Understanding Treatment options for men with Prostate Cancer

Any man who is diagnosed with localized prostate cancer will find the decision making an enormous task. There is a need to individualise each patient’s diagnosis by the medical professional.

To Treat or not to treat?

Is the prostate cancer life threatening?
This will depend on a number of factors including, the PSA level, grade of the cancer shown as the Gleason score or WHO/ISUP score and the stage of spread.
This will also depend on how old the individual is and whether they have other illnesses which may shorten their lives or make treatment itself too risky? (The European Randomised Study of Screening for Prostate Cancer suggests that men with a life expectancy less than 7 years may not benefit from early detection and treatment of their cancers..). Some patients will need to ask whether it is better to do ‘watchful waiting’ with the patient choosing to observe their disease AND intervene with hormone treatment if and when they develop symptoms such as urinary obstruction or pain.
Low risk cancer is defined as:

  • PSA <10ng/ml and
  • Gleason <6 and
  • The percentage of involved cores is <50% or
  • Intermediate risk with only 1 positive core

Intermediate risk cancer is defined as:

  • Gleason score of 7 or
  • PSA of 10 – 20

High risk cancer is defined as:

  • Gleason >8 or
  • PSA >20 and

How do I choose between the different treatment options?
Factors that will influence decision making include the individual patient’s values and experience of cancer.
Factors to consider when deciding between definitive treatments include can be broken down into:
Tumour Factors:

  • The stage as measured by tests such as the MRI, CT and bone scans or PET scans
  • The Gleason Score – pattern measured out of 10 – 6 less aggressive; 7 moderately aggressive; 8/9/10 more aggressive.
  • PSA level as higher levels of PSA may indicate risk that the cancer has already spread.

Prostate Factors:

  • Size – if Brachytherapy used on a big prostate it may cause obstruction issues after treatment
  • Symptoms – obstruction. EBRT may aggravate a situation of urinary urgency which was occurring prior to treatment. In patients with significant urinary symptoms before diagnosis, removal of the prostate may be the best path.

Patient Factors:

  • Health and other illnesses eg. heart disease and obesity may make some patients to unfit to have surgery
  • Sexual function as a priority.
  • Continence and its early return as a priority
  • Personal/cultural/family experience of cancer and treatment
  • Personality (eg technophile, ability to tolerate drawn out treatment such as external beam radiotherapy)
  • Treatment costs
  • Geography (easy access to some treatment)

What are my treatment options for localised prostate cancer?
The Treatment Options:

  • Active surveillance/ watchful waiting
  • Radical prostatectomy (Open; Laparascopic; Robot assisted laparoscopic)
  • Radiotherapy (low dose rate also known as seeds; high dose rate also known as rods; external beam radiotherapy).
  • Focal therapy such as high intensity focal ultrasound, cryotherapy and electroporation

Active surveillance

This where patients defer curative treatments such as surgery or radiotherapy until there is evidence of actual tumour growth such as rising PSA, new lumps on digital rectal examination or repeat biopsy.
Close monitoring is required (3-6 monthly PSA and 6-12 month REPEAT BIOPSY) This option may be more suitable for patients with:

  • Low grade low stage cancer
  • Low PSA which can be easily monitored
  • Sexual function or continence are major priorities
  • Motivated patients able to comply with close PSA follow up and repeat prostate biopsies
  • Older age

Watchful waiting

Where patients choose to OBSERVE their disease AND intervene with treatments such as hormone therapy IF AND WHEN THEY DEVELOP SYMPTOMS such as pain

Radical Prostatectomy:

This the surgical removal of the prostate. It is use to treat localised prostate cancer in men who are fit and well and >10year life expectancy when their age and other illness are taken into account. The main side effects that may arise are Potential incontinence and impotence.

Laparoscopic radical prostatectomy is the keyhole removal of the prostate using special instruments passed through small incisions or “keyhole” into the abdomen. Potential Advantages over traditional open surgery may include, decreased blood loss & risk of transfusion, less postoperative pain medication requirements and decreased wound complications Robotic Assisted Radical Prostatectomy is the use of a robotic device guided by the surgeon to hold the key hole instruments. Advantages over traditional open surgery include shorter hospital stay, less blood loss, less pain medications required in some studies.


Low Dose Rate (Seed) Brachytherapy is radiotherapy delivered from within the prostatenusing tiny radioactive seeds. It has equivalent survival outcomes to surgery in the short term and has benefits including convenience for patients, high potency rate (~50 – 75%), incontinence & rectal side effects are rare. It may have some complications seed migration, urethritis and retention. It is only suitable for some patients with appropriate tumour and prostate features.

High Dose Rate (Rods) Brachytherapy involves the placement of needles into prostate and through which highly radioactive rods are passed for very short periods into the prostate by an automated system. May be given in combination with hormone therapy and external beam radiotherapy. It is generally reserved for the higher risk and more aggressive cancers.

External Beam Radiation Therapy has the advantage of being a non invasive treatment. It generally runs for a period of 7 – 8 weeks of daily treatment using multiple beams of radiation. There are risks of late bladder and bowel side effects. Technological improvement is allowing better targeting of prostate with reductions in side effects. It is of particular usefulness when there is a high likelihood of spread locally outside the prostate.


  • Individualised treatment is vital as one size does not fit all
  • Multidisciplinary care
  • Patient centered approach
  • Patient empowered with information and time to make informed choices

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