A surgical approach toward the treatment of prostate cancer can
be used to remove all or part of the prostate. Typically, men
with early-stage disease or cancer that is confined to the
prostate will undergo radical prostatectomy, or surgical removal
of the entire prostate gland plus some surrounding tissue. This
procedure is described below. Other
surgical procedures may be performed on men with
advanced or recurrent disease.
In the most common type of prostatectomy,
known as radical retropubic prostatectomy, an incision is made
in the abdomen and the prostate is cut out from behind the pubic
bone. After removing the prostate, the surgeon stitches the
urethra directly to the bladder so urine is able to flow.
(Review the roles of the prostate and the surrounding organs in
the Prostate section.)
Because it typically takes a few days for
the body to get used to this new setup, the surgeon will insert
a catheter, or tube, into the bladder. With this in place, urine
flows automatically out of the bladder, down the urethra, and
into a collection bag without the need for conscious control of
the sphincter. The catheter is usually kept in place for about a
week to 10 days.
Another type of surgery, known as radical
perineal prostatectomy, is performed less frequently these days.
In this approach, the surgeon makes the incision in the
perineum, or the space between the scrotum and the anus, and the
prostate is removed from behind.
In a nerve-sparing prostatectomy, the surgeon cuts to the
very edges of the prostate, taking care to spare the erectile
nerves that run alongside the prostate. In cases when the nerves
cannot be spared because the cancer extends beyond the prostate,
surgically attaching, or grafting, nerves from other parts of
the body to the ends of the cut erectile nerves might be
In laparoscopic surgery, very small
incisions are made in the abdomen, into which the surgeon
inserts narrow instruments fitted with cameras and/or surgical
tools, allowing the surgeon to visualize and operate on the
internal structures without cutting open the entire abdomen.
With a robotic interface, the surgeon maneuvers the robotís
arms, which in turn control the cameras and instruments inserted
in the abdomen.
The Importance of
Prostatectomy, like many surgical procedures, is very delicate
work, and the difference between a good surgeon and a great
surgeon can affect outcomes. When choosing a surgeon, at a
minimum, ensure that he or she is someone in whom you have
confidence, and someone who has enough experience to not only
perform the operation, but to also make an informed clinical
judgment and change course should the need arise.
Radiation involves the killing of cancer
cells and surrounding tissues with directed radioactive
exposure. (Review the roles of the prostate and the surrounding
organs in the About
the Prostate section.)
The use of radiation therapy as an initial
treatment for prostate cancer is described below. Some forms of
radiation therapy can also be used in men with advanced
or recurrent prostate cancer.
The most common type of radiation therapy is external beam
radiotherapy. CT scans and MRIs are used to map out the location
of the tumor cells, and x-rays are targeted to those areas. With
3D conformal radiotherapy, a computerized program maps out the
exact location of the prostate tumors so that the highest dose
of radiation can reach the cancer cells within the gland.
Intensity-modulated radiation therapy (IMRT)
allows oncologists to modulate, or change, the intensity of the
doses and radiation beams to better target the radiation
delivered to the prostate, while at the same time delivering
lower doses to the tumor cells that are immediately adjacent to
the bladder and rectal tissue. In some centers, proton-based
therapy is used during IMRT rather than the more traditional
photon-based therapy. Although early studies have shown that
oncologists may be able to manipulate these beams even more
precisely, this technology is not yet widely available.
Because the treatment planning with these
types of radiation therapy are far more precise, higheróand
more effectiveódoses of radiation can be used with less chance
of damaging surrounding tissue.
Regardless of the form of external
radiation therapy, treatment courses usually run five days a
week for about seven or eight weeks, and are typically done on
an outpatient basis.
With brachytherapy, tiny little metal pellets containing
radioactive iodine or palladium are inserted into the prostate
via needles that enter through the skin behind the testicles. As
with 3D conformal radiation therapy, careful and precise maps
are used to ensure that the seeds are placed in the proper
Over the course of several months, the
seeds give off radiation to the immediate surrounding area,
killing the prostate cancer cells. By the end of the year, the
radioactive material degrades, and the seeds that remains are
Compared with external radiation therapy,
brachytherapy is less commonly used, but it is rapidly gaining
ground, primarily because it doesnít require daily visits to
the treatment center.
The Importance of
Just as surgical skill can play an important role in determining
outcomes from prostatectomy, technical skill and manual
dexterity can play an important role in determining outcomes
from radiation therapy. The use of computer software to assist
with the dose planning and target prostate tissue helps greatly,
but, in the end, the skill and experience of the radiation
oncologist will make the biggest difference.
When choosing a radiation oncologist, at a
minimum, make sure he or she has broad experience with
an assortment of approaches and can objectively help to decide
on the best course of treatment.
Prostate cancer cells are just like all
other living organismsóthey need fuel to grow and survive.
Because the hormone testosterone serves as the main fuel for
prostate cancer cell growth, it is a common target for
therapeutic intervention in men with prostate cancer.
Hormone therapy, also known as
androgen-deprivation therapy or ADT, is designed to stop
testosterone from being released or to prevent the hormone from
acting on the prostate cells. Although hormone therapy plays an
important role in men with advancing prostate cancer, it is
increasingly being used before, during, or after local treatment
The majority of cells in prostate cancer
tumors respond to the removal of testosterone. But some cells
grow independent of testosterone, and therefore remain
unaffected by hormone therapy. As these hormone-independent
cells continue to grow unchecked, over time, hormone therapies
have less and less of an effect on the growth of the tumor.
Hormone therapy is therefore not a perfect
strategy in the fight against prostate cancer, and does not cure
the disease. But it remains an important step in the process of
managing advancing disease, and will likely be a part of every
manís therapeutic regimen at some point during his fight
against recurrent or advanced prostate cancer.
The most common types of hormone therapy
are described below. Although each of these therapeutic options
is effective at controlling prostate cancer growth, the loss of
testosterone confers significant side effects in nearly all men.
(A review of how best to manage side effects from testosterone
loss can be found in the Side
Because about 90% of testosterone is produced by the testicles,
surgical removal of the testicles, or orchiectomy, is an
effective solution to blocking testosterone release. This
approach has been used successfully since the 1940s, but because
itís a permanent and irreversible surgical solution, most men
opt for drug therapy instead.
For men who choose this option, the
procedure is typically done on an outpatient basis in the
urologistís office. Recovery tends to be rather quick and no
further hormone therapy is needed, making orchiectomy a very
attractive choice for someone who prefers a low-cost, one-time
LHRH, or luteinizing-hormone releasing hormone, is one of the
key hormones released by the body before testosterone is
produced. (Note that LHRH is sometimes called GnRH, or
gonadotropin-releasing hormone.) Blocking the release of LHRH
through the use of LHRH agonists or LHRH analogues is one of the
most common hormone therapies used in men with prostate cancer.
Drugs in this class, including leuprolide
(Eligard, Lupron, and Viadur), goserelin (Zoladex), and
triptorelin (Trelstar), are given in the form of regular shots:
once a month, once every three months, once every four months,
or once per year.
The term "chemotherapy" refers
to any type of therapy that uses chemicals to kill or halt the
growth of cancer cells. The drugs work in a variety of ways, but
are all based on the same simple principle: stop the cells from
dividing and you stop the growth and spread of the tumor.
Until recently, chemotherapy was used only
to relieve symptoms associated with very advanced or metastatic
disease. With the publication of two studies in 2004 showing
that the use of docetaxel (Taxotere) can prolong the lives of
men with prostate cancer that no longer responds to hormone
therapy, more and more doctors are recognizing the potential
benefits of chemotherapy for the men they treat with advanced
Building on these successes, there are now
dozens of clinical trials studying various combinations of
chemotherapy drugs, some using new mixes of older drugs and some
using newer drugs. Some trials are looking to find a
chemotherapy regimen thatís more tolerable or more effective
than docetaxel in men with metastatic disease, others are
looking to find a chemotherapy regimen that can delay the onset
of metastases, and still others are seeking to improve upon the
results with docetaxel by adding to it other novel agents and
testing the combination.
Paramount in all researchersí minds is a
way to maximize benefit while minimizing side effects.
Chemotherapy, like all powerful drugs, can take a toll on the
body. A review of how to best manage the side effects of
chemotherapy can be found in the Side
Off-Label Chemotherapy Use
Strictly speaking, few chemotherapy agents
have been approved by the FDA for use in prostate cancer. But
over the years, doctors have found that some medications that
are regularly used in other types of cancers can be used rather
effectively in men with prostate cancer.
Off label use of a drug means that the
drug is approved by the FDA for use in one disease but is being
used in another. The drug is known to be safe overall, and
has been proven effective for the disease in which itís
approved. That doesnít mean itís not effective in prostate
cancer as well; it just means that the drug hasnít been
rigorously tested in prostate cancer, so thereís no formal
"proof" that itís effective. Nevertheless, off-label
use of chemotherapy is common, and its use is often found to be
beneficial in men with prostate cancer.
Because very few drugs will score a home
run in every person, second-line chemotherapy has a long and
valued tradition in the treatment of cancer. In this setting,
off-label drugs are common, and are chosen specifically because
they work somewhat differently than what was used first,
providing another chance to see a benefit.
Other Treatment Options
Surgery and radiation therapy remain the
standard treatment for localized prostate cancer, but other,
less popular treatment options might be beneficial as well. As
time goes on and the benefits of these treatment options are
further explored, itís possible that they will move more into
the mainstream. For now, though, none are seen as standard
treatments for localized prostate cancer.
Cryotherapy, also known as cryosurgery or cryoablation, has been
around for years, but until a few years ago, it was rarely used.
With this approach, probes are inserted into the prostate
through the perineum (the space between the scrotum and the
anus), and argon gas or liquid nitrogen is delivered to the
prostate, literally freezing to death the prostate cells and any
prostate tumors. (Review the roles of the prostate and the
surrounding organs in the About
the Prostate section.)
Over the years, a number of modifications
were made to avoid freezing damage to the nearby structures, but
the rates for both erectile and urinary dysfunction remain high,
and data on long-term outcomes are limited.
Cryotherapy is also used as a secondary
local therapy in men who underwent radiation therapy as initial
treatment for early-stage prostate cancer. Note that men with
more well-confined disease tend to fare better, while those who
received hormone therapy in addition to radiation therapy tend
to fare worse.
High-Intensity Focused Ultrasound
High-intensity focused ultrasound, or HIFU, works in exactly the
opposite way compared with cryotherapy: with HIFU, the prostate
cells are heated to death. A probe is inserted into the rectum,
from which very high-intensity ultrasound waves are delivered to
the target area. Although this technique remains experimental in
the United States, itís been used in Europe for a number of
years with a fair amount of success.
Primary Hormone Therapy
Hormone therapy, also known as androgen-deprivation therapy or
ADT, is designed to stop testosterone from being released or to
prevent the hormone from acting on the prostate cells. (A review
of common hormone therapy strategies can be found in the Hormone
Although there is little, if any, data to
show that hormone therapy alone is an effective treatment
strategy for men with localized prostate cancer, it is
increasingly being used in this setting. Because it is not
invasive, it is possible that the therapy is seen as a middle
ground between active surveillance and local therapy.
In labs around the world, researchers are
busy identifying new drugs, new regimens, and new treatment
approaches that might prove beneficial to men with prostate
cancer. Most of these investigational agents are being tested in
men with advanced prostate cancer: Therapy options for men at
this stage of disease are often not effective enough to halt
progression of the disease, and men are typically affected by
side effects from the disease and/or the medications that
theyíre taking. Itís therefore the perfect stage at which to
test out new drugs because any improvement will likely be
rapidly noticed and much appreciated.
The Goal of Targeted Therapies
Chemotherapy drugs can play an important role
in improving the lives of men with advanced prostate cancer, but
they often donít distinguish between tumor cells and healthy
cells and can kill off some normal cells along the way.
So-called targeted therapies, by contrast, are drugs that are
specifically designed to interfere with the way cancer cells
grow, with the way cancer cells interact with each other, and/or
with the way that the immune system interact with the cancer.
There are a number of different kinds of
targeted therapies being investigated for prostate cancer. As of
yet, none have been approved by the FDA for use in prostate
cancer, but the excitement generated by some of the early
studies have led many researchers to believe that itís only a
matter of time before a targeted therapy is found that can
result in better outcomes overall.
Interfering With Cancer Cell Growth
All cells in the body, including cancer
cells, rely on a complex communication system to know when to
grow, when to divide, and when to die. This system uses
specialized proteins, fats, and other substances to tell the
different cells or parts of cells how to act. Over the years,
cancer researchers have been studying ways to interfere with the
signaling system that regulates the growth of cancer cells.
So far, interfering with cellular
signaling to halt cancer cell growth hasnít yet proven to be a
very effective strategy in prostate cancer. But in the process
of learning which drugs might work and why, researchers found
that the strategy of adding a "targeted therapy" to
other effective drugs in order to see better results than with
either drug alone is an important part of cancer research. The
idea is to exploit the synergy between the two drugs, or the
ways in which the two drugs might work together to fight off the
Interfering With Cancer Cell Spread
As cancer cells divide and start to spread,
new blood vessels sprout from the old ones to help supply the
necessary nutrients to the new tumor site via a process called
angiogenesis. If angiogenesis could be inhibited, researchers
theorized, the new tumor cells would die and the cancerís
growth would be halted.
In 2004, the angiogenesis inhibitor
bevacizumab (Avastin) was approved by the FDA for use in
colorectal cancer. Since then, it has been shown to improve
outcomes in women with breast cancer, and is currently being
studied in a number of other cancer types, including prostate
cancer. Although no other drugs currently available were
designed to specifically act as an angiogenesis inhibitor,
researchers have found that the drug thalidomide (Thalomid) has
some anti-angiogenic properties, and is also currently being
tested in men with prostate cancer.
Harnessing the Immune System to Fight Off Cancer Cells
In order for the immune system to fight off
foreign invaders, it has to learn to recognize whatís normal
and whatís not normal. Unfortunately, because cancer cells
start out as normal healthy cells, the immune system never has a
chance to learn to distinguish between the normal cell and the
Unlike preventive vaccines, which are
designed to teach the immune system to develop a way to fight
off a specific virus should it come into contact with that same
virus again, therapeutic vaccines stimulate the immune system to
recognize and fight certain proteins specific to cancer cells.
Each of the therapeutic vaccines currently being tested in men
with advanced prostate cancer works in a slightly different
fashion, but all are designed to harness the immune systemís
ability to fight off disease and teach it to fight off prostate
The Prostate Cancer Foundation has put together a comprehensive
list of useful resources, including publications and links,
to better educate and assist those individuals seeking
Prostate Cancer Guides
The Prostate Cancer
Foundation has produced three prostate cancer guides that can be
ordered or downloaded from this website:
Introduction to Prostate Cancer
This brief introductory guide is designed to help men and their
families and friends understand the risk factors for prostate
cancer, find out how prostate cancer is diagnosed, and look at
the different treatment options that can be used. (7 pages)
a free copy or download
a copy in PDF format.
to the Nation: A Guide for Men and Their Families
This guide provides in-depth information about the diagnosis of
prostate cancer, the available treatment options at each stage
of the disease and more. The Guide highlights key
issues that men with prostate cancer face at every step of the
way, and includes a set of tear-out, wallet-sized cards with
questions to ask their doctors at each stage of disease. (108
the Guide online, order
a free paper copy by completing the registration form or download
a copy in PDF format.
and Prostate Cancer
The Nutrition and Prostate Cancer guide summarizes the
"best of the best" data and information available in
the research arena today, and is designed to help everyone
affected by or at risk for prostate cancer understand how key
nutritional strategies can be incorporated into everyday life.
a free paper copy by completing the registration form or download
a copy in PDF format.
of Key Terms
About Prostate Cancer