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Thinking About Treatment Choices
Medical Test and Terms
Tumor Stages
Types of Treatment
Watchful waiting, surgery, and radiation therapy are the
standard treatment choices for early-stage prostate cancer
(see Types of Treatment). Each has benefits (how
treatment can help) and risks (problems treatment may
cause). There is seldom just one "right" treatment choice.
"The bottom line is to have enough information
to know what treatment to choose."
- Ken
Treatment choices depend on several factors:
Prostate cancer characteristics. This includes the size
of your prostate, prostate-specific antigen (PSA) score,
Gleason score, and stage of cancer. (Go to Medical Tests
and Terms to learn more.) Health problems, other than prostate cancer.
This means whether you have heart problems, diabetes,
or other illnesses or have had a previous surgery for an
enlarged prostate. Having such health problems may
affect which treatment you choose. Age. If you are older, you may view treatment choices
differently than younger men because the benefits and
risks of treatment vary with age. Type of care available to you. The skills of specialists
and types of treatment can vary. You will need to ask
what you may feel are tough questions to make sure that
you get the best care and outcomes. See Talking with Your Medical Team and Asking Questions for questions to ask. Balancing what you value most.Your unique
experiences in life shape your feelings and perceptions
about how to deal with your prostate cancer. Keep in
mind what is important to you personally to help guide
your decision.
Many men may ask their doctor, "What would you do, if
you were me?" Try to remember, the doctor isn't you and
his or her personal values may be different from yours.
How do you view the potential risks and benefits of the
treatment options offered to you? Are you a person who
could cope with knowing cancer is in your body? Would
you rather have the cancer treated and know that there
could be side effects? Do you know of other men's
experiences with prostate cancer that may influence
your decision? Spouse or partner. Even though the treatment
decision is yours, involve your spouse, partner, or
caregiver to help you sort out what is most important
to you and your family. Your treatment choice will
affect your spouse or partner.
By now you may have had several tests to find out the extent
of your cancer. Your doctor will take into account your
physical exam, PSA level, Gleason score, and stage when
discussing your treatment options. What do these mean?
Prostate-Specific Antigen (PSA) test. PSA is a
protein made by normal cells and prostate cancer cells.
PSA is found in the blood and is measured with a blood
test. Doctors sometimes watch the rate of change in
your PSA levels over time. A score of 4 nanograms (ng)
or higher is often the trigger for further tests. Gleason score of your biopsy. When you had a biopsy,
tissue samples (called "cores") were taken from several
areas in your prostate. The pathologist checked for
cancer in the samples using a microscope. He or she can
also estimate how much cancer there is by looking
at how many tissue samples are positive. A Gleason
score (or sum) on a scale of 2 to 10 is assigned to the
cancer. This score tells how different the prostate cancer
tissue looks from the normal prostate tissue and helps
estimate how likely it is that the tumor cells will spread
(how aggressive the cancer is).
A low-risk score is 2 to 4. A low score means that the
cancer tissue still looks similar to normal prostate tissue,
and the tumor cells are less likely to spread. A score of 5
to 7 means moderate risk, while a score of 8 to 10 means
higher risk. As the score gets higher, it means that the
prostate cancer tissue becomes more and more different
from normal tissue and that the tumor cells are more
likely to spread.Most men with early-stage prostate
cancer have a Gleason score of 5, 6, or 7. Stage. The stage of cancer is an important factor in
choosing a treatment. The stage tells how much the
cancer may have grown within the prostate and
whether it has spread to other tissues or organs.
Doctors use a standard rating system to describe the
stage, called the TNM System. T means the size of the
main tumor, N means whether nearby lymph nodes are
involved, and M means whether the cancer has spread
beyond the region around the prostate.
First, the doctor will assess the stage of your prostate
cancer based on clinical findings (such as a physical
exam, digital rectal exam, or DRE, and biopsy). If you
have surgery to remove your prostate, seminal vesicles
or nearby lymph nodes, then your cancer can be
assessed from a pathologic stage. This means that by
looking at what is removed, doctors are better able to
predict your outcome and survival.
Your doctor may also suggest other tests such as a bone
scan, MRI, CT scan, removing lymph nodes in the
pelvis, or a seminal vesicle biopsy.
Prostate cancer tumor stages range from stage T1 to T4.
They may also be further classified a, b, or c. This
article addresses early stages, which are Stage T1 and
T2, where the cancer is confined to the prostate.
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 Sometimes cancer is found
"by accident," or incidentally
(called T1a or T1b) when
men have surgery to correct
a non-cancerous prostate
enlargement. T1 means that a
tumor is not usually felt
during a digital rectal exam.
Since most prostate cancer
is found through PSA
testing, T1c is the stage
most often diagnosed
through biopsy.
A stage of T2 means that
prostate cancer can be felt
during a digital rectal exam
but that it is still confined
to the prostate gland. Your
doctor may also assign a, b,
or c stages depending on
the cancer's size and
location in the prostate.
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Surgery is often a treatment choice for men who have earlystage
prostate cancer and are in good health. Surgery to
remove the prostate is called prostatectomy (PRAHS-ta-
TEK-toe-mee). There are two approaches that are typically
used by surgeons:
| Other Options |
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Cryosurgery freezes and thaws tissue to kill prostate cancer
with the surgeon being guided by ultrasound. Also called
cryotherapy, it is often used when the prostate has more
advanced, yet still confined disease, and when surgery is not
an option. The prostate is not removed with this approach.
Cryosurgery can result in injury to the rectum, incontinence,
swelling of the scrotum, pain or numbness in the penis, or
blocked urine flow. In 1 in 200 cases, a hole (called a fistula)
appears between the rectum and prostate. Results depend
highly on the doctor's skill and experience. Success rates may
not be as high as with prostatectomy or with any form of
external beam radiation therapy. Long-term results for this
type of treatment are not yet known.
Laparoscopic surgery is the newest type of surgery to
remove the prostate. It is done with smaller incisions using a
slender tube with a camera on the end (laparoscope), which
may be robotically controlled. The scope is inserted through
the navel, and the surgeon can see a highly enlarged image of
the prostate. Compared with other types of prostatectomy, this
technique may lead to shorter hospital stays, faster recovery,
and less blood loss and pain. However, it is fairly new and not
widely used. Some surgeons have limited experience with this
type of surgery. Since it is newer, researchers have not had the
chance to follow its effectiveness for as long as they have for
standard surgery.
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This type of treatment uses high doses of radiation energy
to treat cancer. Radiation therapy is an option when cancer
is in your prostate but has not spread to other organs. It is
also used when you cannot have surgery because of your
age, health, or personal choice. There are two types of
radiation therapy:
- External beam radiation. A machine aims radiation at
your cancer cells. It rotates around your body, sending
radiation from many directions. After the doctor maps
out the exact part of your body that needs radiation,
treatment usually happens once a day, 5 days a week,
for 6 to 8 weeks. Each treatment session usually lasts
about 15 minutes. The latest types of radiation are
called 3-D Conformal Radiation Therapy and
Intensity-Modulated Radiation Therapy (IMRT).
These types of radiation are more precise in destroying
cancer while leaving nearby healthy cells unharmed.
They are designed to lower the exposure of the rectum
and bladder to radiation to help lessen side effects.
- Brachytherapy (BRA-kee-THAYR-uh-pee). This is a
type of internal radiation therapy. It is also called
seed implants. Radiation is delivered inside your body by
implanting tiny seeds in your prostate. Usually 40 to
130 seeds are inserted into the prostate, depending on
the size of your prostate. Each seed has a small amount
of radioactive material that emits radiation within an
inch of its surroundings. Low-dose seeds are left in the
prostate permanently, although their radiation lasts for
only 3 to 6 months. This procedure is usually done on
an outpatient basis, without a hospital stay.
Both types of radiation can be used together (placing
radioactive seeds internally and using external beam
radiation to kill any cancer that may be close to the
prostate) or with hormone therapy.
Watchful waiting is often called "active surveillance" or
"observation" and means that you decide to have no active
treatment now. Your doctor will want to follow you closely
to look for any signs that the disease may be changing. You
will have tests like the ones you've already had such as
digital rectal exams, PSA tests, and repeat biopsies. You can
change your mind and decide to have treatment at any time.
Watchful waiting is based on the fact that many early-stage
prostate cancers grow so slowly that they may never cause
problems or become life threatening. In some cases, it
may be a way to avoid the harms of treatment without
shortening life expectancy. Or it can be a decision based on
your age and other serious health problems - older men in
their 70s and 80s may not have the same views about
undergoing surgery or radiation therapy as younger men.
| About Hormone Therapy |
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Hormone therapy may be used in combination with other
treatment, such as radiation therapy, when the tumor is large.
Male sex hormones such as testosterone make prostate
tumors grow. Hormone therapy slows a tumor's growth by
stopping or blocking testosterone from entering the cancer
cells. Hormone therapy can be given for several years. Side
effects usually occur during treatment, but they go away after
treatment is over. Side effects may include loss of sex drive,
impotence, and hot flashes.
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The chart in the next section lists common questions and answers
for the three options outlined in this booklet. As mentioned
earlier, most men will need more information than this
booklet gives to reach their decisions. You may use this
chart as a guide for talking with your doctor or researching
your options.
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