What is Prostate Cancer?

Prostate cancer is cancer of the prostate gland. It is the second-leading cause of cancer death for men in the United States. About 1 in 7 men will be diagnosed with it in their lifetime. About 1 in 39 men will die from it. Growths in the prostate can be benign (not cancer) or malignant (cancer).

Benign growths (such as benign prostatic hypertrophy):

  • Are rarely a threat to life
  • Don't invade the tissues around them
  • Don't spread to other parts of the body
  • Can be removed and can grow back very slowly (however, it doesn't usually grow back)

Malignant growths (prostate cancer):

  • May sometimes be a threat to life
  • Can invade nearby organs and tissues (such as the bladder or rectum)
  • Can spread to other parts of the body
  • Often can be removed but sometimes grow back

Prostate cancer cells can spread by breaking away from a prostate tumor. They can travel through blood vessels or lymph vessels to reach other parts of the body. After spreading, cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues. When prostate cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary (original) tumor. For example, if prostate cancer spreads to the bones, the cancer cells in the bones are actually prostate cancer cells. The disease is metastatic prostate cancer, not bone cancer. For that reason, it's treated as prostate cancer, not bone cancer.

To understand prostate cancer, it helps to know how the prostate normally works.

The Prostate

Male reproductive system
Male reproductive system

The prostate is part of the male reproductive system. It is about the size of a walnut and weighs about an ounce. The prostate is below the bladder and in front of the rectum. The prostate goes all the way around a tube called the urethra. The urethra carries urine from the bladder out through the penis. The main job of the prostate is to make fluid for semen. During ejaculation, sperm made in the testicles moves to the urethra. At the same time, fluid from the prostate and the seminal vesicles also moves into the urethra. This mixture—semen—goes through the urethra and out of the penis.



What Are The Symptoms of Prostate Cancer?

In its early stages, prostate cancer often has no symptoms. When symptoms do occur, they can be like those of an enlarged prostate or BPH. Thus, it is vital to talk to your health care provider when you have urinary symptoms. Later symptoms include:

  • Dull pain in the lower pelvic area
  • Frequent urinating
  • Trouble urinating, pain, burning, or weak urine flow
  • Blood in the urine or semen
  • Painful ejaculation
  • Pain in the lower back, hips or upper thighs
  • Loss of appetite
  • Loss of weight
  • Bone pain


What Causes Prostate Cancer?

We don't know exactly why and how prostate cancer starts. Autopsy studies show that one in every three men over age 50 have signs of prostate cancer. Up to 80% had small, low grade tumors. A study of organ donors found prostate cancer in 1 in 3 men age 60–69 and in 46% of men over age 70.

What causes prostate cancer is still unknown. Research hopes to find the answer soon. Modern theory is that many things can raise a man's risk for prostate cancer.

What Are The Risk Factors for Prostate Cancer?

Age

As men age, their risk of prostate cancer goes up. The American Cancer Society says prostate cancer causes about 10% of cancer–related deaths in men 60 to 79 years old. It causes nearly 25% of cancer deaths in men over age 80. It is rarely found in men younger than 40.

Ethnicity

African–Americans are in the highest risk group. There are more than 200 cases per 100,000 black men. White and Asian men have about half as many cases as African-Americans. African–American men tend to be diagnosed when the disease is more advanced. They are more likely to die of prostate cancer than white or Asian men.

Family History

Men with a family history of prostate cancer also face higher risk. The more close relatives (father, son, brother) diagnosed with prostate cancer, the higher your risk. The age when a close relative was diagnosed can also raise your risk. If you have a family history, you are 2 to 11 times more at–risk than men with no family history.

If your father, brother or other close relative had prostate cancer, you are at higher risk. This is true if two or more close relatives had prostate cancer. It is also true if a close relative was diagnosed before age 55.

Smoking

Studies show prostate cancer risk may double for heavy smokers. Within 10 years of quitting smoking, your risk goes down to that of a non–smoker the same age.

World Area

Prostate cancer numbers and deaths vary around the world. Numbers are low but rising in Asian countries. Numbers are medium in Central America and Western Africa. They are higher in North America and Northern Europe. The higher rates may be due to better screening, heredity, diet and environment.

The differences may also be linked to soy proteins in the diet. In some Asian countries, soy intake in tofu, soy milk, and miso is up to 90 times higher than in the U.S. Prostate cancer numbers and deaths are much lower in those countries. A study of more than 40 nations found soy, per calorie, to be the most protective dietary factor. This may be linked to chemicals in soy. They may act as weak estrogens. Estrogens are female hormones. They slow down prostate cancer growth. Some experts think high intake of green tea in Asia may also have an effect. But, there are no clear answers yet.

Diet

Diet and lifestyle may affect the risk of prostate cancer. It isn't clear exactly how. The risk may be higher for those who eat more calories, fat and refined sugar and not enough fruits, vegetables and exercise. Obesity is linked to increased risk for death from prostate cancer. One way to avoid death from prostate cancer is to lose weight, and keep it off.

Can Prostate Cancer Be Prevented?

There is no known way to prevent prostate cancer. But if you do things that are heart healthy, you will also keep your prostate healthy. Eating right, exercising, watching your weight, and not smoking can improve your health and help avoid prostate cancer.
There is still debate on how to prevent prostate cancer. Some health care providers believe drugs like finasteride (Proscar) and dutasteride (Avodart) can prevent it. Others believe they only slow progress. In studies, men taking these drugs were less likely to be diagnosed with prostate cancer. It is not known if the drugs slow the cancer and lower the death risk.



How is Prostate Cancer Diagnosed?

Screening

Screening is when you test for a disease even if you have no symptoms. Health care providers use the prostate specific antigen (PSA) test and digital rectal examination (DRE), to screen for prostate cancer. They advise both for early detection. There is debate on how often men should have a PSA test. Abnormality in either test is usually not due to cancer, but to other common conditions.

The American Urological Association (AUA) recommends talking with your health care provider about if you should be screened and when. To find out if prostate cancer screening is right for you, take our Risk Assessment Test. Take your results to your next appointment and talk with your health care provider about the benefits and risks of screening. There are two types of screenings, they are:

PSA Test

The prostate-specific antigen (PSA) blood test is the main method for screening for prostate cancer. This blood test measures the level of prostate-specific antigen (PSA) in the blood. PSA is a protein made only by the prostate gland. The PSA test can be done in a lab, hospital or health care provider's office. There is no special preparation. The PSA test should come before the health care provider does a DRE. Ejaculation can raise the PSA level for 24 to 48 hours. So the patient should not ejaculate for two days before a PSA test.

Very little PSA is found in the blood of a man with a healthy prostate. A low PSA is better for prostate health. A rapid rise in PSA may be a sign that something is wrong. One possible cause of a high PSA level is benign (non-cancer) enlargement of the prostate. Inflammation of the prostate, called prostatitis is one more common cause of high PSA levels. Prostate cancer is the most serious cause of a high PSA result. Talk with your health care provider about whether the PSA test is right for you. If you decide to get tested, be sure to talk about changes in your PSA score with your provider.

DRE

Digital Rectal Exam (DRE)
Digital Rectal Exam (DRE)
Alan Hoofring (Illustrator), National Cancer Institute

The digital rectal examination (DRE) is done with the man bending over or lying curled on his side. The health care provider puts a lubricated gloved finger into the rectum. The health care provider will feel the prostate. They will be looking for abnormal shape or thickness in the prostate. The DRE can help your health care provider find prostate problems.

Who Should Get Screened?

Talk to your healthcare provider about prostate cancer screening if you are a man:

  • Between 55–69 years old
  • African–American
  • Have a family history of prostate cancer

What are the benefits and risks of screening?

The PSA test may put your mind at ease. It may find prostate cancer early, before it spreads. Early treatment helps slow the spread of cancer. This may help some men live longer.

The risks of a PSA test are that it may miss detecting cancer (a "false negative"). Or the test may be a "false positive," suggesting something is wrong. This may lead to a biospy that isn't needed. The test might also detect very slow growing cancer that will never cause problems.

DRE is not expensive. It is safe and easy to do. But the DRE by itself cannot detect early cancer. It should always be done with a PSA test.

Biopsy

Transrectal prostate biopsy
Transrectal prostate biopsy
© 2005 Terese Winslow, U.S. Govt. has certain rights

Biopsy is the only way to find out for sure if you have prostate cancer. The decision to have one should be based on PSA and DRE results. It should consider such things as family history of prostate cancer, ethnicity, biopsy history, and other health factors.

Prostate biopsy is best done with ultrasound and a probe. You may get an enema and take antibiotics before the biopsy. You will lay on your side and the probe goes into the rectum.

First, your health care provider takes a picture of the prostate using ultrasound. Your health care provider will note the prostate gland's size, shape and any abnormalities. The most common abnormalities are shadows, which might be prostate cancer. But not all prostate cancers can be seen. And not all shadows are cancer.

The prostate gland is then anesthetized through a needle passed through the probe. Your health care provider will do the biopsy. The health care provider removes a slice of prostate tissue about ¾ inch long and 1/16 inch wide. Usually 10 or more biopsies are performed. The number depends on the size of the prostate gland, PSA test results, and past biopsies.

The biopsy takes 10 to 20 minutes. A pathologist (a health care provider who specializes in tissue) studies the biopsy tissue. The pathologist sees if there is cancer.

After a biopsy, you may have blood in the ejaculate, urine and stool. This stops within a few days for urine and a few weeks for semen. About 1 to 2% of patients have high fever. You will need to take an antibiotic for at least 48 hours after the biopsy.



What Are The Stages of Prostate Cancer?

Grading and staging tell the progress of cancer and whether it has spread:

Grading

The Gleason Scale
The Gleason Scale

If prostate cancer is found, the pathologist gives it a grade. The grade is a measure of how quickly the tumor is likely to grow and spread. The most common grading system is called the Gleason score. These scores range from 2 to 10. To determine the grade of a tumor, the pathologist scores each bit of tissue from the biopsy and then adds the two most common values together to determine the Gleason score. Although a score of 2 to 4 shows low aggressiveness, these numbers are almost never seen following a biopsy. The lowest score that is usually found is 5; as a result, that is the least aggressive score. A Gleason score of 6 is more aggressive. Gleason 7 tumors show even higher aggressiveness. These scores come in two varieties. A 4+3 tumor is more aggressive than a 3+4 tumor because more of the higher aggressive grade tumor was found. Gleason 8, 9 and 10 tumors are the most aggressive. These usually have already spread by the time they are found.

Talk to your health care provider about your Gleason score.

Staging

Tumor stage shows the size and spread of the cancer. As with other tumors, cancer that involves only a small part of the prostate has a better chance of being treatable than cancer that has spread all through the gland. Likewise, tumors found only in the prostate are more successfully treated than those that have spread outside the prostate (metastasized). Finally, tumors that have spread to places far from the prostate such as to the lymph nodes or bone have the poorest results. The system used for tumor staging is the TNM system, which stands for Tumor, Nodes and Metastasis.

Prostate Cancer Staging Chart

Using the "T" part of the system, localized prostate cancer is staged as:

  • T1: Health care provider cannot feel the tumor
  • T1a: Cancer present in less than 5% of the tissue removed and low grade (Gleason < 6)
  • T1b: Cancer present in more than 5% of the tissue removed or is of a higher grade (Gleason > 6)
  • T1c: Cancer found by needle. Biopsy done because of a high PSA
  • T2: Health care provider can feel the tumor with a DRE but the tumor is confined to prostate
  • T2a: Cancer found in one half or less of one side (left or right) of the prostate
  • T2b: Cancer found in more than half of one side (left or right) of the prostate
  • T2c: Cancer found in both sides of the prostate
  • T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles
  • T3a: Cancer extends outside the prostate but not to the seminal vesicles
  • T3b: Cancer has spread to the seminal vesicles
  • T4: Cancer has spread to nearby organs such as the urethral sphincter, rectum, bladder, or pelvis wall.
  • N0 stage, there is no sign of the cancer moving to the lymph nodes in the area of the prostate
  • M0 stage, there is no sign of tumor metastasis
  • If the cancer is spreading to the lymph node or if the tumor has spread to other parts of the body, the stage is changed to either N1, for node, and/or M1, for metastasis.

Prostate Cancer Stage Groupings

Prostate Cancer Stage Groupings
Prostate Cancer Stage Groupings
© 2010 Terese Winslow, U.S. Govt. has certain rights

The T stage is found by DRE and other tests such as ultrasound scan, CT scan, MRI scan, or MR spectroscopy scan. These tests may help find if the cancer is still just in the prostate or has spread. The health care provider may order a CT or MRI scan of the pelvis. This will tell if cancer has spread to the lymph nodes or bones. Sometimes follow-up images are needed to evaluate abnormalities found on the bone scan. These tests are not for men with a Gleason grade lower than 7 and a PSA lower than 10. They rarely show disease.

Imaging Test

Prostate cancer usually spreads from the prostate into nearby tissues. Then it spreads to the seminal vesicles, the lymph nodes, the bones, lungs, and other organs. Your health care provider may recommend a pelvic CT scan, an MRI scan or a bone scan to check if your cancer has spread.

Not all men with prostate cancer need to have imaging tests. PSA levels and cancer grade can estimate the risk of spread. A bone scan is not used for:

  • Newly diagnosed untreated prostate cancer
  • Patients with no symptoms from their cancer
  • Gleason score of less than 7 with PSA less than 10 ng/ml (lower grade cancers)
  • PSA less than 15 ng/ml, unless the Gleason score is 7 or higher

What Are The Survival Rates For Prostate Cancer?

Due to better screening, 5–year survival is up and death rates are down. Today, 99% of men with prostate cancer live at least 5 years. Most prostate cancers are slow growing. They take many years to progress and cause death. An older man with a tumor is at lower risk of problems in his lifetime than a younger man. Many men with prostate cancer will die from other causes.

But only 33% survive 5 years if their cancer is diagnosed after it has spread to other parts of the body.



How is Prostate Cancer Treated?

Deciding what treatment you should get can be complex. It depends on the stage and grade of the cancer. It also depends on your age and health. When thinking about which treatment to choose, you should consider side effects, long–term effects and outcomes of each. No one treatment is perfect for every man.

Some cancers grow so slowly that treatment may not be needed. But some grow fast and are life–threatening. Your health care provider will review your PSA level, T stage, Gleason score, and biopsy results. The results from these test will help your health care provider predict the likelihood of your cancer progressing or coming back. With all of this information you and your health care provider should decide the best treatment option for you. To help you make the best decision visit Michigan Cancer Consortium to review their materials on how to choose the best treatment for you.

The treatment choices for prostate cancer are:



Active Surveillance

What is Active Surveillance?

Active surveillance uses regular PSA tests, DRE and biopsies to watch cancer. If the cancer begins to grow, your health care provider may suggest treatment such as surgery or radiation.

The goal of active surveillance is to allow men to keep their quality of life. Treatment action is done only if the disease changes or grows.

What are the Benefits, Risks and Side Effects of Active Surveillance?

The two benefits of this treatment choice are that it is low cost and safe.

The risk of active surveillance is that the cancer could grow and spread between tests. This would make it harder to treat.

There are no direct side effects to this treatment. However, if you choose this option you should be prepared to have regular prostate biopsies to monitor your cancer.

Who are Good Candidates for Active Surveillance?

Active Surveillance is best if you have a small slow growing cancer. It is for those who do not have symptoms. It is also for those whose cancer is not expected to grow fast. It is a choice for you if you want to avoid sexual, urinary or bowel complications.



Watchful Waiting

What is Watchful Waiting?

Watchful waiting is a choice for you if you have localized prostate cancer and do not want therapy. It is watching without treating, and pain relief therapy if the cancer progresses.

What are the Benefits, Risks and Side Effects of Watchful Waiting?

The two advantages of this treatment choice are low cost and no complications.

The risk of watchful waiting is that the cancer could grow and spread between follow-ups. This makes it harder to treat.

There are no direct side effects to this treatment.

Who are Good Candidates for Watchful Waiting?

Watchful waiting is best if you are an older man and are not a good candidate for surgery or radiation. It is also good for older men who have serious health problems that make cancer harder to treat.

This is a good treatment for all men without high risk cancer and with less than 5 year life expectancy. It is also a choice if you have low-risk cancer and a life expectancy under 10 years.



Radiation Therapy

What is Radiation Therapy?

Radiation therapy uses high-energy rays to kill cancer cells. Radiation can be used as primary treatment for prostate cancer (in place of surgery). It can also be used after surgery if the cancer is not completely removed or if it returns. Imaging tests are run to find the exact location of the tumor. There are two kinds of radiation therapy:

External Beam Radiotherapy

Patient Receiving External Radiation
Patient Receiving External Radiation
NIH Medical Arts, National Cancer Instutute (NCI)

External beam radiation therapy (EBRT) sends a targeted beam of radiation to the prostate. Before the first treatment, your medical team will take detailed images of your prostate. This will help them to know how much radiation is needed and where to target it. Your medical team will work to limit the radiation to your organs, such as the bladder and rectum, which is not affected by the cancer. A small amount of radiation is delivered in daily doses outside of the body to the prostate, over 7 to 8 weeks. Your health care provider may use three dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT).

Prostate Brachytherapy (Internal Radiation Therapy)

Low dose rate (LDR) brachytherapy
Low dose rate (LDR) brachytherapy
Cancer Research UK

High Dose Rate (HDR) Brachytherapy
High Dose Rate (HDR) Brachytherapy
Cancer Research UK

With brachytherapy, radioactive material is placed into the prostate using needles or a catheter. There are two types of brachytherapy: low dose rate (LDR) brachytherapy and high dose rate (HDR) brachytherapy.

LDR brachytherapy - is when your doctor uses a needle to insert radioactive "seeds" about the size of a rice grain into the prostate. These seeds send out radiation, killing the prostate cancer cells nearby. In LDR, the seeds are left in the prostate even after treatment is finished.
HDR brachytherapy - is when your doctor will insert radiation into your prostate using a catheter. This catheter may remain in your body until treatment is complete. But the radiation source is only inserted in your prostate temporarily. Once your treatment is finished, all radioactive material is removed.

Surgery and anesthesia are required for both LDR and HDR brachytherapy. In addition you may need to stay in the hospital overnight to complete your treatment.

What are the Benefits, Risks and Side Effects of Radiation Therapy?

The benefit of radiation therapy is that it is less invasive than surgery. Both types of radiation are effective for early stage prostate cancer. You may need to get the two types of radiation combined. If you have advanced or aggressive cancer, hormone therapy is added to improve cancer control.

One disadvantage of radiation therapy is that it leaves the prostate in the body. If you choose this treatment you are at higher risk of the cancer coming back.

The main side effects of radiotherapy are incontinence and bowel problems. Erectile dysfunction (ED) is also common. ED appears to get worse with time. Modern radiation causes less harm to normal tissues. Long-term effects to normal tissues are unknown.

Who are Good Candidates for Radiation Therapy?

Radiation therapy can be a good choice for you if:

The prostate cancer is only in the prostate
The prostate cancer has spread to organs and tissue near the prostate and you are using hormone therapy
The prostate cancer has returned after treatment
You want to reduce the symptoms of advanced prostate cancer



Surgery

What is Radical Prostatectomy (Surgery) for Prostate Cancer?

Before and after radical prostatectomy
Before and after radical prostatectomy
Cancer Research UK

Radical prostatectomy is surgically removing the prostate, seminal vesicles, nearest parts of the vas deferens, nearby tissue, and some nearby pelvic lymph nodes. Because cancer may be scattered in the prostate gland, the prostate must be removed. This makes sure cancer cells are not left behind to grow.

The pelvic lymph nodes are small oval or round bodies along blood vessels. They filter fluid from the lymph nodes. Prostate cancer usually spreads first to the soft tissues around the prostate. Then, it spreads to the seminal vesicles, lymph nodes, bones and other organs. There are many other lymph nodes. So the body will not be harmed by removing these few lymph nodes.

The surgery requires anesthetic. You will be in the hospital for one to three days.

There are four types of radical prostatectomy surgery:

Retropubic Open Radical Prostatectomy

Retropubic radical prostatectomy
Retropubic radical prostatectomy

This is the most common type of prostate surgery. Your surgeon will make a cut (incision) in your lower belly and remove the prostate through this opening. This type of surgery allows your physician to assess the prostate gland and surrounding tissue at the same time, while reducing injury to nearby organs. The prostate gland is removed with limited blood loss. The neurovascular bundles are preserved, and so is erectile function.

Perineal Open Radical Prostatectomy

Perineal radical prostatectomy
Perineal radical prostatectomy

The prostate is removed through a cut between the anus and scrotum. Because the complex pelvic veins are avoided, bleeding is rare. This type of surgery is not usually performed today.

Laparoscopic Radical Prostatectomy

Incisions (cuts) made for laparoscopic and robotic-assisted prostatectomy
Incisions (cuts) made for laparoscopic
and robotic-assisted prostatectomy

Your surgeon will make six 1-inch incisions in your belly. Small surgical tools and video camera fit through the incisions to remove the prostate. Small instruments including a camera are passed through ports in your belly. The prostate gland is removed. This surgery has been replaced with robotic assisted laparoscopic surgery.

Robotic Assisted Laparoscopic Radical Prostatectomy (RALP)

The prostate is removed through ports in your belly using a robotic system. The system holds and guides the laparoscopic surgical instruments and camera. RALP surgery is one of the most common types of prostate surgery today. In experienced hands, there are no major outcome differences between RALP and retropubic prostatectomy. However, the success of this surgery is dependent upon how experienced your surgeon is. The more surgeries your doctor has done, the better he/she will be at performing this procedure.

After the prostate has been removed, the urinary tract and the bladder are reconstructed. Then a catheter is passed through the urethra into the bladder. This is to drain the urine while the new connection between the bladder and urethra (the "anastomosis") heals. The catheter will stay in place one to two weeks after the surgery.

One or two suction drains are at times left beside the bladder, deep in the pelvic cavity. They are brought out through the lower belly to drain any fluid in the wound. They help lower the risk of infection and pressure from fluid. The drains are usually removed before you are discharged from the hospital.

Most people do not pass flatus (gas) for one to two days. Most do not have a bowel movement until the third day after surgery. This depends on the amount of narcotic pain medication. The goal of the first few days will be to prevent breathing and circulation problems. You will need to walk at least 100 yards three to four times a day.

The catheter is removed on a return visit to your surgeon. You should begin exercises to strengthen the urinary control valve (Kegel exercises) after the catheter is removed.

Once your surgeon has the final pathology report, he/she will make a plan. The surgeon reads the final pathology report. Based on this, the health care provider makes a plan. If the report is favorable, the plan includes regular health care provider's visits and a PSA test every 6-12 months. The post-operative PSA level should be in the "undetectable" ranger (less than 0.1 ng/mL).

If the pathology report shows cancer at the surgical margin or spread of cancer into surrounding tissues, seminal vesicles, or lymph nodes, more therapy may be needed. Therapy may include radiation therapy and/or hormone treatment. This would begin 2 to 4 months after surgery.

What Are The Benefits, Risks and Side Effects of Surgery?

The main benefit of a radical prostatectomy is that the cancer is removed with the prostate. This is true as long as cancer hasn't spread outside the prostate. Surgery also helps the health care provider find out whether the cancer has moved beyond the prostate.

If your prostate cancer is confined to the prostate, the cahcne of cure with surgery alone at 10 years (undetectable PSA) is more than 90 percent. If your cancer has gone beyond the prostate gland, surgery is also a good choice.

A study comparing radical prostatectomy to watchful waiting showed that prostate removal improved a man's chance of survival. In the study, men were randomly assigned to radical prostatectomy or watchful waiting. Men treated with surgery had a significant survival improvement.

But most men whose tumors were watched did not die from prostate cancer. And some men who had surgery did die from prostate cancer. About 20 operations were needed to save one life from prostate cancer. The likelihood of cure varies. It depends on the cancer removed. Usually one must have PSA test values of less than 0.1 ng/mL for 10 years before cure is certain.

The main risk of any surgery is complications that could happen from the operation. Some happen early and some later. Bleeding can happen in any major operation. About 1-2% of men develop deep venous thrombosis (DVT blood clots in the leg or pelvic veins) or pulmonary embolism (blood clot that goes to the lung).

With surgery, there are two big side effects, you may develop - erectile dysfunction and incontinence.

Nerves surround the prostate gland
Nerves surround the prostate gland
NIH Medical Arts, National Cancer Instutute (NCI)

Surgery may damage the nerve bundles that control blood flow to the penis; causing ED. Nerves involved in the erection process surround the prostate gland. While most surgeons try to perform a newve sparing procedure, it is not always possible. In addition, there could be a decreased amount of blood flowing to the penis after treatment. The chance of ED after treatment depends on many things. For more information on how prostate cancer surgery can affect your erections, read our After Treatment: Erectile Dysfunction Issues After Prostate Cancer Treatment section (This section is near the beginning of the After Treatment page.)

With surgery, there is also the risk for developing Peyronie's disease (a curve to the penis). This can be from scarring which comes from treating your ED with injections to the same spot. Or it could come from the penis kinking or buckling while having intercourse without a strong erection.

The ability to have an orgasm (climax) is not lost after radical prostatectomy. This is true even though there is no erection. There will be very little, if any, fluid with orgasm. Any fluid is usually mucus from the Cowper's gland. There is sometimes urine if urinary sphincter muscles have not fully recovered.

You can no longer cause a pregnancy during intercourse. This is because the prostate and seminal vesicles were removed and the cas deferens was divided. Artificial insemination can be used to cause a pregnancy.

Incontinence can sometimes occur as a result of treatment for prostate cancer. Incontinence is the inability to control your urine. After prostate cancer surgery, you may experience four different types of Incontinence.

  • Stress Incontinence - is the most common, is urine leakage when coughing, laughing, sneezing or exercising.
  • Overflow Incontinence - is the inability to empty the bladder completely, taking longer to urinate and when you do urinate, it is not a powerful stream.
  • Overactive Bladder (Urge Incontinence) - is the sudden need to go to the bathroom even when the bladder is not full because the bladder is overly sensitive.
  • Mixed Incontinence - is a combination of stress and urge incontinence with symptoms from both types.
  • Continuous Incontinence - is not common. It is the inability to control urine at any time.

Because incontinence may affect your physical and emotional recovery, it is important to understand what your options are for treatment. For more information on how prostate cancer surgery can affect your incontinence, read our After Treatment: Incontinence Issues After Prostate Cancer Treatment section (This section is near the end of the After Treatment page.)

Who Are Good Candidates for Surgery?

Prostate cancer surgery is best if your prostate cancer is in clinical stage T1 or T2. That means it is confined to the prostate gland. It is also used if your disease is clinical stage T3. There are no absolute cut-offs. But if you have a PSA level less than 20 ng/mL and a Gleason score of less than 8 you have a higher chance of cure.

Prostate cancer surgery is usually restricted to men who are healthy enough to tolerate a major operation. You should also have a 10-year or more life expectancy. Life expectancy is based on your age and health. Surgery may be offered to men with different circumstances.



Cryotherapy

What is Cryotherapy?

Cryotherapy or cryoblation for prostate cancer is the controlled freezing of the prostate gland. The freezing destroys cancer cells. Cryotherapy is done under general or spinal anesthesia. The prostate is imaged and measured. An aiming program projects images on a screen.

Special needles called "cryoprobes" are placed in the prostate under the skin, guided by ultrasound. Argon gas creates an "ice ball" that kills cells in the area. Monitoring lowers the risk of injury to the nearby normal tissues. The procedure is usually done in 2 hours.

Cryotherapy is not cancer specific. The treatment will affect all cells in the targeted area. Freezing can damage molecular, cellular and whole tissue. Cryotherapy causes immediate cell death, delayed death from lack of oxygen, and programmed cell death. The immune system may be able to better fight cancer once cancer cells are killed.

The cells are not the only structures damaged during freezing. Connective tissue and the smallest blood vessels (capillaries) are damaged. They will then lose blood supply. That is also believed to kill the cancer cells.

Each type of cryotherapy has different probes and placement. All aim to freeze the prostate, tumor(s) and nearby tissue-except the urethral area. A urethral warming catheter keeps the urethra warm. It is kept active for about 20 minutes after the final thaw cycle. This prevents the urethra from freezing. Small temperature probes are placed in and around the prostate. They monitor the rectal wall and urinary sphincter temperatures. This helps lower side effects like incontinence and rectal fistula.

Freezing starts at the front of the prostate by activating the probes. Then the middle and finally the back parts are frozen. This allows monitoring by ultrasound and sculpting of the ice balls. The health care provider knows when to stop freezing.

There are usually two freezing cycles. Between them, the prostate is allowed to thaw passively or actively using helium or argon gas. If the prostate is longer than the probe, a pullback move freezes the top of the prostate. Double freezing is performed again.

After the final thaw, a catheter (a drainage tube in the bladder through the lower belly) is inserted. Your health care provider will remove it in a few days, when you are able to urinate.

A PSA test is usually done at three months. A biopsy may be done later. This will check to make sure your prostate was destroyed and all cancer cells are dead. This is done especially if the PSA level keeps climbing. Once the PSA level is stable, the PSA may be checked every 6 months or yearly. If the PSA level keeps changing, your health care provider will monitor it closely.

What Are The Benefits, Risks and Side Effects of Cryotherapy?

You may be pleasantly surprised to find there is little to no pain after treatment. Recovery is usually in the first week. Cryotherapy offers:

  • A minimally invasive, outpatient procedure
  • Favorable success rate
  • Low toxicity profile (complication rate)
  • High quality of life
  • A short recovery
  • No blood transfusions
  • Minimal anesthesia
  • Effective use for high grade cancers
  • Good margins by extending the ice beyond the confines of the prostate
  • Trauma to prostate cancer that resists radiation, hormones or chemotherapy
  • Primary treatment or treatment for those who have failed radiation treatment
  • The possibility of repeating the procedure if the first treatment did not completely kill the cancer
  • The choice to use radiation therapy, radical prostatectomy, or hormonal therapy if the procedure fails
  • Less than half the cost of the traditional treatment

The biggest risk of treatment is a fistula. A fistula is a channel between the urethra and the rectum. This may cause diarrhea from urine in the rectum. It may cause sever infection from bacteria in the bladder. This is rarely seen with today's technology. A recent study of over 1000 patients in the COLD registry (Cryo On Line Database) showed a rectal fistula rate of only 0.4%.

There is a high risk of erectile dysfunction when freezing the entire prostate Your health care provider will have ways to better preserve erections if you are a candidate for a nerve-preserving procedure.

When you leave the hospital you will have a catheter in place for drainage. This treatment procedure will cause your prostate to swell. The catheter is removed when the swelling goes down.

You must be able to urinate on your own. The catheter may need to be reinserted if there is still swelling. Most men can urinate in about 5 to 15 days. But some may take longer. You may need oral antibiotics or other medicines to help urination or reduce catheter irritation. Your health care provider decides this.

Other rare side effects include long-term incontinence and urinary retention. Permanent, sever incontinence is rare (about 1%). Abscess and permanent numbness of the penis are also rare. Scrotal swelling, passage of flecks of tissue, pain or burning when urinating, and increased urinary frequency or urgency are other rare side effects. The most common symptoms are from the catheter: urinary urgency and blood in the urine.

The new technology has fewer side effects. A new urethral warming device has lowered urethral complications. Better spacing of the probes makes the procedure safer and effective. Improved ultrasound monitoring of the freezing and temperature can help your doctor control the size and shape of the ice balls.

Who Are Good Candidates for Cryotherapy?

This is a good treatment if you have just had radiation therapy and your prostate cancer comes back. This is also good if you have organ-confined prostate cancer or little spread beyond the prostate (up to T3a). you may receive this treatment if you are having prostate cancer treatment for the first time. You may also get this treatment if your cancer returned after radiation treatment (external beam or brachytherapy). Cryotherapy is effective removing cancers of any Gleason grade.

Smaller needles may be able to destroy the area of the prostate with cancer rather than the entire prostate. This new form of cryotherapy may change the way prostate cancer is treated in the future.



Hormonal Therapy

What is Hormonal Therapy?

Prostate cancer cells rely on the male hormone testosterone to help them grow. Hormonal therapy uses drugs to block or lower testosterone and other male sex hormones that fuel cancer. This can stop or slow growth and spread of cancer. It is used for men who choose not to have other therapies. It is also used for men who cannot be treated with other therapies.

Reducing testosterone production can be achieved surgically or through the use of medications.

  • Surgery: Testosterone levels can be reduced by removing the testicles, a procedure called an orchiectomy.
  • Medication to reduce the production of testosterone: Injecting medications called luteinizing hormone releasing hormones (LH-RHs) suppresses the body's natural production of testosterone.
  • An additional option that blocks the effects of all male hormones: In this treatment option, an orchiectomy or LH-RH treatment is combined with medications called non-steroidal anti-androgens - drugs that block testosterone from the prostate and adrenal gland from reaching cancer cells. This combination adds additional block aid to male hormone effects on the growth of prostate cancer cells.

What Are The Benefits, Risks and Side Effects of Hormone Therapy?

The major side effects of hormone therapy are:

  • Nausea and vomiting
  • Hot flashes
  • Anemia
  • Lethargy
  • Osteoporosis
  • Swollen and tender breasts
  • Erectile dysfunction

Hormone therapy has also been linked to heart disease and increased risk of heart attack, as well as potential increased risks of developing diabetes. If your cancer is resistant to hormonal treatments, you and your doctor may discuss chemotherapy, which consists of single drugs or a combination of several medications aimed at killing the cancer cells.

Who are Good Candidates for Hormone Therapy?

If you do not want or cannot have other prostate cancer treatments this is the best option for you. If you have this treatment you must not have heart disease or diabetes.



Chemotherapy

What is Chemotherapy?

Chemotherapy uses drugs to destroy cancer cells. The drugs circulate in the bloodstream. They kill any rapidly growing cells, including both cancerous prostate cancer cells and non-cancerous ones. Dose and frequency are carefully controlled.

Many chemotherapy drugs go directly into a vein through a tube. Others are taken by mouth. They are given in the health care provider's office or at home. You generally do not need to stay in the hospital for chemotherapy.

Often, chemotherapy is not the primary therapy for prostate cancer patients, but for men with advanced stages of prostate cancer, or whose cancer has metastasized, or spread from the prostate gland to other parts of the body.

What are The Benefits, Risks and Side Effects of Chemotherapy?

Over the last 10 years, chemotherapy drugs have helped patients who have prostate cancer that has spread. Overall survival rate increased with new drugs. Chemotherapy boosts the immune system's ability to fight cancer.

The risks are that the chemotherapy might not work and that the drugs kill healthy cells in the body. There is an increased risk of infections because of the lower blood cell count.

Side effects depend on the drug, the dosage, and how long the treatment lasts. The most common side effects are fatigue (feeling very tired), nausea, vomiting, diarrhea, hair loss, change in the sense of taste and decrese in blood cell counts that result in an increased risk of infections.

To minimize the side effects, chemotherapy drugs are carefully monitored according to the amount and number of times they are administered by your physician. Supportive medication is also given to further help offset the side effects caused by the drugs. Most side effects disappear once chemotherapy is stopped.

Who are Good Candidates for Chemotherapy?

Because chemotherapy improves survival and relieves symptoms of advanced prostate cancer, if your cancer has spread you may be a good candidate for this treatment. It is important to talk about treatment with your health care provider. Chemotherapy is an aggressive treatment with side effect.



Active Surveillance

What is Active Surveillance?

Active surveillance uses regular PSA tests, DRE and biopsies to watch cancer. If the cancer begins to grow, your health care provider may suggest treatment such as surgery or radiation.

The goal of active surveillance is to allow men to keep their quality of life. Treatment action is done only if the disease changes or grows.

What are the Benefits, Risks and Side Effects of Active Surveillance?

The two benefits of this treatment choice are that it is low cost and safe.

The risk of active surveillance is that the cancer could grow and spread between tests. This would make it harder to treat.

There are no direct side effects to this treatment. However, if you choose this option you should be prepared to have regular prostate biopsies to monitor your cancer.

Who are Good Candidates for Active Surveillance?

Active Surveillance is best if you have a small slow growing cancer. It is for those who do not have symptoms. It is also for those whose cancer is not expected to grow fast. It is a choice for you if you want to avoid sexual, urinary or bowel complications.



Watchful Waiting

What is Watchful Waiting?

Watchful waiting is a choice for you if you have localized prostate cancer and do not want therapy. It is watching without treating, and pain relief therapy if the cancer progresses.

What are the Benefits, Risks and Side Effects of Watchful Waiting?

The two advantages of this treatment choice are low cost and no complications.

The risk of watchful waiting is that the cancer could grow and spread between follow-ups. This makes it harder to treat.

There are no direct side effects to this treatment.

Who are Good Candidates for Watchful Waiting?

Watchful waiting is best if you are an older man and are not a good candidate for surgery or radiation. It is also good for older men who have serious health problems that make cancer harder to treat.

This is a good treatment for all men without high risk cancer and with less than 5 year life expectancy. It is also a choice if you have low-risk cancer and a life expectancy under 10 years.



Radiation Therapy

What is Radiation Therapy?

Radiation therapy uses high-energy rays to kill cancer cells. Radiation can be used as primary treatment for prostate cancer (in place of surgery). It can also be used after surgery if the cancer is not completely removed or if it returns. Imaging tests are run to find the exact location of the tumor. There are two kinds of radiation therapy:

External Beam Radiotherapy

Patient Receiving External Radiation
Patient Receiving External Radiation
NIH Medical Arts, National Cancer Instutute (NCI)

External beam radiation therapy (EBRT) sends a targeted beam of radiation to the prostate. Before the first treatment, your medical team will take detailed images of your prostate. This will help them to know how much radiation is needed and where to target it. Your medical team will work to limit the radiation to your organs, such as the bladder and rectum, which is not affected by the cancer. A small amount of radiation is delivered in daily doses outside of the body to the prostate, over 7 to 8 weeks. Your health care provider may use three dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT).

Prostate Brachytherapy (Internal Radiation Therapy)

Low dose rate (LDR) brachytherapy
Low dose rate (LDR) brachytherapy
Cancer Research UK

High Dose Rate (HDR) Brachytherapy
High Dose Rate (HDR) Brachytherapy
Cancer Research UK

With brachytherapy, radioactive material is placed into the prostate using needles or a catheter. There are two types of brachytherapy: low dose rate (LDR) brachytherapy and high dose rate (HDR) brachytherapy.

LDR brachytherapy - is when your doctor uses a needle to insert radioactive "seeds" about the size of a rice grain into the prostate. These seeds send out radiation, killing the prostate cancer cells nearby. In LDR, the seeds are left in the prostate even after treatment is finished.
HDR brachytherapy - is when your doctor will insert radiation into your prostate using a catheter. This catheter may remain in your body until treatment is complete. But the radiation source is only inserted in your prostate temporarily. Once your treatment is finished, all radioactive material is removed.

Surgery and anesthesia are required for both LDR and HDR brachytherapy. In addition you may need to stay in the hospital overnight to complete your treatment.

What are the Benefits, Risks and Side Effects of Radiation Therapy?

The benefit of radiation therapy is that it is less invasive than surgery. Both types of radiation are effective for early stage prostate cancer. You may need to get the two types of radiation combined. If you have advanced or aggressive cancer, hormone therapy is added to improve cancer control.

One disadvantage of radiation therapy is that it leaves the prostate in the body. If you choose this treatment you are at higher risk of the cancer coming back.

The main side effects of radiotherapy are incontinence and bowel problems. Erectile dysfunction (ED) is also common. ED appears to get worse with time. Modern radiation causes less harm to normal tissues. Long-term effects to normal tissues are unknown.

Who are Good Candidates for Radiation Therapy?

Radiation therapy can be a good choice for you if:

The prostate cancer is only in the prostate
The prostate cancer has spread to organs and tissue near the prostate and you are using hormone therapy
The prostate cancer has returned after treatment
You want to reduce the symptoms of advanced prostate cancer



Surgery

What is Radical Prostatectomy (Surgery) for Prostate Cancer?

Before and after radical prostatectomy
Before and after radical prostatectomy
Cancer Research UK

Radical prostatectomy is surgically removing the prostate, seminal vesicles, nearest parts of the vas deferens, nearby tissue, and some nearby pelvic lymph nodes. Because cancer may be scattered in the prostate gland, the prostate must be removed. This makes sure cancer cells are not left behind to grow.

The pelvic lymph nodes are small oval or round bodies along blood vessels. They filter fluid from the lymph nodes. Prostate cancer usually spreads first to the soft tissues around the prostate. Then, it spreads to the seminal vesicles, lymph nodes, bones and other organs. There are many other lymph nodes. So the body will not be harmed by removing these few lymph nodes.

The surgery requires anesthetic. You will be in the hospital for one to three days.

There are four types of radical prostatectomy surgery:

Retropubic Open Radical Prostatectomy

Retropubic radical prostatectomy
Retropubic radical prostatectomy

This is the most common type of prostate surgery. Your surgeon will make a cut (incision) in your lower belly and remove the prostate through this opening. This type of surgery allows your physician to assess the prostate gland and surrounding tissue at the same time, while reducing injury to nearby organs. The prostate gland is removed with limited blood loss. The neurovascular bundles are preserved, and so is erectile function.

Perineal Open Radical Prostatectomy

Perineal radical prostatectomy
Perineal radical prostatectomy

The prostate is removed through a cut between the anus and scrotum. Because the complex pelvic veins are avoided, bleeding is rare. This type of surgery is not usually performed today.

Laparoscopic Radical Prostatectomy

Incisions (cuts) made for laparoscopic and robotic-assisted prostatectomy
Incisions (cuts) made for laparoscopic
and robotic-assisted prostatectomy

Your surgeon will make six 1-inch incisions in your belly. Small surgical tools and video camera fit through the incisions to remove the prostate. Small instruments including a camera are passed through ports in your belly. The prostate gland is removed. This surgery has been replaced with robotic assisted laparoscopic surgery.

Robotic Assisted Laparoscopic Radical Prostatectomy (RALP)

The prostate is removed through ports in your belly using a robotic system. The system holds and guides the laparoscopic surgical instruments and camera. RALP surgery is one of the most common types of prostate surgery today. In experienced hands, there are no major outcome differences between RALP and retropubic prostatectomy. However, the success of this surgery is dependent upon how experienced your surgeon is. The more surgeries your doctor has done, the better he/she will be at performing this procedure.

After the prostate has been removed, the urinary tract and the bladder are reconstructed. Then a catheter is passed through the urethra into the bladder. This is to drain the urine while the new connection between the bladder and urethra (the "anastomosis") heals. The catheter will stay in place one to two weeks after the surgery.

One or two suction drains are at times left beside the bladder, deep in the pelvic cavity. They are brought out through the lower belly to drain any fluid in the wound. They help lower the risk of infection and pressure from fluid. The drains are usually removed before you are discharged from the hospital.

Most people do not pass flatus (gas) for one to two days. Most do not have a bowel movement until the third day after surgery. This depends on the amount of narcotic pain medication. The goal of the first few days will be to prevent breathing and circulation problems. You will need to walk at least 100 yards three to four times a day.

The catheter is removed on a return visit to your surgeon. You should begin exercises to strengthen the urinary control valve (Kegel exercises) after the catheter is removed.

Once your surgeon has the final pathology report, he/she will make a plan. The surgeon reads the final pathology report. Based on this, the health care provider makes a plan. If the report is favorable, the plan includes regular health care provider's visits and a PSA test every 6-12 months. The post-operative PSA level should be in the "undetectable" ranger (less than 0.1 ng/mL).

If the pathology report shows cancer at the surgical margin or spread of cancer into surrounding tissues, seminal vesicles, or lymph nodes, more therapy may be needed. Therapy may include radiation therapy and/or hormone treatment. This would begin 2 to 4 months after surgery.

What Are The Benefits, Risks and Side Effects of Surgery?

The main benefit of a radical prostatectomy is that the cancer is removed with the prostate. This is true as long as cancer hasn't spread outside the prostate. Surgery also helps the health care provider find out whether the cancer has moved beyond the prostate.

If your prostate cancer is confined to the prostate, the cahcne of cure with surgery alone at 10 years (undetectable PSA) is more than 90 percent. If your cancer has gone beyond the prostate gland, surgery is also a good choice.

A study comparing radical prostatectomy to watchful waiting showed that prostate removal improved a man's chance of survival. In the study, men were randomly assigned to radical prostatectomy or watchful waiting. Men treated with surgery had a significant survival improvement.

But most men whose tumors were watched did not die from prostate cancer. And some men who had surgery did die from prostate cancer. About 20 operations were needed to save one life from prostate cancer. The likelihood of cure varies. It depends on the cancer removed. Usually one must have PSA test values of less than 0.1 ng/mL for 10 years before cure is certain.

The main risk of any surgery is complications that could happen from the operation. Some happen early and some later. Bleeding can happen in any major operation. About 1-2% of men develop deep venous thrombosis (DVT blood clots in the leg or pelvic veins) or pulmonary embolism (blood clot that goes to the lung).

With surgery, there are two big side effects, you may develop - erectile dysfunction and incontinence.

Nerves surround the prostate gland
Nerves surround the prostate gland
NIH Medical Arts, National Cancer Instutute (NCI)

Surgery may damage the nerve bundles that control blood flow to the penis; causing ED. Nerves involved in the erection process surround the prostate gland. While most surgeons try to perform a newve sparing procedure, it is not always possible. In addition, there could be a decreased amount of blood flowing to the penis after treatment. The chance of ED after treatment depends on many things. For more information on how prostate cancer surgery can affect your erections, read our After Treatment: Erectile Dysfunction Issues After Prostate Cancer Treatment section (This section is near the beginning of the After Treatment page.)

With surgery, there is also the risk for developing Peyronie's disease (a curve to the penis). This can be from scarring which comes from treating your ED with injections to the same spot. Or it could come from the penis kinking or buckling while having intercourse without a strong erection.

The ability to have an orgasm (climax) is not lost after radical prostatectomy. This is true even though there is no erection. There will be very little, if any, fluid with orgasm. Any fluid is usually mucus from the Cowper's gland. There is sometimes urine if urinary sphincter muscles have not fully recovered.

You can no longer cause a pregnancy during intercourse. This is because the prostate and seminal vesicles were removed and the cas deferens was divided. Artificial insemination can be used to cause a pregnancy.

Incontinence can sometimes occur as a result of treatment for prostate cancer. Incontinence is the inability to control your urine. After prostate cancer surgery, you may experience four different types of Incontinence.

  • Stress Incontinence - is the most common, is urine leakage when coughing, laughing, sneezing or exercising.
  • Overflow Incontinence - is the inability to empty the bladder completely, taking longer to urinate and when you do urinate, it is not a powerful stream.
  • Overactive Bladder (Urge Incontinence) - is the sudden need to go to the bathroom even when the bladder is not full because the bladder is overly sensitive.
  • Mixed Incontinence - is a combination of stress and urge incontinence with symptoms from both types.
  • Continuous Incontinence - is not common. It is the inability to control urine at any time.

Because incontinence may affect your physical and emotional recovery, it is important to understand what your options are for treatment. For more information on how prostate cancer surgery can affect your incontinence, read our After Treatment: Incontinence Issues After Prostate Cancer Treatment section (This section is near the end of the After Treatment page.)

Who Are Good Candidates for Surgery?

Prostate cancer surgery is best if your prostate cancer is in clinical stage T1 or T2. That means it is confined to the prostate gland. It is also used if your disease is clinical stage T3. There are no absolute cut-offs. But if you have a PSA level less than 20 ng/mL and a Gleason score of less than 8 you have a higher chance of cure.

Prostate cancer surgery is usually restricted to men who are healthy enough to tolerate a major operation. You should also have a 10-year or more life expectancy. Life expectancy is based on your age and health. Surgery may be offered to men with different circumstances.



Cryotherapy

What is Cryotherapy?

Cryotherapy or cryoblation for prostate cancer is the controlled freezing of the prostate gland. The freezing destroys cancer cells. Cryotherapy is done under general or spinal anesthesia. The prostate is imaged and measured. An aiming program projects images on a screen.

Special needles called "cryoprobes" are placed in the prostate under the skin, guided by ultrasound. Argon gas creates an "ice ball" that kills cells in the area. Monitoring lowers the risk of injury to the nearby normal tissues. The procedure is usually done in 2 hours.

Cryotherapy is not cancer specific. The treatment will affect all cells in the targeted area. Freezing can damage molecular, cellular and whole tissue. Cryotherapy causes immediate cell death, delayed death from lack of oxygen, and programmed cell death. The immune system may be able to better fight cancer once cancer cells are killed.

The cells are not the only structures damaged during freezing. Connective tissue and the smallest blood vessels (capillaries) are damaged. They will then lose blood supply. That is also believed to kill the cancer cells.

Each type of cryotherapy has different probes and placement. All aim to freeze the prostate, tumor(s) and nearby tissue-except the urethral area. A urethral warming catheter keeps the urethra warm. It is kept active for about 20 minutes after the final thaw cycle. This prevents the urethra from freezing. Small temperature probes are placed in and around the prostate. They monitor the rectal wall and urinary sphincter temperatures. This helps lower side effects like incontinence and rectal fistula.

Freezing starts at the front of the prostate by activating the probes. Then the middle and finally the back parts are frozen. This allows monitoring by ultrasound and sculpting of the ice balls. The health care provider knows when to stop freezing.

There are usually two freezing cycles. Between them, the prostate is allowed to thaw passively or actively using helium or argon gas. If the prostate is longer than the probe, a pullback move freezes the top of the prostate. Double freezing is performed again.

After the final thaw, a catheter (a drainage tube in the bladder through the lower belly) is inserted. Your health care provider will remove it in a few days, when you are able to urinate.

A PSA test is usually done at three months. A biopsy may be done later. This will check to make sure your prostate was destroyed and all cancer cells are dead. This is done especially if the PSA level keeps climbing. Once the PSA level is stable, the PSA may be checked every 6 months or yearly. If the PSA level keeps changing, your health care provider will monitor it closely.

What Are The Benefits, Risks and Side Effects of Cryotherapy?

You may be pleasantly surprised to find there is little to no pain after treatment. Recovery is usually in the first week. Cryotherapy offers:

  • A minimally invasive, outpatient procedure
  • Favorable success rate
  • Low toxicity profile (complication rate)
  • High quality of life
  • A short recovery
  • No blood transfusions
  • Minimal anesthesia
  • Effective use for high grade cancers
  • Good margins by extending the ice beyond the confines of the prostate
  • Trauma to prostate cancer that resists radiation, hormones or chemotherapy
  • Primary treatment or treatment for those who have failed radiation treatment
  • The possibility of repeating the procedure if the first treatment did not completely kill the cancer
  • The choice to use radiation therapy, radical prostatectomy, or hormonal therapy if the procedure fails
  • Less than half the cost of the traditional treatment

The biggest risk of treatment is a fistula. A fistula is a channel between the urethra and the rectum. This may cause diarrhea from urine in the rectum. It may cause sever infection from bacteria in the bladder. This is rarely seen with today's technology. A recent study of over 1000 patients in the COLD registry (Cryo On Line Database) showed a rectal fistula rate of only 0.4%.

There is a high risk of erectile dysfunction when freezing the entire prostate Your health care provider will have ways to better preserve erections if you are a candidate for a nerve-preserving procedure.

When you leave the hospital you will have a catheter in place for drainage. This treatment procedure will cause your prostate to swell. The catheter is removed when the swelling goes down.

You must be able to urinate on your own. The catheter may need to be reinserted if there is still swelling. Most men can urinate in about 5 to 15 days. But some may take longer. You may need oral antibiotics or other medicines to help urination or reduce catheter irritation. Your health care provider decides this.

Other rare side effects include long-term incontinence and urinary retention. Permanent, sever incontinence is rare (about 1%). Abscess and permanent numbness of the penis are also rare. Scrotal swelling, passage of flecks of tissue, pain or burning when urinating, and increased urinary frequency or urgency are other rare side effects. The most common symptoms are from the catheter: urinary urgency and blood in the urine.

The new technology has fewer side effects. A new urethral warming device has lowered urethral complications. Better spacing of the probes makes the procedure safer and effective. Improved ultrasound monitoring of the freezing and temperature can help your doctor control the size and shape of the ice balls.

Who Are Good Candidates for Cryotherapy?

This is a good treatment if you have just had radiation therapy and your prostate cancer comes back. This is also good if you have organ-confined prostate cancer or little spread beyond the prostate (up to T3a). you may receive this treatment if you are having prostate cancer treatment for the first time. You may also get this treatment if your cancer returned after radiation treatment (external beam or brachytherapy). Cryotherapy is effective removing cancers of any Gleason grade.

Smaller needles may be able to destroy the area of the prostate with cancer rather than the entire prostate. This new form of cryotherapy may change the way prostate cancer is treated in the future.



Hormonal Therapy

What is Hormonal Therapy?

Prostate cancer cells rely on the male hormone testosterone to help them grow. Hormonal therapy uses drugs to block or lower testosterone and other male sex hormones that fuel cancer. This can stop or slow growth and spread of cancer. It is used for men who choose not to have other therapies. It is also used for men who cannot be treated with other therapies.

Reducing testosterone production can be achieved surgically or through the use of medications.

  • Surgery: Testosterone levels can be reduced by removing the testicles, a procedure called an orchiectomy.
  • Medication to reduce the production of testosterone: Injecting medications called luteinizing hormone releasing hormones (LH-RHs) suppresses the body's natural production of testosterone.
  • An additional option that blocks the effects of all male hormones: In this treatment option, an orchiectomy or LH-RH treatment is combined with medications called non-steroidal anti-androgens - drugs that block testosterone from the prostate and adrenal gland from reaching cancer cells. This combination adds additional block aid to male hormone effects on the growth of prostate cancer cells.

What Are The Benefits, Risks and Side Effects of Hormone Therapy?

The major side effects of hormone therapy are:

  • Nausea and vomiting
  • Hot flashes
  • Anemia
  • Lethargy
  • Osteoporosis
  • Swollen and tender breasts
  • Erectile dysfunction

Hormone therapy has also been linked to heart disease and increased risk of heart attack, as well as potential increased risks of developing diabetes. If your cancer is resistant to hormonal treatments, you and your doctor may discuss chemotherapy, which consists of single drugs or a combination of several medications aimed at killing the cancer cells.

Who are Good Candidates for Hormone Therapy?

If you do not want or cannot have other prostate cancer treatments this is the best option for you. If you have this treatment you must not have heart disease or diabetes.



Chemotherapy

What is Chemotherapy?

Chemotherapy uses drugs to destroy cancer cells. The drugs circulate in the bloodstream. They kill any rapidly growing cells, including both cancerous prostate cancer cells and non-cancerous ones. Dose and frequency are carefully controlled.

Many chemotherapy drugs go directly into a vein through a tube. Others are taken by mouth. They are given in the health care provider's office or at home. You generally do not need to stay in the hospital for chemotherapy.

Often, chemotherapy is not the primary therapy for prostate cancer patients, but for men with advanced stages of prostate cancer, or whose cancer has metastasized, or spread from the prostate gland to other parts of the body.

What are The Benefits, Risks and Side Effects of Chemotherapy?

Over the last 10 years, chemotherapy drugs have helped patients who have prostate cancer that has spread. Overall survival rate increased with new drugs. Chemotherapy boosts the immune system's ability to fight cancer.

The risks are that the chemotherapy might not work and that the drugs kill healthy cells in the body. There is an increased risk of infections because of the lower blood cell count.

Side effects depend on the drug, the dosage, and how long the treatment lasts. The most common side effects are fatigue (feeling very tired), nausea, vomiting, diarrhea, hair loss, change in the sense of taste and decrese in blood cell counts that result in an increased risk of infections.

To minimize the side effects, chemotherapy drugs are carefully monitored according to the amount and number of times they are administered by your physician. Supportive medication is also given to further help offset the side effects caused by the drugs. Most side effects disappear once chemotherapy is stopped.

Who are Good Candidates for Chemotherapy?

Because chemotherapy improves survival and relieves symptoms of advanced prostate cancer, if your cancer has spread you may be a good candidate for this treatment. It is important to talk about treatment with your health care provider. Chemotherapy is an aggressive treatment with side effect.



What Happens After Treatment?

While treatment choices differ, each year more men are surviving prostate cancer and winning back their lives. Prostate cancer can be a manageable disease if caught early and treated appropriately.

Once you have finished treatment it is time to think about any side effects you may have. It's also time to go on with your life. Talk to your health care provider about any side effects or problems you have after your treatment. You and your health care provider can decide what will be best for you.

What are The Emotional Effects Following Treatment?

After treatment, you may feel very emotional and even overjoyed. You could also feel anxious. You may worry about cancer returning. Whatever you're feeling, talk to your health care provider. Work together. Build a plan with your health care provider. And make a plan for dealing with side effects.

What are The Physical Effects Following Treatment?

Erectile dysfunction and urinary incontinence are the side effects reported most often:

Erectile Dysfunction (ED) Issues After Prostate Cancer Treatment

After prostate cancer, men can experience various side effects including erectile dysfunction. Your doctor can help you understand the causes of ED, and therapies that could help you recover.

What Causes ED After Prostate Cancer Treatment?

Surgery may damage the nerve bundles that control blood flow to the penis, causing ED. Nerves involved in the erection process surround the prostate galnd. While most surgeons try to perform a nerve sparing procedure, it is not always possible. In addition, there could be a decreased amount of blood flowing to the penis after treatment. The chance of ED after treatment depends on many things. It depends on your:

  • Age
  • Health
  • Sexual function before treatment
  • Stage of the cancer
  • Whether the nerves that control erection were saved

How Long Can ED Last?

An erection happens when sexual arousal causes nerves near the prostate to send signals. The signals cause the blood vessels in the penis to fill with blood. The blood in the vessels makes the penis erect. The two nerve bundles that cause erection are very close to the area where prostate cancer most often starts. It's often possible to save these nerves in surgery, except when there is a chance that cancer cells will remain.

Since the main goal of prostate treatment is to remove the cancer, these nerve bundles may be completely or partly destroyed. There is still a chance of getting erectile function back, unless both nerves are destroyed. Erectile function return may be slow. It can take up to 24 months or longer before you are able to have a full erection. Some men recover sooner. The average time for erections that allow intercourse is 4 to 24 months. In some men, it takes longer.

Men under age 60 have a better chance of regaining erections than older men. Even with nerve–sparing surgery, erections do not return right away. The recovery period can take up to 2 years. Erections do not always return fully to pre–surgery function. But they may recover enough for sex. There are medicines and devices to treat ED.

Even with full recovery, most men find that erections are less strong and long–lasting than before surgery. Younger men recover sooner. Men with strogner erections before the operation have a better chance of recovery than those who had weak erections before surgery.

Are There Treatments for ED After Prostate Cancer Treatment?

Erectile rehabilitation is usually advised treatment. There are treatments that can help ED. They include pills, vacuum pumps, urethral suppositories, penile injections, and penile implants. All may have side effects. A health care provider can help you decide if one would be right for you.

Incontinence Issues After Prostate Cancer Treatment

Incontinence can sometimes occur as a result of treatment for prostate cancer. Incontinence is the inability to control your urine. After prostate cancer treatment, you may experience four different types of Incontinence.

  • Stress Incontinence — is the most common, is urine leakage when coughing, laughing, sneezing or exercising.
  • Overflow Incontinence — is the inability to empty the bladder completely, taking longer to urinate and when you do urinate, it is not a powerful stream.
  • Urge (OAB) Incontinence — is the sudden need to go to the bathroom even when the bladder is not full because the bladder is overly sensitive.
  • Mixed Incontinence — is a combination of stress and urge incontinence with symptoms from both types.

Because incontinence may affect your physical and emotional recovery, it is important to understand what your options are.

What Causes Incontinence After Prostate Cancer Treatment?

Whether you have incontinence after your prostate cancer treatment depends on your age, former bladder function, and experience of your doctor. With more experienced surgeons, the risk of permanent incontinence is rare after prostate cancer treatment. Sometime during surgery there is scarring. Scar tissue may form at the bladder outlet where the prostate was removed. If your urine flow is blocked, you may need more surgery to fix the blockage.

How Long Will Incontinence Last?

Short–term incontinence after surgery is a common side effect. You may need to wear a pad for a few weeks to months. Usually incontinence does not last long. But it can last as long as six to twelve months. Most men will recover urinary control. Physical therapy focusing on the pelvic floor may help you recover bladder control. Your health care provider can write a prescription for the therapy. Most insurance will cover the therapy.

Long–term (after 1 year) incontinence is rare. It happens in less than 5–10 percent of all surgical cases. When it does occur, there are ways to solve the problem.

Incontinence depends mostly on the surgeon's experience. Your age and bladder health also matter.

Are there Treatments for Incontinence After Prostate Cancer Treatment?

Treatment is based on numerous factors including the type and severity of your incontinence. There are a variety of treatment options which can potentially help you regain complete control:

  • Kegel Exercises – strengthen your bladder control muscles.
  • Lifestyle Changes – include modifying your diet, losing weight and regular emptying of the bladder can decrease urination frequency.
  • Medication – affect the nerves and muscles around the bladder, helping to maintain better control.
  • Neuromuscular Electrical Stimulation – strengthens bladder muscles.
  • Surgery – consists of injecting collagen to tighten the bladder sphincter, implanting a urethral sling to tighten the bladder neck, or an artificial sphincter device used to control urination. There are also many products available that do not treat incontinence but help maintain a high quality of life.

What if Prostate Cancer Returns?

Prostate cancer may return. The likelihood of cure varies. It depends on the cancer. You need a PSA test (the screening test for prostate cancer) of less than 0.1 ng/mL for 10 years before the cancer is considered cured. If the cancer returns, you and your health care provider will talk about treatment choice.



More Information

Questions to Ask My doctor

  • How advanced is my prostate cancer?
  • What is its stage? (How far does it seem to have spread?)
  • What is my cancer's grade? (How fast is it likely to spread?)
  • Is it likely that my cancer will spread?
    • Do I need to be tested more frequently?
    • What do experts recommend about the frequency of testing?
  • What are my treatment choices (including watchful waiting and active surveillance)?
    • What are the advantages and disadvantages of each?
  • What are the chances for treatment to cure my cancer?
  • What are the chances of complication from each treatment?
    • What kinds of complications are likely from each?
    • When are they likely to occur?
  • How are possible treatment side effects managed—for example, urinary incontinence or erectile dysfunction?
  • How soon and how well will my urinary function occur?
  • How soon and how well will my sexual potency recover?
  • How much will each prostate treatment cost?
  • How much will treating possible side effects cost?
  • What types of surgery are available?
  • If I choose a traditional open surgery, how long will I need to fully recover?
  • If I choose minimally invasive robotic–assisted surgery, how long will I need to fully recover?
  • What is your experience with each of these option?
  • How long will I have a catheter after the operation?
  • If I choose radiation therapy, how much recovery time will be required?
  • What are the potential side effects of radiation, both immediately and in the long term?
  • Will I need to take time off from work or other activities?
  • What is likely to happen if I choose no treatment (watchful waiting or active surveillance)?
    • How frequently will I need examinations?
  • Following treatment, how often will I need examinations?
  • What are the chances of my survival in 10 years for each treatment?