Understanding Your Prostate Cancer Diagnosis and Treatment Options

A prostate cancer diagnosis can be unsettling, but many cases can be managed successfully. Outcomes have improved over time, in part because of earlier detection and advances in prostate cancer treatment.

More than 3.5 million men in the U.S. who have been diagnosed with prostate cancer are alive today, according to the American Cancer Society.

Survival is especially high when prostate cancer is found before it has spread. The five-year relative survival rate is greater than 99% when cancer is confined to the prostate or nearby areas. For prostate cancer that has spread to distant parts of the body, the rate is about 38%.

“Healthy men diagnosed with early-stage prostate cancer have a long natural life expectancy. For many patients, a prostate cancer diagnosis does not require urgent, immediate treatment decisions,” says Ramsey Chichakli, MD, a urologist at Scripps Cancer Center and Scripps Clinic.

Understanding your cancer stage and prostate cancer treatment options can help you and your care team choose an approach that fits your health, needs and treatment goals.

Prostate cancer may be found through screening or after symptoms develop. A prostate-specific antigen (PSA) blood test measures the level of PSA in the blood. A high PSA level may lead to further testing, but it does not necessarily mean cancer is present.

If prostate cancer is suspected, your doctor may recommend:

• A digital rectal exam
• Prostate MRI
• Prostate biopsy

A biopsy is used to confirm whether prostate cancer is present and helps determine how aggressive it may be.

When symptoms occur, they may include:

• A slow or weak urine stream
• Difficulty starting urination or being unable to urinate
• Blood in the urine or semen
• Pain in the back, hips or pelvis

These symptoms can have many causes other than prostate cancer.

If prostate cancer is found, your care team determines how much cancer is present, whether it has spread and how likely it is to grow or return.

Doctors use information such as the tumor’s size and extent, PSA level, Grade Group or Gleason score — which indicate how aggressive the cancer appears under a microscope — and imaging results to help plan treatment.

Imaging may also be used to check nearby lymph nodes and other parts of the body. For some patients, especially those with high-risk disease or suspected recurrence, a PSMA PET scan can help show whether the cancer has spread and where it is located.

“The goal is to get a complete picture of the cancer before deciding what comes next,” Dr. Chichakli says. “That can mean treating it right away or, in some cases, monitoring it closely.”

Prostate cancer treatment options depend on the cancer’s stage, risk, and growth rate. They also depend on your age, health, and treatment goals.

For localized prostate cancer, common approaches include active surveillance, surgery and radiation therapy. Selected patients also may be candidates for focal therapy, including high-intensity focused ultrasound (HIFU).

For advanced or metastatic prostate cancer, treatment may include hormone therapy, chemotherapy, targeted therapy, immunotherapy, radiopharmaceutical therapy and other treatments, often in combination.

Active surveillance means closely monitoring prostate cancer instead of treating it right away. It may be a good option when the cancer is growing slowly and is unlikely to spread quickly.

“Men who have just been diagnosed can often take time to make thoughtful decisions about how to proceed, based on factors like their age and overall health, lifestyle and goals. This is not a one-size-fits-all diagnosis,” Dr. Chichakli says.

Active surveillance may include:

• Regular PSA tests
• Digital rectal exams as recommended
• Prostate imaging
• Periodic prostate biopsies

If testing shows the cancer is growing or becoming more aggressive, your doctor may recommend treatment such as surgery or radiation therapy.

Active surveillance can help some men delay or avoid treatment and its possible side effects. It differs from watchful waiting, which generally involves less intensive monitoring and focuses on managing symptoms if they develop.

Surgery may be an option when prostate cancer is confined to the prostate or has limited spread to nearby tissues.

The main surgery for prostate cancer is a radical prostatectomy, which removes the prostate gland and seminal vesicles. Nearby lymph nodes also may be removed depending on the cancer’s risk.

Radical prostatectomy may be performed through open, laparoscopic or robot-assisted surgery. Minimally invasive approaches use smaller incisions and may shorten the hospital stay and recovery.

Possible risks and side effects include:

• Bleeding or infection
• Urinary incontinence
• Erectile dysfunction
• Complications from anesthesia

Radiation therapy uses high-energy rays or particles to destroy prostate cancer cells. It may be used when cancer is confined to the prostate or has spread to nearby tissues or lymph nodes.

Because the prostate is close to the bladder and rectum, doctors carefully plan treatment to target the cancer while limiting radiation exposure to nearby healthy tissue.

Depending on the cancer’s stage and risk, radiation may be used alone or with hormone therapy. It also may be recommended after surgery if cancer remains or returns.

Possible side effects include:

• Fatigue
• Urinary problems
• Bowel changes
• Sexual dysfunction

Hormone therapy helps slow prostate cancer by lowering levels of male sex hormones called androgens or blocking their effects on cancer cells. Testosterone is the main androgen involved.

This treatment is often called androgen deprivation therapy (ADT). Depending on the treatment, hormone therapy may lower testosterone and other androgen levels or prevent androgens from stimulating prostate cancer cells.

Hormone therapy may be used:

• With radiation therapy for some higher-risk prostate cancers
• If cancer comes back after surgery or radiation
• If the cancer has spread beyond the prostate
• Before radiation in some cases to reduce the size of the cancer and help with treatment

Possible side effects include:

• Hot flashes
• Fatigue
• Reduced interest in sex or erectile dysfunction
• Weight gain
• Loss of bone density

Advanced or metastatic prostate cancer often requires more than one type of treatment. Hormone therapy is often part of the treatment plan and may be combined with other therapies, depending on how the cancer behaves and how it responds to treatment.

Other treatment options may include:

Chemotherapy: Uses drugs to kill cancer cells or slow their growth.

Targeted therapy: Acts on specific features in cancer cells and may be an option when certain genetic changes are found.

Immunotherapy: Helps the immune system recognize and attack cancer cells and may be appropriate for selected patients.

Radiopharmaceutical therapy: Uses radioactive medicines that travel through the body and target prostate cancer cells or areas where cancer has spread. At Scripps, some patients with advanced prostate cancer may receive this type of treatment through theranostics.

Bone-directed therapy: May help protect bones, reduce complications and manage symptoms when prostate cancer has spread to the bones.

Your doctor may also recommend genetic or molecular testing to help determine whether certain targeted therapy or other specialized treatments may be appropriate.

There is no single best prostate cancer treatment for everyone. The right approach depends on the cancer’s stage and risk, your overall health and your personal preferences.

Your care team can help you compare the benefits, risks and possible side effects of each option and understand how treatment may affect your daily life and quality of life.

“Choosing a treatment is a shared decision,” Dr. Chichakli says. “Our role is to help patients understand their options, what to expect and how each approach may affect their quality of life so they can feel confident moving forward.”

Watch the video featuring Dr. Chichakli discussing how prostate cancer is diagnosed, staged and treated.