of benefit (survival, less-advanced disease) and balances it against the evidence of harm, and then often uses some weighting to include personal values. These types of analyses reflect the complexity of prostate cancer screening and treatment decisions. They are somewhat controversial, partly because of the weaknesses of the evidence, and partly due to the subjective nature of the weighing of values (also called utilities).

The best-known decision analysis shows that the greatest treatment advantage occurs in the youngest men with the most poorly differentiated (most aggressive-appearing) disease. When adjusted for quality of life, the survival benefit was at best about one year, but usually less. There was no advantage in men over the age of 70, and there was even a net harm from treatment. Other decision analysis studies have produced even more pessimistic results of treatment, including a net loss of life expectancy per person screened.

Dr. Marc B. Garnick, MD
Hematologist & Oncologist

There are several options for treating prostate cancer: active surveillance; surgically removing the prostate gland; radiation, including external beam or implanted pellets; cryotherapy; high-intensity focused ultrasound (still considered experimental in the United States); hormone therapy; and chemotherapy. These treatments may be used alone or in combination, depending on a man's age, the stage of the cancer, and personal preferences regarding the side effects of the treatments and the lifestyle changes they may entail. These treatments are continuously being improved and refined in ways that increase their effectiveness and reduce the unwanted side effects, such as urinary incontinence and erectile dysfunction.

But the wide variety of treatments can be confusing for patients and doctors alike. In fact, the American Urological Association's Prostate Cancer Clinical Guidelines Panel concluded that, at present, no treatment can be proved to be better than another. For example, the panel recommends that men with early prostate cancer, depending upon certain cancer characteristics,  be given a choice of active surveillance, radiation, or surgery.

As you evaluate your treatment options, think not only about your situation today, but also about where you expect to be in five or 10 years—because chances are, you'll still be alive. For example, if you look forward to spending as many years as possible with your spouse and grandchildren, you might choose the treatment that gives you the best chance of survival, with less regard for possible side effects. On the other hand, if you are a sexually active single man, you may want to focus on treatment options that give you the best chance to preserve sexual function.

Treatment options for prostate cancer include surgical procedures, radiation therapy, and sometimes anti-testosterone therapy. Watch urologist Harry Fisch, MD, discuss how prostate cancer is treated, and the main side effects of these options.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.