For men with prostate cancer that requires treatment, the choices depend largely on the stage and characteristics of the cancer. For cancer that is still confined to the prostate, the major options often include surgery or radiation.
There is not always one clearly superior treatment. Surgery and modern radiation can both provide excellent cancer control for appropriately selected patients, but their side effects and impact on quality of life can differ.
Important considerations include the aggressiveness and location of the cancer, age and overall health, urinary and sexual function before treatment, and the individual's priorities.
For many men, getting opinions from both a urologic surgeon and a radiation oncologist before making a decision can be valuable.
The standard surgical treatment is a radical prostatectomy, in which the prostate and seminal vesicles are removed. Today, many prostatectomies are performed robotically through several small incisions.
Surgery has the advantage of removing the prostate and providing a complete examination of the cancer. After surgery, PSA should fall to a very low or undetectable level, which makes subsequent monitoring relatively straightforward.
The major potential side effects are urinary incontinence and erectile dysfunction. The likelihood and severity vary considerably depending on age, health, function before surgery, the location of the cancer, and whether the surgeon can preserve the nerves involved in erections.
An important factor is the experience of the surgeon and medical center. For someone considering surgery, it is reasonable to ask how frequently the surgeon performs prostatectomies and about that surgeon's results for cancer control, urinary continence, and sexual function.
Radiation therapy uses high-energy radiation to destroy cancer cells while limiting damage to surrounding tissue. Modern treatment can target the prostate with considerable precision.
Two major approaches are external beam radiation, delivered from outside the body over a series of treatments, and brachytherapy, in which radioactive material is placed temporarily or permanently inside the prostate. The best approach depends on the characteristics of the cancer and the individual patient.
Radiation avoids surgery and generally has a lower immediate risk of urinary incontinence. Erectile dysfunction can develop gradually after treatment. Some men experience urinary irritation or bowel symptoms, although modern techniques have reduced these problems.
For higher-risk cancers, radiation may be combined with androgen-deprivation (hormone) therapy for a period of time.
As with surgery, the experience of the radiation oncologist and treatment center is important.
Focal therapy treats the area of the prostate containing the cancer rather than treating or removing the entire prostate. The goal is to control the cancer while reducing the risk of urinary and sexual side effects.
Several techniques are used, including high-intensity focused ultrasound (HIFU), which destroys tissue with focused sound waves, and cryotherapy, which destroys cancer cells by freezing them.
Focal therapy may be an option for carefully selected men with localized prostate cancer, particularly when imaging and biopsy show a clearly identifiable area of clinically significant cancer.
The potential advantage is fewer side effects than whole-prostate treatment. The tradeoff is that prostate tissue remains, so careful follow-up with PSA, MRI, and sometimes repeat biopsy is necessary. Long-term evidence is also less extensive than it is for surgery and radiation.
For someone considering focal therapy, experience in selecting appropriate patients and performing the procedure is particularly important.
Immunotherapy uses the body's immune system to recognize and attack cancer cells. It is not a standard treatment for most localized prostate cancers, but it can be useful for certain men with advanced disease.
Sipuleucel-T (Provenge) is an FDA-approved cellular immunotherapy for some men with metastatic castration-resistant prostate cancer. A patient's immune cells are collected, specially treated, and returned to the body to stimulate an immune response against the cancer.
Pembrolizumab (Keytruda) is a different type of immunotherapy called a checkpoint inhibitor. It may benefit a small subset of men whose prostate cancers have particular genetic characteristics, including MSI-H or dMMR.
Immunotherapy is an active area of prostate cancer research, including studies combining it with other treatments.
Both surgery and radiation can successfully treat localized prostate cancer, but their side effects tend to differ.
Urinary control: Incontinence is more common immediately after surgery and often improves over time. Significant incontinence is generally less common after radiation, although radiation can cause urinary frequency, urgency, or irritation.
Sexual function: Erectile dysfunction can occur after either treatment. After surgery it may occur immediately and sometimes improve with time. After radiation, erectile function may decline more gradually.
Bowel function: Bowel problems are uncommon after surgery but can occur after radiation because the rectum is close to the prostate. Modern radiation techniques have reduced this risk.
The likelihood of side effects varies considerably from person to person. Age, health, urinary and sexual function before treatment, cancer characteristics, and the experience of the treatment team can all affect the outcome.
For many men, the best choice involves balancing excellent cancer control with the side effects that matter most to their quality of life.
Because prostate cancer can often be treated in several different ways, getting a second opinion can be especially valuable.
A urologic surgeon naturally has particular expertise in surgery, while a radiation oncologist specializes in radiation. Men considering focal therapy may also want an opinion from a physician experienced with that approach.
A second opinion can also include having the biopsy slides reviewed by another pathologist, particularly one who specializes in prostate cancer. A change in the Gleason score or Grade Group could affect the recommended treatment.
When time permits, understanding the alternatives before choosing treatment can help patients make a decision that fits both the characteristics of their cancer and their personal priorities.
An overview of treatment choices for prostate cancer.
PCRI compares surgery and radiation for localized prostate cancer, including their effectiveness, side effects, and factors that may help a patient choose between them.