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The Treatment of Prostate Cancer: An Overview

Last Revised October 10, 1997
(some procedures may have changed since)

Introduction | The problem of misstaging | Watchful waiting | Surgery
| Cryotherapy | Radiation | Hormone therapy | Chemotherapy


Currently available treatment options for some stages of prostate cancer are potentially curative. However, patients with locally advanced disease are less likely to be cured by today's treatments, and for those patients first diagnosed with metastatic prostate cancer medicine is unable to offer hope of a cure at the moment. This section is designed to give you a very basic introduction to the possible treatments for prostate cancer and why they all have problems. Further, more extensive information is available elsewhere in these Web pages.

The problem of misstaging

If your doctor finds that you have prostate cancer after carrying out a biopsy, the next question that he has to try to answer is, "What is the stage of this cancer?" Unfortunately, this is a very hard question to answer in any particular case except that of clearly metastatic disease.

Let us say that Hank J. recently had a DRE and a PSA, and went on to have a biopsy. Hank's urologist found the following:

  • He thought he could feel a small suspicious nodule on the left lobe of Hank's prostate when he did the DRE.
  • Hank's PSA was 8.9 ng/ml.
  • The ultrasound-guided biopsy confirmed prostate cancer in one small nodule in the left lobe of Hank's prostate, close to the capsule (or wall) of the prostate.
On a classical basis, Hank has all the indications of stage T2a disease -- locally confined prostate cancer in one lobe of the prostate detectable by DRE.

Unfortunately, it is later discovered that Hank's prostate cancer is in fact locally advanced. Despite the fact that there was no good reason to expect this, prostate cancer cells also are found in Hank's seminal vesicles. Even later, despite an excellent response to surgical treatment, Hank's PSA starts to rise again. Hank has recurrent prostate cancer.

Of course, Hank's doctor knew that this outcome was possible, and he told Hank that this was a possibility when they discussed treatment options together. That doesn't make anyone any happier. But it happens often.

There is a strong desire on the part of patients and physicians to want to believe and thus to act as though individual cases of prostate cancer are curable -- particularly those cases of prostate cancer which look as though they have a good chance of being curable -- like Hank's! After all, who wants to throw in the towel on the grounds that the worst case is bound to happen? As a result, there is a tendency to get the initial (clinical) stage of prostate cancer wrong. Most often, when the stage is wrong, the cancer is subsequently found to be of higher stage than the doctor first thought. In Hank's case, the cancer was actually stage T3c/No/M1a, with a tiny degree of extension of the cancer into one of Hank's seminal vesicles and micrometastasis to a non-regional lymph node, but no one knew.

There is, in fact, no way that anyone could have known Hank's precise stage at the time of diagnosis. Even if his doctor had given him an RTPCR test or a ProstaScint test, the degree of accuracy of these tests is currently not sufficient to confirm distant metastasis in one of the non-regional lymph nodes, and given the position of the apparently small tumor clearly confined in the prostate, there was also no apparent need to biopsy the seminal vesicles.

The point of this discussion is only, once again, to advise you that there are no certainties in the treatment of prostate cancer. Despite everyone's best attempts, there will be many occasions on which the best is not good enough. Until we are able to develop absolutely definitive tests that can tell any patient whether there is any cancer outside his prostate, this situation will continue to be the case.

Watchful waiting

It is important that you understand that "watchful waiting" or "active surveillance" really is a form of treatment. For carefully selected men it may well be the best possible option. It comes with no side effects. It avoids all of the socially problematic and expensive aspects of treatment. Finally, if it turns out that the cancer is not particularly active, the result can often be that the patient easily outlives the risk of clinically active prostate cancer.

In watchful waiting, the doctor will carefully and regularly monitor the potential indicators of progression, including carrying out regular PSA tests and DREs, as well as other possible tests such as transrectal ultrasound. Although there is a risk that the cancer will progress, and that it may become clinically active disease which might have been cured if the cancer had been removed when it was first found, on the other hand the quality of the patient's life has been utterly unaffected by this form of treatment.

Watchful waiting is generally practiced on patients who, for some reason, the physician believes will be better served by avoiding curative treatments such as surgery or radiation. This may be because of their age, or because of concomitant healthy problems, or just because the patient believes strongly that he would prefer the risk of disease progression to the risks associated with curative treatments.


Surgical treatment for prostate cancer is most common among younger, healthy patients whose tumors are believed to be confined to the prostate (i.e., stages T1 or T2). A number of clinical tests may be performed in an attempt to clearly rule out gross evidence that the tumor has metastasized. These tests potentially include a bone scan and an acid phosphatase test. Greater detail on the use of surgical procedures in the treatment of localized disease is available elsewhere in The Prostate Cancer InfoLink.

In selected patients, it has become customary to carry out a "laparoscopic lymphadenectomy" prior to radical surgery. A laparoscopic lymphadenectomy is a relatively new, less invasive surgical technique which can be used to decide whether a patient has signs of cancer in his pelvic lymph nodes before making the decision to go ahead with radical surgery. By knowing whether a patient has signs of prostate cancer in the lymph nodes, it becomes possible to make more informed decisions about the possible risk-benefit equation in proceeding with actual removal of the prostate.

There are two basic forms of radical surgery for removal of the prostate: radical retropubic prostatectomy and radical perineal prostatectomy. The only difference between these two techniques which is of importance to the patient is that the surgeon uses different routes to reach the prostate. In radical retropubic prostatectomy the surgeon cuts down to the prostate through the lower abdomen. In a radical perineal prostatectomy, the surgeon cuts up to the prostate between the anus and the scrotum.

All forms of surgery for removal of the prostate are associated with complications. These include lack of bladder control (urinary incontinence), urethral stricture (difficulty in urination), impotence, and the normal risks associated with anesthesia and a major surgical procedure. There is general agreement that lower complication rates are usually found among those surgeons who carry out a significant number of prostatectomies on a regular basis. In other words, practice makes the surgeon more competent. However, even the best surgeons have patients with unexpected complications. Any form of prostatectomy is a major operation and has risks attached.


Cryotherapy (also known as cryosurgery or cryoablation) is an old technique which has been reborn as a result of advances in technical capability. Rather than removing the prostate (as in conventional surgery) or using radiation therapy with different forms of x-rays, cryotherapy is a method of freezing the prostate and other appropriate nearby tissues to extremely low temperatures with liquid nitrogen. This technique is designed to kill all the prostate cancer tissue without having to take the risks involved in carrying out invasive surgery.

While cryotherapy is certainly an interesting and potentially important addition to the options which physicians can offer patients with prostate cancer, it should probably still be considered an investigational technique at this time. Even physicians who have carried out several hundred cryosurgical procedures for prostate cancer will still say that they are unsure of the precise future role for this form of therapy. You can find an interesting assessment of the current state of cryosurgery by a well-known cryosurgeon elsewhere on The Prostate Cancer InfoLink. [The cited document was written in 1995. Cryotherapy procedures have evolved since then. - Webmaster, Phoenix5]

If you decide that cryotherapy is an option which you wish to consider, you should certainly seek out a physician who has considerable experience with this technique. You should ask that physician very specific questions about whether cryosurgery is appropriate for you. Specifically, you should ask whether that physician believes that cryosurgery can be used to cure your cancer or whether it would be given to primarily reduce the amount of cancer in your body.

It would be most appropriate if you could find a physician who was interested in talking to you about cryotherapy within a carefully controlled trial comparing the effectiveness and safety of this technique to the effectiveness and safety of other, traditional first-line curative treatments (i.e., surgery and radiation therapy).

The known side effects of cryotherapy can include impotence (in about 80% of patients), scarring of the urethra and urinary dysfunction (which are relatively unusual), and irritation of the bladder, the urethra, the rectal wall, and the genitalia. This last group of side effects can include pain on urination, a burning sensation during urination, frequent and unexpected urination, blood in the urine (hematuria), and swelling of the penis or the scrotum.

Radiation therapy

[Reminder: This document was written in 1997. There have been further developments in radiation.]

Patients who elect to have some form of radiation therapy which is intended to cure their prostate cancer should have cancer that is confined to the prostate and/or the surrounding tissues (i.e., clinical stages T1, T2, and T3). Additional information on the use of radiotherapy in the treatment of localized disease is available. As with patients who elect surgery, gross metastatic disease should be clearly ruled out prior to therapy. A lymph node dissection to establish the status of the pelvic lymph glands is not necessary -- however, it may be valuable in some patients.

So-called "definitive" radiation therapy is delivered using an external beam of x-rays carefully directed to the areas of the pelvis that include the prostate. Other forms of radiation therapy are "interstitial brachytherapy" (commonly known as seed implantation), in which the radiation oncologist and a surgeon implant radioactive pellets or "seeds" into the prostate, and those pellets radiate the prostate and the surrounding tissue over time. It is not uncommon for brachytherapy and external beam radiation therapy to be used in combination in appropriate patients. (One group of radiation oncologists has given the name "ProstRcision" to this technique.)

Like surgery, all forms of radiation therapy are associated with complications, including acute cystitis, proctitis, and enteritis. In addition, most series of radiotherapy patients have been associated with some subsequent urinary and sexual dysfunction.

As with surgery, patients are advised that better outcomes tend to be associated with radiotherapy centers carrying out treatment on large numbers of patients with prostate cancer.

Hormone therapy

[Reminder: this document was last revised in 1997. Hormone therapy has developed considerably since then.]

Hormone therapy is primarily used to treat patients who have prostate cancer which is not confined to the prostate. It is not curative. The intent of hormone therapy is first to delay the progression of the cancer and second to increase the patient's survival while simultaneously maximizing his quality of life. Greater detail on the treatment of advanced prostate cancer with hormonal therapies is available. [The National Cancer Institute site at has considerable information.]

An increasing number of options are becoming available as methods of implementing hormone therapy. However, they all fall into one of the following groups of actions:

Patients who fail first line hormonal therapy may also be appropriate for second line hormonal manipulation prior to chemotherapy. The available options are addressed in the section on secondary hormonal therapy for the treatment of hormone-refractory disease.

The critical factors in choosing a particular form of hormone therapy can include the cost of the treatment (and who is paying for it), the effectiveness and safety of the various treatment options, and the effects of the different forms of treatment on the patient's quality of life. It is common for different forms of hormone therapy to be combined with each other. In addition, it is increasingly common to find hormonal therapies being combined with definitive therapies as ways to provide additional clinical coverage for the patient in case the definitive treatment is not successful.


In the past, it was generally believed that chemotherapy had no significant value in the treatment of prostate cancer. In other words, people generally thought that once a patient started to fail hormonal therapy his options became extremely limited. Recently, however, medical oncologists with specific expertise in prostate cancer, such as Howard Scher, MD, at Memorial Sloan-Kettering Cancer Center in New York, have started to express a more positive view about some forms of chemotherapy for some patients.

The views expressed by Dr Scher can be encapsulated briefly as follows. In the past, when most patients were only diagnosed with prostate cancer when the disease was comparatively advanced, the patients were so sick by the time they had failed hormonal therapy that no form of chemotherapy had a reasonable chance of providing the patient with any benefit -- to a great extent because the patients were incapable of handling the toxic effects of chemotherapies. Today, with prostate cancer being diagnosed earlier, the patients become eligible for chemotherapy before they have reached the degree of sickness that we used to see. As a consequence, some forms of chemotherapy have started to show potential in some patients who fail hormonal therapy.

Some of the currently available information on the use of chemotherapy and chemohormonal combinations has been provided as one subsection in the section on the treatment of hormone-refractory prostate cancer. The Prostate Cancer InfoLink expects substantial new information on this topic to come available in the not too distant future.

While there is little evidence as yet that any particular forms of chemotherapy have major clinical impact on disease progression or survival of prostate cancer patients, the argument put forward by Dr Scher seems reasonable. The Prostate Cancer InfoLink would advise all patients who are interested in potential chemotherapy following the failure of hormonal therapy to consider their options with great care. Clearly the advice of one or more medical oncologists may be appropriate. In addition, it may well be that certain types of chemotherapy should be considered only in a clinical trial setting. In general it would be wise to seek treatment from a medical oncologist with considerable specific experience in the management of patients with hormone-refractory prostate cancer.

Suramin is a compound that has frequently been mentioned as having potential in the treatment of hormone-refractory prostate cancer. While this is the case, and clinical trials of Suramin are proceeding, patients should understand that Suramin is a potentially highly toxic drug, and that the results from some trials appear not to be as positive as was once hoped. The Prostate Cancer InfoLink suggests that patients should only be treated with Suramin in a clinical trial setting under the guidance of experienced clinical investigators.

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The content in this section of the Phoenix 5 site was originally developed by CoMed Communications (a Vox Medica company) as part of The Prostate Cancer InfoLink. It is reproduced here with the permission of Vox Medica.

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