Prostate Cancer

Overview

Cancer begins when normal cells in the prostate begin to change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

About the prostate gland

The prostate is a walnut-sized gland located behind the base of the penis, in front of the rectum, and below the bladder. It surrounds the urethra, the tube-like channel that carries urine and semen through the penis. The prostate's main function is to make seminal fluid, the liquid in semen that protects, supports, and helps transport sperm.

Types of prostate cancer

Prostate cancer is a malignant tumor that begins in the prostate gland of men. Some prostate cancers grow very slowly and may not cause symptoms or problems for years. In this situation, the cause of death is usually not from prostate cancer, but other causes. Many times, when a man develops prostate cancer much later in life, it is unlikely to cause symptoms or shorten the man’s life; aggressive treatment may not be needed. However, if cancer does metastasize (spread) to other parts of the body, it can cause pain, fatigue, and other symptoms. Prostate cancer is somewhat unusual, compared with other types of cancer, because many tumors that are diagnosed do not spread from the prostate. And often, even metastatic prostate cancer can be successfully treated, with the person surviving in good health for some years.

More than 95% of prostate cancers are adenocarcinomas, cancer that develops in glandular tissue. A rare type of prostate cancer known as neuroendocrine cancer or small cell anaplastic cancer tends to spread earlier, but usually does not make prostate-specific antigen (PSA), a tumor marker discussed later in the Risk Factors and Prevention section. Read more about neuroendocrine tumors.

Looking for More of an Overview?

If you would like additional introductory information, explore these related items on Cancer.Net:

• ASCO Answers Fact Sheet
: Read a one-page fact sheet (available in PDF) that offers an easy-to-print introduction for this type of cancer.

• Cancer.Net Patient Education Video
: View a short video led by an ASCO expert in this type of cancer that provides basic information and areas of research.

• Cancer.Net En Español
: Read this full section in Spanish or a one-page summary in an ASCO Answers Fact Sheet.

Find out more about basic cancer terms used in this section.

Statistics

Prostate cancer is the most common cancer among men. In 2010, an estimated 217,730 men in the United States will be diagnosed with prostate cancer. It is estimated that 32,050 deaths from this disease will occur this year.

Prostate cancer is the second leading cause of cancer death in men. Although the number of deaths from prostate cancer is declining among all men, the death rate remains more than twice as high in black men than in white men.

More than 90% of all prostate cancers are found when the disease is located only in the prostate and nearby organs. Nearly all men who develop prostate cancer are expected to live at least five years after diagnosis. The 10-year and 15-year relative survival rates (the percentage of people who survive at least 10 or 15 years after the cancer is detected, excluding those who die from other diseases) are 91% and 76%, respectively. These survival rates are a combination of early-stage and later-stage prostate cancers; a man’s individual survival depends on the type of prostate cancer and the stage of the disease.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a man how long he will live with prostate cancer. Because survival statistics are often measured in multi-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2010.

Risk Factors and Prevention

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health care choices.

Because the exact cause of prostate cancer is still unknown, it is also unknown how to prevent prostate cancer. The following factors can raise a man’s risk of developing prostate cancer:

Age. The risk of prostate cancer increases with age, rising rapidly after age 50. More than 80% of prostate cancers are diagnosed in men who are 65 or older.

Race/ethnicity. African American men have a higher risk of prostate cancer than white men. They are more likely to develop prostate cancer at an earlier age and to have aggressive tumors that grow quickly. The exact reasons for these differences are not known and probably involve both biologic and socioeconomic factors. Some scientists believe that a high-fat diet, which can be common in many parts of the African American community, plays a role in the development of prostate cancer (see the Diet heading below for more detail). It may also be due to genetic factors within the African American community, but the specific genes are not known. Prostate cancer occurs most often in North America and northern Europe and is less common in Asia, Africa, and Latin America. However, it appears that prostate cancer is increasing among Asian people living in urbanized environments, such as Hong Kong, Singapore, as well as North American and European cities and particularly among those who have a more western lifestyle.

Family history. A man who has a father or brother with prostate cancer has a higher risk of developing the disease than a man who does not. Researchers have discovered specific genes that may possibly be associated with prostate cancer, although these have not yet been shown to cause prostate cancer or to be specific to this disease. Learn more about the genetics of prostate cancer.

Diet. No study has shown conclusively that diet and nutrition can directly cause or prevent the development of prostate cancer, but many studies indicate there may be a link. There is not enough information yet to make clear recommendations about the role diet plays in prostate cancer, but the following may be helpful:

• A diet high in fat, especially animal fat, may increase prostate cancer risk. In fact, many doctors believe that a low-fat diet may help to reduce the risk of prostate cancer.

• A diet high in vegetables, fruits, and legumes (beans and peas) may decrease risk of prostate cancer. It is unclear which nutrients are directly responsible. Lycopene, found in tomatoes and other vegetables, may slow or prevent cancer growth. In any case, such a diet does not cause harm and can lower a person’s blood pressure and risk of heart disease.

• Selenium, an element that people get in very small amounts from food and water, and vitamin E have been tested to find out if either or both of these nutrients can lower the risk of prostate cancer. However, in a clinical trial (a research study involving people) of more than 35,000 men called the Selenium and Vitamin E Cancer Prevention Trial (SELECT), researchers found that selenium and vitamin E supplements (pills), taken alone or together for an average of five years, did not prevent prostate cancer and may even cause harm in some men. Because of this risk, the National Cancer Institute has stopped the SELECT study. Men should talk with their doctor before taking selenium and vitamin E supplements to prevent prostate cancer.

It’s important to remember that specific changes to diet may not stop or slow the development of prostate cancer and it’s possible such changes would need to begin early in life to have an effect.

Viruses. Researchers have discovered a virus called xenotropic murine leukemia virus (XMRV) in tissue from some men with prostate cancer. Men infected with this virus may be more likely to develop prostate cancer, but more studies are needed to understand the role of XMRV in prostate cancer.

Hormones and chemoprevention. High levels of testosterone (a male sex hormone) may speed up or cause the development of prostate cancer. For instance, it is very uncommon for a man whose body no longer makes testosterone to develop prostate cancer, and stopping the body’s production of testosterone, called androgen deprivation therapy, often shrinks advanced prostate cancer.

A class of drugs called 5-alpha-reductase inhibitors (5-ARIs) that include finasteride (Proscar) and dutasteride (Avodart) may lower a man’s risk of prostate cancer. In clinical trials, both drugs lowered the risk of prostate cancer. Initially, one of these trials suggested that a very small percentage of men who took finasteride had a higher risk of developing a more aggressive type of prostate cancer than the patients who did not receive finasteride. With further review, it now seems that finasteride causes the prostate gland to shrink, which may have allowed the doctors to find these more aggressive cancers in the biopsies (tissue removed for further examination) taken after treatment. But, the data is still being reviewed, the subject is very controversial, and these drugs have not been approved yet for prostate cancer prevention by the U.S. Food and Drug Administration (FDA). Learn about finasteride for prostate cancer prevention.

Prostate cancer screening

Screening for prostate cancer is done to find evidence of cancer in otherwise healthy men. Two tests are commonly used to screen for prostate cancer: the prostate-specific antigen (PSA) blood test and digital rectal examination (DRE, a test in which the doctor inserts a gloved, lubricated finger into a man's rectum and feels the surface of the prostate for any irregularities). PSA is found in higher-than-normal levels in men with various conditions of the prostate, including benign prostatic hyperplasia (BPH, an enlarged prostate), inflammation or infection of the prostate, and prostate cancer.

There is controversy about using the PSA test to screen large numbers of men with no symptoms for prostate cancer. On one hand, the PSA test is useful for detecting early prostate cancer, which helps men get the treatment they need before the cancer spreads. On the other hand, PSA screening has not yet been proven to lower death rates from prostate cancer in the general community, detects conditions that are not cancer, and misses some prostate cancers.

Unlike other types of cancer, prostate cancer grows slowly in many men—so slowly that in some men it would not threaten their life even if not treated. Because of this, screening for prostate cancer may mean that some men have surgery and other treatments that may not ever be needed. For this reason, many men and their doctors may consider active surveillance (watchful waiting; see Treatment) of their cancer rather than immediate treatment.

Because prostate cancer treatments have significant side effects, such as impotence (inability to get an erection) and incontinence (inability to control urine flow), treating it unnecessarily may seriously affect a man's quality of life. However, it is important to note that it is not easy to predict which tumors will grow and spread quickly and which will grow slowly. This has led some doctors to believe that it is prudent to use relatively safe screening tests, such as the PSA test, to detect aggressive cancers early, even if it means that some patients will receive unnecessary treatment.

Three clinical trials have reported results on prostate cancer screening:

• In the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, researchers found more cancers with screening, but they also found no difference in deaths from prostate cancer in men who were screened with PSA and DRE compared with men who were not screened for up to 11 years after the screening began.

• In the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial, researchers saw a small reduction in prostate cancer deaths of men who were screened for prostate cancer (7 deaths per 10,000 men screened), but the overall survival was the same in the two groups.

• Another recent clinical trial called the Göteborg Trial found prostate cancer screening reduced deaths from prostate cancer by almost half. However, the study did not look at whether the screening improved the survival of the men diagnosed with prostate cancer, and many men needed to be screened and diagnosed in order to prevent one death from prostate cancer.

Every man should discuss his individual situation and risk of prostate cancer and work with his doctor to make a decision. For example, men older than 75 may not need screening.

No study definitely proves that screening is more beneficial for men at higher risk of prostate cancer, or for African American men versus white men. Many experts feel that it is generally safer to use screening for these men in the hope of finding aggressive types of prostate cancer earlier when it may be easier to treat. However, as noted above, this has not been proven in clinical trials. Read about talking with your doctor about PSA screening.

Symptoms

Often, prostate cancer is found through a PSA test or DRE (see Risk Factors and Prevention) in otherwise healthy men who have not had any symptoms or signs. When prostate cancer does cause symptoms or signs, they may include the following:

• Frequent urination

• Weak or interrupted urine flow

• Blood in the urine

• The urge to urinate frequently at night

• Blood in the seminal fluid

• Pain or burning during urination (much less common)

None of these symptoms is specific to prostate cancer. The same symptoms occur in men who have a noncancerous condition known as BPH, or enlarged prostate. Urinary symptoms also can be caused by an infection or other conditions. In addition, sometimes men with prostate cancer do not have any of these symptoms.

If cancer has spread outside of the prostate gland, a man may experience:

• Pain in the back, hips, thighs, shoulders, or other bones

• Unexplained weight loss

• Fatigue

If you are concerned about a symptom or sign on this list, please talk with your doctor.

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis, but this situation is rare for prostate cancer. For example, a biopsy may not be done when a patient has another medical problem that makes it difficult to do a biopsy, or when a person has a very high PSA level and a bone scan that indicates cancer. Imaging tests may be used to find out whether the cancer has spread. Your doctor may consider these factors when choosing a diagnostic test:

• Age and medical condition

• The type of cancer suspected

• Severity of symptoms

• Previous test results

In addition to a physical examination, the following tests may be used to diagnose prostate cancer:

PSA test. As described in Risk Factors and Prevention, PSA is a type of protein released by prostate tissue that is found in higher levels in a man's blood when there is abnormal activity in the prostate, including prostate cancer, BPH, or inflammation of the prostate. Doctors can look at features of the PSA value—such as absolute level, change over time, and level in relation to prostate size—to decide if a biopsy is needed. In addition, a version of the PSA test allows the doctor to measure a specific component, called the “free” PSA, which can sometimes help determine if a tumor is benign (noncancerous) or malignant.

DRE. This test is used to find abnormal areas in the prostate by feeling the area using a finger (see Risk Factors and Prevention). It is not very precise; therefore, most men with early prostate cancer have a normal DRE test.

If the PSA or DRE test results are abnormal, the following tests can confirm a diagnosis of cancer:

Transrectal ultrasound (TRUS). A doctor inserts a probe into the rectum that takes a picture of the prostate using sound waves that bounce off the prostate.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. To get a tissue sample, a surgeon most often uses TRUS and a biopsy tool to take very small slivers of prostate tissue. The sample removed with the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). This procedure is usually done as an outpatient procedure, and the patient is given local anesthesia beforehand to numb the area.

To find out if cancer has spread outside of the prostate, doctors may perform the following imaging tests:

Bone scan. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.

Learn more about what to expect when having common tests, procedures, and scans.

Find out more about common terms used during a diagnosis of cancer.

Staging

Our staging illustrations are currently being updated to comply with the new 2010 American Joint Committee on Cancer staging guidelines. We apologize for the inconvenience.

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Staging for prostate cancer also involves reviewing test results to determine if the cancer has spread from the prostate to other parts of the body. Knowing the stage helps the doctor decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

There are two types of staging for prostate cancer:

• The clinical stage is based on the results of tests done before surgery, such as a biopsy, x-rays, CT scans, and bone scans. X-rays, bone scans, and CT scans may not always be needed. They are recommended based on the level of serum PSA, the grade and volume (size) of the cancer, and the clinical stage of the cancer.

• The pathologic stage is based on information found during surgery, plus the laboratory results (pathology) of the prostate tissue removed during surgery (which often includes the removal of the entire prostate and some lymph nodes).

One tool that doctors use to describe the stage is the TNM system, developed by the American Joint Committee on Cancer (AJCC) and the Union International Contre le Cancer (UICC). This system is most commonly used in the United States and uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are four stages: stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

After gathering information with the TNM method, the results can be grouped together into a simpler set of stages (called stage grouping). Many doctors do not use the TNM system and prefer another method called the Jewett-Whitmore staging system (stages A, B, C, and D). Both are described below.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

• How large is the primary tumor and where is it located? (Tumor, T)

• Has the tumor spread to the lymph nodes? (Node, N)

• Has the cancer metastasized to other parts of the body? (Metastasis, M)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of a tumor in the prostate.

T1: The tumor cannot be felt during the DRE and is not seen during imaging (any test that produces pictures of the inside of the body, such as a CT scan). It may be found when surgery is done for another reason, usually for BPH, or abnormal growth of benign prostate cells.

T1a: The tumor is in 5% or less of the prostate tissue removed through surgery.

T1b: The tumor is in more than 5% of the prostate tissue removed through surgery.

T1c: The tumor is found during a needle biopsy, usually because the patient has an elevated PSA level.

T2: The tumor is found only within the prostate, not other areas of the body. It is large enough to be felt during the DRE.

T2a: The tumor has invaded one-half of one lobe (part or side) of the prostate.

T2b: The tumor has spread to more than one-half of one lobe of the prostate, but not to both lobes.

T2c: The tumor has invaded both lobes of the prostate.

T3: The tumor has grown through the prostate capsule (into the tissue just outside the prostate on one side).

T3a: The tumor has grown through the prostate capsule either on one side or on both sides of the prostate or has spread to the neck of the bladder.

T3b: The tumor has invaded the seminal vesicle(s), the tube(s) that carry semen.

T4: The tumor is fixed, or it is invading nearby structures besides the seminal vesicles, such as the external sphincter (part of the muscle layer that helps to control urination), the rectum, levator muscles, and/or the pelvic wall.

Nodes. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the prostate in the pelvic region are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0: The cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to the regional lymph node(s).

Distant metastasis. The "M" in the TNM system indicates whether the prostate cancer has spread to other parts of the body, such as the lungs or the bones.

MX: Distant metastasis cannot be evaluated.

M0: The disease has not metastasized.

M1: There is distant metastasis.

M1a: The cancer has invaded nonregional, or distant, lymph node(s).

M1b: The cancer has invaded bone(s) in the body.

M1c: The cancer has spread to another part of the body, with or without spread to the bone.

PSA test. As described in Risk Factors and Prevention, PSA is a measurement of prostate-specific antigen levels in a man’s blood. These results are usually reported as nanograms per milliliter (ng/mL), such as 7 ng/mL, for a PSA level of 7. For men already diagnosed with prostate cancer, the PSA level (and the Gleason score, described below) helps the doctor understand and predict a patient’s prognosis. This measurement gives doctors more information about the cancer to help make treatment decisions. It’s important to note that some prostate cancers do not cause an increased PSA level, so a normal PSA does not always mean that there is no prostate cancer.

Gleason score for grading prostate cancer. Prostate cancer is also given a grade called a Gleason score, which is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less dangerous tumors generally look more like healthy tissue, and more dangerous tumors that are more likely to invade and spread to other parts of the body look less like healthy tissue.

The Gleason System is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 1 to 5. Cancer cells that look similar to healthy cells are given a low score, and cancer cells that look less like healthy cells are given a higher score. To assign the numbers, the doctor first looks for a dominant pattern of cell growth (area where the cancer is most prominent), looks for any other less widespread pattern of growth, and gives each one a score. The scores are added to come up with an overall score between 2 and 10. The interpretation of the Gleason score by doctors has changed recently. Originally, there was a broader spread, with doctors using a range of scores. Today, doctors tend to describe a score of 6 as a low-grade cancer, 7 as medium-grade, and a score of 8, 9, or 10 as high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a cancer with a higher grade.

Gleason X: The Gleason score cannot be determined.

Gleason 6 or lower: The cells are well-differentiated.

Gleason 7: The cells are moderately differentiated.

Gleason 8, 9, or 10: The cells are poorly differentiated or undifferentiated .

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classification, the PSA level, and the Gleason score. As mentioned above, some doctors prefer to use the Jewett-Whitmore staging system (stages A, B, C, and D). See the table below for all of the TNM combinations for each stage.

Stage I or Stage A: Cancer is found in the prostate only, usually during another medical procedure. It cannot be felt during the DRE or seen on imaging tests. A stage I cancer usually has well-differentiated cells and is likely to grow slowly. The PSA level is under 10 and the Gleason score is 6 or lower. This can also be called stage A1 prostate cancer when it is in only one lobe of the prostate and stage A2 when both prostate lobes are involved.

Stage IIA and IIB or Stage B: This stage describes a tumor that is too small to felt or seen on imaging tests, with a higher PSA level and/or Gleason score (see table below for details). Or, it describes a slightly larger tumor that can be felt during a DRE, with a lower PSA level and Gleason score. The cancer has not spread outside of the prostate gland, but the cells are usually more abnormal and may tend to grow more quickly. It has not spread to lymph nodes or distant organs. Stage II prostate cancer may also be called stage A2, stage B1, or stage B2 prostate cancer.

Stage III or Stage C: The cancer has spread beyond the outer layer of the prostate into nearby tissues. It may also have spread to the seminal vesicles, the glands in men that help make semen. A stage III cancer may have any PSA level or Gleason score.

Stage IV or Stage D: This describes any tumor of any PSA level and any Gleason score that has spread to other areas of the body, such as the bladder, rectum, bone, liver, lungs, or lymph nodes. Stage IV prostate cancer may also be called stage D1 or D2 prostate cancer.

Recurrent: Recurrent prostate cancer is cancer that comes back after treatment. It may come back in the prostate area again or in other parts of the body.

Stage Grouping Chart

Stage

T

N

M

PSA Level

Gleason Score

I

T1a, T1b, or T1c

N0

M0

Lower than 10

6 or lower

(or stage A in the

T2a

N0

M0

Lower than 10

6 or lower

Jewett-Whitmore system)

Any T1 or T2a

N0

M0

Unknown

Unknown

 

 

 

 

 

 

IIA

T1a, T1b, or T1c

N0

M0

Lower than 20

7

(or stage B)

T1a, T1b, or T1c

N0

M0

10 to lower than 20

6 or lower

 

T2a

N0

M0

10 to lower than 20

6 or lower

 

T2b

N0

M0

Lower than 20

7 or lower

 

T2b

N0

M0

Unknown

Unknown

 

 

 

 

 

 

IIB

T2c

N0

M0

Any PSA level

Any score

 

Any T1 or T2

N0

M0

20 or higher

Any score

 

Any T1 or T2

N0

M0

Any PSA level

8 or higher

 

 

 

 

 

 

III

T3a or T3b

N0

M0

Any PSA level

Any score

(or stage C)

 

 

 

 

 

 

 

 

 

 

 

IV

T4

N0

M0

Any PSA level

Any score

(or stage D)

Any T

N1

M0

Any PSA level

Any score

 

Any T

Any N

M1

Any PSA level

Any score

 

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net.

Treatment

The treatment of prostate cancer depends on the size and location of the tumor, whether the cancer has spread, and the man’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, see the Clinical Trials section.

It is important to discuss the goals and possible side effects of treatment with your doctor before treatment begins, including the likelihood of success of that treatment, the potential side effects of therapy (including possible urinary, bowel, sexual, and hormone-related side effects), and the patient’s preferences. Men should talk with their doctor about how the various treatments affect recurrence (the return of the cancer after treatment), survival, and quality of life. In addition, the success of any treatment often depends on the skill and expertise of the physician or surgeon, so it is important to find doctors who have experience treating prostate cancer.

Descriptions of the most common treatment options for prostate cancer are listed below.

Active surveillance (watchful waiting), for early-stage cancer

If a prostate cancer is in an early stage, growing slowly, and if treating the cancer would cause more discomfort than the disease itself, a doctor may recommend watchful waiting, also called active surveillance or watch-and-wait. The cancer is monitored closely with periodic PSA testing, DRE tests, and watching for symptoms. Treatment would begin only if the tumor shows signs of becoming more aggressive or spreading, causes pain, or blocks the urinary tract. This approach may be used for much older patients, those with other serious or life-threatening illnesses, or those who wish to delay active treatment because of possible side effects. However, real caution must be taken not to make errors of judgment about the disease. In other words, doctors must collect as much information as possible about the patient’s other illnesses and potential life expectancy, so they don’t miss the chance to detect an early, aggressive prostate cancer. For this reason, many doctors recommend a repeat biopsy shortly after diagnosis to confirm that the cancer is in an early stage and growing slowly before considering active surveillance for an otherwise healthy man. New information is becoming available all the time, and it is important for men to discuss these issues with their doctor to make the best decision about treatment.

Surgery

Surgery is used to try to cure cancer before it has spread outside the prostate. A surgical oncologist is a doctor who specializes in treating cancer using surgery. For prostate cancer, a urologist or urologic oncologist is the surgical oncologist involved in treatment. The type of surgery depends on the stage of the disease, the man’s general health, and other factors.

Radical (open) prostatectomy. A radical prostatectomy is the surgical removal of the whole prostate and seminal vesicles; lymph nodes in the pelvic area may also be removed. This operation has the risk of interfering with sexual function. Nerve-sparing surgery, when possible, increases the chance that a man can maintain his sexual function after surgery by avoiding surgical damage to the nerves that allow erections and orgasm to occur. Orgasm can occur even if some nerves are cut since these are two separate processes. Urinary incontinence (inability to control urine flow) is also a possible side effect of prostatectomy. To help resume normal sexual function, men can receive drugs, penile implants, or injections. Sometimes, another surgery can fix urinary incontinence.

Robotic or laparoscopic prostatectomy. This type of surgery is possibly much less invasive than an open radical prostatectomy and may reduce recovery time. A camera and instruments are inserted through small, keyhole incisions in the patient’s abdomen. The surgeon then directs the robotic instruments to remove the prostate gland and surrounding tissue. In general, robotic prostatectomy has less bleeding and less pain, but sexual and urinary side effects can be similar to an open radical prostatectomy. This procedure has not been available for as long a time as open radical prostatectomy, so longer-term follow-up information, including permanent cure rates, are not yet certain. Talk with your doctor about whether your treatment center offers this procedure and how it compares with the results of the conventional open radical prostatectomy.

Transurethral resection of the prostate (TURP). TURP is most often used to relieve symptoms of a urinary blockage, not to cure cancer. In this procedure, with the patient under a full anesthetic, a surgeon inserts a cystoscope (a narrow tube with a cutting device) into the urethra and into the prostate to remove prostate tissue. This is rarely used to treat prostate cancer in current clinical practice.

Cryosurgery. This procedure is commonly used only in research studies. Cryosurgery (also called cryotherapy or cryoablation) is the freezing of cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that contains the testicles. Cryosurgery may be useful for early-stage cancer and for men who cannot have a radical prostatectomy. A common side effect of cryosurgery is impotence, so this approach is not recommended for men who desire to preserve their sexual function. Another side effect may be the development of fistulae (holes between the prostate and the bowel), although this appears to be much less common with newer cryosurgery techniques.

Learn more about cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy rays to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a specific time.

External-beam radiation therapy. External-beam radiation therapy focuses a beam of radiation on the area with the cancer. Some cancer centers use conformal radiation therapy (CRT), in which computers help precisely map the location and shape of the cancer. CRT reduces radiation damage to healthy tissues and organs around the tumor by directing the radiation therapy beam from different directions with the intention of focusing the dose on the tumor.

Intensity-modulated radiation therapy (IMRT). IMRT is a form of three-dimensional (3-D) CRT. CRT uses CT scans to form a 3-D picture of the prostate before treatment. With IMRT, high doses of radiation can be directed at the prostate without increasing the risk of damaging nearby organs.

Brachytherapy. Brachytherapy is the insertion of radioactive sources directly into the prostate. These sources (called seeds) give off radiation just around the area they are inserted in and may be used for hours (high-dose rate) or for weeks (low-dose rate). Low-dose rate seeds are left in the prostate permanently, even after all the radioactive material has been used up.

Radiation therapy may cause such side effects as diarrhea or other problems with bowel function; increased urinary urge or frequency; fatigue; impotence (erectile dysfunction); and rectal discomfort, burning, or pain. Most of these side effects usually go away after treatment, but erectile dysfunction is usually permanent. Learn more about radiation therapy.

Hormone therapy

Because prostate cancer growth is driven by male sex hormones known as androgens, lowering levels of these hormones can help slow the growth of the cancer. Hormone treatment is also called androgen ablation or androgen deprivation therapy. The most common androgen is testosterone. The production of testosterone can be lowered either surgically, with surgical castration (removal of the testicles), or with drugs that turn off the function of the testicles (see below).

Hormone therapy is used to treat prostate cancer that has continued to grow after surgery and radiation therapy, or when it is widespread at the time of diagnosis. More recently, hormone therapy has also been used with radiation therapy for men with a cancer that is more likely to recur. For some men, hormone therapy will be used first to shrink a prostate cancer tumor before radiation therapy or surgery. In some men with prostate cancer that has spread locally (as found during a radical prostatectomy), hormone therapy is given after the surgery for two to three years as adjuvant therapy (treatment that is given after the first treatment).

Traditionally, hormone therapy was used until it stopped controlling the cancer. Then the cancer was said to be hormone refractory (meaning that the hormone therapy has stopped working), and other treatment options were considered. Recently, researchers have begun studying intermittent hormone therapy, which is hormone therapy that is given for certain periods and then stopped temporarily according to a schedule. Giving hormones in this way appears to lower the symptoms of this therapy. In addition, intermittent hormone therapy may possibly maintain hormone responsiveness for a longer time than standard (continuous) hormone treatment; this approach is currently being tested in clinical trials.

One important side effect of hormonal therapy is the risk of developing metabolic syndrome. Metabolic syndrome refers to a set of conditions, such as high levels of blood cholesterol and high blood pressure that increases a person’s risk of heart disease, stroke, and diabetes. Currently, it is not certain how often this happens or exactly why it happens, but it is quite clear that patients who undergo a surgical or medical castration with hormone therapy (even a temporary medical castration) have an increased risk of developing metabolic syndrome. The risks and benefits of castration should be carefully discussed with your doctor. For men with metastatic prostate cancer, especially if it is advanced and causing symptoms, most doctors believe that the benefits of castration far outweigh the risks of metabolic syndrome.

Types of hormone therapy

Bilateral orchiectomy. Bilateral orchiectomy is the surgical removal of both testicles. Even though this is surgery, it is called a hormone treatment because it removes the main source of testosterone production, the testicles. This surgery is permanent and cannot be reversed.

LHRH agonists. LHRH stands for luteinizing hormone-releasing hormone. LHRH agonists are drugs that reduce the body's production of testosterone by interfering with hormonal control mechanisms within the brain, which control the functioning of the testicles.

Anti-androgens. While LHRH agonists lower testosterone levels in the blood, anti-androgens block testosterone from binding to so-called “androgen receptors,” chemical structures in the cancer cells that allow testosterone and other male hormones to enter the cells.

LHRH antagonist. This type of drug, also called a gonadotropin-releasing hormone (GnRH) antagonist, stops the testicles from producing testosterone by acting like LHRH. The FDA has approved one drug, degarelix (Firmagon), given by injection, to treat advanced prostate cancer. This drug may cause a severe allergic reaction.

Female hormones. Estrogen can lower testosterone levels. When this drug is given as a pill, side effects can include heart problems and blood clots. More recently, estrogens have been given as injections or as skin patches, and this type of treatment may be associated with a lower chance of heart and clotting side effects.

Combined androgen blockade. Sometimes, LHRH agonists are used in combination with peripheral-blocking drugs, such as anti-androgens, to more completely block male hormones. Many doctors feel that this combined approach is the safest way to start hormone treatment, as this prevents a potential flare-up or increase in activity of the prostate cancer cells that sometimes happens because of a temporary surge in testosterone production by the testicles (in response to the LHRH agonists). Major studies have not shown a big difference in long-term survival from the use of combined androgen blockade as permanent therapy; therefore, some doctors prefer to give combined drug treatment only for the first two to three months.

Hormone therapy may cause significant side effects. Side effects generally go away after hormone treatment is finished, except in men who have had an orchiectomy. Patients may experience impotence, loss of libido (sexual desire), hot flashes, gynecomastia (enlarged breasts), and osteoporosis (weakening bones). Men who have received LHRH agonists for more than two years will often have ongoing hormonal effects, even if the drugs are no longer given.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. Some people may receive chemotherapy in their doctor's office or outpatient clinic; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time.

Chemotherapy can be taken orally (by mouth) or intravenously (injected into a vein), and it may help patients with advanced or hormone-refractory prostate cancer. There is no standard chemotherapy for prostate cancer, but clinical trials are exploring chemotherapy for advanced prostate cancer. The most popular, current approach is the use of a drug called docetaxel (Taxotere) given with a steroid called prednisone (multiple brand names). This combination has been shown to help men with advanced prostate cancer live longer than another chemotherapy, mitoxantrone (Novantrone), which is most useful for controlling prostate cancer symptoms.

The FDA has approved the drugs mitoxantrone and docetaxel for use in men with prostate cancer that is resistant to hormone therapy. Also, the drugs paclitaxel (Taxol) and estramustine (Emcyt) have shown some beneficial effects in treating advanced prostate cancer. Estramustine is being used less often in current clinical practice because of its side effects, which include an increased risk of blood clots. Although clinical trials have shown that docetaxel increases survival and has a higher rate of remission (temporary or permanent absence of disease) than mitoxantrone, the difference in survival is only an average of a few additional months, and the side effects of mitoxantrone are generally milder than for docetaxel. Many new medications for prostate cancer are in development and may be available in clinical trials.

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications.

Learn more about your prescriptions by using searchable drug databases.

Advanced prostate cancer

Prostate cancer that develops the ability to grow without using male sex hormones and causes hormone treatments to stop working is called androgen-independent cancer, hormone-refractory prostate cancer, or castrate resistant. Although there is no cure for this type of cancer, it is often treatable with radiation therapy or chemotherapy.

In 2010, the FDA approved cabazitaxel (Jevtana) for patients with hormone-refractory prostate cancer who have already received treatment with docetaxel. Cabazitaxel is similar to docetaxel, but research studies have shown that it can be effective for prostate cancer that is resistant to docetaxel. The side effects are similar to docetaxel and include low white blood cell counts, increased risk of infections, allergic reactions, nausea, vomiting, diarrhea, and kidney and liver problems.

Another option for men may be an immunotherapy called sipuleucel-T (Provenge). Immunotherapy (also called biologic therapy) is designed to boost the body's natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune system function.

In 2010, the FDA approved sipuleucel-T for men with hormone-refractory metastatic prostate cancer with few or no symptoms after it increased survival by an average of a little more than two months. Sipuleucel-T is adapted for each patient. Before treatment, blood is removed from the patient in a process called leukapheresis. Special immune cells are separated from the patient’s blood, modified in the laboratory, and then put back in the patient. At this point, the patient’s immune system recognizes and kills the prostate cancer cells. Because this treatment is tailored for each patient, it may not be available in many areas.

These clinical trials were sponsored by industry; critics have suggested that the small increase in survival comes at a significant cost, and many doctors are waiting for results of independent clinical trials. Learn more about immunotherapy.

If all treatments have failed to control prostate cancer, or if cancer comes back after treatment, a patient may experience pain, fatigue, and weight loss. At this point, the goal of treatment switches from curing the cancer to slowing it down and relieving symptoms.

It is important to note that many men outlive their prostate cancer, even those with advanced disease. Often, the prostate cancer grows slowly, and there are now effective treatment options that extend life even further. A few drugs can help treat the symptoms of advanced cancer to enhance the quality of the patient’s life; this may be called palliative or supportive care.

Chemotherapy (see above). Chemotherapy is most commonly used for patients with advanced, hormone-refractory prostate cancer. It can be effective in relieving symptoms, such as pain, weight loss, and fatigue, and may prolong life for some patients.

Strontium and samarium. Given by injection, these radioactive agents are absorbed near the area of bone pain. The radiation that is released helps relieve the pain, probably by causing local tumor shrinkage.

Pamidronate (Aredia) and zoledronic acid (Zometa). Given by injection, these drugs reduce the level of calcium in the blood and cause a reduction of bone complications (such as pain, fracture, and need for surgery) due to metastases. A high calcium level is called hypercalcemia and is sometimes found in men with advanced prostate cancer.

Hormone therapy. Some types of hormone therapy may be used to treat advanced cancer (see above). Read more about hormone therapy for advanced prostate cancer.

Find out more about common terms used during cancer treatment.

Clinical Trials Resources

Doctors and scientists are always looking for better ways to treat patients with prostate cancer. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. The clinical trial may be evaluating a new drug, a new combination of existing treatments, a new approach to radiation therapy or surgery, or a new method of treatment or prevention. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating prostate cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future men with prostate cancer.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

To join a clinical trial, patients participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.

For specific topics being studied for prostate cancer, learn more in the Current Research section.

Side Effects

Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur.

Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health.

Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them.

In addition to physical side effects, you may experience psychosocial (emotional and social) effects as well. Learn more about the importance of addressing such needs, including concerns about managing the cost of your medical care.

Learn more about late effects or long-term side effects by reading the After Treatment section or talking with your doctor.

After Treatment

After treatment for prostate cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is complete.

Men recovering from prostate cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about healthy living after cancer.

Learn more about coping with cancer, including important topics for men with prostate cancer, such as self-image and cancer, dealing with cancer recurrence, fertility and cancer treatment, and talking with your spouse or partner.

Find out more about common terms used after cancer treatment is complete.

Current Research

Research for prostate cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor.

Finding causes of prostate cancer. Researchers continue to explore the link between nutrition and lifestyle factors in the development of prostate cancer.

PSA test improvements. Researchers are developing a better PSA test, either a more specific and precise test or another test altogether. With improved testing, larger numbers of healthy men could be screened for prostate cancer, so more prostate cancers can be found and treated early.

Improved surgical techniques. Better techniques for nerve-sparing surgery can improve the likelihood that men who need radical prostatectomy retain their urinary continence and sexual function after surgery.

Shorter courses of radiation therapy. With better, more precise external-beam radiation therapy, researchers are exploring much shorter and more convenient treatment schedules. Instead of 40 treatments, researchers are evaluating 28, 12, or only five treatments.

High-intensity focused ultrasound (HIFU). This procedure, which is still being researched in the United States, uses transrectal ultrasound to heat and destroy cancer cells.

Tests that evaluate the success of treatment. These tests can help doctors know if chemotherapy is working.

• Circulating tumor cells (cells that have broken free of the tumor) can be used to monitor the effectiveness of treatment; this test uses a patient’s blood sample to collect the circulating tumor cells.

• A biomarker called prostate cancer gene 3 (PCA3), measured with a urine test, is a test designed to help decide who needs immediate treatment and who can wait. Learn more about research on PCA 3.

Therapy for advanced prostate cancer. Researchers are exploring different chemotherapy options for advanced prostate cancer through a series of clinical trials. In addition, several other immunotherapy options are being tested in clinical trials.

Reducing side effects from bone metastases. Recent research has looked at the use of denosumab (Prolia) to help slow the damage to bone from metastases and reduce bone side effects for men with castration-resistant prostate cancer. Results indicate that denosumab may be more effective at protecting the bones than zoledronic acid (see Treatment).

To find clinical trials specific to your diagnosis, talk with your doctor or search online clinical trial databases now.

Questions to Ask the Doctor

Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:

Before diagnosis/risk reduction and screening

• What type of prostate cancer screening schedule do you recommend for me, based on my individual medical profile and family history?

• Are there any changes I can make to my diet that can help me lower my risk of prostate cancer?

After a diagnosis of prostate cancer

• What type of prostate cancer do I have?

• What stage and grade is my prostate cancer, and what does this mean?

• Can you explain my pathology report (laboratory test results) to me?

• What are my treatment options?

• What clinical trials are open to me?

• What treatment plan do you recommend and why?

• What is the goal of this treatment?

• Who will be part of my health care team, and what does each member do?

• Who will be coordinating my overall treatment and follow-up care?

• What are the possible side effects of each treatment option, both in the short term and the long term?

• What experience do you have in treating this type of cancer?

• How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

• Will this treatment affect my fertility (ability to produce children)?

• Could this treatment affect my sex life?

• What type of recovery should I expect following treatment?

• What follow-up care tests will I need, and how often will I need them?

• If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?

• What support services are available to me? To my family?

Patient Information Resources

In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease.

View organizations that offer information on this specific type of cancer.