Prostate cancer

Treatment

Prostate cancer is complex. There are a lot of things to think about before you and your doctor choose a treatment plan. First, know that if it’s detected early, prostate cancer is highly treatable, and most men with prostate cancer survive. 

Experts at Seattle Cancer Care Alliance (SCCA) offer comprehensive prostate cancer care and can talk with you about your unique situation and the best prostate cancer treatment for you. SCCA brings together leading cancer specialists and researchers from UW Medicine and Fred Hutchinson Cancer Research Center.

Unless your doctor tells you otherwise, you can probably take one to three months after diagnosis to learn more, get a second opinion and carefully consider your options.

While the choices you make for your treatment are personal, a key to making good decisions is getting input from experienced prostate cancer specialists who know the outcomes and quality-of-life issues associated with each type of treatment. 

We have an experienced, compassionate team ready to help. 

Prostate cancer expertise at SCCA

Prostate cancer survival rates

Data collected from cancer centers across the country show that men who begin their prostate cancer treatment at SCCA have higher survival rates on average than those who started treatment at other centers.

Everything you need is here

We have world-class urologic oncologists, medical oncologists, radiation oncologists and pathologists who specialize in prostate cancer; the most advanced diagnostic, treatment and recovery programs; and extensive support.

Innovative prostate cancer therapies

SCCA patients have access to advanced treatments being explored in ongoing prostate cancer clinical trials conducted at SCCA, Fred Hutch and UW Medicine. Our doctors and scientists are at the forefront of research to better prevent, diagnose and treat prostate cancer and to improve quality of life for survivors, including through the Institute for Prostate Cancer Research, a Fred Hutch–UW Medicine collaboration. 

Prostate cancer treatment tailored to you

Your SCCA doctors will explain all your options and recommend a treatment plan based on the grade and stage of your prostate cancer and several other factors, including your age, your general health, potential side effects and the probability of curing your disease, extending your life or relieving your symptoms.

Team-based approach

You may choose to visit one of our prostate specialists for a specific type of treatment, or you may choose a multidisciplinary team approach, where SCCA prostate specialists collaborate, discuss all your options and then recommend a plan. Additional experts will be involved in your care if you need them — experts like a geneticist, social worker, physical therapist or dietitian.

Ongoing care and support

After treatment, your team continues to provide follow-up care for at least 10 years on a schedule tailored to you. Our patients say they find it reassuring to see the same doctors who treated them for their follow-up visits. The SCCA Survivorship Clinic is also here to help you live your healthiest life as a prostate cancer survivor.

Overview of treatment options

Your treatment options will depend in part on whether your disease is localized, high risk, recurrent or advanced.

Treating localized prostate cancer

For nearly eight in 10 men with prostate cancer, the disease is diagnosed early, in the local or regional stages. Most will be cured. Active surveillance, watchful waiting, radiation therapy and surgery are the most common treatments.

Treating high-risk or recurrent prostate cancer

Two in 10 men with prostate cancer are diagnosed with high-risk disease — localized prostate cancer that has a tendency to spread. Among these men, three or four in 10 will have cancer that comes back after treatment.

Doctors use hormone therapy, along with surgery and radiation therapy, to treat prostate cancers that might have spread. Learn more about the special considerations for treating high-risk or recurrent prostate cancer. 

Treating advanced prostate cancer

If your cancer has already spread when you are diagnosed (advanced, or metastatic, prostate cancer), new treatments may put your cancer in remission and give you a good quality of life for years, even though the cancer can’t be cured. 

SCCA offers immunotherapy, hormone therapy, chemotherapy, radiation therapy and access to promising therapies in clinical studies that your community doctor may not know about.

Active surveillance and watchful waiting 

If your cancer is not causing any symptoms, is slow growing or is small and confined to the prostate, your doctor may suggest active surveillance or watchful waiting.

  • Active surveillance means your doctor closely monitors your cancer using prostate-specific antigen (PSA) tests, digital rectal exams, ultrasounds and biopsies. If a change indicates your cancer is becoming more aggressive, your doctor will talk with you about treatment options.
  • Watchful waiting involves less testing. You and your doctor monitor any changes in your symptoms to determine if you need treatment.
Who is a candidate?

Prostate cancer can take 10 or more years to spread enough to become life threatening, so if you already have a life expectancy of less than 10 years, it might not make sense to undergo aggressive cancer treatment, and your doctor might suggest active surveillance or watchful waiting. 

These methods might also be appropriate if:

  • You have a low-grade cancer and wish to defer treatment and potential side effects until treatment is necessary.
  • You prefer not to undergo aggressive treatment.
  • You want to avoid side effects of aggressive treatment.
  • You have health problems that prevent you from being a candidate for other types of treatment.

Treatment types

Treatment looks different for different people depending on your diagnosis. We tailor your treatment plan to you. Learn more about the treatment types offered at SCCA. 

Surgery

If your cancer is in the early stages or localized to your prostate, your doctors may recommend surgery to remove your prostate (prostatectomy) to try to cure the disease.

Surgery for SCCA patients is performed at University of Washington Medical Center by experienced UW Medicine surgeons who are leaders in prostate cancer surgery.

The experience level of your surgeon can affect your results. We recommend choosing a surgeon who has done at least 250 prostatectomies total and who does at least 40 a year. Read more about choosing your prostate cancer surgeon. 

Radical prostatectomy

The most common surgery for prostate cancer is a radical prostatectomy — removing the entire prostate gland, some lymph nodes and other nearby tissue, such as the seminal vesicles.

This offers a very good chance for a cure and gives your doctors detailed information about your cancer, including how aggressive it is, which can help guide other treatment decisions.

Your SCCA team will:

  • Talk with you in detail about what to expect. 
  • Carefully consider the risk of side effects from surgery.
  • Plan ways to reduce any risks you may face. 
  • Provide advice and care to support your recovery. 

Typically patients stay in the hospital overnight after surgery and then need to recuperate at home for one to four weeks before returning to work. 

Nerve-sparing prostate surgery

Your SCCA surgeon will try to save the tiny bundles of nerves, one on each side of your prostate, that control your ability to have an erection (nerve-sparing surgery). If your cancer is growing into or very close to the nerve bundles, these nerves may need to be removed.

Open surgery vs. robot-assisted laparoscopic prostatectomy

Your surgeon may operate using one of these approaches:

  • Through an incision in your lower abdomen (retropubic prostatectomy)
  • Through an incision between your anus and scrotum (perineal prostatectomy, less common) 
  • Laparoscopicaly, meaning through multiple very small incisions using special instruments and cameras

The potential advantages of laparoscopic surgery include faster recovery, less pain, less blood loss and lower risk of infection than with a conventional (open) retropubic or perineal procedure. 

If you are having laparoscopic surgery, your UW Medicine surgeon may use a robotic surgery system. This is sometimes called robot-assisted or robotic prostatectomy. With the da Vinci Surgical System, your surgeon uses hand and foot controls to move robotic arms that hold a laparoscope (camera) and surgical instruments. The system allows your surgeon to perform very precise, complex motions and helps prevent fatigue.

Your SCCA surgeon will talk with you about the approach they recommend for you and why and will answer all your questions about your options.

Cryosurgery for prostate cancer

If you have early-stage prostate cancer or your cancer recurred after radiation therapy, your team may recommend cryosurgery. In this procedure, your surgeon makes a small incision to insert probes that freeze and kill prostate tissue. Your surgeon may use ultrasound imaging, along with a catheter and precise temperature monitoring of nearby tissues, to help target your prostate and minimize any damage to healthy tissue.

Choosing a prostate cancer surgeon

When you are choosing a surgeon to treat your prostate cancer, it is important to select someone you trust and have confidence in. He or she should have enough experience to not only perform the operation you need but also to make an informed clinical judgment and change course, if necessary. 

The prostate cancer experts at Seattle Cancer Care Alliance recommend choosing a surgeon who has done at least 250 prostatectomies (prostate removals) total and who does at least 40 a year. 

As you consider your options, you might want to ask your surgeon these questions.

  1. Which procedure does your surgeon prefer and why?
  2. What type of surgery does he or she recommend for you?
  3. Is nerve-sparing surgery an option? 
  4. How many of these surgeries has he or she performed?
  5. How many of these surgeries does he or she do each year?
  6. What are the statistics on incontinence and impotence for your surgeon’s patients?
Surgery

If your cancer is in the early stages or localized to your prostate, your doctors may recommend surgery to remove your prostate (prostatectomy) to try to cure the disease.

Radiation therapy

Radiation therapy is an option for men with various stages of prostate cancer. 

  • If you have localized prostate cancer, your doctor will probably give you a choice of treating your disease with either radiation or surgery because cure rates are about the same for both treatments and studies haven’t definitively proved one is better than the other. 
  • If your cancer returns, you may have radiation therapy after surgery.
  • If you have advanced prostate cancer, you may have radiation therapy in combination with other therapies.
  • If cancer has spread elsewhere in your body, such as to your bone, radiation may help relieve pain at these sites.

Two main types of radiation therapy are used for prostate cancer: internal radiation therapy and external-beam radiation therapy. You might have both types.

Internal radiation therapy 

For prostate cancer, internal radiation therapy typically means surgically implanting radioactive seeds in the prostate to kill the cancer (brachytherapy). The seeds deliver low doses of radiation for weeks or months. This method is generally used in men with the earlier stages of localized cancer. 

Another option, radium 223 dichloride (Xofigo), is used for advanced prostate cancer that is resistant to testosterone-lowering treatments and has spread to the bones. It is given by intravenous (IV) injection every four weeks for six cycles.

External-beam radiation therapy 

External-beam radiation therapy (EBRT) aims radiation beams from outside your body at your cancer. This treatment can be used to cure localized prostate cancers or help relieve symptoms of cancer that has spread. 

SCCA incorporates the latest technology to provide the most precise treatment possible.

Depending on your exact needs, your radiation oncologist will likely recommend one of these forms of external-beam radiation:

  • Proton therapy, an advanced form of radiation treatment. Because doctors can focus proton beams so precisely on tumors, limiting radiation to surrounding healthy tissues, we use proton therapy most often for anatomically complex tumors, like prostate cancer, where it’s imperative to avoid damaging nearby structures, like the bladder and rectum. Learn more about proton therapy for prostate cancer.
  • IMRT, or intensity modulated radiation therapy, which uses a computer-controlled linear accelerator to move around the patient to deliver radiation. In addition to shaping the beams and aiming them at the tumor from several angles, the intensity of the beams can be adjusted to lessen the dose that reaches sensitive normal tissue. 
  • VMAT, or volumetric modulated arc therapy, is a type of IMRT. Similar to IMRT, the beam shape and intensity are varied to contour the radiation to the tumor. However, VMAT is delivered in one continuous arc of the linear accelerator around the patient. This maximizes the contouring and typically takes even less time than IMRT. Monitoring tools and 3D volumetric imaging allow doctors to accurately locate the tumor and precisely deliver the dose.

Aligning your body for treatment

Typically, doctors place markers into your prostate before EBRT to align you with the radiation beam for your daily treatment sessions. Different markers can be used, including gold markers that are imaged each day by computed tomography (CT) scanning built into the linear accelerator. 

Another marker, known as the Calypso System, allows electromagnetic tracking of your tumor’s position without needing daily CT scans. If your prostate moves during treatment, the radiation can be adjusted in real time — so the tumor receives the correct amount and nearby organs don’t receive radiation not meant for them. SCCA radiation oncologists were involved in developing the Calypso System, also known as GPS for the Body.

In some cases, doctors inject gel between the prostate and rectum before radiation treatment starts. This spacer separates the rectum from the prostate and protects the rectum from the radiation.

Radiation therapy

Radiation therapy is an option for men with various stages of prostate cancer. 

Hormone treatment

Hormonal therapy keeps prostate cancer cells from getting testosterone, the main androgen (male hormone) in men, which may cause prostate cancers to grow. It reduces androgen levels in the body or prevents androgen from reaching prostate cancer cells.

Hormone therapy is among the most effective forms of systemic therapy (about 85 to 90 percent effective) for this disease. Used alone, it does not cure prostate cancer, but it does stop the disease from progressing for a while. 

Your doctor may suggest hormone therapy if any of these is true: 

  • You have advanced or high-risk prostate cancer at the time of diagnosis.
  • Your PSA level is rising despite previous treatment for prostate cancer.
  • You can’t have surgery or radiation therapy for your disease. 

Several types of hormone therapy are available, including:

  • Medicines that prevent the production of testosterone in the body
  • Medicines that block the action of testosterone that has already been produced
  • Surgery to remove the testicles, the main source of testosterone in men

Hormone therapy is also called androgen-deprivation therapy or androgen-suppression therapy.

Prostate cancer may become resistant to hormone therapy over time. Much work by SCCA investigators has focused on trying to prevent this.

Hormone treatment

Hormonal therapy keeps prostate cancer cells from getting testosterone, the main androgen (male hormone) in men, which may cause prostate cancers to grow. It reduces androgen levels in the body or prevents androgen from reaching prostate cancer cells.

Immunotherapy

Immunotherapies are designed to use the patient’s own immune system to fight cancer. Vaccines are one form of immunotherapy.

Sipuleucel-T (Provenge) is a vaccine for advanced, metastatic prostate cancer that is no longer responding to hormone therapy (called castration-resistant disease) and that is causing few or no symptoms. 

  • Sipuleucel-T is made from your own immune cells.
  • Your white blood cells are collected and sent to a facility where they are activated by exposure to a protein found in most prostate cancers (prostatic acid phosphatase). This is linked to a protein that stimulates the immune system, enhancing the response of your immune cells against the cancer. 
  • Then your treated immune cells are returned to the clinic and infused into your bloodstream.

This treatment does not lower your PSA level or treat prostate cancer symptoms, and it has not been shown to cure metastatic prostate cancer. However, it has been shown to prolong life by about four months on average.

SCCA was the location for several of the clinical studies that led to the approval of sipuleucel-T. Though no other immunotherapies are approved for treating prostate cancer, we're actively developing clinical trials of novel immunotherapy agents. .

Immunotherapy

Immunotherapies are designed to use the patient’s own immune system to fight cancer. Vaccines are one form of immunotherapy.

Chemotherapy

Chemotherapy does not cure prostate cancer, which is one reason it is not used to treat localized prostate cancer the first time it occurs. 

Your doctor may recommend chemotherapy as an option to extend your life or improve your quality of life if:

  • You have been diagnosed with advanced prostate cancer.
  • Your cancer has returned after treatment.

For prostate cancer, chemotherapy is typically given as a single medicine, orally or by injection. Prostate cancer is usually treated with one of the following:

  • Docetaxel (Taxotere)
  • Cabazitaxel (Jevtana)
  • Mitoxantrone (Novantrone)
  • Carboplatin (Paraplatin)
Chemotherapy

Chemotherapy does not cure prostate cancer, which is one reason it is not used to treat localized prostate cancer the first time it occurs. 

Potential side effects

Unfortunately, all treatments for prostate cancer have side effects, including some that may have a negative impact on urinary and sexual health. Infertility, urinary incontinence (inability to control urine flow), reduced sexual desire, impotence or erectile dysfunction, and changes in orgasm are all potential side effects of prostate cancer treatment.

Your Seattle Cancer Care Alliance (SCCA) team will talk with you about the side effects you can expect. This page provides some general information. The side effects you might experience will depend on a number of factors, including the details of your cancer (location, stage, and grade), your age, your general health, your treatment, and the skill of your doctor. Your team will help you weigh the benefits and risks of your treatment options and will do everything possible to reduce the risk of side effects and to help you manage any side effects that occur.

SCCA offers extensive support for patients being treated here. If you have psychological concerns or concerns related to sexuality and cancer, learn about SCCA’s psychosocial and sexuality resources that are available to you.

Infertility

If you have surgery to remove your prostate (prostatectomy), you will lose your fertility and no longer be able to father a child. If you have radiation therapy to your pelvic region, you probably will be infertile as well. If infertility is a concern for you, talk to your doctor about options such as freezing your sperm before your treatment so that it will be available if you want to father a child in the future.

Incontinence

Urinary incontinence is the loss of bladder control or involuntary leakage of urine. Before and after treatment for prostate cancer, doing Kegel exercises to strengthen your pelvic-floor muscles may help minimize incontinence.

You may need to wear a small pad to catch leaking urine. Ask your doctor about medications that may help. Severe incontinence can often be corrected later with surgery.

Short-term incontinence, lasting a few weeks or months, is a common side effect after a radical prostatectomy. With an expert surgeon, the life-long risk of severe incontinence is less than 5 percent.

With radiation therapy, urinary incontinence is also a possible side effect; however, severe incontinence is uncommon. The likelihood of needing to wear a pad for mild leakage several years after treatment is less than 5 percent in younger men and around 10 percent in men who are older. The typical incontinence experienced is usually a mild urge to urinate with a small amount of leakage.

Reduced sexual desire

Lack of sexual desire, or low libido, is a continued lack of desire to have sex. In men it can be caused by aging and physical factors that reduce testosterone as well as emotional distress that may come with having cancer. Reduced sexual desire occurs in most men being treated with hormone therapy.

Impotence

Impotence, or erectile dysfunction, is the inability to have or maintain an erection. Treatment may completely or partially injure the two nerve bundles near the prostate that are responsible for allowing a normal erection.

During surgery, unless both nerve bundles are sacrificed due to the extent of the cancer, there is a chance of recovering erectile function, but it may be very slow, taking up to two years after surgery for full recovery.

Both external-beam radiation therapy and internal radiation therapy frequently cause impotence as well. Usually it does not occur right after radiation therapy but develops slowly over several years. The majority of men who undergo radiation therapy notice some decrease in their erectile function, with more than 50 percent having a permanent change.

Recovery of erectile function is related to your age, erectile function prior to treatment, and whether the nerve bundles were damaged by treatment. In general, the younger you are and the better your sexual function before surgery, the more likely you will be to regain function after treatment. Some men notice that their erections are less rigid and durable, even after they get return of some function. Ask your doctor about medications or devices that can help.

Changes in orgasm

You will still be able to experience orgasm after a radical prostatectomy or radiation therapy, even if you have erectile dysfunction, but you may note a change in the nature of the sensation of orgasm and there will be very little, if any, ejaculate. Some men may experience the release of urine with orgasm (climacturia) after surgery

Quality-of-life outcome studies

Outcome studies measure changes in quality of life, including bowel, urinary and erectile function, after prostate cancer treatment. The results vary between centers and between doctors based on their technical skill. SCCA tracks outcomes of prostate cancer care, and our results have been consistently better than those typically seen. 

Treating high-risk or recurrent cancer

SCCA  is at the forefront of developing new treatment strategies designed to improve results in men with high-risk prostate cancer. 

For nearly 80 percent of men with prostate cancer, doctors diagnose the disease early, in the local or regional stages. Doctors expect most of these men will be cured with radiation or surgery (prostatectomy). 

However, one in five men with prostate cancer is diagnosed with high-risk disease — which has a tendency to spread even though, by all clinical appearances, it is localized. Despite having been treated for prostate cancer, about 30 to 40 percent of men suffer a relapse, meaning their cancer returns. Among these men, fewer than 50 percent are cured.

The only therapy that has been adequately tested in clinical studies to treat prostate cancers that might have spread is hormone therapy, which lowers serum testosterone, depriving prostate cancer cells of a growth factor critical for their survival. Hormone therapy is commonly used in combination with radiation therapy or after surgery for men whose cancer has spread to lymph nodes. It is also used to treat cancers that weren’t cured with either radiation or surgery. 

The new approaches we’re working on involve treating both the cancer in the prostate and any cancer that might have spread. A new generation of systemic therapies is showing clinical promise when combined with surgery or radiation therapy. Learn more about prostate cancer clinical studies at SCCA.

Risk of relapse despite treatment

Various tools have been developed to help patients and doctors decide on treatment for prostate cancer by predicting how effective surgery or radiation is likely to be and how likely these treatments are to cure the patient’s disease. 

The main pretreatment factors that predict the likelihood of cure (ability to suppress and maintain low levels of prostate-specific antigen without androgen deprivation) are: 

  • Prostate-specific antigen (PSA) level
  • Clinical stage by digital rectal exam
  • Gleason score
  • Extent of disease by biopsy 

These factors are a general means of assessing the volume and biologic aggressiveness of prostate cancer and, thus, the likelihood that the cancer will spread beyond the prostate.

Researchers have evaluated how the PSA doubling time (how quickly PSA is rising) before treatment affects cure. Some studies have found that an increase in PSA of greater than 2 ng/mL in the year preceding the diagnosis predicted a higher risk of recurrence and a higher likelihood of death despite therapy.

Studies have shown that some patients are at high risk for biochemical progression (further cancer growth), regardless of whether they had surgery or radiation, if they had a pretreatment PSA level greater than 20 ng/mL or advanced cancer (stage T2b or greater) or high-grade disease (Gleason score of 8 to 10). Many men with a PSA level of 10 to 20 ng/mL or stage T2a cancer or intermediate-grade disease (Gleason score of 7) also have an unacceptably high risk of relapse.

Talk with your doctor about the specific features of your prostate cancer, how to understand your risk of relapse and all your treatment options. 

Detecting prostate cancer recurrence

An imaging test called an Axumin positron emission tomography (PET) scan may help detect prostate cancer that has come back in men whose PSA levels rise after they've had treatment. Before the scan, you receive an injection of fluciclovine F 18 (Axumin), a radioactive agent that tends to collect in areas of cancer activity, which then light up on your scan.

This may be a way to detect cancer that has spread and may make you eligible for clinical trials looking for new ways to eradicate prostate cancer. SCCA researchers are working on trials to better find and get rid of low-volume disease.

Diet and exercise

There are many ways you can positively influence your health. Lifestyle choices, such as diet, exercise, and smoking or drinking, are influenced by habit, culture, and preferences and are different for each individual. Every day the foods you choose to eat and the amount of physical activity you get can impact your overall health as well as your prostate cancer risk, recovery, and survival.