Prostate cancer treatment

Active surveillance aims to avoid unnecessary treatment of harmless cancers, while still providing timely treatment for men who need it. Around one half to two thirds of men with low-risk prostate cancer do not need treatment.

Surveillance is a safe strategy, which provides a period of observation to gather extra information over time to see whether the disease is changing. 

Active surveillance involves you having regular PSA tests and MRI scans. If these tests reveal the cancer is changing or progressing, further treatment can be discussed.

A radical prostatectomy is the surgical removal of your prostate gland and is typically undertaken using a robotic technique. This treatment is an option to attempt to cure localised and locally advanced prostate cancer.

During the procedure, a surgeon controls keyhole surgery (laparoscopic) instruments while seated in the operating room beside the patient. Robotic surgery is used to remove the prostate, seminal vesicles (tube-like glands which make semen) and occasionally lymph nodes. 

Radiotherapy involves using radiation to kill cancerous cells. This treatment is an option to attempt to cure localised and locally advanced prostate cancer. Radiotherapy can also be used to slow the progression of metastatic prostate cancer and relieve symptoms. 

You may receive hormone therapy before undergoing radiotherapy to increase the chance of successful treatment. Hormone therapy may also be recommended after radiotherapy to reduce the chances of cancerous cells returning. 

There are short-term and long-term side effects associated with radiotherapy. Short-term effects of radiotherapy can include discomfort around the rectum and anus, diarrhoea, loss of pubic hair, tiredness, and cystitis (an inflammation of the bladder lining, which can cause painful urination).

Possible long-term side effects can include erectile dysfunction, urinary incontinence and bowel problems (diarrhoea, bleeding, discomfort).

HIFU is a targeted therapy for prostate cancer which uses high-frequency ultrasound waves to destroy cancer cells in the prostate. HIFU is used to treat men with localised prostate cancer that has not spread beyond their prostate.

An ultrasound probe inserted into the rectum and releases high-frequency sound waves through the wall of the rectum. These sound waves kill cancer cells in the prostate gland by heating them to a high temperature.

The risk of side effects from HIFU is usually lower than other treatments. However, possible side effects can include impotence or urinary incontinence. 

Bowel problems are rare. Fistulas (an abnormal channel between the urinary system and rectum) are also rare, because the treatment targets the cancer area only and not the whole prostate.

Cryotherapy is a method of killing cancer cells by freezing them. It is sometimes used to treat men with localised prostate cancer that has not spread beyond their prostate gland.

Tiny probes called cryo-needles are inserted into the prostate gland through the wall of the rectum. They freeze the prostate gland and kill the cancer cells, but some normal cells also die. 

The aim is to kill cancer cells while causing as little damage as possible to healthy cells. The side effects of cryotherapy can include erectile dysfunction and incontinence. It is rare for cryotherapy to cause rectal problems or fistulas.

Brachytherapy is a form of radiotherapy where the radiation dose is delivered inside the prostate gland. It is also known as internal or interstitial radiotherapy. The radiation is delivered using tiny radioactive seeds that are surgically implanted into the tumour. This is called low-dose-rate brachytherapy. 

The risk of sexual dysfunction and urinary problems is the same as with external beam radiotherapy, although the risk of bowel problems is slightly lower.

Hormone therapy is often used in combination with radiotherapy. For example, you may receive hormone therapy before undergoing radiotherapy to increase the chance of a successful treatment.

Hormone therapy may also be recommended after radiotherapy to reduce the chances of cancerous cells returning. 

Hormone therapy alone should not normally be used to treat localised prostate cancer in men who are fit and willing to receive surgery or radiotherapy. This is because it does not cure the cancer on its own.

Hormone therapy can be used to slow the progression of advanced prostate cancer and relieve symptoms. Hormones control the growth of cells in the prostate. Prostate cancer needs the hormone testosterone to grow. 

The purpose of hormone therapy is to block the effects of testosterone, either by stopping its production or by stopping your body being able to use testosterone. Hormone therapy can be given as:

• injections to stop your body making testosterone, called luteinising hormone-releasing hormone (LHRH) agonists
• tablets to block the effects or reduce the production of testosterone, called anti-androgen treatment
• combined LHRH and anti-androgen treatment.

The main side effects of hormone treatment are caused by their effects on testosterone. They usually go away when treatment stops. They include loss of sex drive and erectile dysfunction (this is more common with LHRH agonists than anti-androgens).

Chemotherapy is mainly used to treat prostate cancer that has spread to other parts of the body (metastatic prostate cancer) and which is not responding to hormone therapy. Chemotherapy destroys cancer cells by interfering with the way they multiply. 

Chemotherapy does not cure prostate cancer, but can keep it under control and reduce symptoms (such as pain) so everyday life is less affected.

The main side effects of chemotherapy are caused by their effects on healthy cells.

These include infections, tiredness, hair loss, sore mouth, loss of appetite, nausea and vomiting. Many of these side effects can be prevented or controlled with other medicines, which your doctor can prescribe for you.

Watchful waiting is often recommended for older men, when it is unlikely that the cancer will affect their natural life span.

If the cancer is in its early stages and not causing symptoms, patients decide to delay treatment, and wait to see if any symptoms of progressive cancer develop. If this happens, hormone medication to control prostate cancer are usually used. 

Watchful waiting may also be recommended for people with a higher risk of prostate cancer if:

• their general health means they are unable to receive any form of treatment
• their life expectancy means they will die with the cancer, rather than from it.

If the cancer has reached an advanced stage, it is no longer possible to cure it. However, it may be possible to slow its progression, prolong the patient’s life and relieve symptoms.

Treatment options include:

•    radiotherapy
•    hormone treatment
•    chemotherapy.