Learning about Prostate Cancer Treatment
- A recently published opinion piece by a retired colonel urges congress to pass legislation to improve prostate cancer care in the Department of Veterans Affairs (VA) health care system in honor of Veteran’s Day. Though SurvivorNet steers largely clear of politics, we wanted to highlight important information about this disease and provide an in-depth explanation of treatment options.
- Prostate cancer is the most common cancer in American men. Symptoms of prostate cancer are inconsistent and hard to pinpoint but may include changes in urinary function like urinating more or less often or waking up at night to go more than usual.
- Treatment for prostate cancer can vary greatly from person to person, so it’s important to know all your options and consider getting multiple opinions.
- Early-stage prostate cancers can be treated with many options including: active surveillance, watchful waiting, surgery, radiation and focal therapies, among other things.
- There are treatment options available for people facing late-stage prostate cancer. In fact, an oral medication called Nubeqa (darolutamide) was just approved by the Food and Drug Administration (FDA) in August 2022 for use in combination with Taxotere (docetaxel) for adult patients with metastatic hormone-sensitive prostate cancer (mHSPC).
- Nubueqa is in a category of anti-androgens or anti-testosterone drugs, and it works by blocking the effects of testosterone to slow the growth and spread of prostate cancer.
Nearly 489,000 prostate cancer patients are in the Department of Veterans Affairs (VA) health system. 16,000 of these patients have metastatic prostate cancer.Read More
“It is critical that Congress acts now by increasing access to preventative prostate cancer care and mandating the creation of a standardized clinical treatment pathway within the Department of Veterans Affairs (VA) to help ensure that more veterans do not unnecessarily die from prostate cancer,” retired Army Colonel Paul Taylor wrote.
And for Taylor, this mission is personal. He was diagnosed with stage four prostate cancer in 2012.
“At the time, I was only 41 years old, and I was serving as a commander in the U.S. Army’s 101st Airborne Division,” he wrote. “After the initial shock of a cancer diagnosis, my military training kicked in, helping me figure out my next steps and my plan for fighting cancer.
“My treatment has included hormone therapy, chemotherapy, surgery, and immunotherapy, and so far, has helped me hold the disease in check.”
Taylor hopes congress will pass legislation to “expand access to prostate cancer care and help protect Veterans.” And though SurvivorNet steers largely clear of politics, we always want to educate people about cancer and break down treatment options. So, in order to do that, let’s first take a look at what this disease entails.
Understanding Prostate Cancer
Prostate cancer is the most common cancer in American men – except for skin cancers. About one in eight men will be diagnosed with this disease during his lifetime. The disease begins in the walnut-shaped prostate gland located between the rectum and bladder. This gland produces the fluid that nourishes sperm.
Symptoms of the disease are generally inconsistent and hard to pinpoint.
“Prostate cancer is a very odd disease in that it doesn’t have a particular symptom,” Dr. Edwin Posadas, director of translational oncology and the medical director of the Urologic Oncology Program at Cedars-Sinai, explained.
But changes in urinary function like urinating more or less often or waking up at night to go more than usual could be a sign of the disease. However, it’s important to note that these potential symptoms could also could be caused by a urinary tract infection or even an enlargement of the prostate gland (which is not cancer). Still, you should always consult a medical professional if any changes to your health arise.
Doctors who have spoken with SurvivorNet shared a hopeful outlook when considering a prostate cancer diagnosis because there are many treatment options and there’s been significant treatment progress over the past decade.
Surgical and radiation options, for example, have made improvements in reducing side effects of treatment while still providing excellent cure rates. Even for men with an advanced-stage diagnosis, many new options exist to treat prostate cancer and help them maintain an excellent quality of life.
Treating Early-Stage Prostate Cancer
Treatment for early-stage prostate cancer can vary greatly from person to person. Doctors’ treatment recommendations will depend on multiple factors, including the stage of the cancer, but they will also look at things like how aggressive your particular cancer is in nature. Additionally, prostate cancer is a disease where many doctors have differing opinions on what is the best treatment path to take. So, it can be a good idea to get multiple opinions.
One option for people with early-stage, low-risk prostate cancer is to undergo active surveillance.
“The concept of active surveillance is you’re watching a man, and if something changes while the cancer is still in the prostate, you treat it then,” Dr. James Brooks, the chief of urologic oncology at Stanford Medicine and director of the U54 Stanford O’Brien Urology Research Center, told SurvivorNet. “An ideal man for active surveillance might be a man, for instance, in his late 60s who has a barely elevated PSA, let’s say just above 4, who undergoes a biopsy and is found to have one of the 12 biopsy cores with a small percent of low grade, what we call, Gleason grade 3 plus 3 prostate cancer.
“That man has a very low probability, it’s certainly less than 1% chance, of dying of prostate cancer in 10 years.”
Perhaps the biggest consideration for active surveillance is the fact that it allows you to preserve your normal functioning.
“You don’t have to suffer some of those potential side effects of sexual dysfunction or urinary dysfunction,” Dr. Brooks explained.
But even if you opt for active surveillance, there is still the chance you’ll require treatment later down the line. About 50% of men who opt for active surveillance will have changes within five years that require active treatment, says Dr. Brooks.
In addition to active surveillance, watchful waiting may also be an option for older adults and those with other serious or life-threatening illnesses who are expected to live less than 5 years. Routine PSA tests, digital rectal examinations and biopsies are not usually performed if you’ve decided on watchful waiting, but treatment may be recommended if the prostate cancer causes symptoms, such as pain or blockage of the urinary tract,
For early-stage patients who do undergo active treatment, local treatments like surgery and radiation may get rid of the prostate cancer completely.
When surgery is performed, you can either have traditional open surgery or laparoscopy. The latter is more commonly used nowadays since traditional surgery requires a surgeon to make a large incision and laparoscopic surgery offers a smaller incision and a shorter recovery time. And a newer approach, known as a robotic-assisted laparoscopic prostatectomy (RALP), or robotic surgery, allows surgeons to make these small incisions with more precision.
Brachytherapy is an internal form of radiation where small radioactive seeds are placed inside the prostate. The two forms of this therapy are permanent low-dose brachytherapy and temporary high-dose brachytherapy. The temporary option means you can have it done as an outpatient procedure that only takes one to two hours. If you choose the permanent therapy, doctors will place radioactive seeds directly into the prostate and leave them there to slowly release radiation over several weeks or months.
External beam radiation, on the other hand, delivers high doses of radiation to the tumor in the prostate in a non-invasive way. Experts say developing technology has allowed for more precision in the aim and amount of radiation administered.
“Over the last ten to fifteen years, we have done remarkable things with our technology that allows us to aim much more carefully, reduce the amount of radiation that nearby critical structures get, and thereby get a higher dose in a quicker period of time,” Dr. Patrick Swift, a radiation oncologist and a Clinical Professor of Radiation Oncology at Stanford, previously told SurvivorNet.
Focal therapies are another option for small prostate tumors. These less-invasive treatments can include cryosurgery (also called cryotherapy or cryoablation) and high-intensity focused ultrasound (HIFU).
Cryosurgery involves freezing cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that holds the testicles. But it’s crucial to note that this is NOT an established therapy or standard of care to treat newly diagnosed prostate cancer.
High-intensity focused ultrasound uses high-frequency ultrasound energy to heat and kill cancer cells in the prostate. This relatively new treatment is usually only offered to men with early stage, localized cancer that is in one area of the prostate, though it is admittedly rare to see a prostate cancer confined just to one area of the prostate.
But if patients do have such a diagnosis, HIFU can “reset the time clock on the cancer so they can avoid the full treatments until a later date,” according to Dr. Swift. Still, you should be aware that the long-term effectiveness of HIFU is still being determined.
Depending on the stage and aggressiveness of your cancer, other treatments like hormone therapies and anti-androgen drugs may be recommended (which will be discussed more below). No matter what, you should feel confident in your treatment plan. Don’t be afraid to get multiple opinions and really consider all your options.
Hope for Patients with Late-Stage
People with late-stage prostate cancer usually undergo some combination of treatments. And new approvals are being made all the time to give people more options to treat this advanced disease.
The drug nubeqa (also known as darolutamide), for instance, was just approved by the Food and Drug Administration (FDA) in August 2022 for use in combination with taxotere (docetaxel) for adult patients with metastatic hormone-sensitive prostate cancer (mHSPC).
This oral medication is in a category of anti-androgens or anti-testosterone drugs, and it works by blocking the effects of testosterone to slow the growth and spread of prostate cancer.
“If we take away testosterone, we can shrink down the tumor and hold it in check for often years and years and years,” Dr. Stephen Freedland, a urologist at Cedars-Sinai Medical Center, previously told SurvivorNet of androgen deprivation therapy in prostate cancer.
Xtandi (enzalutamide) is another androgen deprivation therapy. This oral medication is FDA-approved to treat non-metastatic (nmCRPC) and metastatic castration-resistant prostate cancer (mCRPC) and metastatic castration-sensitive prostate cancer (mCSPC).
Erleada (apalutamide) is another FDA-approved oral medication for advanced prostate cancer. It can be used for people with metastatic castrate-sensitive prostate cancer (mCRPC).
In addition to androgen-depravation drugs, PARP inhibitors can also be a good option for some people with advanced prostate cancer. These drugs work by stopping the activity of poly (ADP-ribose) polymerase, a protein involved in DNA repair. This, in turn, causes DNA to be unable to repair itself in cancer cells and therefore leads to the death of these cancer cells.
The two PARP inhibitors currently approved by the FDA are lynparza (olaparib) and rubraca (rucaparib). They are specifically approved for use in people with metastatic castration-resistant prostate cancer (mCRPC) – this distinction means the prostate cancer has spread beyond the prostate and does not respond to hormone therapy.
Some prostate cancers express the protein PSMA which can be targeted with medication. In March 2022, another FDA approval paved the way for the drug pluvicto (lutetium Lu 177 vipivotide tetraxetan) to treat patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer (mCRPC).
“The approval of lutetium is a major step in the development of personalized treatment for advanced prostate cancer,” Dr. David Penson, of Vanderbilt University Medical Center, told SurvivorNet in a previous interview. “This agent specifically targets PSMA-positive metastasis and represents the first theranostic agent for use in castration-resistant metastatic prostate cancer.”
This medication is considered “theranostic” because it combines diagnostic and therapeutic capabilities by identifying the presence of PSMA on a patient’s cancer cells and then treating it directly with minimal exposure to normal tissues.
In addition to the above treatments, there are plenty of other options for advanced prostate cancer patients to turn to when dealing with their disease. Talk with your doctor about your options, and consider asking if a clinical trial might be right for you.