Early Prostate Cancer Treatment

Due to the prevalence of prostate cancer and the heightened rate of early detection following the introduction of prostate-specific antigen (PSA) testing, there exists a significant risk of over-diagnosis and subsequently over-treatment of the disease.

Given that all curative treatment choices for early prostate cancer entail potential significant side effects, there is a need to consider a conservative approach for patients with a low risk of mortality from their prostate cancer (early stage and Gleason grade group 1 disease).

Learn more: Advanced Prostate Cancer Treatment

Two distinct strategies for conservative prostate cancer management which avoid over-treatment include: active surveillance and watchful waiting.

Active surveillance is designed to prevent unnecessary treatment and, consequently, avoidable side effects in men diagnosed with early prostate cancer (and a life expectancy of 10 years or more). It is intended for individuals who don't require immediate treatment but still ensures that treatment is received at the right time for those who may eventually need it.

Patients are closely monitored through structured surveillance programs, involving regular follow-ups that include PSA testing, clinical examinations, magnetic resonance imaging (MRI) and repeat prostate biopsies. Curative treatment is initiated based on pre-defined thresholds that may indicate the presence of more aggressive disease.

For the vast majority of patients with early disease and otherwise lethal cancer (Gleason grade group 2 and above), curative treatment options include surgical treatment or radiation treatment.

Generally, active surveillance is targeted towards those with low-risk prostate cancer and a life expectancy of over 10 years and beyond. This strategy of regular testing helps keep a close eye on your cancer while allowing you to live your life without needing to risk the difficulties that accompany treatment.

On the other hand, if you are older or have other serious health issues that lower your life expectancy below 10 years, it’s quite likely that early prostate cancer will never grow fast enough to disrupt your life. In this case, watchful waiting would be recommended. This strategy prioritizes comfort rather than cure as you age, meaning fewer tests for you, while still watching for any need to intervene to mitigate painful symptoms.

A radical prostatectomy may be recommended if the tumor is localized at the prostate. This procedure involves the complete surgical removal of the prostate (including the pelvic lymph nodes in certain situations) and is often performed via a minimally invasive approach with robotic assistance.

The possible side effects of prostate removal include incontinence and impotence besides the general surgical risks. These side effects may also occur with other forms of treatment for prostate cancer. You and your doctor should be able to decide the best choice for you, based on your risk and personal preferences.

Radiation therapy is another established treatment option for those who prefer to directly treat early prostate cancer. Options can include externally-delivered radiotherapy also known as external beam radiation therapy (EBRT), low dose-rate brachytherapy or high dose-rate brachytherapy.

Radiation therapy differs from surgical treatment (radical prostatectomy) in the duration of treatment as multiple sessions may be needed (externally delivered radiotherapy) and in the side effect profile. The most important side effects arise from the collateral damage done to surrounding organs within the radiation field (e.g. the bladder and rectum), which leads to passing of blood in the urine or bowel motion.

There is also a higher risk of developing a second cancer due to the DNA damage that radiation causes in normal tissues, around five to ten years post-treatment.

Learn more: Is Prostate Cancer Radiotherapy Safe?

In addition to radical prostatectomy, EBRT and brachytherapy, alternative modalities have emerged as potential therapeutic choices for patients with early prostate cancer. These novel approaches have been developed as minimally invasive procedures to offer comparable oncological safety, reduced toxicity, and improved functional outcomes.

Some of these modalities of focal therapy include high-intensity focused ultrasound (HIFU) and cryoablation of the prostate (also known as cryotherapy). However, there is insufficient data available to establish them as a mainstay of prostate cancer treatment and longer-term data is awaited for these treatment modalities. Your doctor will be able to discuss the availability and suitability of your cancer for these treatments.

If you feel uncertain about deciding on a specific treatment, the following questions could help guide your decision:

• What do you think about issues with urinary or sexual function? Are you able to accept the risk of facing difficulties with them?
• Are you able to accept living with the possibility of cancer progressing?
• Are you okay with the risk of needing to continue with radiotherapy even after surgery?
• Have you spoken to others who have undergone treatments?

Rest assured that early prostate cancer has a near 100% chance of survival up to ten years after diagnosis. For your next step, you will need to balance between your prognosis, the risks of each treatment strategy and how you wish to live your life after cancer, before coming to a treatment decision with your doctor.

The best treatment for early prostate cancer is having the right plan, personalized to your preferences. Ideally, it should allow you to live life as you envision while minimizing the possible side effects and disruptions to your life.