What are the treatment options for prostate cancer?

The treatment of prostate cancer depends on:

• the stage;
• size and location of the tumor;
• benefit/ risk assessment;
• patient overall health.

Treatment is generally discussed by a multidisciplinary team of specialists, including surgeons, urologists, oncologists, and radiotherapists. Patient is also a part of the team.

When several treatment options are available, doctors should involve patients in making decisions. In this case, patients will be fully informed and involved in treatment decision-making.

Immediate treatment may not always be necessary.

Active surveillance

Low-grade prostate cancer may not need treatment right away. For some, treatment may never be needed, as many patients can live a normal life with slow-growing prostate cancer for several years. Doctors recommend active surveillance in such cases.

Active surveillance may include:

• regular follow-up blood tests;
• rectal exams;
• prostate biopsies;
• MRI scans^1,2.

These tests will help to monitor the progression of the cancer.

Active surveillance may be an option for men with low- or intermediate-risk localized prostate cancer³.

If tests show cancer progressing, patients may opt for a prostate cancer treatment such as surgery or radiation therapy.

Surgery

• Radical prostatectomy is the operation to remove the entire prostate gland and surrounding tissues, including the seminal vesicles and nearby lymph nodes. Radical prostatectomy aims to remove the tumor mass and cure the cancer completely. It is suitable for patients with localized or locally advanced prostate cancer³. For treating advanced prostate cancer, it is often used alongside other therapies.
• Surgical removal of the testicles, orchidectomy, is used in patients with advanced prostate cancer to control its growth by reducing testosterone secretion. It can relieve symptoms or help control the spread.

Radiotherapy

Radiotherapy uses ionizing radiation to damage and kill cancerous cells. It is a recommended treatment option for men with localized or locally advanced prostate cancer³.

Two types of curative radiation therapy may be used to treat prostate cancer:

• External beam radiotherapy (radiation comes from a machine outside the body). During external beam radiation therapy, a patient lies on a table, and the machine moves around the body to direct high-powered energy beams (such as X-rays or protons) to the cancer.
• Brachytherapy (radiation source placed inside the body) directs radiation to cancer from a radioactive source placed either permanently or temporarily through catheters inside the prostate gland. An advantage of this radiotherapy type is the limitation of the dose to the surrounding organs.

In some situations, doctors combine different radiation therapy methods.

Following External Beam Radiation Therapy (EBRT) modalities allow for more precise targeting of radiation on the tumor: 

• Modulated Radiation Therapy (IMRT) is a sophisticated form of external beam radiation therapy where oncologists can customize the intensity and the shape of the radiation beams. The radiation targets cancer cells in the prostate, minimizing exposure to the bladder and rectal tissue.
• Proton Beam Therapy is a specialized form of external beam radiation therapy that is becoming more common in centers equipped to provide it. The main benefit of proton therapy is the proton’s beam ability to stop at the tumor’s borders, preventing an “exit dose” that could affect nearby, healthy tissues in areas outside of the prostate target.
• Stereotactic Body Radiation Therapy (SBRT) or Stereotactic Ablative Radiation Therapy (SABR) delivers large doses of radiation over a short period to a precise area. SBRT can offer some patients with localized prostate cancer the convenience of fewer treatments while maintaining treatment effectiveness and safety. SBRT may also be used to treat metastatic prostate cancer.
• Image-guided Radiation Therapy (IGRT) is used for daily imaging to check the tumor target’s position. Most often, this may include a low-dose X-ray or CT scan. For some patients, gold or platinum fiducial markers may be placed in the prostate before treatment. These markers show up on imaging scans and help the radiation oncologist see the tumor’s position
• Radium-223 Therapy is used to treat men with metastatic prostate cancer that no longer responds to hormone therapy. Because it mimics calcium, the radium is selectively absorbed into areas where prostate cancer invades bone (it is important when metastatic prostate cancer spreads to the bones).

Hormone therapy

Hormone therapy does not cure prostate cancer on its own; it is used in combination with surgery or radiotherapy.

Prostate cancer cells need testosterone to grow. Hormone therapy drugs block or lower the amount of testosterone in the body that can help to:

• reduce the risk of prostate cancer coming back after treatment;
• slow the growth of the cancer.

Hormone therapy can effectively keep cancer under control but, on its own, is not a curative treatment. 

Main types of hormone therapy used in the treatment of prostate cancer:

• Androgen deprivation therapy. It stops the testicles from producing testosterone. There are two types of androgen deprivation therapy:
  • Luteinizing hormone-releasing hormone agonists (e.g., leuprorelin, goserelin, buserelin, triptorelin);
  • Gonadotropin-releasing hormone antagonists (e.g., degarelix).

These drugs are given by injection or in implants.

• Anti-androgens (e.g. bicalutamide, flutamide, enzalutamide, apalutamide, darolutamide). This type of hormone therapy prevents testosterone from reaching the cancer cells.

Chemotherapy

Chemotherapy (e.g., docetaxel, cabazitaxel) destroys rapidly growing cells, including cancer cells. Chemotherapy can be administered through an intravenous infusion, taken as tablets, or both.

Chemotherapy may be considered as a treatment for prostate cancer that has spread to other parts of the body or for cancers that do not respond to hormone therapy, which is the primary drug therapy for prostate cancer.

Steroids may be prescribed alongside chemotherapy to make it more effective and lower the risk of side effects.

Targeted therapy

Targeted therapy focuses on specific biological processes present in cancer cells. The doctor can prescribe targeted therapy drugs if the prostate cancer:

• has spread from the prostate to other parts of the body;
• doesn’t respond to hormone treatments;
• has specific genetic changes or mutation.

As an example, the drug Olaparib blocks the actions of an enzyme involved in DNA repair. It is used in some men with metastatic prostate cancer who do not respond to hormone therapy and have mutations in the BRCA1 or BRCA2 genes.

Targeted therapy can be combined with radionuclide therapy. In this case, the targeted agent binds to markers expressed on tumor cells and thus delivers radiation to the tumor. This method allows for reducing side effects to surrounding normal tissues.

As mentioned in the article “Prostate Cancer – Overview”, treatment protocols for prostate cancer depend on the size, location and stage of the tumor.

Patients can be divided into 5 groups depending on the above criteria for prostate cancer. There are patients with:

• localized prostate cancer;
• locally advanced prostate cancer;
• prostate cancer that returns after treatment (recurrent prostate cancer);
• non-metastatic castration-resistant prostate cancer;
• metastatic prostate cancer.

Despite the best possible options for treatment and diagnosis, there is still a possibility that prostate cancer may return. Cancer that comes back is called a recurrent one.

PSA levels are monitored following the first-line treatment. If PSA levels rise, further treatment may be needed.

Recurrent prostate cancer can be treated with radiotherapy, surgery, and/or hormone therapy.

Prostate cancer that continues to grow despite treatment with androgen deprivation therapy is known as castration-resistant prostate cancer (CRPC). Non-metastatic CRPC is unusual because CRPC typically develops AFTER the detection of metastases. There are a few treatment options for this group of patients: anti-androgens apalutamide, darolutamide, and enzalutamide³.

More than 900 clinics worldwide treating prostate cancer are here: https://doctor.global/results/diseases/prostate-cancer. For example, radical prostatectomy is performed in more than 700 clinics all over the world for an approximate price of:

• Turkey – $5.1 K;
• Germany – $21.5 K;
• Saudi Arabia – $7 K;
• India – $7 K;
• South Korea – $13.4 K;
• Mexico – $3.5 K.

References:

1. Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Approved by the ESMO Guidelines Committee: February 2002, last update June 2020. Ann Oncol. 2015;26(suppl 5):v66-v77.

2. Mayo Clinic’s recommendations about prostate cancer. Prostate cancer – Diagnosis and treatment – Mayo Clinic. Accessed 08.04.2024

3. Parker C, Castro E, Fizazi K, et al. ESMO Guidelines Committee. Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2020;31(9):1119–1134.

The overview of prostate cancer and treatment information is in the video hereunder: