What Determines My Prostate Cancer Treatment Options?


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The number of prostate cancer treatment options can be overwhelming for men when they first receive a diagnosis of prostate cancer. One of their first thoughts is, “How should I treat it?” At a basic level, when choosing treatment for prostate cancer, you need to look at the numbers; that is, you and your healthcare provider look at specific numbers assigned to critical factors–PSA (prostate-specific antigen), cancer stage, and Gleason scores–and then evaluate the information to make decisions about your prostate cancer treatment options. Other factors your doctor will consider also include numbers: your age, life expectancy, and the chances the cancer will recur after treatment.

Prostate cancer treatment options by the numbers

First, it’s necessary to understand what the numbers mean. Men who have an elevated PSA level have an indication that there could of a problem with the prostate. However, an elevated PSA level (loosely defined as a level of 4.0 ng/mL or higher) could indicate anything from the presence of an enlarged prostate (benign prostatic hyperplasia, BPH) to an infection, having had sex within the last 24 hours, regularly riding a bike, or prostate cancer. Therefore, an elevated PSA is far from a definite indication of prostate cancer.

Prostate cancer can be divided into four main stages, and each stage considers the following information: extent of the primary tumor, whether the cancer has spread to nearby lymph nodes, and the absence or presence of distant metastasis (spread). Healthcare providers use this information along with PSA and Gleason scores to help determine prostate cancer treatment options.

The Gleason score is determined by adding together the grades of cancer in a prostate biopsy. The higher the Gleason score, the more likely the cancer is to have spread beyond the prostate. Therefore, scores of 2-5 are low-grade prostate cancer, 6-7 are intermediate, and 8-10 are high-grade cancer.

Here is a basic idea of how healthcare providers approach prostate cancer treatment by the numbers. Naturally, every man has a unique set of circumstances that must be considered when he and his medical team work together to discuss the most appropriate of the prostate cancer treatment options.

Stage I: Men who have a stage I prostate cancer have a small, slow-growing tumor, low Gleason scores, and few if any symptoms. Prostate cancer treatment options include watchful waiting (active surveillance), radiation therapy (external beam or brachytherapy), or radical prostatectomy. However, removal of the prostate may seem drastic for such an early stage of prostate cancer. Results of a recent study published in the New England Journal of Medicine reported that among 731 men with localized prostate cancer who were randomly assigned to prostatectomy or active surveillance, the risk of dying was similar between the two groups over a 10-year follow-up period: 47% of men died in the surgical group and 49.9% died in the surveillance group. The authors concluded that “among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality, as compared with observation, through at least 12 years of follow-up.”

Stage II: Among men in stage II who are not experiencing any symptoms, who are elderly, and/or who have other serious health problems, active surveillance is often suggested, although radical prostatectomy, external beam radiation, or brachytherapy may be considered as well. For younger, otherwise healthy men, healthcare providers may suggest hormone therapy followed by prostatectomy, radiation therapy only (either external beam alone, brachytherapy alone, or a combination of the two), or cryosurgery. In some cases, physicians may recommend hormone therapy plus radiation.

Stage III: Prostate cancer in this stage has spread beyond the prostate gland but has not affected the lymph nodes or distant organs, such as the bladder or rectum. Both prostatectomy and radiation therapy are less likely to be effective at this stage. If a healthcare provider suggests prostatectomy, the procedure will typically involve removal of the pelvic lymph nodes and may be preceded by hormone therapy. Other prostate cancer treatment options for stage III include hormone therapy alone, external beam radiation along with hormone therapy, or active surveillance for older men who have no symptoms or who also have other serious illnesses.

Stage IV: Stage IV prostate cancer has spread to the bones, bladder, lymph nodes, or other distant organs. Recommended treatment includes hormone therapy, transurethral resection of the prostate (TURP, for symptom relief), external beam radiation plus hormone therapy (suitable for some cases), or active surveillance for older men who have no symptoms or who have another serious illness. Chemotherapy may be recommended for men who have not responded to hormone therapy and whose cancer continues to spread (see “Prostate cancer treatment options when cancer returns”). Men who experience bone pain may be prescribed pain medication.

Prostate cancer treatment options when cancer returns

According to the Prostate Cancer Foundation, about 90% of men with prostate cancer are diagnosed when they are in stages I or II of the disease, when the cancer is local or regional and the five-year survival rate is nearly 100%. In about 20% to 30% of prostate cancer cases, however, cancer returns after five years. When prostate cancer comes back after treatment, it can return in the same site (local recurrence) or in distant sites (called metastasis), such as bone or the bladder.

When a man and his doctor need to choose prostate cancer treatment options for recurrent cancer, they need to think about which therapies a man has already undergone, where the cancer has recurred, and its severity. For example, a man who was originally treated for stage II prostate cancer with external beam radiation may choose radical prostatectomy or cryosurgery if his cancer recurs in the prostate (localized).

If, however, a man was originally treated for stage III or stage IV prostate cancer with hormone therapy and the cancer returns (referred to as hormone-resistant or hormone refractory prostate cancer), other prostate cancer treatment options need to be considered. Hormone refractory cancers are not uncommon, and among the prostate cancer treatment options available are several new therapies.

  • Abiraterone (Zytiga®) is a new hormone therapy for men who have metastatic hormone therapy resistant prostate cancer that also has not responded to the chemotherapy drug docetaxel. Abiraterone helps stop production of testosterone in three areas: the testicles, adrenal glands, and the prostate tumor, which no other hormone therapy can do. Once daily treatment with abiraterone also includes twice daily dosing with prednisone. This combination has resulted in an overall mean survival of 14.8 months compared with 10.9 months among men who took placebo. The average treatment course is 8 months.
  • Cabazitaxel (Jevtana®) is a chemotherapy that has been approved for men with advanced metastatic prostate cancer that has not responded to hormone therapy or docetaxel. Cabazitaxel is used along with prednisone and works by preventing cancer cells from dividing properly. Use of cabazitaxel has resulted in a mean survival of 15.1 months compared with 12.7 months in men who received chemotherapy (mitoxantrone) alone. The average treatment course is six months.
  • Sipuleucel-T (Provenge) is the only immunotherapy available for treatment of prostate cancer. The Food and Drug Administration (FDA) approved Provenge for treatment of asymptomatic or minimally symptomatic metastatic hormone resistant prostate cancer. However, the manufacturer is seeking approval for use during early stage prostate cancer because Provenge has demonstrated good overall average survival (25.8 months compared with 21.7 months in men who did not receive the treatment). These results were supported in a subsequent trial as well. Provenge for prostate cancer treatment is unique because it supports the immune system and helps the body fight cancer using its inherent healing nature rather than works to break it down or to destroy cancer cells, which places the body in a weakened position. The average treatment course for this immunotherapy for prostate cancer is five to six weeks.
  • Enzalutamide (Xtandi) is a form of hormone therapy that interferes with testosterone and dihydrotestosterone receptors on prostate cancer cells, which in turn prevents them from reacting with the hormones. Xtandi was approved on August 31, 2012, for men who have advanced prostate cancer that has spread or recurred despite treatment with hormone therapy and chemotherapy with docetaxel. Compared with Provenge and Zytiga, Xtandi was shown to increase survival longer: a mean of 4.8 months.
  • Radium-223 (Xofigo) uses radiation decay to kill prostate cancer cells. Radium-223 was approved on May 15, 2013. It targets bone tumors and is for metastatic prostate cancer that has spread to the bones but not other organs. In a clinical trial, men treated with radium-223 lived a mean of 14 months compared with 11.2 months in men who took placebo

Future prostate cancer treatment options

A number of future prostate cancer treatments are on the horizon. Men should talk to their healthcare providers so they know when they may become available.

  • Cabozantinib hinders the development of blood vessels that provide nourishment to prostate tumors and thus reduces the spread of cancer. So far study results suggest it may be helpful for men with hormone-resistant metastatic prostate cancer and especially for those whose cancer has spread to the bone. Trials are still underway.
  • Orteronel (TAK-700) is currently involved in phase III clinical trials in men with metastatic hormone-resistant prostate cancer that has resisted treatment with chemotherapy docetaxel. The drug is a type of hormone therapy that works by inhibiting the activity of a specific enzyme in the testicles and adrenal glands. In earlier trials, orteronel reduced both PSA and testosterone levels.

Prostate cancer treatment options involve lots of numbers, but they also involve much thought and research. Men who have been diagnosed with prostate cancer have a wide range of prostate cancer treatment options, and they owe it to themselves and their loved ones to fully explore them to determine which ones are most appropriate for their needs.

Read more in our Prostate Cancer Health Center.

Reference

Wilt TJ et al. Radical prostatectomy versus observation for localized prostate cancer. NEJM 2012 Jul 19; 367(3): 203-13