Prostate cancer treatment is designed to cure the disease or relieve symptoms such as erectile dysfunction and urinary incontinence. The type of treatment you get depends on the size of your prostate cancer and whether it has spread.
A doctor in a lab examines prostate cells from a biopsy to find out how aggressive they are (Gleason score). This helps decide on the best treatment for you.
Hormone therapy
Because testosterone serves as the main fuel for prostate cancer cells, lowering testosterone levels with hormone therapy can help keep the disease under control. Hormone therapy is often combined with other treatments to improve the chance of a cure.
The first step in hormone therapy is to take a drug called a steroidal anti-androgen, such as dexamethasone. These drugs prevent the body from making testosterone and block the action of other male hormones on prostate cancer cells, such as androgens. Newer types of hormone therapy include abiraterone, apalutamide and darolutamide. Your medical team can tell you if these drugs are right for you.
Hormone therapy can cause side effects such as fatigue, loss of muscle mass and a heightened risk for cardiovascular disease. Because of these burdensome side effects, doctors are careful to use hormone therapy only for as long as necessary. However, it can be difficult to determine how long this is in individual patients.
Your MDT care team will also give you information about other treatments that may be right for you, including clinical trials. This is a time for “shared decision-making,” where you and your doctor discuss the goals of each treatment option and how it might affect your quality of life, such as urinary, bowel and sexual side effects.
Radiation can be used in conjunction with hormone therapy to kill any remaining cancer cells. Your medical team may recommend image-guided external radiation systems, such as TomoTherapy or TrueBeam, to precisely target the area of your prostate that contains the cancer. The radiation can then be sculpted to minimize exposure of your bladder, rectum and other organs. You may also receive brachytherapy, in which radiation is delivered through a number of tiny radioactive seeds surgically implanted in the prostate gland.
Chemotherapy
For people with advanced prostate cancer that has spread to other parts of the body, chemotherapy is often used. It can’t cure the cancer, but it may help to keep it under control and reduce symptoms so that you can live longer. Chemotherapy destroys cancer cells by interfering with their ability to grow and divide. It is usually given together with radiation therapy and hormone treatment.
Some doctors have also tried a procedure called cryosurgery, which involves freezing cancer cells with a metal probe that is inserted into the area between the rectum and scrotum (the skin sac that holds the testicles). It isn’t available outside clinical trials and its long-term effectiveness is not yet known. Its effect on urinary and sexual function is also not well understood.
If your cancer has spread, it’s important to discuss all the treatment options with your doctor. He or she will consider the latest research and your preferences. A second opinion from another specialist is also an option.
Your care team may recommend radiotherapy if surgery and hormone therapy are not an option. The type of radiotherapy you have depends on the stage of your cancer and your Gleason score. It’s possible to have radiotherapy to only the affected area of your prostate, which can cause fewer side effects.
A type of radiotherapy called brachytherapy has a lower risk of urinary and bowel problems than external beam radiation, but it can’t target all areas of the prostate. It’s also possible to have radiotherapy delivered through a small number of radioactive seeds that are surgically implanted in the prostate. This type of radiotherapy is called low dose rate brachytherapy or high dose rate brachytherapy.
Immunotherapy
Immunotherapy uses the body’s own immune system to target cancer cells and stop them from growing or spreading. It involves medications, such as immune checkpoint inhibitors, that block the protein PD-1 on immune cells to help them recognize and attack cancerous ones. Immunotherapy can be used alone or in combination with hormone therapy or radiation therapy.
Immunotherapies are relatively new, and only a small number of people respond to them. Scientists are working hard to determine ways to predict which patients will respond to these types of treatments. They are also researching combinations of immunotherapy with other types of treatment to overcome resistance to this type of care.
One such combination involves the drug nivolumab (Opdivo), which targets a protein on immune cells called PD-1, and another medicine that blocks a protein on cancerous tumors called PD-L1 to help the immune system recognize them. Nivolumab plus ipilimumab (Tesaro) has shown promising results in mCRPC patients. [58, 61] However, the results are limited by low levels of infiltrating immune cells in the tumors.
Researchers at MSK have developed several immunotherapies that are designed to target specific proteins on prostate cancer cells and make them more visible to the immune system. For example, they developed sipuleucel-T (Provenge), an immunotherapy that is made by taking a person’s own immune cells and engineering them to target prostate cancer cells.
Other immunotherapy options include chimeric antigen receptor T-cell therapy, which turns T lymphocytes into more efficient cancer-fighting machines. These treatments can be particularly effective in metastatic castrate-resistant prostate cancer (mCRPC), which often carries the PD-1 mutation. A study published in Cancer Cell(link is external and opens in a new window) found that combining a PD-1 inhibitor with androgen deprivation therapy can trigger robust T-cell infiltration into metastatic mCRPC tumors.
External beam radiation
This treatment uses X-ray beams to damage cancer cells and stop them from growing. You get radiation for 1 to 5 minutes at a time, five days a week for seven or eight weeks. Your care team will plan your treatment using a special computer that calculates the right dose and targets for each session.
For some people, this type of radiotherapy is the only treatment they need. It’s also very effective for men with advanced prostate cancer. One large study found that external beam radiation is as good, and in some cases better, than other common treatment options like surgery or brachytherapy.
Your care team may use an external beam radiation machine called a linear accelerator to deliver the radiation. You lie on a table or couch, and the machine rotates around you to deliver the radiation from different angles.
The care team will take a series of detailed images to help them plan your treatment and make sure the radiation goes where it should. They may ask you to move a little from time to time during the treatment session so they can adjust the position of the radiation beams.
You may be given a mould or other equipment to ensure your body is in the right position during each session. You might need to remove some clothing or wear a gown, depending on where the tumour is located. You won’t feel the radiation as it passes through your skin, but you might have a warm sensation in the area during the session.
The care team may offer you a new type of external beam radiation called stereotactic body radiotherapy (SBRT). With SBRT, the care team uses an imaging machine to shape the prostate and surrounding tissue before each treatment session. This allows the team to give very precise doses of radiation and limit any exposure to nearby healthy tissues.
Brachytherapy
During brachytherapy, radioactive seeds are put inside your prostate. They give off radiation to kill the cancer cells and are left in place for several months. You have fewer side effects with this treatment than with other types of radiation therapy. Before you have brachytherapy, tell your doctor about any medicines you take, especially ones that make it hard for your blood to clot, such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), vitamin E, or clopidogrel (Plavix).
You will have a planning session before you have the seeds put in. Your specialist will use ultrasound or a CT scan to help plan and position the seeds in your prostate. On the day of treatment you will have a local anaesthetic and the seed insertion will take just a few minutes. It may hurt a little. You will be able to go home shortly after this.
The seeds can be placed with a template or a catheter. If you have HDR brachytherapy your physician will use a template with pre-drilled holes surrounded by flexiguides. These flexiguides are attached to a remote afterloader that feeds thin wires with radioactive material into the prostate at precise locations. These radioactive wires are left in for a short time to deliver the prescribed radiation dose.
The physician will use the template to guide the flexiguides into place around your prostate and then suture the template to your perineum. The template allows them to flare the flexiguides out into larger prostates and also enables them to treat extracapsular extension or seminal vesicles. The procedure is usually done in a day and only requires one or two nights in hospital. It is usually combined with external beam radiation therapy.
