How to choose the right prostate cancer treatment

Just been diagnosed with prostate cancer? It’s natural to feel a little worried. But take this to heart: Prostate cancer is one of the most curable forms of cancer. The toughest part may be deciding which treatment to go with. 

“The prognosis is quite good,” says Stacy Loeb, M.D., professor of urology and population health at NYU Langone. “There are lots of treatment options available. You and your doctor will work together to choose the best one for you.” 

Ready to take the first step? Let’s go. 

Step 1: Know your numbers 

Not only are there many varieties of prostate cancer treatments, but there are also many varieties of prostate cancers. That makes it important to take some time to learn about yours and discuss your options with your doctor. “Treatment varies according to your individual cancer,” says Dr. Loeb. “It’s really important to learn about the specific features of your case.” 

Ask your doctor or nurse or check your patient portal to find out: 

• Your prostate specific antigen (PSA) level. This will be your baseline number based on a blood test at diagnosis. Your doctor will use it to track the progress of your treatments. The higher the number, the more likely that you have prostate cancer.
• Your grade. When you had your biopsy, your doctor likely removed some small cylindrical pieces of tissue from your prostate, examined them under a microscope, and then used a grading system to score your cancer. The classic system is the Gleason score, which assigns your cancer a number from 6 to 10. The higher the number, the more advanced your cancer is.
• Your clinical stage. This can range from T1 to T4. The lower the number, the more contained your cancer cells are within the prostate. Having higher numbers means that the cancer has begun to move beyond the walls of your prostate into neighboring organs, such as your bladder or your rectum. 
• Your M score. This score is used to determine whether the cancer has spread (metastasized) into other organs of your body, such as your lymph nodes or your bones. M0 means it hasn’t spread, while M1 means it has. 

Step 2: Know your options 

Now that you know your scores, you and your doctor can have a conversation about your treatment. 

If you’re at low risk
If your cancer is localized (meaning it’s confined to a small area of your prostate) and the grade is low, your doctor may recommend a strategy called “active surveillance.” Even though prostate cancer treatments are hugely successful, sometimes the side effects can be tough.  

Because prostate cancer grows slowly, if your numbers show that you’re in the low-risk category, your doctor may suggest this wait-and-see approach, rather than jumping right into treatment. Studies show that as many as 40% of patients are overtreated, and that can put them at unnecessary risk for those uncomfortable side effects. 

“Active surveillance means no upfront treatments,” says Dr. Loeb. “If the cancer is low grade, lower than a Gleason score of 6, and if the PSA is low, we monitor the cancer carefully over time.” 

What this means: Repeat the PSA test every six months, repeat exams every year, and repeat biopsies every one to five years. Historically, the results from this method have been excellent: One trial from the United Kingdom showed that for men with early-stage prostate cancer, there’s no difference in outcomes between those who were actively monitored and those who underwent surgery or radiation. 

If you’re at medium risk
If your cancer is still confined to your prostate, but the grade is higher and has moved beyond one spot, your doctor may suggest a more aggressive treatment. “When your Gleason is 7 or higher, the longstanding gold standard for treatment is surgery or radiation therapy,” explains Dr. Loeb. 

They’re both highly effective, so you and your doctor should work together to decide which option is best for you.

Radiation: First, a computer will take a three-dimensional image of your prostate. Then, a team of radiation oncologists will use that information to plan your treatment. They’ll be able to aim high-energy X-ray beams to exactly the right place, killing the cancer cells, but leaving everything else pretty much untouched. 

You can also get radiation to treat prostate cancer through external beam radiation therapy (EBRT), which uses an X-ray machine to send radiation to your prostate over a period of eight or nine weeks. You may also receive a newer version, called hypofractionated radiation therapy, which sends larger doses of radiation to your prostate over shorter periods of time. Finally, you may receive brachytherapy, which uses tiny radioactive pellets implanted in the prostate to send internal radiation to the tumor. The pellets emit radiation until they eventually die off. 

Surgery: If your health is good, your doctor may consider you an optimal candidate for surgery. The surgeon will remove your prostate and surrounding tissues, and possibly the lymph nodes in your pelvis. You’ll probably stay in the hospital for one or two days after the operation. 

If you’re at high risk 
If your Gleason score shows that your cancer has spread beyond your prostate into surrounding organs, or even into your bones, your cancer has metastasized. Dr. Loeb notes that you shouldn’t necessarily fret: There are still many effective treatment options available. “The prognosis is better than ever. It’s a really hopeful time for men with advanced prostate cancer.” 

Take a look at your treatment options.

Chemotherapy: If your cancer is advanced, chemotherapy, which includes drugs targeted at killing your cancer cells, may be effective at helping you live longer, improving your quality of life, and reducing any pain. “Since 2004, there’s been a boom in the development of new drugs and combinations of drugs,” explains Dr. Loeb. If you go the chemotherapy route, your medical oncologist will be an important part of your team.

Hormone therapy: Prostate cancer is supercharged by hormones called androgens, such as testosterone. So, to slow down the cancer’s growth, hormone therapy can cut off the supply with a treatment called androgen deprivation therapy, which has you receive periodic injections at your doctor’s office or take pills at home. When your cancer cells stop getting testosterone, they die off, which makes this a highly effective treatment. Often, it’s also used in higher-risk localized cases alongside radiation. 

Step 3: Know the side effects of each 

Your doctor will help guide you to the best treatment — but ultimately, the decision is yours. Begin with a positive attitude and a healthy lifestyle. Take steps to stay mentally and emotionally strong, such as finding a support group. 

And be aware of what you can expect during your course of treatment. “There’s no silver bullet for prostate cancer,” says Dr. Loeb. “There are advantages and disadvantages to each treatment.” 

Knowledge is power: Here’s what you need to know to be prepared for any possible side effects. Be sure to talk to your doctor about any concerns. There’s almost always a solution. 

Active surveillance: Men who choose active surveillance sometimes experience anxiety, which could lead them to jump into more invasive treatments that aren’t truly necessary. 

And active surveillance is on the rise. In fact, a recent study revealed that between 2014 and 2021, rates of active surveillance among U.S. men diagnosed with low-risk prostate cancer more than doubled. 

Radiation: Soon after your radiation is over, there’s a good chance that you will experience some urinary and bowel irritation, as well as problems with erections. “There might be urinary issues because radiation is so close to the bladder, and some sexual dysfunction,” Dr. Loeb adds, “since the radiation is around the area where the nerves control erections.” Talk to your doctor about possible solutions. 

Surgery: Though bowel problems are rare following surgery, urinary control may be worse than following radiation, and problems with erections are common. But Dr. Loeb explains, “You’re undergoing an invasive procedure and the worst of everything happens right up front. With surgery, the side effects start immediately and tend to improve over time.” 

Chemotherapy: Chemotherapy may have a bad reputation, but modern drugs are tolerated well by most patients. A small percentage of men might experience a low white-blood-cell count, but that’s usually easy to address with certain medications. Other side effects may include hair loss, fatigue, and numbness in your fingers and toes. However, most of these issues are treatable or go away on their own. 

Hormone therapy: Cutting off the testosterone supply has side effects ranging from hot flashes and mood swings to weight gain, muscle loss, and erectile dysfunction. Studies show that exercise and diet can go a long way toward addressing weight gain and muscle loss. And your doctor can help you find ways to address erectile dysfunction. As is the case with all treatment side effects, don’t be afraid to speak up if you’re confused, concerned, or simply have questions. 

Dr. Loeb’s advice: Talk to your doctor about what type of treatment is best in your case. “Every year, new clinical trials are coming out showing great success for patients.”