Let’s Talk About Treatments and Medications for Prostate Cancer
The "C" word can be scary, but with early detection and treatment the vast majority of men who get prostate cancer survive.by Matt McMillen Health Writer
You’ve just been told you have prostate cancer. Or, maybe someone you love has. That’s frightening, and no doubt you’ll want to know what’s coming next. The good news? We’re here for you, ready to explain your many treatment options—because there are plenty of them, including surgery, radiation, chemotherapy, hormone therapy, immunotherapy, and more. And if you need an extra dash of hope right now, know that most men—we’re talking a solid 98%—live at least 10 years following a diagnosis of this disease. In fact, some men never need any treatment at all. Keep reading. We’ll tell you all we know.
Our Pro Panel
We went to some of the nation's top experts in prostate cancer treatments to bring you the most up-to-date information possible.
Edmund Folefac, M.D.
Ohio State University Comprehensive Cancer Center
Isla P. Garraway, M.D.
Associate Professor and Director of Research
Department of Urology, David Geffen School of Medicine at UCLA
Daniel Ari Landau, M.D.
Medical Oncology and Hematology Specialty Section, Orlando Health UF Health Cancer Center
Not necessarily. Many prostate cancers grow so slowly that they will not cause symptoms or do any harm during your lifetime. Because of its side effects, treatment in such cases may do more harm than good. Talk with your doctor about the best approach for you before deciding which approach you feel most comfortable pursuing.
For many men with early stage prostate cancer, treatment can cure the disease. In fact, nearly 100% of men with such cancers live at least five years after diagnosis. However, if your cancer has spread beyond your prostate, or metastasized, your chance of a cure drops significantly. Only one in three men live five years after that has occurred.
In many cases, they can be managed to some extent. Your doctor may recommend anti-nausea medications during chemotherapy, for example. Exercise may help offset hormone therapy side effects such as muscle loss and fatigue. And there are many options available to help with erectile dysfunction.
You will undergo regular follow-up exams to be sure that your cancer has not come back. These include PSA tests and digital rectal exams. Your doctor will determine the best schedule for follow-up care. It’s normal to be worried about the possible return of your cancer, so make sure to have an emotional support network in place to help you, including friends, family, counselors, and other prostate cancer survivors.
First, What Is Prostate Cancer, Again?
Your prostate is located in front of your rectum and below your bladder. This one-ounce, walnut-shaped gland helps produce semen, that milky fluid that carries sperm through and then out of your penis when you ejaculate. It gets some assistance from the glands called seminal vesicles, which are attached to your prostate. Nearby nerves, blood vessels, and muscles help get your penis erect in the first place.
But things can go wrong with your prostate. Cells may start to grow and multiply in ways that they shouldn’t, eventually forming a tumor. While prostate cancer is the most common cancer in men, the good news is that it tends to grow very slowly—so slowly, in fact, that there are many methods to successfully treat it, with some men never requiring treatment, at all. And because prostate cancer most frequently occurs in men age 66 or older, those who have it are more likely to die of other causes.
However, prostate cancer can sometimes be aggressive. When this happens, it can grow quickly into a life-threatening disease. One of out of every 41 with prostate cancer will die from the disease. In 2020, it is expected to take the lives of more than 33,000 men. This makes it critical for you to understand the complexities of prostate cancer screening to up your odds of early detection, and to understand what kinds of treatment options await should you be diagnosed with the disease.
How Is the Best Treatment for My Prostate Cancer Determined?
There are lots of ways to treat prostate cancer, including surgery, radiation, hormone therapy, and chemotherapy. Again, for some men, the best option may be no treatment.
The biggest takeaway here? There’s no “one size fits all” approach. Your cancer treatment will be tailored to your specific needs. It may even change over time to respond to what’s happening in your prostate and other places in your body if the cancer has spread.
Let’s take a look at the major factors that guide treatment decisions.
The stage of your cancer. When you receive a diagnosis of prostate cancer, your doctor also will tell you its stage. Staging refers to how far the disease has progressed, ranging from stage 1 to stage 4. The higher the stage, the more advanced your cancer is. In stage 4, prostate cancer has spread well beyond the prostate to other parts of your body. This makes it much more challenging to treat. Fortunately, most prostate cancers are caught in the early stages, before they have metastasized, or spread. That makes them highly treatable—and often curable.
Your PSA level. Short for prostate-specific antigen, the PSA is a blood test that gives your doctor an idea of how aggressive, or fast-growing, your cancer is. For example, a PSA test result of 10 nanograms per milliliter or less indicates that your cancer may still be in Stage I. As the number climbs, however, so does your chance of having a more aggressive cancer.
Your Gleason score. Prostate tissue samples collected during your biopsy are examined by a pathologist, who scores them according to how different they appear compared to normal prostate tissue samples. The higher the score, the more aggressive, or dangerous, your cancer is. Gleason scores range from 6 to 10.
Why Does Prostate Cancer Sometimes Go Untreated?
It's about weighing which approach does the least harm. All treatment options come with possible side effects, and some of those side effects can be quite serious and potentially permanent. Ask your doctor for a thorough review of both the pros and cons of any proposed treatment plan.
We’ll first walk you through why your doctor might opt for no treatment, followed by the range of treatments options available if medications, surgery, or other therapies are instead deemed to be the best course of action.
No Immediate Treatment
If your doctor tells you that you have stage 1 or stage 2 prostate cancer, it’s very likely not life-threatening. (And isn’t that great news!) In fact, it may be growing so slowly that it will not cause you any harm or side effects during your lifetime.
If that’s the case, you have a couple of options that do not involve treatment, or at least not right away. These options include:
Active surveillance. While you won’t be treated for prostate cancer, your doctor will give you PSA tests and digital rectal exams (DRE) on a regular basis to make sure that your cancer remains at bay. (A rise in your PSA, however, would indicate that your cancer has become more aggressive.) Your doctor also may recommend that you undergo biopsies every 1 to 3 years. This will allow a specialist to closely examine tissue from your prostate to determine if there have been any changes not picked up by either the PSA or DRE.
Watchful waiting. If your doctor recommends watchful waiting, you will not undergo regular tests. Instead, your follow up care will focus mostly on symptoms that you eventually may experience. If symptoms do develop, you and your doctor will then decide whether or not treatment makes sense for you based on your age and current state of health.
One more thing to remember: Some doctors use the terms active surveillance and watchful waiting interchangeably, so don’t hesitate to ask for clarification when you first have the discussion.
What Are All the Treatment Options for Prostate Cancer?
If your doctor determines through screening and other tests that your prostate cancer requires treatment, there are a range of options to choose from, depending on your health and how aggressive your cancer may be. They include:
Surgery (Radical Prostatectomy)
If you have stage 1 or stage 2 prostate cancer, which means your cancer remains confined to your prostate, and have opted to undergo treatment, surgery may be the right option for you.
Most likely, you will have your entire prostate removed, as well as the seminal vesicles which are attached to it and some of the other surrounding tissue. Called a radical prostatectomy, it has an excellent chance of curing your prostate cancer.
This type of treatment kills or damages cancers cells, leaving them unable to grow and multiply. It may be recommended for any stage of prostate cancer.
Two main types of radiation therapy exist. They include:
External beam radiation therapy (EBRT). An external device blasts the cancer cells in your body with radioactive beams. (In different radiation clinics you may hear this approach called by different names, including CyberKnife, Gamma Knife, and X-Knife, which are simply the names of the companies that make the machines). These beams are guided by maps of your cancer that your doctor creates using imaging techniques like magnetic resonance imaging (MRI) and computerized tomography (CT, which creates cross-sectional images of your body using rotating X-ray machines). These images allow radiation specialists to pinpoint cancerous trouble spots and to calculate the appropriate dose of radiation and how many sessions you will need. That number can be as low as five, but it may be as high as 45. You’ll likely be offered EBRT if you have early-stage cancer. If your cancer has spread to your bones, it may also be used to help relieve the pain that this can cause.
Brachytherapy. For this treatment, small amounts of radioactive material are placed permanently inside your prostate. While there, it emits radiation that can kill cancer cells. Its effects are concentrated in a very small area to limit the effects of radiation on healthy cells. In one method, specialists permanently implant tiny radioactive pellets, or "seeds", into your prostate. These low-dose seeds become harmless after a year. A less common, high-dose brachytherapy approach is done using small tubes called catheters. A specialist inserts small catheters, or tubes, which have been filled with cancer killing radioactive material, into your prostate. The treatment takes place over two days, during which you will undergo one to four sessions that last 5 to 15 minutes. Often used to treat early-stage, slow-growing cancers, brachytherapy may be combined with EBRT if your cancer is likely to spread beyond your prostate.
Note: If you are treated with radioactive implants, avoid contact longer than five minutes at a time with children and pregnant women. This will protect them from the harmful effects of radiation.
Potential Side Effects of Surgery and Radiation
Surgery and radiation have equal track records for curing prostate cancer when it's caught early. But both come with the possibility of significant side effects, many of which are quite similar. You'll want to review the pros and cons of each option with your doctor, and then make the decision based on what you're most comfortable with. Possible side effects of surgery and radiation include:
Urinary and/or bowel issues. Leakage, sudden urges to pee, and difficulty getting the last drops out: All can occur after prostate cancer surgery. A rarer side effect from this procedure is the complete loss of bladder control. But there’s positive news, too: You can count on these difficulties disappearing over time, usually within several weeks to several months post-op. Men who choose radiation may also experience incontinence, as well as a burning sensation when they pee, and they may be more likely to experience diarrhea and/or irritation in the rectum, since radiation treatments can damage the bowel. According to the Mayo Clinic, such side effects from radiation are generally mild, tolerable, and temporary, although they may appear months to years after the procedure—and serious late-term side effects are uncommon.
Erectile dysfunction (ED). If you choose surgery, your surgeon will try to spare the nerves that control your ability to have an erection, which are located on the sides of your prostate. However, this is not always possible, especially if cancer cells can be found in those nerves or in nearby tissue. In such cases, the nerves must be removed, and you’ll be unable to have an erection on your own going forward. If your nerves don’t need to be removed, you may still have ED, but it will most likely be temporary. Radiation, on the other hand, can damage blood vessels in the penis, which over time can also mess with your erections, meaning you might not feel the effects of this treatment right away, but rather months or even years down the line. However, drugs and devices can help restore your ability to have sex, no matter which treatment option you choose.
Ejaculation problems. Your prostate and seminal vesicles play major parts in the production of semen, that milky fluid that carries sperm from your testicles to the outside world when you ejaculate. If both are surgically removed, that no longer happens. That may be tough to accept but know this: Your orgasm is not going anywhere. Yes, it will be “dry,” but more than likely it will still feel good. However, the American Cancer Society does warn that orgasms may not be as intense in your post-surgery life. For a small but not insignificant number of men, orgasms may even be painful. This pain may also occur after radiation therapy, although dry ejaculation does not always occur, and you may experience a drop in the amount of semen you ejaculate. Ask your doctor about what you can expect from surgery and radiation, including how it can affect your sex life.
Fertility loss. Depending on how old you are, this may not be an issue. After all, prostate cancer normally does not develop until long past the age when most men father children. The average age at diagnosis is 66, according to the ACS. But if this is a concern, especially if you’re still young, consider sperm banking, in which several sperm samples of yours will be frozen and stored until you need them.
Testosterone, a male sex hormone or androgen, fuels the growth of prostate cells, both healthy and cancerous. Hormone therapy, a.k.a. androgen deprivation therapy, cuts off that fuel supply, which can slow or stop your cancer, at least temporarily.
This approach also controls the production of your other main androgen, dihydrotestosterone (DHT), which also fuels the growth of prostate cells. Cancer doctors, called oncologists, most frequently employ hormone therapy if your cancer that has spread beyond the prostate, or metastasized. For some men with early-stage cancers, this treatment may be helpful when used in conjunction with radiation therapy.
Several different types of hormone therapy exist. They include:
Orchiectomy (surgical castration). This procedure removes your testicles, the primary producers of testosterone and DHT. This is an effective treatment, but for obvious reasons, most men are reluctant to choose it. In 2020, a study found that only 6% of men treated with hormone therapy underwent castration, despite it being the least expensive option in the U.S. Instead, the vast majority chose the equally effective medical alternative, LHRH agonists, which we’ll detail next.
LHRH (luteinizing hormone-releasing hormone) agonists. These drugs reduce the production of testosterone just as effectively as surgical castration. Given as injections or implanted under the skin in the form of pellets, you will receive this treatment ranging from once a month to once a year. This treatment is sometimes referred to as medical castration. The important distinction between medical and surgical castration? Your testicles are NOT removed. LHRH medications include:
Lupron Depot (leuprolide)
Zoladex (goserelin acetate)
LHRH (luteinizing hormone-releasing hormone) antagonists. This injectable drug treats advanced prostate cancer by lowering your testicles’ production of testosterone. The only FDA-approved drug in this class is Firmagon (degarelix).
Anti-androgens. Another type of hormone therapy, anti-androgens prevent male hormones like testosterone from binding with cancer cells. By doing so, they keep tumors at bay. They’re often used alongside other hormone therapies for advanced cancer. Drugs in this class include:
Casodex (bicalutamide )
Eulexin (flutamide )
Zytiga (abiraterone acetate)
The various types of hormone therapy are not without unpleasant side effects. They can affect your quality of life, mood, and energy levels. Yes, pretty much everything. Side effects include:
Lower libido or lack of sexual desire
Shrinkage of both your penis and testicles
Growth of breasts (called gynecomastia) and tenderness in breasts
Loss of muscle
Depression and decreased mental alertness
High blood pressure
Osteoporosis (or bone thinning that can lead to fractures)
If you have a very aggressive cancer that has spread outside your prostate, or hormone therapy has not worked for you, you may benefit from chemotherapy. For prostate cancer, this type of drug is typically delivered via infusion.
Different drugs will require different treatment schedules, but they usually are given every three weeks. How long you will continue on chemotherapy depends on how much the drugs help and how well you are able to tolerate the side effects. Chemotherapy drugs are not likely to cure your cancer, according to the ACS. Instead, you take them in order to live longer.
These are the chemotherapy drugs used to treat prostate cancer:
Chemotherapy can cause unpleasant but temporary side effects, such as:
Nausea, vomiting, and diarrhea
Bruising and bleeding
Numbness and tingling in your hands and feet, a condition called neuropathy, which may linger after chemo has ended.
This treatment enlists your immune system in your battle with cancer. It’s more effective in some cancers than others, and so far it has not been very successful in treating prostate cancer. Even so, researchers are hard at work studying ways to make it more beneficial for men with prostate cancer, especially those for whom hormone therapy no longer works. In 2019, more than 100 studies were being conducted to that end.
These are the immunotherapy drugs currently used for prostate cancer:
Provenge (sipuleucel-T) is for men with advanced cancer that has spread beyond the prostate. According to the FDA, men whose cancer had metastasized lived four months longer after taking this medication than men who did not take it.
Keytruda (pembrolizumab) showed in a 2018 study that it offered men with very advanced prostate cancer an additional 7.9 months before they succumbed to the disease.
Drugs in this class attack cancer cells without harming nearby healthy cells, which is why this approach is known as targeted therapy. Two different drugs, Rubraca (rucaparib) and Lynparza (olaparib), both target prostate cancers that involve BRCA gene mutations, the same mutation responsible for many cases of breast and ovarian cancers. Your doctor may recommend them if you no longer respond to hormone treatments. Scientists are investigating whether this type of medication is beneficial when combined with other types of treatment for prostate cancer.
Much about your treatment and medication regimen will be determined by the specific details of your prostate cancer when it’s diagnosed. Just know that you will likely have options from which to choose—and the vast majority of men who face this condition before it’s had the chance to spread survive it. Even those with metastatic disease have more powerful treatments available to them than ever before. If you’re struggling with treatment decisions, don’t hesitate. Talk to your doctor, or seek support from the American Cancer Society’s virtual resource.
Prostate Cancer : American Cancer Society. (2019). “What Is Prostate Cancer?” cancer.org/cancer/prostate-cancer/about/what-is-prostate-cancer.html
Prostate Cancer : American Urological Association. (2018). “What Is Prostate Cancer?” urologyhealth.org/urologic-conditions/prostate-cancer
Prostate Cancer Surgery: American Urological Association. (2018). “What Is Prostate Cancer?” urologyhealth.org/urologic-conditions/prostate-cancer
Prostate Cancer Radiation Therapy: Prostate Cancer Foundation. (n.d.). “What Is Radiation Therapy?” pcf.org/about-prostate-cancer/prostate-cancer-treatment/radiation-prostate-cancer
Prostate Cancer Hormone Therapy: American Cancer Society. (2019). “Hormone Therapy for Prostate Cancer.” cancer.org/cancer/prostate-cancer/treating/hormone-therapy.html
Prostate Cancer Chemotherapy: American Cancer Society. (2019). “Chemotherapy for Prostate Cancer.” cancer.org/cancer/prostate-cancer/treating/chemotherapy.html
Prostate Cancer Targeted Therapy: American Cancer Society. (2020). “Targeted Therapy for Prostate Cancer.” cancer.org/cancer/prostate-cancer/treating/targeted-therapy.html
Prostate Cancer Immunotherapy: American Cancer Society. (2019). “Immunotherapy for Prostate Cancer.” cancer.org/cancer/prostate-cancer/treating/vaccine-treatment.html