Treatment for prostate cancer

This is a way of closely monitoring low-risk prostate cancer that isn’t causing any symptoms or problems. The aim is to avoid unnecessary treatment, while looking for changes that mean treatment should start.

Active surveillance may be suggested for prostate cancers with a PSA level under 10 ng/mL, stage T1–2, and Gleason 6 or less (Grade Group 1 and some Grade Group 2). About 70% of Australians with low-risk prostate cancer choose active surveillance.

Active surveillance usually involves PSA tests every 3–6 months; a digital rectal examination every six months; and repeat mpMRI scans and biopsies as advised by your urologist. Ask your doctor how often you need check-ups. If results show the cancer is growing faster or more aggressively, your specialist may suggest starting active treatment.

Choosing active surveillance avoids treatment side effects, but you may feel anxious about not having active treatment. Talk to your doctors about ways to manage any worries, or call Cancer Council
13 11 20.

Watchful waiting is another way of monitoring prostate cancer. This approach may be suggested if you are older and the cancer is unlikely to cause a problem in your lifetime. It may be an alternative to active treatment if the cancer is advanced at diagnosis. It can also be an option if you have other health problems that would make it hard to handle treatments such as surgery or radiation therapy.

The aim of watchful waiting is to maintain quality of life rather than to treat the cancer. If the cancer spreads or causes symptoms, you will have treatment to relieve symptoms or slow the growth of the cancer, rather than to cure it. Watchful waiting usually involves fewer tests than
active surveillance. You will have regular PSA tests and you probably won’t need to have a biopsy.

Choosing watchful waiting avoids treatment side effects, but you may feel anxious about not having active treatment. Talk to your doctors about ways to manage any worries, or call Cancer Council
13 11 20.

The main type of surgery for localised and locally advanced prostate cancer is a radical  prostatectomy. This involves removing the prostate, part of the urethra and the seminal vesicles. After the prostate is removed, the urethra will be rejoined to the bladder and the vas deferens (tubes that carry sperm from the testicles to the penis) will be sealed.

Some people are able to have nerve-sparing surgery, which aims to avoid damaging the nerves  that control erections. Your doctor will discuss whether this is an option for you. Nerve-sparing radical prostatectomy is more suitable for lower-grade cancers and is only possible if the cancer is not in or close to these nerves. It works best for those who had strong erections before diagnosis. Problems with erections are common even if nerve-sparing surgery is performed.

Cancer cells can spread from the prostate to nearby lymph nodes. For intermediate-risk or high-risk prostate cancer, nearby lymph nodes may also be removed (pelvic lymph node dissection).

How the surgery is done

Different surgical methods may be used to remove the prostate:

• open radical prostatectomy – usually done through one long cut in the lower abdomen
• laparoscopic radical prostatectomy (keyhole surgery) – small surgical instruments and a camera are inserted through several small cuts in the abdomen. The surgeon performs the procedure by moving the instruments using the image on the screen for guidance
• robotic-assisted radical prostatectomy – laparoscopic surgery performed with help from a robotic system. The surgeon sits at a control panel to see a three-dimensional picture and move robotic arms that hold the instruments.

Click on image to enlarge

Making decisions about surgery

Talk to your surgeon about the surgical methods available to you. Ask about the advantages and disadvantages of each option. There may be extra costs involved for some procedures and they are not all available at every hospital. You may want to consider getting a second opinion about the most suitable type of surgery.

The surgeon’s experience and skill are more important than the type of surgery offered. Compared to open surgery, both standard laparoscopic surgery and robotic-assisted surgery usually mean a
shorter hospital stay, less bleeding, a smaller scar and a faster recovery. Current evidence suggests that the different approaches have a similar risk of side effects (such as urinary and erection problems) and no difference in long-term outcomes.

What to expect after surgery

Recovery time – Whichever surgical method is used, a radical prostatectomy is major surgery and you will need time to recover. You can expect to return to your usual activities within about six weeks of the surgery. Usually you can start driving again in a couple of weeks, but heavy lifting should be avoided for six weeks.

Pain and discomfort – It’s common to have pain after the surgery, so you may need pain relief for a few days.

Having a catheter – After a radical prostatectomy you will have a thin, flexible tube (catheter) in your bladder to drain your urine into a bag. The catheter will be removed after 1–2 weeks once the wound has healed.

Side effects of prostate cancer surgery

You may experience some or all of the following side effects:

Nerve damage – The nerves needed for erections and the muscle that controls the flow of urine (sphincter) are both close to the prostate. It may be very difficult to avoid these during surgery, and any damage can cause problems with erections and bladder control. Sometimes the nerves will need to be removed to try to ensure all cancer is removed.

Loss of bladder control – You can expect to have some light dribbling or trouble controlling your bladder for some weeks to months after a radical prostatectomy. This is known as urinary incontinence or urinary leakage. You can use continence pads to manage urinary leakage. Bladder control usually improves in a few weeks and will continue to improve for up to a year after the surgery. In the long term, some people will continue to have some light dribbling. Some people may consider having an operation to fix urinary incontinence. In rare cases, people have no control over their bladder.

Changes in erections (impotence) – Problems getting and keeping erections after prostate surgery are common. Erections may improve over months to a few years. It’s more likely you won’t get strong erections again if erections were already difficult before the operation.

Changes in ejaculation – During a radical prostatectomy, the tubes from the testicles (vas deferens) are sealed and the prostate and seminal vesicles are removed. This means semen is no longer ejaculated during orgasm (a dry orgasm). Your orgasm may feel different – for some people it may be uncomfortable or, rarely, painful. Some people may leak a small amount of urine during orgasm (this is not harmful to you or your partner).

Infertility – A radical prostatectomy will cause infertility and you will not be able to conceive a child without medical assistance. If you wish to have children, talk to your doctor before treatment about sperm banking or other options.

Changes in penis size – You may notice that your penis gradually becomes a little shorter after surgery. Talk to your doctor about whether vacuum erection devices and prescription medicines may help.

Download our booklet ‘Understanding Surgery’

Also known as radiotherapy, radiation therapy uses a controlled dose of radiation to kill or  damage cancer cells so they cannot grow, multiply or spread. Radiation therapy may be used:

• for localised or locally advanced prostate cancer – it has similar rates of success to surgery in controlling prostate cancer that has spread to the lymph nodes
• if you are not well enough for surgery or are older
• after a radical prostatectomy for locally advanced disease, if there are signs of cancer left behind or the cancer has returned where the prostate used to be
• for prostate cancer that has spread to other parts of the body.

There are two main ways of delivering radiation therapy: from outside the body (external beam radiation therapy) or inside the body (brachytherapy). You may have one of these or a combination of both.

In intermediate and high-risk prostate cancer, radiation therapy is often combined with androgen deprivation therapy (ADT).

External beam radiation therapy (EBRT)

In EBRT, a machine precisely directs radiation beams from outside the body to the prostate. Each treatment session takes about 15 minutes. You will lie on the treatment table under the radiation machine. The machine does not touch you but may rotate around you. You will not see or feel the radiation.

There are different types of EBRT. Your radiation oncologist will talk to you about the most suitable type for your situation. Usually, EBRT for prostate cancer is delivered every weekday for 4–9 weeks. Some newer forms of EBRT are delivered in 5–7 treatments over two weeks.

EBRT does not make you radioactive and there is no danger to the people around you. Most people feel well enough to continue working, driving, exercising or doing their normal activities  throughout treatment.

Reducing the risk of bowel side effects

Radiation therapy can have side effects, including bowel changes. To move the bowel away from the prostate, the radiation oncologist may suggest a spacer. Before the treatment course begins, a
temporary gel or balloon is injected into the space between the prostate and bowel. This procedure is usually done by a urologist as a day procedure under a light anaesthetic.

Using a spacer may help prevent bowel side effects in some people. However, the cost is not subsidised by Medicare. Ask your doctors what you will have to pay and the benefits for your  situation.

The radiation therapists may advise you to drink fluids before each treatment session so you have a full bladder. This will expand your bladder and push the bowel higher up into the abdomen, away from the radiation. They may also advise you to empty your bowels before each treatment to help ensure the prostate is in the same position every time.

Internal radiation therapy (brachytherapy)

Brachytherapy is a type of targeted internal radiation therapy where the radiation source is placed inside the body. Giving doses of radiation directly into the prostate may help to limit the radiation dose to nearby tissues such as the rectum and bladder.

There are two different types of brachytherapy: permanent or temporary. If you already have significant urinary symptoms or a large prostate, brachytherapy is not suitable.

How brachytherapy is done

Permanent brachytherapy (seeds)

• Also called low-dose-rate (LDR) brachytherapy.
• Most suitable for people with few urinary symptoms, and small tumours with a low PSA level (less than 10) and a low to intermediate Gleason score or Grade Group.
• Multiple radioactive “seeds”, each about the size of a grain of rice, are put into the prostate under a general anaesthetic.
• The doctor uses needles to insert the seeds through the skin between the scrotum and anus  perineum). Ultrasound is used to guide the seeds into place.
• The procedure takes 1–2 hours and you can usually go home the same or next day.
• The seeds slowly release radiation to kill prostate cancer cells.
• The seeds lose their radioactivity after about one year. They are not removed from the prostate.

Temporary brachytherapy

• Also called high-dose-rate (HDR) brachytherapy.
• May be offered to people with a higher PSA level and a higher Gleason score or Grade Group. It is often given with a short course of EBRT.
• The radiation is delivered through hollow needles that are inserted into the prostate while you are under anaesthetic.
• The needle implants stay in place for several hours or, in some cases, overnight. You usually will have 1–3 brachytherapy treatments during this time.
• For each treatment, radioactive wires will be inserted into the needles for a few minutes to deliver a high dose of radiation to the prostate in a short time.
• The needle implants are taken out after the final radiation dose is delivered.
• In some cases, the implant procedure is repeated 1–2 weeks later.

Side effects of radiation therapy

The side effects you experience will vary depending on the type and dose of radiation, and the areas treated. You may experience some of the following side effects. Most side effects are temporary and tend to improve gradually in the weeks after treatment ends, though some may continue for longer. Some side effects may not show up until many months or years after treatment. These are known as late effects. Talk to your doctor or treatment team about ways to manage any side effects you have.

Short-term side effects

fatigue – The effects of radiation on your body may mean you become tired during treatment. Fatigue may build up during treatment and usually improves 1–2 months after treatment ends, but occasionally can last up to three months.

urinary problems – Radiation therapy can irritate the lining of the bladder and the urethra. This is known as radiation cystitis. You may pass urine more often or with more urgency, have a burning feeling when urinating or a slower flow of urine. If you had urinary issues before treatment, you may be more likely to have issues with urine flow. Blood may appear in the urine, which may require further treatment. If you are unable to empty your  bladder (urinate) right after brachytherapy, you may need a temporary catheter for a few days or weeks.

bowel changes – Radiation therapy can irritate the lining of the bowel and rectum. Symptoms may include passing smaller, more frequent bowel motions, needing to get to the toilet more quickly, or feeling that you can’t completely empty the bowel. Less commonly, there may be some blood in  the faeces (poo or stools). If this happens, let your doctor know as there are treatments that can stop the bleeding.

ejaculation changes – You may notice that you feel the sensation of orgasm but ejaculate less or no semen after radiation therapy. This is known as dry orgasm, which may be a permanent side effect. In some rare cases, you may experience pain when ejaculating. The pain usually eases over a few months.

Long-term or late effects

infertility – Radiation therapy to the prostate usually causes infertility. If you might want to have children, speak to your doctor before treatment about sperm banking or other options.

urinary problems – Bladder changes, such as frequent or painful urination, can also be late effects, appearing months or years after treatment. After brachytherapy, scarring can occur around the urethra, which can block the flow of urine and require corrective procedures. It is important to let your doctor know if you have any problems with urinating or bleeding.

bowel changes – Bowel changes, such as diarrhoea, wind or constipation, can also be late effects, appearing months or years after treatment. Bleeding from the rectum can also occur. In rare cases, there may be loss of bowel control (faecal incontinence) or blockage of the bowel. It is important to let your doctor know about any bleeding or if you have pain in the abdomen and difficulty opening your bowels.

erection problems – The nerves and blood vessels that control erections may become damaged. This can make it difficult to get and keep an erection, especially if you’ve had these problems before treatment. Having ADT can also contribute to problems with erections. Erection problems  may take a while to appear and can be ongoing.

Safety precautions after brachytherapy

If you have permanent brachytherapy your body may give off some radiation for a short time. The levels will gradually fall over time. This radiation only travels a short distance, which means there is little radiation outside your body.

You will still need to take care with prolonged close contact around pregnant women and young children for a few weeks or months after the seeds are inserted – your treatment team will explain the precautions to you. You will be advised to use a condom during sexual activity for the first few weeks after treatment in case a seed comes out during sex (though this is rare).

If you have temporary brachytherapy, you will not be radioactive once the wires are removed after treatment, and there is no risk to other people and no special precautions are needed during sex.

Download our booklet ‘Understanding Radiation Therapy’

Prostate cancer needs testosterone to grow. Reducing how much testosterone your body  makes may slow the cancer’s growth or shrink the cancer temporarily. Testosterone is an androgen (male sex hormone), so this treatment is called androgen deprivation therapy (ADT). It is also known as hormone therapy.

ADT for locally advanced cancer may be used after a radical prostatectomy or with radiation therapy. It may also be given to help control advanced prostate cancer. There are different types of ADT:

ADT injections – The most common form of ADT involves injecting medicine to block the  production of testosterone. The injections can be given by your GP or specialist. How often you  have injections depends on the drug – they may be given monthly, every three months or every six months. They can help slow the cancer’s growth for years.

ADT injections may also be used before, during and after radiation therapy to increase the chance of getting rid of the cancer. They are sometimes combined with chemotherapy.

Intermittent ADT – Occasionally ADT injections are given in cycles and continue until your PSA level is low. Injections can be restarted if your PSA rises again. This is known as intermittent ADT. In some cases, this can reduce side effects. It is not suitable for everyone.

Anti-androgen tablets – Often called hormone tablets, anti-androgen tablets may be given in combination with ADT injections.

Removing the testicle (orchidectomy) – This surgery is not a common way to lower testosterone production. If you have advanced prostate cancer, you may choose surgery over regular ADT  injections or tablets.

Surgery to remove both testicles is called a bilateral orchidectomy. It is possible to have a silicone prosthesis put into the scrotum to keep its shape. Removing only the inner part of the testicles (subcapsular orchidectomy) also lowers testosterone and does not need a prosthesis.

Side effects of ADT

ADT may cause side effects because of the lower levels of testosterone in the body. Side effects may include:

• tiredness that doesn’t go away with rest (fatigue)
• reduced sex drive (low libido)
• erection problems
• shrinking of the testicles and penis
• loss of muscle strength
• hot flushes and sweating
• weight gain, especially around the middle
• breast swelling and tenderness, genital shrinkage
• mood swings, depression, trouble with thinking and memory
• loss of bone density (osteoporosis) – calcium and vitamin D supplements and regular exercise help reduce the risk of osteoporosis
• higher risk of diabetes, high cholesterol and heart disease – your doctor will assess these risks with you.

For ways to manage side effects, talk to your treatment team. To find out more about ADT, contact the Prostate Cancer Foundation of Australia on 1800 22 00 99 or visit prostate.org.au.