Prostate Cancer Treatments

Localised Prostate Cancer Treatment 

Treatment Options for Localised Prostate Cancer

The following is a list of treatment options for clinically localised prostate cancer. It is important to note that no treatment is effective 100% of the time. 



This is a general summary, and treatment options will vary depending on your situation.

• Active Surveillance
• Surgery - Radical Prostatectomy
• External Beam Radiotherapy
• Brachytherapy Seeds  (Low dose Rate or High Dose Rate Radiotherapy
• Focal therapy  (HIFU, Cryotherapy, Irreversible Electroporation)
• Hormonal therapy

Active Surveillance

Not all prostate cancers that are detected are considered to be clinically significant. Active surveillance aims to prevent the overtreatment of clinically insignificant cancers that may never cause you a problem. 

If the prostate cancer appears to be potentially insignificant, then it is monitored periodically with PSA tests, MRIs and repeat biopsies. 

If cancer progresses, then active primary therapy can be performed at that stage. The active surveillance criteria continue to evolve but generally include low-volume low-grade disease. Studies have shown in this group of patients there is very low risk of metastasis and mortality. 

Active surveillance protocols are constantly refined and yet to be fully validated. 

Active Surveillance Advantages

• Avoiding unnecessary treatment: Active surveillance allows men with low-risk prostate cancer to prevent the side effects and complications of immediate treatment, such as impotence and incontinence.
• Monitoring for progression: Active surveillance allows for close monitoring of the cancer, which can help to detect any signs of progression early on and then take action when necessary.
• Quality of life: Active surveillance allows men to continue with their normal daily activities without treatment related disruption and recovery time.

Active Surveillance Disadvantages

• Uncertainty: Active surveillance requires regular monitoring, which can be anxiety-provoking for some men. Additionally, there is always a risk that cancer may progress during active surveillance, and the patient will need to start treatment.
• Risk of progression: Although active surveillance is considered safe for men with low-risk prostate cancer, there is still a risk that cancer will progress and require treatment.
• Limited follow-up options: Active surveillance is unsuitable for men with intermediate- or high-risk prostate cancer; if cancer progresses, it will have to be treated with surgery or radiation, which may have more severe side effects than if treated early on.

Radical Prostatectomy Surgery

Surgery involves the complete removal of the prostate gland. It is a highly effective treatment with good long-term results in the appropriately selected patient. 

Surgery may be performed as follows:

• Laparoscopic (key-hole),
• Robotic-Assisted Laparoscopic (key-hole using a computer interface),
• Open Surgery

The results of all of these in terms of cancer control, potency and continence are the same. 

Laparoscopic and robotic approaches offer faster recovery with less blood loss and transfusion risk. 

Radical Prostatectomy Advantages 

• The prostate gland is completely removed.
• Additional radiotherapy can still be applied if the cancer is at a high risk of recurring or shows signs of local recurrence.
• It effectively controls prostate cancer and prevents its spread to other body parts.

Radical Prostatectomy Disadvantages 

• Major surgery, even if it is performed using key-hole techniques
• Bleeding (but a very low risk of transfusion with robotic surgery)
• Surrounding tissue or organ injury (rectum, ureter)
• Blood clots in the legs (DVT) and lungs (PE)
• The risk of a positive margin may imply that the cancer has not been completely cleared.
• Possible need for radiotherapy or hormonal therapy after the operation.

Possible Risks with Radical Prostatectomy

Irrespective of how a Radical Prostatectomy surgery is performed, the significant long-term side effects include impotence and incontinence.

• Impotence - The risk of impotence varies depending on your age and health and whether the nerves to the penis are removed or whether one or both are spared.

Suppose you have excellent erections before the operation. In that case, your chance of regaining your erections at one year, either spontaneously or with tablets, is approximately 70% if both nerves are spared and 20-30% if only one is spared. 

• Incontinence - You will likely leak urine after your operation and must wear continence pads for the first few weeks or months. You must perform pelvic floor exercises. In general, 
• 25% of patients are pad free within four weeks, 
• 70% within three months and 
• 91-95% in one year. 

Therefore, there is a 5-9% chance that you may need to wear incontinence pads one year after the operation. Usually, this is a security pad to catch small amounts of urine; however, approximately 1-2% of patients have severe incontinence, which may require further surgery by injectable agents, a male urethral sling or an artificial sphincter. 

The incontinence may be permanent.

External Beam Radiotherapy

External beam radiotherapy is an effective treatment option for localised prostate cancer. It typically involves daily treatment for approximately 6-8 weeks; however, shorter protocols can also be used. 

In some cases, extra radiation can be delivered to the prostate by inserting small tubes through the skin behind the scrotum. 

These are used for a short time to deliver iridium, a radioactive substance, to the prostate to provide extra radiation to control more aggressive cancers. 

This is called high dose rate (HDR) brachytherapy. High Dose Rate cannot be performed if: 

• your prostate is too large; and 
• you have severe urinary symptoms already.

Radiotherapy Advantages

• Avoids major surgery.
• It can treat areas beyond the confines of the prostate if there is a high risk that cancer has spread outside of the prostate gland into the adjacent tissues or lymph nodes.

Radiotherapy Disadvantages & Risks

• Six weeks of treatment.
• Salvage treatments are limited in cases of cancer recurrence and are associated with high complication rates.
• Impotence - Erectile function deteriorates over time at around 10% per year producing impotence rates of approximately 50% at five years and then declines by roughly a further 5% per year after that.
• Severe urinary and rectal toxicity - approximately 5% of patients experience long-term problems with urinary urgency, frequency and bleeding, and rectal urgency, frequency and bleeding.
• Urethral scarring (stricture) produces a blockage of the urethra (water pipe that passes from the bladder through the penis) and is mainly a risk in HDR, where the rate is about 8%. The strictures can be dense and very difficult to treat.
• Fistula (an abnormal connection between the urinary tract and the rectum).

The major disadvantage is that limited options are available if the cancer is not cleared. This is because radiation damages the tissues and inhibits healing processes. 

Options After Radiotherapy for Prostate Cancer

In cases of radiation therapy failure, the options are:

• Surgery
• Focal therapy - ultrasound treatment (HIFU), Irreversible electroporation (nano knife), and Freezing of the prostate (cryotherapy) 

Still, the complication rates of these salvage treatments can be significant. Radiotherapy is also associated with potential long-term adverse effects such as radiation cystitis/proctitis or even secondary malignancy. For these reasons, radiotherapy is generally not recommended in very young men.

Brachytherapy

LDR Brachytherapy Seeds

Low-dose rate brachytherapy is a treatment option for localised prostate cancer that involves using radioactive seeds placed into the prostate.

Typically, 80 or more seeds of radioactive iodine-125 are placed into the prostate gland under a general anaesthetic. The procedure usually takes approximately 2 hours. 

Low levels of radiation are emitted by the seeds directly to the prostate. Very little radiation penetrates outside of the prostate gland. 

This allows the prostate to be treated explicitly while minimising the effects on adjacent tissue. The procedure takes approximately 2 hours. A catheter will be placed in your bladder, and an ultrasound probe will be placed in your rectum to visualise the prostate gland. 

Approximately 80 seeds are inserted into the prostate under ultrasound guidance using needles between the scrotum and the anus. 

The needles are removed, and the seeds are left within the prostate gland. You will then be admitted to the ward, and your catheter will be removed the following morning. A postoperative CT scan will be obtained either the next day or 1-3 months after the procedure.

High-dose Rate (HDR) Brachytherapy

High Dose Rate Brachytherapy is based on similar principles to that of LDR Brachytherapy, but the delivery is a bit different.

Before treatment starts, a doctor will place tiny catheters (hollow tubes) throughout your prostate.

For each treatment, the doctor will place one or more sources of high-dose radiation in the prostate through the catheters. The doctor uses wires that contain the radioactive substance iridium. This radioactive source produces gamma rays at different intensity levels and has the same effect on cancer cells as X-rays. Iridium radiation delivers a more intense but short-lived dose of radiation.

Then the doctor will remove the radioactive material after a few minutes. These sources are removed from the patient at the end of each treatment session.

Typically HDR Brachytherapy is over three sessions and is used for more high-risk but localised prostate cancers. HDR Brachytherapy is often given in conjunction with External Beam Radiation Therapy.

The catheters will remain in place for the entire course of your treatment. But once you have received your treatments, the catheters will be removed. You will stay in the hospital or radiation clinic for the entire course of treatment.

Brachytherapy Advantages

• Minimally invasive
• Short recovery time
• High cancer control rate
• Preservation of sexual function

Brachytherapy Disadvantages

• Not all patients are suitable for brachytherapy.
• Salvage treatments are limited in cases of cancer recurrence and are associated with high complication rates.
• Impotence- The risk of impotence is approximately 22% one year after the implant and is about 50% at five years. Impotence then worsens by about 5% per year after that.
• Stricture (5%) - There is a slight chance that scar tissue may form in the urethra. The urethra is the tube that carries urine from the bladder through the prostate and penis. It is the tube that you pass urine through to urinate. In these instances, the scar tissue may need to be opened with further surgery.
• Dysuria (pain with urination) and urinary urgency and frequency are experienced by most (over 70%) men at three months. This typically resolves over time. At one year, the risk of some ongoing urinary symptoms may be up to 20%. In two years, it is approximately 2.5%. At three years, 1.25%, and 1% at five years.
• Retention (2-3%) - There is a risk that you may not be able to pass urine after the procedure. This is due to swelling of the prostate gland. If this occurs, you may need to learn to pass catheters (small plastic tubes) intermittently into the bladder each time you pass urine. You may have to do this for some months. You may also require a rebore of the prostate (TURP) at a much later date to help you pass urine. There is a higher risk of incontinence associated with TURP following brachytherapy.
• Approximately 1% of patients will experience a syndrome of urinary frequency, pain and reduced bladder volume in the long term.
• Rectal toxicity - Up to 5% of patients may notice increased bowel movements and blood frequency in the bowel motion.
• Incontinence - There is a risk that you will leak urine after the procedure. This risk is approximately 2% at about five years.
• Fistula - There is a 1% risk that you may form an abnormal connection between the bladder and the bowel, which can result in ongoing urine infections and may require further complex surgery.

Focal Therapy

Focal therapy is a treatment option for men with early-stage, localised prostate cancer. It is a minimally invasive treatment option that aims to treat only the part of the prostate that contains cancer rather than the whole gland.These options are still considered experimental currently.

There are several types of focal therapy, including:

• High-intensity focused ultrasound (HIFU): which uses high-energy ultrasound waves to heat and destroy the cancerous tissue
• Cryotherapy: which uses freezing temperatures to destroy the cancerous tissue
• Laser ablation: this uses a laser to heat and destroy the cancerous tissue

Focal Therapy Advantages

• Minimally invasive
• Preservation of sexual function
• Preservation of urinary continence

Focal Therapy Disadvantages

• Limited availability: Focal therapy is not widely available and may only be offered in some locations.
• Long-term data: There needs to be more long-term data on the effectiveness and safety of focal therapy.
• Not suitable for all patients: Focal therapy may not be ideal for men with more extensive prostate cancer or advanced prostate cancer.

Hormonal Therapy

Hormonal therapy is a treatment option for men with prostate cancer that has spread beyond the prostate gland or has come back after initial treatment. It works by blocking the production of the male hormone testosterone, which is needed for the growth of prostate cancer cells.

Hormonal Therapy Advantages

• Effective in slowing or stopping the growth of prostate cancer
• It can be used in combination with other treatments
• Well-tolerated with minimal side effects

Hormonal Therapy Disadvantages

• Not curative, and cancer may eventually progress despite treatment
• It can cause side effects such as hot flashes, loss of libido, impotence, and osteoporosis.