Treatment Options for Prostate Cancer

A Keck Medicine of USC urologist discusses factors to consider when contemplating treatment options for prostate cancer.

Recommended options for treating prostate cancer can really vary from patient to patient, depending on personal and lifestyle preferences. One in eight men in the United States will get prostate cancer, according to the American Cancer Society. If you or someone you know has just been diagnosed with prostate cancer, you might be wondering what type of treatment is best.  

“There are various treatment options for prostate cancer, and a lot of them are designed based on what the patient values the most,” says Sij Hemal, MD, a urologic oncologist with USC Urology, part of Keck Medicine of USC. Whether you choose to do radiation, surgery, focal therapy or brachytherapy, there are going to be different side effects, he explains. “Not every patient and cancer is built the same. Depending on the grade of the cancer, the aggressiveness of the cancer and the size of the prostate gland, the recommended treatment plan might be different.” 

Treatment options for prostate cancer 

1. Active surveillance 

Active surveillance is a treatment strategy for prostate cancer that is typically performed for low-risk and favorable, intermediate-risk prostate cancer patients, Dr. Hemal says. This means every few months you will do blood tests and periodically you will undergo MRI imaging and biopsies to monitor whether your cancer is progressing or growing.  

“If you have been given a diagnosis of low-risk prostate cancer or favorable intermediate-risk prostate cancer, a urologist should offer you active surveillance, with blood tests of your prostate-specific antigen (PSA) level every three to six months, MRI scans every 18-24 months and biopsies every two to three years, depending on several factors,” Dr. Hemal says.  

“If there’s any change in the grade of your cancer, or if you get upstaged to a higher cancer grade on pathology or have worsening MRI findings or worrisome PSA kinetics, then we will recommend more aggressive treatment,” Dr. Hemal says. 

2. Surgery 

The gold standard treatment of clinically localized prostate cancer is a radical prostatectomy, which removes all of the prostate gland as well as the seminal vesicles and nearby lymph nodes, Dr. Hemal says. “This is the best option when your cancer is limited to the prostate gland,” he says.  

The most common side effects of surgery are incontinence and erectile dysfunction, however the degree to which a patient experiences these side effects depends.  

One thing that can affect these side effects is whether a nerve sparing prostatectomy can be performed, which is determined by the biological aggressiveness of the cancer and whether the cancer is also invading the surrounding nerves based on findings from the MRI. This is because the nerves that run adjacent to the prostate gland play a vital role in a man’s erectile function and to a certain extent to his continence, Dr. Hemal says.  

The prostate is a very deep organ that is surrounded by “hood” structures such as the detrusor apron, puboprostatic ligament complex, arcus tendinious and endopelvic fascia, which all contribute to a patient’s continence.  

“If the cancer allows me, and I am able to preserve these critical structures in addition to performing a nerve sparing procedure, patients may recover continence in as fast as one to three months after surgery, and their erectile function in about 6-12 months,” Dr. Hemal says. In patients with more aggressive prostate cancer, continence recovery may take up to a year to and patients may need other types of medical therapies to promote erectile function recovery such as medication, intracavernosal injections and/or penile prosthesis, he says.  

Younger patients tend to do quite well with surgery, and many can regain their erectile function within a few months.  

USC Urology physicians routinely perform radical prostatectomy with the help of the robotic multiport (Xi) platform. “The benefit to doing this surgery robotically is that with the magnification and the 3D vision, the surgeon can carefully preserve the architecture surrounding the prostate, which includes the various nerves, ligaments and blood vessels that are important for a man’s ability to have erections and continence,” Dr. Hemal says. However, if the cancer is invading other structures, more widespread removal may be required, which can affect erectile function and continence, he says.  

Another option offered at USC Urology is a single port radical prostatectomy. The benefits of a single-port prostatectomy are everything that conventional multi-port robotic surgery offers, plus the fact that all the instruments enter through a single 3.5-centimeter incision directly below the belly button or right above the pubic bone, Dr. Hemal says.  

“Single port robotic surgery has great utility in patient that have undergone previous abdominal surgeries, as we are able to regionalize our surgical approach to the areas outside of the abdominal cavity and thus reduce risk of any bowel or vascular injury,” Dr. Hemal says. Another option is to do a transvesical radical prostatectomy, where surgeons perform the surgery directly through the bladder itself. 

“These options can reduce pain, improve the cosmetic outcome, minimize narcotics use with patients taking only Tylenol and ibuprofen for pain and give a patient faster recovery times, with some patients able to resume playing sports within two weeks, for instance,” Dr. Hemal says. 

3. Radiation 

Radiation can be done in several ways, Dr. Hemal says. With external beam radiation, high-energy beams deliver targeted therapy to the abnormal cells of the prostate from outside your body.  

For intermediate and high-risk prostate cancers, radiation is also given in conjunction with androgen deprivation therapy. Androgen deprivation therapy is a form of hormone therapy that helps to reduce levels of male hormones such as testosterone, which stops these hormones from allowing the prostate cancer cells to grow. “Unfortunately, this treatment may lead to several side effects such as lack of libido, hot flashes, fatigue, loss of lean muscle mass, heart disease, osteoporosis and cognitive decline,” Dr. Hemal says.  

There is also brachytherapy, which is a type of internal radiation therapy in which the radiation oncologists place radioactive seeds in your prostate. This method can help selectively target the prostate while preserving surrounding healthy tissue.  

For patients with symptoms of prostate enlargement, such as difficulties urinating, weak stream or urinary urgency and frequency, surgery can be a better option as it can often alleviate the symptoms of prostate enlargement while treating the prostate cancer, Dr. Hemal says, because radiation can worsen those symptoms.  

“However, for someone with heart problems or lung problems, or someone who is a smoker or not a good surgical candidate, radiation/focal therapy may be the better alternative as surgery could potentially put a patient at higher risk for blood clots, heart attacks, or strokes during surgery,” Dr. Hemal says. Patients 75 years or older who desire treatment of their prostate cancer may also be better suited towards focal therapy and or radiation. 

4. Focal therapy 

Focal therapy is a newer therapy using high-intensity focused ultrasound waves or cryotherapy, which means freezing the part of the prostate where the cancer is, Dr. Hemal says. You can also use laser ablation or photodynamic therapy. These techniques can help mitigate some of the side effects that come with surgery or radiation, he says. However, with this type of therapy you have a higher chance of your cancer coming back compared to surgery or standard radiation. 

5. Hormone therapy 

For more aggressive stages of prostate cancer (mainly when cancer is metastatic), hormone therapy is the first line treatment option that is occasionally paired with radiation, Dr. Hemal says.  

At USC Urology, each treatment option is uniquely tailored to a patient’s situation and lifestyle preferences. “When we choose treatment plans, we utilize shared decision making with a patient, as a lot of what we do is designed based on what the patient values the most,” Dr. Hemal says.  

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