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Prostate Cancer Treatment

It is important to understand all of the various prostate cancer treatment options before making a decision that’s right for you. It is also important to consult with a urologist and a oncologist when making this decision. These specialists will be able to provide a comprehensive assessment of available treatments as well as expected outcomes.

Your treatment decision will be based on a number of clinical and psychological factors such as the need for therapy, your level of risk, your personal circumstances, and your own desires for therapy based on risks and benefits. In general terms it will be important for you to determine from your doctor several key factors that will affect treatment options.

These include:

  1. how aggressive is your cancer

  2. how good is your health,

  3. what is your anticipated life expectancy, and

  4. will prostate cancer treatment change your life expectancy.

It is important to note that there is still much to learn about prostate cancer therapy. There is uncertainty about what the best therapies are for different men and even whether some men require immediate therapy. Clinical trials are being conducted to better our understanding of various treatment options.

Learn more about:

Perineal Prostatectomy
Robotic Prostatectomy
Active Surveillance
Radiation Therapy
Hormone Therapy
Chemotherapy

Prostate Cancer Management and Treatment

If diagnosed with localized prostate cancer — cancer that has not spread to distant sites, like the bone and lymph nodes — management can take many forms, and it depends on the risk category of disease.

Active Surveillance of Prostate Cancer

Patients with very low-volume, low-grade disease (Gleason sum 6) who are very low risk, and even patients with low-risk disease (slightly more Gleason sum 6 disease), can consider active surveillance. This involves monitoring prostate cancer in its localized stage by serial PSAs and biopsies so that curative local treatment can be deferred until the disease progresses to a risk that warrants it.

The vast majority of data suggests this form of management for very low-risk prostate cancer. There is less data regarding low-risk disease, particularly in younger men. To ensure you are a candidate for surveillance, many providers favor the use of mpMRI, particularly in low-risk men, to make sure that more aggressive cancer is not being missed. The Johns Hopkins Hospital has offered surveillance in a highly organized program since 1994, and while surveillance is straightforward, it is encouraged that men on surveillance be managed by providers with expertise in prostate cancer.

More Information About Prostate Cancer Treatment from Johns Hopkins Medicine

How to Make Active Surveillance Safer

For carefully screened patients, active surveillance can prevent the unnecessary treatment of prostate cancer. However, this approach is not without potential side effects. Researchers are working to protect patients by helping them prevent infections from biopsies and reduce the risk of misclassified cancer.

Learn how to get the most out of active surveillance.

Watchful Waiting for Prostate Cancer

This is a very different strategy than active surveillance. Watchful waiting is intended for men that are too old or sick to benefit from local therapy. In these men, the intent is to observe the cancer until such time that it has spread to distant sites (metastasized) or is causing symptoms. This is typically performed by serial PSA measurement and imaging. Unlike surveillance, the intent of this strategy is not to capture the disease when at a curable stage. While not heavily practiced in the United States, level 1 evidence — the best evidence we have — supports this strategy in select men with limited life expectancy and low-risk or very low-risk disease.

Prostate Cancer Surgery

Men with localized prostate cancer that is intermediate risk or higher and with more than a limited life expectancy benefit from local therapy and are not good candidates for active surveillance. Surgery for localized prostate cancer is considered the gold standard. Surgery is now beginning to play a larger role in more aggressive prostate cancer, and it is beginning to be studied even in the setting of metastatic disease. For aggressive prostate cancer, surgery is usually part of a multimodal approach to cancer treatment, which is best orchestrated by a multidisciplinary team that includes urologists, radiation oncologists and medical oncologists.

In general, surgery can be performed in several ways. Primarily, surgeries will be either open radical prostatectomies via the retropubic approach or robot-assisted laparoscopic prostatectomies. Surgery should preferentially be performed in centers of expertise and by providers with expertise in prostate cancer. Not surprisingly, surgeries performed in high-volume centers by providers who routinely perform them result in the best outcomes. Robotic and open radical prostatectomies performed at expert centers like Johns Hopkins have very similar hospital courses, oncologic outcomes and functional outcomes. Some patients may benefit more from one approach or the other, but many are candidates for either. You should ask your provider which form of surgery is best for you.

  • Open radical prostatectomy : The prostate gland and seminal vesicles, as well as in some cases the draining lymph nodes of the pelvis, are removed in this surgery. This is done through an approximate 4-inch incision below the bellybutton toward the pubic bone (the bone above the penis). The surgery remains outside of the abdominal cavity.

  • Robot-assisted laparoscopic radical prostatectomy : This surgery is performed with the aid of a robot controlled by a surgeon. Multiple small incisions are made in the abdomen to allow for the robotic arms and camera. The camera incision is then extended to allow for removal of the prostate.

Surgery for prostate cancer requires a stay in the hospital. Typical hospital stays are one to two days.

Regardless of approach, you should expect to be walking the night of or the day after surgery, and you are usually eating normal food by the afternoon of the day after surgery. During surgery, a urinary catheter will be inserted, which will allow the bladder to heal to the urethra. This is typically kept in place for 10 to 14 days after surgery.

Robotic Prostate Surgery | Q&A

Thanks to advances made by surgeons like Dr. Patrick Walsh, The Brady Urological Institute at Johns Hopkins offers unparalleled prostatectomy expertise. Learn more about prostate cancer surgery and the difference between open and robotic procedures from Dr. Mohamad Allaf.

Recovery from Prostatectomy

Prostate cancer surgery is both oncologic (involves removal of the cancer) and reconstructive. In addition, the nerves that control erection run along the prostate, and even if completely spared, they are very delicate and can take time to recover. Recovery from prostate cancer usually involves a process of regaining urinary control (continence) and erectile function (potency).

  • Incontinence: Incontinence is the inability to control urine and may result in leakage or dribbling of urine. Incontinence is common just after surgery, but some men may be dry immediately following catheter removal. Normal control returns for many patients within several months, with the minority of patients remaining permanently incontinent.

  • Impotence: Impotence is the inability to have an erection of the penis. Full erectile recovery can take two to three years. While recovering, many men will benefit by the use of oral medicals, like sildenafil, and some may benefit from injection therapy. The nerves controlling sensation to the prostate and orgasm are not affected by prostate surgery. The degree of erectile dysfunction relates to the cancer burden, how much of the nerves the surgeon must remove, the patient’s ability to have an erection before surgery and the patient’s age.

Radiation for Prostate Cancer

Radiation is also an effective treatment for prostate cancer. Radiation can be delivered in several ways, including use of seeds (brachytherapy) and external beam radiation. Radiation is performed by radiation oncologists and is best delivered in high-volume centers of excellence.

For low-risk disease, brachytherapy or external beam radiation can be performed. If disease is of higher risk (intermediate and above), strategies that combine radiation with short- or long-term androgen deprivation or that combine brachytherapy with external beam radiation are employed, with a goal of either weakening the prostate cancer or exposing it to a higher dose of radiation. External beam radiation should be given with image guidance and intensity modulation. Radiation can be useful not only for localized prostate cancer, but also for metastatic sites. Stereotactic radiation to these sites is being investigated.

The side effects of radiation for localized disease include irritation to the bowel and bladder, and erectile dysfunction, though the development of erectile dysfunction is different than surgery, with it taking longer to occur. Radiation is very rarely associated with severe side effects.

More Information About Prostate Cancer Treatment from Johns Hopkins Medicine

Radical Prostatectomy vs. Radiation: How to Compare the Results

Making a decision about prostate cancer treatment is not easy. When considering radiation therapy or radical prostatectomy, one of your top concerns is seeking reassurance that your cancer will be cured following treatment.

Find out how to manage your PSA levels and your expectations after both types of treatment.

Systemic Therapy for Prostate Cancer

When disease is spread throughout the body, a component of treatment should also include systemic therapy, which can affect cancer cells spread throughout the body. Typically, this was through the use of androgen deprivation through chemical castration. New evidence suggests that the combination of androgen deprivation with chemotherapy may be beneficial, particularly in men with high-volume metastatic disease. Further, multiple new therapies and treatment regimens for metastatic prostate cancer have emerged. Consultation with a medical oncologist specializing in prostate cancer is important for those men with widespread disease. In addition to its typical role in metastatic prostate cancer, chemical castration is commonly employed when using radiation therapy for intermediate or high-risk prostate cancer for a short term — four to six months — or a longer term — two to three years. Further, in very high-risk, localized disease, often thought to be micrometastatic, systemic therapies are thought to be of possible benefit. Standard and novel therapies are being tested in this setting.

More Information About Prostate Cancer Treatment from Johns Hopkins Medicine

A Major Game-changer for Men with Metastatic Prostatic Cancer

A study has proven that early treatment with both chemotherapy and hormonal therapy has a major impact on survival and quality of life.

Learn more about the results.

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