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Treatment for prostate cancer

There are different options for managing and treating prostate cancer, and more than one treatment may be suitable for you. Your specialist will let you know your options based on the stage and grade of the prostate cancer as well as your general health, age and preferences.

Management or treatment options by stage

  • localised early
    • active surveillance
    • surgery and/or radiation therapy
    • watchful waiting
  • locally advanced
    • surgery and/or radiation therapy
    • androgen deprivation therapy (ADT) may also be suggested
  • advanced/metastatic (at diagnosis)
    • usually androgen deprivation therapy (ADT)
    • sometimes chemotherapy or radiation therapy
    • watchful waiting may be an option
    • newer treatments as part of a clinical trial

This is a way of monitoring prostate cancer that isn’t causing any symptoms or problems. The aim is to avoid or delay active treatment if the cancer is unlikely to spread or cause symptoms.

Active surveillance may be suggested if the cancer is low risk. This means the PSA level is under 10 ng/mL, stage T1–2, and the cancer is expected to grow slowly based on the Grade Group score. About 70% of Australians with low-risk prostate cancer choose active surveillance.

Typically, active surveillance involves PSA tests every 3–6 months, digital rectal examination every six months, mpMRI scans and biopsies at one year and three years. 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 having a cancer diagnosis but no 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. The aim is to avoid active treatment unless you develop symptoms. Watchful waiting usually involves fewer tests than active surveillance. You’ll have regular PSA tests and you probably won’t need to have a biopsy. If the cancer spreads or causes symptoms, you’ll have treatment to relieve symptoms or slow the growth of the cancer, rather than to cure the prostate cancer.

Watchful waiting 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 cancer 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.

Choosing watchful waiting avoids treatment side effects, but you may feel anxious about having a cancer diagnosis but no 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 prostate cancer is a radical prostatectomy. This involves removing the prostate, part of the urethra, and the seminal vesicles.

For intermediate-risk or high-risk prostate cancer, nearby lymph glands may also be removed (pelvic lymph node dissection). After the prostate is removed, the urethra will be rejoined to the bladder and the vas deferens (tubes that carry sperm from the testes to the penis) will be sealed.

Click on image to enlarge

A radical prostatectomy can be done in different ways:

open radical prostatectomy – This is usually done through a single long cut in the lower abdomen.

laparoscopic radical prostatectomy – Sometimes the prostate can be removed via keyhole surgery (also called laparoscopic surgery). Small surgical instruments are inserted through several small cuts in the abdomen. The surgeon performs the procedure by moving the instruments while watching a screen.

robotic-assisted radical prostatectomy (RARP) – Laparoscopic surgery can be performed using a robotic device. The surgeon sits at a control panel to see a three-dimensional picture and move robotic arms that hold the instruments. RARP uses more specialised instruments than those used for standard laparoscopic surgery.

nerve-sparing radical prostatectomy – This surgery aims to avoid damaging the nerves that control erections. 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. It involves removing the prostate and seminal vesicles without damaging nearby nerves. Problems with erections are common even if nerve-sparing surgery is performed.

Making decisions about surgery

Talk to your surgeon about what types of surgery are 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 is 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 and no difference in outcomes.

Whichever surgical approach is used, a radical prostatectomy is major surgery and you’ll need time to recover.

Side effects of prostate cancer surgery

You can expect to return to your usual activities within about six weeks after surgery for prostate cancer. Usually you can start driving again in a couple of weeks, but heavy lifting should be avoided for six weeks. 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.

Loss of bladder control – You may have some light dribbling or trouble controlling your bladder after a radical prostatectomy. This is known as urinary incontinence or urinary leakage. You may need to use a pad to manage urinary leakage for some days or weeks after the operation. Bladder control usually improves in a few weeks but it can take up to a year after the surgery. For about 5% of people, incontinence is ongoing and may need an operation to fix. In rare cases, incontinence may be permanent.

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 prostatectomy, the tubes from the testicles (vas deferens) are sealed and the prostate and seminal vesicles are removed, so semen is no longer ejaculated during orgasm. This is known as a dry orgasm.

Infertility – Surgery can cause infertility. 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. Regularly using a vacuum erection device can help maintain penis size. Changes to the size of your penis can be difficult to deal with.

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 is recommended:

  • for localised or locally advanced prostate cancer – it has similar rates of success to surgery
  • if you are not well enough for surgery
  • sometimes after a prostatectomy for locally advanced disease
  • for prostate cancer that has spread to a small number of areas in other parts of the body.

Radiation therapy can be delivered from outside the body using external beam radiation therapy or inside the body using brachytherapy. In higher risk prostate cancer, radiation therapy may be combined with androgen deprivation therapy (ADT).

External beam radiation therapy (EBRT)

Each EBRT 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. Usually, EBRT for prostate cancer is delivered every weekday for up to 4–8 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 the course of their treatment.

There are different types of EBRT:

intensity-modulated radiation therapy (IMRT) – IMRT shapes the radiation beams to allow different doses to be given to different areas. Volumetric modulated arc therapy (VMAT) is a specialised form of IMRT that delivers radiation continuously as the treatment machine rotates around the body.

image-guided radiation therapy (IGRT) – IGRT uses a treatment machine that takes CT scans and x-rays at the start of each session to check that you are in the correct position for treatment. This improves accuracy and reduces the risk of side effects. Markers (usually grains of gold) may have been inserted into or near the cancer so they can be seen in the x-rays or scans and used to guide positioning.

stereotactic body radiation therapy (SBRT) – This is a newer treatment and is not widely available. SBRT is delivered in 5–7 treatments over two weeks. Not all prostate cancers are suitable for this very short-course treatment – you can discuss this with your radiation oncologist.

proton therapy – This uses protons rather than x-rays beams. It is useful when the cancer is near sensitive areas, such as the brain, eyes and spinal cord. Proton therapy is not yet available in Australia, but has been used in the USA to treat prostate cancer. At this stage, there is no evidence that it provides better outcomes for prostate cancer than standard radiation therapy with x-ray beams.

Reducing the risk of bowel side effects

To move the bowel away from the prostate, the radiation oncologist may suggest a spacer. Before treatment begins, a temporary gel or balloon is injected into the space between the prostate and bowel. This procedure is usually done as a day procedure under a light anaesthetic.

Side effects of EBRT

You may experience some of the following side effects. Most side effects improve gradually over a few weeks after treatment ends. Less commonly, some side effects develop months or years after treatment. These are known as late effects.

Tiredness – 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, the tube urine comes out of. This is known as radiation cystitis. Symptoms may include the need to pass urine more often or get to the toilet more urgently, 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.

These side effects are usually temporary and tend to improve within a few months of finishing treatment. In rare cases, radiation therapy can cause blood in the urine, which may require further treatment. If you have any problems with urinating or bleeding, let your doctor know.

Bowel problems – Radiation therapy can irritate the lining of the bowel and rectum. Symptoms may include passing smaller, more frequent motions, needing to get to the toilet more quickly, or feeling that you can’t completely empty the bowel. Less commonly, you may bleed when passing a bowel motion. If this happens, let your doctor know. Bowel problems may start during treatment or shortly afterwards and go away within several weeks of finishing treatment. This is different for everyone, and you may have some side effects for longer.

Erection problems (impotence or erectile dysfunction) – 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 problems before treatment. Having ADT can also contribute to problems with erections. Erection problems may take a while to appear and can be ongoing.

Changes in ejaculation – You may notice that you feel the sensation of orgasm but ejaculate less or not at all 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.

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

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.

If you already have significant urinary symptoms or a large prostate gland, brachytherapy is not suitable.

There are two different types of brachytherapy:

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 10–15) and a low to intermediate Grade Group or Gleason score.
  • 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 3–6 months. 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 Grade Group score. It is often given with a short course of EBRT.
  • The radiation is delivered through hollow needles that are inserted into the prostate, usually while you are under general anaesthetic.
  • The needle implants stay in place for several hours. You 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.
  • You may need to stay in hospital overnight.
  • Needle implants are removed before you go home.

Safety precautions during brachytherapy

With brachytherapy your body may give off some radiation for a short time. The levels gradually fall with time. The precautions you need to take will depend on what type of brachytherapy you have. Your doctor will talk to you about what precautions you need to follow.

Radiation from permanent brachytherapy 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. This is in case a seed comes out during sex but this rarely happens.

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

Side effects of brachytherapy

The side effects of brachytherapy are similar to those experienced with external radiation treatment. Symptoms usually start 1–2 weeks after treatment and improve within a couple of months. They may include:

  • passing urine more often and urgently
  • pain when urinating
  • blood in the urine
  • slower urine flow.

A temporary catheter may be needed for a few days or weeks if you are unable to empty your bladder. There is a small chance of bowel problems or bleeding from the back passage. Permanent brachytherapy is less likely to cause erection problems compared with other treatments. However, erection problems and changes in ejaculation (such as pain or dry orgasm) can also occur after temporary brachytherapy.

Talk to your doctor or treatment team about ways to manage these side effects.

The Prostate Cancer Foundation of Australia has a resource on brachytherapy for prostate cancer – call 1800 22 00 99 or visit prostate.org.au. For more details and videos explaining how radiation therapy works, visit targetingcancer.com.au.

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.

There are different types of ADT that may be used:

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 and are usually given every three 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, antiandrogen tablets are usually used with ADT injections.

Removing the testicle (orchidectomy) – Surgery isn’t a common way to lower testosterone production. If you have advanced prostate cancer, you may choose surgery over regular 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) 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 (fatigue)
  • reduced sex drive (low libido)
  • erection problems
  • 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.

This information is reviewed by

This information was last reviewed in March 2020 by the following expert content reviewers: Dr Amy Hayden, Radiation Oncologist, Westmead and Blacktown Hospitals, and Chair, Faculty of Radiation Genito-Urinary Group (FROGG), The Royal Australian and New Zealand College of Radiologists, NSW; Prof Shomik Sengupta, Professor of Surgery and Deputy Head, Eastern Health Clinical School, Monash University, and Visiting Urologist and Uro-Oncology Lead, Urology Department, Eastern Health, VIC; A/Prof Arun Azad, Medical Oncologist, Urological and Prostate Cancers, Peter MacCallum Cancer Centre, VIC; Ken Bezant, Consumer; Dr Marcus Dreosti, Radiation Oncologist, GenesisCare, and Clinical Strategy Lead, Oncology Australia, SA; A/Prof Nat Lenzo, Nuclear Physician, Specialist in Internal Medicine, Group Clinical Director, GenesisCare Theranostics and The University of Western Australia, WA; Jessica Medd, Senior Clinical Psychologist, Department of Urology, Concord Repatriation General Hospital, and HeadwayHealth Clinical and Consulting Psychology Services, NSW; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council Western Australia; Graham Rees, Consumer; Kerry Santoro, Prostate Cancer Specialist Nurse, Southern Adelaide Local Health Network, SA; A/Prof David Smith, Senior Research Fellow, Cancer Research Division, Cancer Council NSW; Matthew Starr, Consumer.