While the 10-year survival rate for men diagnosed with prostate cancer in the United States is approximately 98 percent, many men face difficult decisions about their treatment options. They worry not only about which treatment may be appropriate in fighting their cancer, but also about the impact treatment may have on their quality of life.
In 90 percent of cases, prostate cancer is diagnosed at the local or regional stage, meaning it hasn’t spread beyond the prostate or nearby organs. Men diagnosed with early-stage prostate cancer may have several treatment options with similar outcomes. Men diagnosed with distant cancer, meaning it’s already spread to other areas of the body, face different treatment decisions. Either way, it’s normal to feel anxious after a diagnosis and to want to take action right away.
But you may regret rushing into a treatment plan without considering your options carefully. Prostate cancer treatment has common side effects, especially urinary incontinence and erectile dysfunction, that may negatively impact your quality of life. Because prostate cancer often progresses slowly, most men have time to investigate their options.
Whether you’re already receiving treatment for prostate cancer, or you’re considering new treatment decisions, it’s worth learning about prostate cancer treatment advances that may affect your choices.
Potentially beneficial advances in prostate cancer treatment include:
- PET scan agents that may lead to a more precise staging
- Advanced genomic testing that may predict how aggressive the cancer is or that may reveal a targeted treatment not previously considered
- Robotic-assisted surgery that may reduce surgical side effects
- More precise radiation therapies that may reduce damage to surrounding tissues while delivering high doses of radiation to the targeted area
- Newly developed hormone therapy, targeted therapy and immunotherapies to treat more advanced cancers
Generally speaking, prostate cancer treatment advances over the past 10 to 15 years may improve patients’ quality of life by reducing the severity of treatment side effects. They may also provide more precise information about patients’ cancer stage and/or risk factors, which help drive treatment choices. To help you learn about potential treatment choices and advances in prostate cancer treatment, we examine:
- Advances that lead to more precise staging and risk stratification of prostate cancer
- Specific prostate cancer treatment advances in:
- The pros and cons of active surveillance for prostate cancer
- How to determine which treatment options are appropriate for you
If you’re interested in learning about possible treatment options for your prostate cancer, or if you’d just like to talk with someone at Cancer Treatment Centers of America® (CTCA) about your cancer care, call us or chat online with a member of our team.
Diagnostic advances in prostate cancer
Prostate cancer diagnosis is followed by staging of the cancer. If there’s no evidence of metastasis of the original prostate tumor, meaning the cancer hasn’t spread to other parts of the body, your cancer will also be assigned to a risk stratification group, also known as a risk group. The risk group attempts to predict the likelihood that the disease has spread microscopically outside the prostate. We informally refer to three risk groups: low risk, intermediate risk and high risk, although as many as six different groups exist.
The specific stage and/or risk stratification of your cancer may determine your treatment options. In general:
- The majority of prostate cancer patients are diagnosed with stage 1 to stage 3 disease that falls into the low-risk or intermediate-risk categories. Treatment options often include active surveillance, surgery and radiation therapy. Research indicates that surgery and radiation therapy for low-risk and some favorable intermediate risk patients have similar 10-year outcomes, and that active surveillance may only increase the chance of eventually developing metastatic disease by about 4 percent over that same time period .
- Prostate cancer categorized as high risk is more likely to have undetectable disease outside of the prostate. In these cases, the combined use of external beam radiation with internal radiation (brachytherapy) may be recommended. Results of the prospective randomized research ASCENDE-RT Trial indicate men with high-risk prostate cancer are more likely to have better outcomes if brachytherapy is added to their external beam radiation therapy. Androgen deprivation therapy (ADT) is another important tool in treating high-risk prostate cancer with radiation.
- Stage 4 metastatic cancer is not assigned a risk category because there’s clear evidence that it has spread to other areas. Treatment options for these patients may include chemotherapy, hormone therapy, immunotherapy and/or radiation therapy.
Depending on your specific diagnosis, you may have two or more good treatment choices that have similar outcomes, and you probably have time to investigate those options.
Recent areas of advancement in oncology may provide a more accurate picture of your specific diagnosis, directing you and your doctor to more appropriate treatment options. Two specific developments include prostate-specific PET scan agents that may allow us to get more accurate imaging than we could before and the results of advanced genomic testing, which may help identify more aggressive cancers that are less suitable for active surveillance.
PET scan agents
A positron emission tomography (PET) scan is an advanced nuclear imaging technique that may be used to detect cancer that has spread to other parts of the body. Knowing if and where prostate cancer has spread may lead to more appropriate treatment choices.
During a PET scan, a small amount of a radioactive substance, known as a tracer, is injected into the blood. Cells absorb this substance, allowing the scanner to “see” them. The most common tracer used in PET scans, a glucose solution, isn’t very effective in staging prostate cancer. The development of prostate-specific PET tracers has increased the accuracy of prostate cancer staging.
In December 2020, the U.S. Food & Drug Administration (FDA) approved Gallium 68 PSMA-11 (Ga 68 PSMA-11) for use in PET imaging of men with either suspected prostate cancer metastasis or recurrence. Ga 68 PSMA-11 binds to prostate-specific membrane antigen (PSMA)-positive lesions (areas of abnormal tissue), making them more visible during the scan. It was approved after a randomized clinical trial showed it to be more accurate in finding PSMA-positive lesions than computed tomography (CT) scans, magnetic resonance imaging (MRI) scans and bone scans—the standard imaging techniques.
Advanced genomic testing
Advanced genomic testing studies the DNA profile of a cancerous tumor in an attempt to identify genetic abnormalities that may be driving the growth of the cancer. Results of genomic testing may predict how aggressive your cancer is likely to be. If genomic testing indicates that your cancer is probably not aggressive, active surveillance may be an appropriate option for you. If your cancer appears to be more aggressive, you may be advised to immediately pursue treatment such as surgery or radiation.
When managing metastatic prostate cancer, genomic testing may reveal an abnormality that matches a mutation that has been known to respond to a specific drug therapy. In this case, immunotherapy or another targeted therapy may then be an appropriate treatment option.
Prostate cancer treatment advances
Oncologists and researchers continue to accumulate data through studies and clinical trials, but it takes years for new advances to become part of the standard of care. However, we’ve seen some notable prostate cancer treatment advances over the past few years that are now more widely available to patients. Some advances may attempt to improve treatment outcomes, while others may improve patients’ quality of life by reducing the severity of treatment side effects. While this is not a comprehensive discussion of advances in prostate cancer treatment, the following advancements are noteworthy.
Advances in surgery for prostate cancer
A radical prostatectomy, the surgical removal of the prostate, may be a treatment option for localized prostate cancer. Common short- and long-term side effects of the surgery include erectile dysfunction and urinary incontinence.
Robot-assisted surgery is a minimally invasive alternative to open surgery for a radical prostatectomy. This system requires only a few small incisions in the abdomen rather than the larger incisions required for open surgery. The system’s instrumentation and high-definition camera allow for greater surgical precision and the improved ability to spare surrounding tissue and nerves.
While robotic surgery may not improve long-term disease control, studies show its benefits may include a lower risk of infections or complications, less loss of blood during surgery, less scarring, shorter hospital stays, a faster recovery time and a reduction in the severity and duration of erectile dysfunction and urinary incontinence.
No surgery is without risk. With this in mind, some hospitals have also implemented programs to help improve patients’ post-surgery recovery. At CTCA®, for example, we have implemented the Advanced Surgical Recovery (ASURE) program to help patients recover more quickly and with fewer complications after surgery. Our surgeons, anesthesiologists, nutritionists, nurses and other doctors and clinicians collaborate to accomplish this by using evidence-based protocols, such as nutrition, pain management with non-narcotic pain relievers and physical activity within 24 hours after surgery. If you’re considering a radical prostatectomy to treat your prostate cancer, consider asking if the hospital of your choosing has a similar program in place.
Advances in radiation therapy for prostate cancer
The last 20 years have brought significant improvements in the ability to deliver radiation therapy in ways that spare normal tissues from radiation exposure, while reducing toxicities caused by treatment.
The delivery of external beam radiation therapy (EBRT), the most commonly used radiation therapy, is more precise today than ever. Technological developments, such as image guidance and intensity modulated radiation therapy (IMRT), allow us to closely target cancerous tissue while avoiding healthy tissue. Increasing the intensity of radiation at the same time translates into a shorter course of radiation treatment. A typical course of treatment used to require 40-45 daily treatments. Now, 25-28 is a common number.
Internal radiation therapy, known as brachytherapy, allows radiation to be delivered from inside the body using devices placed inside and/or close to the prostate. High-dose rate (HDR) brachytherapy uses a single radioactive pellet inserted via catheters to deliver high doses of radiation in a few treatments. Low-dose brachytherapy (LDR) is usually a one-time, outpatient procedure for eligible prostate cancer patients. This therapy delivers a course of radiation through tiny, permanent implants over a period of several weeks.
Hydrogel spacers are another innovation that may help reduce damage to tissues surrounding the prostate during radiation therapy. This gel is inserted between the prostate and the rectum to reduce inadvertent injury to the rectum. Use of this gel, which dissolves over time, is designed to reduce treatment-associated side effects.
Advances in hormone therapy for prostate cancer
The body’s production of androgens (male hormones) drives the growth of prostate cancer. Androgen deprivation therapy uses surgery or medication to reduce the production of androgens in the testicles to attempt to slow the growth of the cancer. Hormone therapy may be combined with radiation therapy or other therapies.
Gonadotropin-releasing hormone (GnRH) antagonists are drugs that block the pituitary gland from making hormones that stimulate the production of testosterone.
Relugolix, the first oral GnRH antagonist, was approved by the FDA in December 2020. Relugolix has been shown to be more effective in sustaining testosterone suppression than its alternative, leuprolide, while having fewer side effects.
When prostate cancer continues to grow despite the use of drugs to lower the production of androgens, it’s known as metastatic castration-resistant prostate cancer. Antiandrogen drugs such as enzalutamide, abiraterone acetate, apalutamide, darolutamide and zytiga may be used to attempt to lower the production of androgens or to keep them from binding to androgen receptors on prostate cancer cells to keep the cells from growing.
Advances in immunotherapy for advanced prostate cancer
Immunotherapy is a type of precision medicine tool that stimulates the immune system to recognize and fight cancer cells. It isn’t widely used in treating prostate cancer right now because studies show that while some patients with advanced prostate cancer have responded positively to treatment, most do not.
Two types of immunotherapy that may be used in some cases, however, are the Sipuleucel-T cancer vaccine and checkpoint inhibitors.
Sipuleucel-T (Provenge®) is an FDA-approved vaccine designed to treat advanced metastatic castration-resistant prostate cancer. To create the vaccine, the patient’s own immune cells are collected from a blood sample and stimulated in the lab to help them recognize and fight prostate cancer cells. The inoculation is then injected back into the patient. The vaccine has been shown to extend the lives of some men with advanced cancer by approximately four months.
Checkpoint inhibitors are drugs that block signals between certain cancer cells and proteins on immune cells. A kind of miscommunication sometimes keeps the immune cells from recognizing the cancer cells as dangerous. When that signal is blocked, the immune cells may “wake up” to the danger and attack the cancer cells. In June 2020, the FDA approved pembrolizumab (Keytruda) for prostate cancer with certain genomic biomarkers.
Advances in targeted therapy
PARP inhibitors are a type of targeted therapy drug designed to prevent the DNA of cancer cells from repairing the damage caused by cancer treatment. In May 2020, the FDA approved two PARP inhibitors, rucaparib and olaparib, to treat patients with metastatic castration-resistant prostate cancer whose cancer tumors have certain homologous recombination repair (HRR) genetic mutations and who meet other treatment-related criteria. These drugs are the first of their type to be approved by the FDA to treat prostate cancer.
Active surveillance for prostate cancer
Active surveillance is a plan to monitor low and some intermediate-risk, localized prostate cancer. If, among other criteria, your cancer has not spread beyond the prostate, is not causing symptoms and does not show signs that it may be aggressive, active surveillance may be an appropriate option for you.
Why would you consider active surveillance over immediate, more aggressive treatment like surgery or radiation therapy? It comes down to carefully weighing risks versus quality of life.
We know that, in most men, prostate cancer grows slowly. In some cases, it may take three to 10 years (or more) to reach the point where it needs to be treated. In the meantime, if you can safely postpone treatment, you can avoid the sometimes-immediate and long-term side effects that may have serious consequences on your quality of life.
Having access to some of the advances in prostate cancer treatment discussed earlier in this article may allow you to choose active surveillance with more confidence. For example, if genomic testing predicts that your cancer is not aggressive, and/or a prostate-specific PET scan finds no evidence of cancer cells outside of the prostate, active surveillance may be the right choice for you.
Patients may find guidance and reassurance from the results of the 10-year, randomized Prostate Testing for Cancer and Treatment (ProtecT) clinical trial published in 2016. This study compared the effectiveness and patient-reported quality of life outcomes of radical prostatectomy, external-beam radiotherapy and active surveillance to treat localized prostate cancer.
Survival outcomes for these three treatments were similar. Active surveillance increased the chances of local progression of the cancer by approximately 10 percent and the chances of eventually developing metastatic disease by about 4 percent. So, while there are risks associated with choosing active surveillance over immediate treatment, those risks are usually small.
Active surveillance does not mean that we ignore the cancer. If you and your care team decide it’s an appropriate option for you, your urologist will monitor your disease with regular follow-ups, which may include:
- Prostate-specific antigen (PSA) screenings every six to 12 months
- Digital rectal exams every 12 months
- A yearly MRI
- A prostate biopsy every one to two years
If any concerning changes are detected during these follow-ups, your case will be reevaluated.
Unlike choosing surgery or radiation, choosing active surveillance isn’t a permanent decision. You can change your mind at any time and go back to your doctor to talk about your other treatment options.
How do you determine what’s right for you?
Whether you’ve recently been diagnosed with prostate cancer or you’re dealing with recurrent or metastatic cancer, you may be facing difficult decisions about your treatment. It’s normal to be unsure about what steps to take, and most patients have more than one choice.
Start by talking to your oncologist about the specifics of your case and your options. The American Society of Clinical Oncology has a helpful list of questions to ask your doctor about prostate cancer you may want to reference.
If possible, see a multi-specialty cancer care team to get a bigger picture of your case and your options. This is also important because, sometimes, factors outside of your cancer stage may impact your treatment options. For example, you may have an obstruction in your urinary tract that makes surgery a more appropriate choice than radiation. Or maybe you have another health condition that makes surgery more risky for you. In that case, radiation may be a better choice. You want these doctors to talk to one another about your case; each has expertise that makes an important contribution to the decision-making process. To facilitate this coordination, you may have to set up appointments to see multiple doctors and ask them to discuss your case.
Another option is to seek a second opinion at a facility where a multi-modality assessment is more easily conducted, such as at a cancer center or an academic research hospital. At CTCA, for example, a multidisciplinary team of prostate cancer experts reviews your case before you even arrive for a consultation. If we determine you need additional imaging or other diagnostics, we have the ability to schedule those in advance and to perform them on-site. We develop an individualized, comprehensive treatment plan for you, and we make sure that you have a deep understanding of your treatment options so that you can make the decision that’s right for you without feeling pressured.
Depending on the stage of your prostate cancer, you may be making decisions now that affect the next 10-25 years of your life. It’s important to understand the pros and cons of your options so you can make informed decisions with which you are comfortable.
If you’re interested in getting a second opinion for prostate cancer, or if you’d just like to talk with someone at CTCA about your cancer care, call us or chat online with a member of our team.
