AUA Summit - What is Prostate Cancer?

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What is Prostate Cancer?

What is the Prostate?

The prostate and seminal vesicles are part of the male reproductive system. The prostate is about the size of a walnut. The seminal vesicles are two smaller pairs of glands attached to the back of the prostate. The prostate sits below the bladder, in front of the rectum. It surrounds the urethra, a small tube that carries urine from the bladder out through the penis.

The main job of the prostate and seminal vesicles is to make fluid for semen. During ejaculation, sperm moves to the urethra. At the same time, fluid from the prostate and the seminal vesicles also moves into the urethra. This mixture— semen—goes through the urethra and out of the penis as ejaculates.

What is Prostate Cancer?

Cancer is the result of abnormal cell growth, which takes over the body’s normal cell function, making it harder for the body to work the way it should. Prostate cancer develops when abnormal cells form and grow in the prostate gland. Not all abnormal growths, also called tumors, are cancerous (malignant). Some tumors are not cancerous (benign).

  • Benign growths, such as benign prostatic hyperplasia (BPH), are not life threatening. They do not spread to nearby tissue or other parts of the body. These growths can be removed and may grow back slowly (but often do not grow back).
  • Cancerous growths, such as prostate cancer, can spread (metastasize) to nearby organs and tissues such as the bladder or rectum, or to other parts of the body. If the abnormal growth is removed, it can still grow back. Prostate cancer can be life threatening if it spreads far beyond the prostate (metastatic disease).

What is Early-stage Prostate Cancer?

Prostate cancer stays “localized” when cancer cells are found only in the prostate or even a little bit beyond it (extra-prostatic extension), but do not move to other parts of the body. If the cancer moves to other parts of the body, it is called “advanced” prostate cancer.

Prostate cancer is often grouped into four stages.

  • Early-stage | Stages I & II: The tumor has not spread beyond the prostate. This is often called “early-stage” or “localized” prostate cancer.
  • Locally Advanced | Stage III: Cancer has spread outside the prostate, but only to nearby tissues. This is often called “locally advanced prostate cancer.”
  • Advanced | Stage IV: Cancer has spread outside the prostate to other parts such as the lymph nodes, bones, liver or lungs. This stage is often called “advanced prostate cancer.”

Symptoms

In its early stages, prostate cancer often has no symptoms. When symptoms do occur, they can be like those of an enlarged prostate or BPH. Prostate cancer can also cause symptoms unrelated to BPH. If you have urinary problems, talk with your healthcare provider about them.

Symptoms of prostate cancer can be:

  • Dull pain in the lower pelvic area
  • Frequent urinating
  • Trouble urinating, pain, burning, or weak urine flow
  • Blood in the urine (Hematuria) 
  • Painful ejaculation
  • Pain in the lower back, hips or upper thighs
  • Loss of appetite
  • Loss of weight
  • Bone pain

Updated August 2018

Causes

The cause of prostate cancer is unknown, but researchers know many things can increase a man's risk for the disease.

  • Age: As men age, their risk of getting prostate cancer goes up. Harm to the DNA (or genetic material) of prostate cells is more likely for men over the age of 55.
  • Ethnicity: African American men have a higher rate of the disease. One in six African American men will be diagnosed with prostate cancer. Prostate cancer occurs less often in Asian American and Hispanic/Latino men than in non-Hispanic white men.
  • Family History: Men who have a grandfather, father or brother with prostate cancer face a higher risk of getting the disease. Having family members with breast and ovarian cancer also raises a man’s risk for prostate cancer.
  • Weight: Studies link being overweight in your 50s and later to a greater risk of advanced prostate cancer. Doctors advise keeping to a healthy weight to reduce risk.

What are the Signs of Prostate Cancer?

In its early stages, prostate cancer may have no symptoms. When symptoms do occur, they can be urinary symptoms like those of an enlarged prostate or Benign Prostatic Hyperplasia (BPH). Talk with your doctor if you have any of these symptoms:

  • Dull pain in the lower pelvic zone
  • Frequent need to pass urine
  • Trouble passing urine, pain, burning or weak urine flow
  • Blood in the urine (hematuria)
  • Painful ejaculation
  • Pain in the lower back, hips or upper thighs
  • Loss of hunger
  • Loss of weight
  • Bone pain

Diagnosis

The American Urological Association (AUA) recommends talking with your doctor about the benefits and harms of screening (testing) for prostate cancer. If you fall into any of the groups below, you should think about talking to your doctor to see if screening is right for you:

  • Between 45–69 years old
  • African American
  • Have a family history of prostate cancer
  • Have symptoms

Blood Tests

The PSA blood test measures a protein in your blood called the prostate-specific antigen (PSA). Only the prostate and prostate cancers make PSA. Results for this test are usually shared as nanograms of PSA per milliliter (ng/mL) of blood. The PSA test is used to look for changes to the way your prostate produces PSA. It is used to stage cancer, plan treatment and track how well treatment is going. A rapid rise in PSA may be a sign something is wrong. In addition, your doctor may want to test the level of testosterone in your blood.

The PSA test is not used alone to make a diagnosis. Your doctor may also use a digital rectal exam (DRE) test for a better sense of your prostate health.

Digital Rectal Exam

The digital rectal exam (DRE) is a physical exam used to help your doctor feel for changes in your prostate.

This test is also used to screen for and stage cancer, or track how well treatment is going. During this test, the doctor feels for an abnormal shape, consistency, nodularity or thickness to the gland. For this exam, the doctor puts a lubricated gloved finger into the rectum.

The DRE is safe and easy, but cannot spot early cancer by itself. It is often done with a PSA test. Together, the PSA and DRE can help to find prostate cancer early, before it spreads. Early prostate cancer treatment may stop or slow the spread of cancer.

Biopsy

If screening tests show an issue with the prostate, a prostate biopsy may be performed. This helps make an accurate diagnosis. A biopsy is a tissue sample taken from your prostate or other organs to look for cancer cells. There are many approaches to prostate biopsies. These can be done through a probe placed in the rectum, through the skin of the perineum (between the scrotum and rectum) and may use a specialized imaging device, such as an MRI Scan. The biopsy removes small pieces of tissue for review under a microscope. The biopsy takes 10 to 20 minutes. A pathologist (a doctor who classifies disease) looks for cancer cells within the samples. If cancer is seen, the pathologist will "grade" the tumor.

Staging and Grading

Prostate cancer is grouped into four stages. The stages are defined by how much and how quickly the cancer cells are growing. The stages are defined by the Gleason Score and the T (tumor), N (node), M (metastasis) Score.

Gleason Score

If a biopsy finds cancer, the pathologist gives it a grade. The most common grading system is called the Gleason grading system. The Gleason score is a measure of how quickly the cancer cells can grow and affect other tissue. Biopsy samples are taken from the prostate and given a Gleason grade by a pathologist. Lower grades are given to samples with small, closely packed cells. Higher grades are given to samples with more spread out cells. The Gleason score is set by adding together the two most common grades found in a biopsy sample.

The Gleason Score will help your doctor understand if the cancer is a low-, intermediate- or high-risk disease. The risk assessment is the risk of recurrence after treatment. Generally, Gleason scores of 6 are treated as low-risk cancers. Gleason scores of around 7 are treated as intermediate/midlevel cancers. Gleason scores of 8 and above are treated as high-risk cancers. Some of these high-risk tumors may have already spread by the time they are found.

Staging

The Tumor, Nodes and Metastasis (TNM) is the system used for tumor staging. The TNM score is a measure of how far the prostate cancer has spread in the body. The T (tumor) score rates the size and extent of the original tumor. The N (nodes) score rates whether the cancer has spread into nearby lymph nodes. The M (metastasis) score rates whether the cancer has spread to distant sites.

Tumors found only in the prostate are more successfully treated than those that have metastasized (spread) outside the prostate. Tumors that have metastasized are incurable and require drug-based therapies to treat the whole body.

Stages

How is Prostate Cancer Graded and Staged?

Grading (with the Gleason Score) and staging defines the progress of cancer and whether it has spread:

Grading

When prostate cancer cells are found in tissue from the core biopsies, the pathologist "grades" it. The grade is a measure of how quickly the cells are likely to grow and spread (how aggressive it is).

The most common grading system is called the Gleason grading system. With this system, each tissue piece is given a grade between three (3) and five (5). In the past, we assigned scores of one (1) and two (2). A grade of less than three (3) means the tissue is close to normal. A grade of three (3) suggests a slow growing tumor. A high grade of five (5) indicates a highly aggressive, high-risk form of prostate cancer.

The Gleason system then develops a "score" by combing the two most common grades found in biopsy samples. For example, a score of grades 3 + 3 = 6 suggests a slow growing cancer. The highest score of grades 5 + 5 = 10 means that cancer is present and extremely aggressive.

The Gleason score will help your doctor understand if the cancer is as a low-, intermediate- or high-risk disease. Generally, Gleason scores of 6 are treated as low risk cancers. Gleason scores of around 7 are treated as intermediate/mid-level cancers. Gleason scores of 8 and above are treated as high-risk cancers.

If you are diagnosed with prostate cancer, ask about your Gleason score and how it impacts your treatment decisions.

Staging

Tumor stage is also measured. Staging describes where the cancer is within the prostate, how extensive it is, and if it has spread to other parts of the body. One can have low stage cancer that is very high risk. Staging the cancer is done by DRE and special imaging studies.

The system used for tumor staging is the TNM system. TNM stands for Tumor, Nodes and Metastasis. The "T" stage is found by DRE and other imaging tests such as an ultrasound, CT scan, MRI or bone scan. The imaging tests show if and where the cancer has spread, for example: to lymph nodes or bone.

These staging imaging tests are generally done for men with a Gleason grade of 7 or higher and a PSA higher than 10. Sometimes follow-up images are needed to evaluate changes seen on the bone scan.

Imaging Tests

Not all men need imaging tests. Your doctor may recommend imaging exams based on results from other tests.

Prostate cancer may spread from the prostate into other tissues. It may spread to the nearby seminal vesicles, the bladder, or further to the lymph nodes and the bones. Rarely, it spreads to the lungs and or other organs.

Your healthcare provider may recommend a pelvic CT scan , an MRI scan or a bone scan to check if your cancer has spread.

What Are The Survival Rates For Prostate Cancer?

Many men with prostate cancer will not die from it; they will die from other causes. For men who are diagnosed, it is better if it is caught early.

Survival rates for men with prostate cancer have increased over the years, thanks to better screening and treatment options. Today, 99% of men with prostate cancer will live for at least 5 years after diagnosis. Many men having treatment are cured. Most prostate cancer is slow-growing and takes many years to progress. One out of three men will survive after five years, even if the cancer has spread to other parts of the body.

Updated August 2018

Treatment

Early-stage prostate cancer is a cancer that has grown in the prostate, but not escaped beyond it to other parts of the body, like lymph nodes or bones. Men with early-stage prostate cancer have a very good chance of survival. There are several options for treatment.

Your treatment plan will consider:

  • The stage and grade of the cancer (Gleason score and TNM stage)
  • Your risk category (whether the cancer is low-, intermediate- or high-risk
  • Your age and health
  • Your preferences about side effects and long-term effects of treatment
  • Your treatment goals
  • Results from other diagnostic tests

When you get your prostate cancer diagnosis, think over your range of treatment choices. Learn the odds of survival that different treatments offer and learn about the side effects of each treatment. Keep in mind how side effects of treatment will change your life now and in the future. If you can, get a second or third opinion from different prostate cancer experts. Talking with a urologist and a radiation oncologist can help you make informed choices.

Learn about the skill and reputation of doctors available to treat you. An experienced doctor with a good reputation will likely do the best job for you, especially if the treatment you choose might have side effects like urinary incontinence, erectile dysfunction (ED) or bowel problems. Find out what program your doctor offers to help with the side effects after treatment. Ask other survivors about their experiences.

If you decide on a treatment, use the time before treatment to get or stay healthy. With the guidance of your doctor, eat a well-balanced diet, strive for a healthy weight, exercise and avoid smoking and too much alcohol. This may help you combat prostate cancer.

Here are the treatments that you may want to discuss with your doctor if you are diagnosed with early-stage, localized prostate cancer.

Active Surveillance

Active Surveillance is best if you have a small and slowgrowing cancer. Your doctor will check your prostate cancer by asking you to have tests every few months. Tests that usually help are a blood test to check your PSA, a biopsy and possibly an MRI. Men on active surveillance are generally able to avoid urinary, sexual and bowel side effects. You may want to think of active surveillance as a treatment that helps you keep the quality of your life for as long as possible.

Some men never need to have any other treatment. If the PSA rises and a biopsy shows that the cancer is growing, it is time to talk about taking more action to get rid of the cancer, such as with surgery or radiation therapy. That kind of treatment is called ‘definitive therapy’.

Watchful Waiting

Watchful waiting is a way to track the cancer without treating it. It does not involve routine PSA tests, biopsies or other active surveillance tools. The risk of watchful waiting is that the cancer could grow and spread between follow-up visits. Watchful waiting is sometimes the approach taken with men with early-stage prostate cancer who are older and likely to die of other causes. It is also for men who have other health issues that would make it difficult for them to undergo surgery or radiation.

The two main treatments for early-stage prostate cancer are surgery and radiation therapy. The goal of these treatments is to get rid of the cancer for good. They have about the same success in treating the cancer. You can talk with your doctor about which treatment is best for you.

Surgery

A radical prostatectomy is the surgical removal of the prostate, seminal vesicles and nearby tissue. Often the lymph nodes in the pelvis that drain from the prostate are also removed. This procedure calls for anesthesia and a short hospital stay.

There are four types of radical prostatectomy surgery:

  • Robotic Assisted Laparoscopic Radical Prostatectomy (RALP). In this surgery, five very small incisions (cuts) are made in the lower abdomen through which instruments and a small camera are guided to allow the surgeon access to remove the prostate. RALP surgery is one of the most common types of prostate cancer surgery today.
  • Retropubic Open Radical Prostatectomy. Your surgeon will make a cut in your lower belly and remove the prostate through this opening.
  • Perineal Open Radical Prostatectomy. The prostate is removed through a cut between the anus and scrotum. Because the complex pelvic veins are avoided, bleeding is rare.
  • Laparoscopic Radical Prostatectomy. This surgery uses a video camera and small surgical tools that fit through cuts in the belly to remove the prostate. This surgery has mostly been replaced with robotic assisted laparoscopic surgery.

After surgery, your surgeon will review your final pathology report with you. The pathology report will tell you your final Gleason Score based on all the cancer that was in your prostate.

As with all surgery, there is risk for bleeding, infection and pain in the short term. The main side effects from this surgery are erectile dysfunction (ED) and urinary incontinence (loss of urine control). Most men recover the control of their bladder within several months.

For some men, erections can recover, but sometimes not all the way. Your surgeon can help you manage these side effects or give you a referral to other specialists who can help.

Radiation Therapy

Radiation therapy uses high-energy rays to kill the cancer cells.

External beam radiation therapy (EBRT) sends a targeted photon beam (x-ray) of radiation from outside the body to the prostate. A small amount of radiation is delivered in daily doses to the prostate for a number of weeks. Your health care team will limit radiation going to healthy organs like the bladder and rectum. Newer EBRT technology makes three-dimensional images with conformal radiotherapy (3DCRT), Proton Beam Therapy (PBT) or Stereotactic Body Radiation Therapy (SBRT).

Prostate Brachytherapy (Internal Radiation Therapy) is radiation treatment targeting the prostate from inside the body. Radioactive material is placed in the prostate using needles or a tube. There are two types of brachytherapy:

  • low dose rate (LDR) brachytherapy, and
  • high dose rate (HDR) brachytherapy.

Anesthesia and a short stay in the hospital are needed for both.

Common side effects after radiation are urinary incontinence, bowel problems and ED. Urinary and bowel problems get better for most men. Erections gradually soften over a period of two or more years. Your doctor will discuss these side effects with you and help you manage them. Ask your doctor about the effect of different radiation approaches on your erectile function. Some treatments are less likely to cause ED.

Sometimes radiation therapy is combined with hormone therapy to shrink the prostate before starting treatment. Or hormone therapy may be combined with external beam therapy to make the radiation more effective. Hormone therapy is called Androgen Deprivation Therapy (ADT).

ADT fights prostate cancer by removing testosterone from the body. The loss of testosterone helps fight cancer but may include major side effects such as loss of libido, ED, hot flashes, changes in body fat and emotions. There could be other body changes as well. It is best to talk to your doctor about this.

Whole Gland or Focal Prostate Ablation

Cryotherapy or cryoablation for prostate cancer is the controlled freezing of the prostate gland. The freezing kills cancer cells. Special needles called "cryoprobes", guided by ultrasound, are placed in the prostate to direct the freezing process. Cryotherapy is done under general or spinal anesthesia. After cryotherapy, a patient is checked with routine PSA tests and biopsy. Possible side effects include ED, incontinence and other urinary or bowel problems. Your doctor will discuss with you how to manage them.

Focal therapy is a treatment under study for men with small, early-stage prostate tumors. Small tumors inside the prostate are targeted and destroyed without having to remove or radiate the whole prostate. This targeted approach leads to less intense side effects.

The types of high-intensity focused ultrasound (HIFU) and focal therapy are:

  • High-intensity focused ultrasound (HIFU) uses the energy of sound waves to target and superheat the tumor to kill cells (with the help of MRI scans). It may be used for the whole gland.
  • Focal cryoablation uses a needle-thin probe to circle the tumor with a special mixture that kills the tumor by freezing it.
  • Irreversible electroporation uses a “NanoKnife” to pass an electrical current through the tumor. The electricity makes very tiny holes (called pores) in the tumor’s cells, leading to cell death.

OTHER CONSIDERATIONS

Once you have finished treatment, you may have to manage side effects. You will also make a long-term plan with your doctor for future tests. These tests check to make sure you stay cancer-free.

Erectile Dysfunction

Men may have sexual health problems following their cancer diagnosis or treatments. Erectile dysfunction (ED) is when a man finds it hard to get or keep an erection strong enough for sex. ED happens when there is not enough blood flow to the penis, or when nerves to the penis are harmed.

Cancer in the prostate, colon, rectum and bladder are the most common cancers that can affect a man’s sexual health. Treatments for cancer, along with emotional stress, can lead to ED.

The chance of ED after prostate cancer treatment depends on many things, such as:

  • Age
  • Overall health
  • Medications you take
  • Sexual function before treatment
  • Cancer stage
  • Damage to your nerves or blood vessels from surgery or radiation

There are treatments that may help ED. They include pills, vacuum pumps, urethral suppositories, penile injections and implants. Treatment can be individualized. Some treatments may work better for you than others. They have their own set of side effects. A doctor can talk with you about the pros and cons of each method. They can help you decide which single treatment or combination of treatments is right for you.

There may be a change in orgasm for men treated with surgery as they no longer ejaculate or ejaculate a small volume of urine because the prostate, which makes semen, has been removed. However, it is still possible to have an orgasm.

Incontinence

After prostate cancer surgery or radiation, you may experience a loss of urine control. Incontinence is the inability to control the release of urine and can sometimes happen with prostate cancer treatment. There are different types of incontinence:

  • Stress Incontinence (SUI), when urine leaks with coughing, laughing, sneezing or exercising or with any additional pressure on the pelvic floor muscles. This is the most common type.
  • Urge Incontinence, or the sudden urge to pass urine, even when the bladder is not full because the bladder is overly sensitive. This might be called overactive bladder (OAB).
  • Mixed Incontinence, a combination of stress and urge incontinence with symptoms from both types.

Short–term incontinence after surgery is common. If you have SUI, you may only need to wear a pad for a few weeks to months. Incontinence often does not last long and urinary control will return. For a few men, it can last as long as six to twelve months. Because incontinence may affect your physical and emotional recovery, it is of great value to understand how to manage this problem. There are treatment choices to help incontinence.

  • Kegel exercises may strengthen your bladder control muscles.
  • Lifestyle changes may improve your urinary functions. Try eating healthier foods, limiting smoking, losing weight and making timed visits to the bathroom.
  • Medication may help improve bladder control by affecting the nerves and muscles around the bladder.
  • Neuromuscular electrical stimulation uses a device to help strengthen bladder muscles.
  • Surgery to control urination may include injecting collagen to tighten the bladder sphincter, implanting a urethral sling to tighten the bladder neck, or an artificial sphincter device.
  • Products, such as pads, may help you stay dry but do not treat incontinence.
  • Avoid bladder irritants that include caffeine, alcohol and artificial sweeteners.

Long–term incontinence lasting more than a year is rare. It happens in less than 5–10 percent of all surgical cases. If it does happen, talk to your doctor about your choices for care.

  

Active Surveillance

Active Surveillance is best if you have a small and slowgrowing cancer. Your doctor will check your prostate cancer by asking you to have tests every few months. Tests that usually help are a blood test to check your PSA, a biopsy and possibly an MRI. Men on active surveillance are generally able to avoid urinary, sexual and bowel side effects. You may want to think of active surveillance as a treatment that helps you keep the quality of your life for as long as possible.

Some men never need to have any other treatment. If the PSA rises and a biopsy shows that the cancer is growing, it is time to talk about taking more action to get rid of the cancer, such as with surgery or radiation therapy. That kind of treatment is called ‘definitive therapy’.

Watchful Waiting

Watchful waiting is a way to track the cancer without treating it. It does not involve routine PSA tests, biopsies or other active surveillance tools. The risk of watchful waiting is that the cancer could grow and spread between follow-up visits. Watchful waiting is sometimes the approach taken with men with early-stage prostate cancer who are older and likely to die of other causes. It is also for men who have other health issues that would make it difficult for them to undergo surgery or radiation.

The two main treatments for early-stage prostate cancer are surgery and radiation therapy. The goal of these treatments is to get rid of the cancer for good. They have about the same success in treating the cancer. You can talk with your doctor about which treatment is best for you.

Surgery

A radical prostatectomy is the surgical removal of the prostate, seminal vesicles and nearby tissue. Often the lymph nodes in the pelvis that drain from the prostate are also removed. This procedure calls for anesthesia and a short hospital stay.

There are four types of radical prostatectomy surgery:

  • Robotic Assisted Laparoscopic Radical Prostatectomy (RALP). In this surgery, five very small incisions (cuts) are made in the lower abdomen through which instruments and a small camera are guided to allow the surgeon access to remove the prostate. RALP surgery is one of the most common types of prostate cancer surgery today.
  • Retropubic Open Radical Prostatectomy. Your surgeon will make a cut in your lower belly and remove the prostate through this opening.
  • Perineal Open Radical Prostatectomy. The prostate is removed through a cut between the anus and scrotum. Because the complex pelvic veins are avoided, bleeding is rare.
  • Laparoscopic Radical Prostatectomy. This surgery uses a video camera and small surgical tools that fit through cuts in the belly to remove the prostate. This surgery has mostly been replaced with robotic assisted laparoscopic surgery.

After surgery, your surgeon will review your final pathology report with you. The pathology report will tell you your final Gleason Score based on all the cancer that was in your prostate.

As with all surgery, there is risk for bleeding, infection and pain in the short term. The main side effects from this surgery are erectile dysfunction (ED) and urinary incontinence (loss of urine control). Most men recover the control of their bladder within several months.

For some men, erections can recover, but sometimes not all the way. Your surgeon can help you manage these side effects or give you a referral to other specialists who can help.

Radiation therapy uses high-energy rays to kill the cancer cells.

External beam radiation therapy (EBRT) sends a targeted photon beam (x-ray) of radiation from outside the body to the prostate. A small amount of radiation is delivered in daily doses to the prostate for a number of weeks. Your health care team will limit radiation going to healthy organs like the bladder and rectum. Newer EBRT technology makes three-dimensional images with conformal radiotherapy (3DCRT), Proton Beam Therapy (PBT) or Stereotactic Body Radiation Therapy (SBRT).

Prostate Brachytherapy (Internal Radiation Therapy) is radiation treatment targeting the prostate from inside the body. Radioactive material is placed in the prostate using needles or a tube. There are two types of brachytherapy:

  • low dose rate (LDR) brachytherapy, and
  • high dose rate (HDR) brachytherapy.

Anesthesia and a short stay in the hospital are needed for both.

Common side effects after radiation are urinary incontinence, bowel problems and ED. Urinary and bowel problems get better for most men. Erections gradually soften over a period of two or more years. Your doctor will discuss these side effects with you and help you manage them. Ask your doctor about the effect of different radiation approaches on your erectile function. Some treatments are less likely to cause ED.

Sometimes radiation therapy is combined with hormone therapy to shrink the prostate before starting treatment. Or hormone therapy may be combined with external beam therapy to make the radiation more effective. Hormone therapy is called Androgen Deprivation Therapy (ADT).

ADT fights prostate cancer by removing testosterone from the body. The loss of testosterone helps fight cancer but may include major side effects such as loss of libido, ED, hot flashes, changes in body fat and emotions. There could be other body changes as well. It is best to talk to your doctor about this.

Whole Gland or Focal Prostate Ablation

Cryotherapy or cryoablation for prostate cancer is the controlled freezing of the prostate gland. The freezing kills cancer cells. Special needles called "cryoprobes", guided by ultrasound, are placed in the prostate to direct the freezing process. Cryotherapy is done under general or spinal anesthesia. After cryotherapy, a patient is checked with routine PSA tests and biopsy. Possible side effects include ED, incontinence and other urinary or bowel problems. Your doctor will discuss with you how to manage them.

Focal therapy is a treatment under study for men with small, early-stage prostate tumors. Small tumors inside the prostate are targeted and destroyed without having to remove or radiate the whole prostate. This targeted approach leads to less intense side effects.

Once you have finished treatment, you may have to manage side effects. You will also make a long-term plan with your doctor for future tests. These tests check to make sure you stay cancer-free.

Erectile Dysfunction

Men may have sexual health problems following their cancer diagnosis or treatments. Erectile dysfunction (ED) is when a man finds it hard to get or keep an erection strong enough for sex. ED happens when there is not enough blood flow to the penis, or when nerves to the penis are harmed.

Cancer in the prostate, colon, rectum and bladder are the most common cancers that can affect a man’s sexual health. Treatments for cancer, along with emotional stress, can lead to ED.

The chance of ED after prostate cancer treatment depends on many things, such as:

  • Age
  • Overall health
  • Medications you take
  • Sexual function before treatment
  • Cancer stage
  • Damage to your nerves or blood vessels from surgery or radiation

There are treatments that may help ED. They include pills, vacuum pumps, urethral suppositories, penile injections and implants. Treatment can be individualized. Some treatments may work better for you than others. They have their own set of side effects. A doctor can talk with you about the pros and cons of each method. They can help you decide which single treatment or combination of treatments is right for you.

There may be a change in orgasm for men treated with surgery as they no longer ejaculate or ejaculate a small volume of urine because the prostate, which makes semen, has been removed. However, it is still possible to have an orgasm.

Incontinence

After prostate cancer surgery or radiation, you may experience a loss of urine control. Incontinence is the inability to control the release of urine and can sometimes happen with prostate cancer treatment. There are different types of incontinence:

  • Stress Incontinence (SUI), when urine leaks with coughing, laughing, sneezing or exercising or with any additional pressure on the pelvic floor muscles. This is the most common type.
  • Urge Incontinence, or the sudden urge to pass urine, even when the bladder is not full because the bladder is overly sensitive. This might be called overactive bladder (OAB).
  • Mixed Incontinence, a combination of stress and urge incontinence with symptoms from both types.

Short–term incontinence after surgery is common. If you have SUI, you may only need to wear a pad for a few weeks to months. Incontinence often does not last long and urinary control will return. For a few men, it can last as long as six to twelve months. Because incontinence may affect your physical and emotional recovery, it is of great value to understand how to manage this problem. There are treatment choices to help incontinence.

  • Kegel exercises may strengthen your bladder control muscles.
  • Lifestyle changes may improve your urinary functions. Try eating healthier foods, limiting smoking, losing weight and making timed visits to the bathroom.
  • Medication may help improve bladder control by affecting the nerves and muscles around the bladder.
  • Neuromuscular electrical stimulation uses a device to help strengthen bladder muscles.
  • Surgery to control urination may include injecting collagen to tighten the bladder sphincter, implanting a urethral sling to tighten the bladder neck, or an artificial sphincter device.
  • Products, such as pads, may help you stay dry but do not treat incontinence.
  • Avoid bladder irritants that include caffeine, alcohol and artificial sweeteners.

Long–term incontinence lasting more than a year is rare. It happens in less than 5–10 percent of all surgical cases. If it does happen, talk to your doctor about your choices for care.

What is HIFU and Focal Therapy?

The types of High-intensity Focused Ultrasound (HIFU) and Focal Therapy are:
• High-intensity focused ultrasound (HIFU). HIFU uses the energy of sound waves to target and superheat the tumor to kill cells (with the help of MRI scans). It can be used for the whole gland.

• Focal cryoablation. This uses a needle-thin probe to circle the tumor with a special solution that kills the tumor by freezing it.

• Irreversible electroporation. This uses a "NanoKnife" to pass an electrical current through the tumor. The electricity creates very tiny openings (called pores) in the tumor's cells, leading to cell death.

For men with small, localized prostate tumors, focal therapy may be an option. Focal therapy is a general term for a few methods. They kill small tumors inside the prostate, without destroying the whole gland or healthy tissue nearby. There are a few types of focal therapy in clinical trials.

What are the Benefits, Risks and Side Effects of Focal Therapy?

Ideally, focal therapy would lead to fewer side effects including changes in urinary function. The long-term benefits of focal therapy are not yet known. Research is being done to study this further. Right now, the FDA has approved this method to destroy prostate tissue, but not clearly to treat prostate cancer. Because many of these treatments are so new, insurance coverage is not often available.

Updated August 2018

What is Hormonal Therapy or Androgen Deprivation Therapy (ADT)?

Prostate cancer cells use the hormone testosterone to grow, similar to our need for food. Hormonal therapy is also known as androgen deprivation therapy (ADT). It uses drugs to block or lower testosterone and other male sex hormones that fuel cancer. ADT essentially starves prostate cancer cells of testosterone. ADT is used to slow cancer growth in cancers that are advanced or have come back after initial local aggressive therapy. It is also used for a short time during and after radiation therapy.

Hormone therapy is done surgically or with medication:

Surgery: Removes the testicles and glands that produce testosterone with a procedure called an orchiectomy.

Medication: There are a variety of medications used for ADT. There are two types that are used at first. One is the injection of luteinizing hormone releasing hormone (LH-RHs) inhibitors. These are also called either agonists or antagonists. They suppress the body's natural ability to turn on testosterone production. A second type (which is often given with the first type) are called non-steroidal anti-androgens. These pills block testosterone from working.

These therapies have been used for many years and are often offered as the first option for men who can't have or don't want other treatments. Hormone therapy usually works for a while (maybe for years) until the cancer "learns" how to bypass this treatment.

There are new medications available in recent years that may be used after other hormone therapy fails. This condition is called "castration-resistant prostate cancer" (CRPC). For more information on this, review our Advanced Prostate Cancer website article.

To block the production of androgens in CRPC patients, there are a few options. The drug Abiraterone (Zytiga), given with prednisone, is one option that blocks an enzyme called CYP17, to stop these cells from making androgens. Another option is a drug, enzalutamide (Xtandi ®) that blocks the testosterone from working in a different way. This medication blocks signals in cells that tell it to grow and divide. Like other hormone therapies, these options also only work for a while. When they stop working, chemotherapy may be an option. 

What Are The Benefits, Risks and Side Effects of Hormone Therapy?

Hormone therapy has been linked to heart disease, diabetes and the loss of bone. You should discuss these risks with your doctor before you begin this treatment for prostate cancer.

Hot flashes and fatigue are also short-term side effects of hormone treatment. The same is true for the loss of sexual drive.

Updated August 2018

What is Chemotherapy?

Chemotherapy uses drugs to destroy cancer cells anywhere in the body. It is used for advanced stages of prostate cancer. It is also used when cancer has metastasized (spread) into other organs or tissue. The drugs circulate in the bloodstream. Because they kill any rapidly growing cell, they attack both cancerous cells and non-cancerous ones. Dose and frequency are carefully controlled to reduce the side effects this may cause. Often, chemotherapy is used with other treatments. It is not the main treatment for prostate cancer patients.

Many chemotherapy drugs are given intravenously (with a needle in a vein). Others are taken by mouth. They are given in the healthcare provider's office or at home. You generally do not need to stay in the hospital for chemotherapy. They are often given once per month for several months.

What are the Benefits, Risks and Side Effects of Chemotherapy?

Over the last 10 years, chemotherapy has helped many patients with CRPC. Recently, chemotherapy has also been found to help patients with advanced prostate cancer when given at the same time as standard hormone therapy. Yet, chemotherapy may only works for a while.

The side effects from chemotherapy should be considered. Side effects depend on the drug, the dose and how long the treatment lasts. The most common side effects are fatigue (feeling very tired), nausea, vomiting, diarrhea and hair loss. A change in your sense of taste and touch is also possible. There is an increased risk of infections and anemia because of lower blood cell counts. Most of these side effects can be managed, and lessen once treatment ends.

Updated August 2018

What is Immunotherapy?

Immunotherapy stimulates your body's immune system to find and attack cancer cells. There are several approaches used in immunotherapy. Most of these are now in clinical trials and have not yet been approved for routine use.

Provenge® is one type of immunotherapy that is already FDA approved. It has been shown to help slow cancer growth in men with advanced prostate cancer. For this treatment, the medical team must remove immature immune cells from the man with advanced prostate cancer. Then the cells are re-engineered to recognize and attack prostate cancer cells, and put back into the body.

What are the Benefits, Risks and Side Effects of Immunotherapy?

While cancer doctors are excited about the potential of immune therapies, clinical trials have not yet shown clear successful results. So far, most immunotherapy approaches have only mild to moderate side effects.

Updated August 2018

Lifestyle Changes

Diet

A healthy diet may increase your energy levels and enhance your immune system. It is of great value to think about the foods you eat and to try to maintain a healthy weight. Healthy eating habits can improve your health and risks.

Healthy food choices may include:

  • Plenty of fruits and vegetables
  • High fiber foods
  • Low fat foods
  • Limited amounts of simple sugars
  • Limited amounts of processed foods (especially processed meats like deli foods and bacon)

Because prostate cancer treatment can affect your appetite, eating habits and weight, it is of great value to try your best to eat healthy. If you have a hard time eating well, reach out to a registered dietitian/nutritionist (RDN). There are ways to help you get the nutrition you need.

Exercise

Physical exercise may improve your physical and emotional health. It can also help you manage your weight, maintain muscle and bone strength and help manage side effects.

If approved by your doctor, you may want to exercise one to three hours per week. Cardiovascular exercise and strength/ resistance training may be good choices. This can include walking or more intense exercise. Physical exercise may help you to:

  • Reduce anxiety
  • Improve energy
  • Improve self-esteem
  • Feel more hopeful
  • Improve heart health
  • Reach a healthy weight
  • Boost muscle strength
  • Maintain bone health

Pelvic floor exercise may help men being treated for prostate cancer. The pelvic floor is a group of muscles and structures in your pelvis between your legs. The pelvic floor supports the bowel, bladder and sexual organs. They help with urinary and fecal functions as well as sexual performance. The muscles contract and relax, just like any other muscle in your body. Pelvic floor exercises can help with side effects like erectile dysfunction and urinary incontinence.

Emotional Stress

After treatment, some men feel relieved the cancer is gone. Many men may worry about cancer coming back (recurrence). If the cancer returns, you and your doctor will talk about next steps and make a plan.

Some men are upset by the side effects of treatment. Urinary and erection problems can feel like a loss of one’s usual self. Those feelings are normal and will get better as you learn to manage your side effects and see improvements. Whatever you are feeling, it is worth telling your doctor. Cancer is always stressful and a trained counselor may help you manage your mental health.

If you have a partner, be sure that your partner is a part of what you are going through. Couples cope better when they approach cancer treatment and the side effects of treatment as a team. If you do not have a partner, talk to a friend you trust about what you are going through. If you find you and your partner are not coping well, feel down or very anxious, it may help to talk to a counselor or a sex therapist to get support.

Questions to Ask Your Doctor

Most men choose to talk with their doctors before making a treatment choice. Even if you have done a lot of research on your own, talking with your doctor may help you sort out your thoughts. Here are some sample questions you might ask when you see your doctor:

  • What kind of prostate cancer do I have and how aggressive is it?
  • Are there other tests I should have to understand how advanced my cancer is?
  • What are the treatment options for this grade/stage of this cancer?
  • Which treatment do you recommend for me and why?
  • How long should I try a treatment type before we know whether it works?
  • What can I do to manage my symptoms?
  • What can I do to manage or prevent treatment side effects?
  • What is the average lifespan for people managing my grade/stage of cancer?
  • Can you refer me to another expert for a second (or third) opinion?
  • Can you put me in touch with a support group? ⏹ How can I help my overall health?

Updated February 2023.

Clinical Trials

Clinical trials are research studies involving real patients to test if a new treatment or procedure is safe, effective and maybe better than established options. The goal is to learn which treatments work best for certain illnesses or groups of people.

Clinical trials follow strict scientific standards. These standards help protect patients and produce more reliable study results.

Are you interested in participating in a clinical trial for prostate cancer? Ask your doctor if you qualify for a specific prostate cancer trial. Learn as much as you can about the benefits and risks of the study. To search for information on current clinical trials for the treatment of bladder cancer visit the Clinical Trials Resource Center—you may also visit the National Institutes of Health website.  

Updated January 2020

After Treatment

Each year, more men are surviving prostate cancer and winning back their lives. Prostate cancer can be a manageable disease if caught early and treated appropriately.

Once you have finished treatment, it is time to manage your side effects. It is time to create a long-term schedule with your doctor for future tests. It's also time to go on with your life.

Talk to your healthcare provider about the side effects or problems you have after treatment. You and your healthcare provider can decide your best next steps.

If you haven't yet started treatment, consider the expertise of your doctor before you begin. With more experienced surgeons, the risk of permanent side effects, like incontinence, is lower.

What are the Emotional Effects Following Treatment?

After treatment, you may feel very emotional. You may also worry about cancer returning. Many men still feel anxious and unsure, or upset about treatment side effects.

Whatever you're feeling, it's important to tell your healthcare provider about it. Work together. Build a plan with your provider or a counselor to deal with your emotional health and general wellbeing.

What are The Physical Effects Following Treatment?

Erectile dysfunction and urinary incontinence are the side effects reported most often by men following prostate cancer treatment.

Erectile Dysfunction (ED) Issues After Prostate Cancer Treatment

After prostate cancer, many men experience erectile dysfunction (ED). An erection happens when sexual arousal causes nerves near the prostate to send signals. The signals cause the blood vessels in the penis to fill with blood. The blood in the vessels makes the penis erect. ED happens when this process doesn't work well (or is damaged from surgery or radiation) and a man cannot keep an erection long enough for sexual satisfaction. Your doctor can help you understand the causes of ED and therapies that could help you recover.

What Causes ED After Prostate Cancer Treatment?

Nerves involved in the erection process surround the prostate gland. Surgery may damage the nerve bundles that control blood flow to the penis, causing ED. Or, these nerves may be removed with the cancer. Radiation therapy also can damage the erectile nerves causing ED. In addition, the amount of blood flowing to the penis can decrease after treatment.

While most surgeons try to perform a nerve sparing procedure, it is not always possible.

The chance of ED after treatment depends on many things:

  • Age
  • Health
  • Sexual function before treatment
  • Stage of the cancer
  • Whether the nerves that control erection were damaged after surgery or radiation.

How Long Can ED Last?

If treatment causes ED, there is still a chance for erectile function to come back over time (unless both nerves were destroyed). It may take up to 24 months or longer before you are able to have a full erection, but it is possible. Some men recover sooner. The average time for erections that allow intercourse is between 4 and 24 months. Men under age 60 have a better chance of regaining erections than older men. Even with nerve-sparing surgery, erections do not return right away or to full pre-surgery function. But, they may recover enough for sex. There are medicines and devices to treat ED.

Even with no erection, or a weak erection, men can orgasm.

Are There Treatments for ED After Prostate Cancer Treatment?

There are several treatments that can help ED. They include pills, vacuum pumps, urethral suppositories, penile injections and penile implants. Individual treatments don't work for every patient. They have their own set of side effects. A healthcare provider can talk with you about the pros and cons of each method. They can help you decide which individual or combination of treatments is right for you.

Urinary Incontinence After Prostate Cancer Treatment

Urinary incontinence can sometimes result from prostate cancer treatment . Urinary incontinence is urine leakage without your control. Men may have many types of incontinence after prostate surgery.

  • Stress incontinence - Coughing, laughing, sneezing, or exercising can strain the pelvic floor muscles, causing urine to leak. This is the most common type of urinary incontinence.
  • Urge incontinence - You feel a sudden, urgent need to go to the bathroom, even when the bladder is not full. This happens because the bladder is overly sensitive. Urge incontinence is also called overactive bladder.
  • Urinary frequency - You go to the bathroom very often. You may feel the need to go every 30 to 60 minutes.
  • Mixed incontinence - You have symptoms of more than 1 type of urinary incontinence.
  • Because incontinence may affect your physical and emotional recovery, it is of great value to understand how to manage this problem.

How Long Will Incontinence Last?

It is common to have incontinence for a time after prostate surgery. If you have stress incontinence, you may need to wear pads for a few weeks or months. In most cases, urinary control will return. Still, incontinence may last as long as 6 to 12 months. It's rare for it to last more than a year.

Are there Treatments for Incontinence After Prostate Cancer Treatment?

Treatment for incontinence depends on the type and severity of the problem. Ask your doctor about treatment choices, risks and benefits, and what you should expect.

  • Physical therapy can help you regain bladder control. Your doctor can write you a prescription for it. Most health plans will cover it.
    • Kegel exercises build up the pelvic floor muscles, training them to keep urine in the bladder. If you're going to have prostate cancer surgery, your doctor may suggest that you start doing these exercises before your surgery.
    • Biofeedback may be used with Kegel exercises to help you judge how well the pelvic floor muscles are working and let you know whether you are doing the exercises the right way.
    • Neuromuscular electrical stimulation uses a device that sends electrical impulses to nerves, which causes muscles to contract. It may be used with Kegel exercises to help train the pelvic floor muscles to contract properly.
  • Timed voiding, a way to reduce urinary frequency with planned bathroom visits. It's used to help your bladder spread out so that it can hold more urine. Your nurse or doctor can help you make a plan for timed voiding.
  • Avoiding bladder irritants during the healing period. These foods and drinks can bother the bladder: 
    • Caffeine in coffee, tea, and sodas
    • Acidic drinks such as juices
    • Alcohol
    • Artificial sweeteners
    • Spicy foods
  • Medication can calm bladder irritability and help reduce urine leaks.
  • Surgery is mainly offered if your bladder has tried to heal on its own, but healing is not complete after at least a year. Your doctor will talk with you about these choices if other treatments haven't helped with your urinary problems.
  • Products such as pads can help reduce pain from urine leakage. These products do not treat incontinence but do help keep up a higher quality of life.

What if Prostate Cancer Returns?

Prostate cancer may return. Durable (or long-term) remission depends on the specifics of your cancer. If you'd like to learn more about how to manage advanced prostate cancer, read our advanced prostate cancer article

Updated March 2019

More Information

Questions to Ask Your doctor

About Diagnosis:
  • What is my Gleason score, the grade and the stage of my cancer?
  • How aggressive is this cancer? Is it likely that my cancer will spread? (Has it spread?)
    • If the cancer has spread, where?
  • Do I need more tests now?;
  • What type of schedule should I be on to track changes with this cancer?
About Treatment:
  • What are my treatment choices (including surveillance, localized therapy or systemic therapy)?
    • What are the advantages and disadvantages of each?
    •  What are the time considerations and costs for each?;
    • What is your experience with each option?
    • Would I have to go somewhere special to get treatment?
  • Why do you recommend one type of therapy over another?
  • What are the chances for each treatment to manage my cancer and for how long?
  • What are the chances of complications from each treatment?
    • What kinds of complications are likely from each?
    • When are they likely to occur?
  • What if I choose no treatment (watchful waiting or active surveillance)?
    • How often will I need to take follow-up tests?
  • If I use hormone therapy, what type do you suggest and why?
    • How would we manage potential side effects from hormone therapy?
  • What are the chances that my cancer will return after treatment - and if it does, what options for treatment do I have then?
  • Can we develop a short and long-term plan for my care?
  • Is there someone you would recommend for another opinion?
About Side Effects & Recovery:
  • What are the potential side effects of the treatment you recommend: both immediately and in the long term?
  • How can I manage side effects?
    • How would we manage potential urinary dysfunction and for how long?
    • How would we manage potential erectile dysfunction and for how long?
    • What other side effects should I consider?
  • How much recovery time will be required after surgery?
  • Will I need to take time off from work or other activities to manage treatment and treatment side effects?

Updated August 2018

Related Resources

Prostate Biopsy: What You Should Know

Treatment Options for Localized Prostate Cancer

Life After Prostate Cancer

Genetic Testing for Prostate Cancer


Prostate Cancer: Early Detection for Higher Risk Patients with Dr. Brian McNeil and Dr. Paul Maroni


Prostate Cancer Caregiver Podcast Series

We are proud to announce a new podcast series geared toward helping give support, hope and guidance to prostate cancer caregivers. The goal of this “Prostate Cancer Caregiver Podcast Series” is to help others connect with a diverse group of people who have felt the impact of prostate cancer in their lives and empower them on their journey.


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