Prostate Cancer Treatment

Prostate cancer is a type of cancer that forms in the tissues of the prostate.

The prostate is a gland in the male reproductive system. It lies just below the bladder (the organ that collects and empties urine) and in front of the rectum (the lower part of the intestine). It is about the size of a walnut and surrounds part of the urethra (the tube that empties urine from the bladder). The prostate gland makes fluid that is part of the semen.

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Anatomy of the male reproductive and urinary systems showing the ureters, bladder, prostate gland, urethra, penis, testicles, and other organs.

Prostate cancer is most common in older men. In the United States, about one out of eight men will be diagnosed with prostate cancer.

Signs of prostate cancer include a weak flow of urine or frequent urination.

These and other signs and symptoms may be caused by prostate cancer or by other conditions. Check with your doctor if you have:

• Trouble starting the flow of urine.
• Frequent urination (especially at night).
• Trouble emptying the bladder completely.
• Weak or interrupted ("stop-and-go") flow of urine.

When prostate cancer is detected in an advanced stage, symptoms may include:

• Pain in the back, hips, or pelvis that doesn't go away.
• Shortness of breath, feeling very tired, fast heartbeat, dizziness, or pale skin caused by anemia.

Other conditions may cause the same symptoms. As men age, the prostate may get bigger and block the urethra or bladder. This may cause trouble urinating or sexual problems. The condition is called benign prostatic hyperplasia (BPH), and although it is not cancer, surgery may be needed. The symptoms of benign prostatic hyperplasia or of other problems in the prostate may be like symptoms of prostate cancer.

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Normal prostate and benign prostatic hyperplasia (BPH). A normal prostate does not block the flow of urine from the bladder. An enlarged prostate presses on the bladder and urethra and blocks the flow of urine.

Tests that examine the prostate and blood are used to diagnose prostate cancer.

In addition to asking about your personal and family health history and doing a physical exam, your doctor may perform the following tests and procedures:

• Digital rectal exam (DRE): An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the rectum and feels the prostate through the rectal wall for lumps or abnormal areas.
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  Digital rectal exam (DRE). The doctor inserts a gloved, lubricated finger into the rectum and feels the rectum, anus, and prostate (in males) to check for anything abnormal.
  

• Prostate-specific antigen (PSA) test: A test that measures the level of PSA in the blood. PSA is a substance made by the prostate that may be found in higher than normal amounts in the blood of men who have prostate cancer. PSA levels may also be high in men who have an infection or inflammation of the prostate or BPH (an enlarged, but noncancerous, prostate).
• PSMA PET scan: An imaging procedure that is used to help find prostate cancer cells that have spread outside of the prostate, into bone, lymph nodes, or other organs. For this procedure, a cell-targeting molecule linked to a radioactive substance is injected into the body and travels through the blood. It attaches to a protein called prostate-specific membrane antigen (PSMA) that is found on the surface of prostate cancer cells. A PET scanner detects high concentrations of the radioactive molecule and shows where the prostate cancer cells are in the body. A PSMA PET scan may be used to help diagnose prostate cancer that may have come back or spread to other parts of the body. It may also be used to help plan treatment.
• Transrectal ultrasound: A procedure in which a probe that is about the size of a finger is inserted into the rectum to check the prostate. The probe is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. Transrectal ultrasound may be used during a biopsy procedure. This is called transrectal ultrasound guided biopsy.
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  Transrectal ultrasound. An ultrasound probe is inserted into the rectum to check the prostate. The probe bounces sound waves off body tissues to make echoes that form a sonogram (computer picture) of the prostate.
  

• Transrectal magnetic resonance imaging (MRI): A procedure that uses a strong magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. A probe that gives off radio waves is inserted into the rectum near the prostate. This helps the MRI machine make clearer pictures of the prostate and nearby tissue. A transrectal MRI is done to find out if the cancer has spread outside the prostate into nearby tissues. This procedure is also called nuclear magnetic resonance imaging (NMRI). Transrectal MRI may be used during a biopsy procedure. This is called transrectal MRI guided biopsy.

A biopsy is done to diagnose prostate cancer and find out the grade of the cancer (Gleason score).

A transrectal biopsy is used to diagnose prostate cancer. A transrectal biopsy is the removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure may be done using transrectal ultrasound or transrectal MRI to help guide where samples of tissue are taken from. A pathologist views the tissue under a microscope to look for cancer cells.

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Transrectal biopsy. An ultrasound probe is inserted into the rectum to show where the tumor is. Then a needle is inserted through the rectum into the prostate to remove tissue from the prostate.

Sometimes a biopsy is done using a sample of tissue that was removed during a transurethral resection of the prostate (TURP) to treat benign prostatic hyperplasia.

If cancer is found, the pathologist will give the cancer a grade. The grade of the cancer describes how abnormal the cancer cells look under a microscope and how quickly the cancer is likely to grow and spread. The grade of the cancer is called the Gleason score.

To give the cancer a grade, the pathologist checks the prostate tissue samples to see how much the tumor tissue is like the normal prostate tissue and to find the two main cell patterns. The primary pattern describes the most common tissue pattern, and the secondary pattern describes the next most common pattern. Each pattern is given a grade from 3 to 5, with grade 3 looking the most like normal prostate tissue and grade 5 looking the most abnormal. The two grades are then added to get a Gleason score.

The Gleason score can range from 6 to 10. The higher the Gleason score, the more likely the cancer will grow and spread quickly. A Gleason score of 6 is a low-grade cancer; a score of 7 is a medium-grade cancer; and a score of 8, 9, or 10 is a high-grade cancer. For example, if the most common tissue pattern is grade 3 and the secondary pattern is grade 4, it means that most of the cancer is grade 3 and less of the cancer is grade 4. The grades are added for a Gleason score of 7, and it is a medium-grade cancer. The Gleason score may be written as 3+4=7, Gleason 7/10, or combined Gleason score of 7.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis and treatment options depend on:

• The stage of the cancer (level of PSA, Gleason score, Grade Group, how much of the prostate is affected by the cancer, and whether the cancer has spread to other places in the body).
• The patient's age.
• Whether the cancer has just been diagnosed or has recurred (come back).

Treatment options also may depend on:

• Whether the patient has other health problems.
• The expected side effects of treatment.
• Past treatment for prostate cancer.
• The wishes of the patient.

Most men diagnosed with prostate cancer do not die of it.

After prostate cancer has been diagnosed, tests are done to find out if cancer cells have spread within the prostate or to other parts of the body.

The process used to find out if cancer has spread within the prostate or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The results of the tests used to diagnose prostate cancer are often also used to stage the disease. (See the General Information section.) In prostate cancer, staging tests may not be done unless the patient has symptoms or signs that the cancer has spread, such as bone pain, a high PSA level, or a high Gleason score.

The following tests and procedures also may be used in the staging process:

• Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones with cancer and is detected by a scanner.
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  Bone scan. A small amount of radioactive material is injected into the patient's bloodstream and collects in abnormal cells in the bones. As the patient lies on a table that slides under the scanner, the radioactive material is detected and images are made on a computer screen or film.
  

• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• Pelvic lymphadenectomy: A surgical procedure to remove the lymph nodes in the pelvis. A pathologist views the tissue under a microscope to look for cancer cells.
• Seminal vesicle biopsy: The removal of fluid from the seminal vesicles (glands that make semen) using a needle. A pathologist views the fluid under a microscope to look for cancer cells.
• ProstaScint scan: A procedure to check for cancer that has spread from the prostate to other parts of the body, such as the lymph nodes. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material attaches to prostate cancer cells and is detected by a scanner. The radioactive material shows up as a bright spot on the picture in areas where there are a lot of prostate cancer cells.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

• Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
• Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if prostate cancer spreads to the bone, the cancer cells in the bone are actually prostate cancer cells. The disease is metastatic prostate cancer, not bone cancer.

Denosumab, a monoclonal antibody, may be used to prevent bone metastases.

The Grade Group and PSA level are used to stage prostate cancer.

The stage of the cancer is based on the results of the staging and diagnostic tests, including the prostate-specific antigen (PSA) test and the Grade Group. The tissue samples removed during the biopsy are used to find out the Gleason score. The Gleason score ranges from 2 to 10 and describes how different the cancer cells look from normal cells under a microscope and how likely it is that the tumor will spread. The lower the number, the more cancer cells look like normal cells and are likely to grow and spread slowly.

The Grade Group depends on the Gleason score. See the General Information section for more information about the Gleason score.

• Grade Group 1 is a Gleason score of 6 or less.
• Grade Group 2 or 3 is a Gleason score of 7.
• Grade Group 4 is a Gleason score 8.
• Grade Group 5 is a Gleason score of 9 or 10.

The PSA test measures the level of PSA in the blood. PSA is a substance made by the prostate that may be found in an increased amount in the blood of men who have prostate cancer.

The following stages are used for prostate cancer:

Stage I

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Stage I prostate cancer. Cancer is found in the prostate only. The cancer is not felt during a digital rectal exam and is found by needle biopsy done for high prostate-specific antigen (PSA) level or in a sample of tissue removed during surgery for other reasons. The PSA level is less than 10 and the Grade Group is 1; OR the cancer is felt during a digital rectal exam and is found in one-half or less of one side of the prostate. The PSA level is less than 10 and the Grade Group is 1.

In stage I, cancer is found in the prostate only. The cancer:

• is not felt during a digital rectal exam and is found by needle biopsy (done for a high PSA level) or in a sample of tissue removed during surgery for other reasons (such as benign prostatic hyperplasia). The PSA level is lower than 10 and the Grade Group is 1; or
• is felt during a digital rectal exam and is found in one-half or less of one side of the prostate. The PSA level is lower than 10 and the Grade Group is 1.

Stage II

In stage II, cancer is more advanced than in stage I, but has not spread outside the prostate. Stage II is divided into stages IIA, IIB, and IIC.

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Stage IIA prostate cancer. Cancer is found in the prostate only. Cancer is found in one-half or less of one side of the prostate. The prostate-specific antigen (PSA) level is at least 10 but less than 20 and the Grade Group is 1; OR cancer is found in more than one-half of one side of the prostate or in both sides of the prostate. The PSA level is less than 20 and the Grade Group is 1.

In stage IIA, cancer:

• is found in one-half or less of one side of the prostate. The PSA level is at least 10 but lower than 20 and the Grade Group is 1; or
• is found in more than one-half of one side of the prostate or in both sides of the prostate. The PSA level is lower than 20 and the Grade Group is 1.

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Stage IIB prostate cancer. Cancer is found in the prostate only. Cancer is found in one or both sides of the prostate. The prostate-specific antigen level is less than 20 and the Grade Group is 2.

In stage IIB, cancer:

• is found in one or both sides of the prostate. The PSA level is lower than 20 and the Grade Group is 2.

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Stage IIC prostate cancer. Cancer is found in the prostate only. Cancer is found in one or both sides of the prostate. The prostate-specific antigen level is less than 20 and the Grade Group is 3 or 4.

In stage IIC, cancer:

• is found in one or both sides of the prostate. The PSA level is lower than 20 and the Grade Group is 3 or 4.

Stage III

Stage III is divided into stages IIIA, IIIB, and IIIC.

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Stage IIIA prostate cancer. Cancer is found in the prostate only. Cancer is found in one or both sides of the prostate. The prostate-specific antigen level is at least 20 and the Grade Group is 1, 2, 3, or 4.

In stage IIIA, cancer:

• is found in one or both sides of the prostate. The PSA level is at least 20 and the Grade Group is 1, 2, 3, or 4.

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Stage IIIB prostate cancer. Cancer has spread from the prostate to the seminal vesicles or to nearby tissue or organs, such as the rectum, bladder, or pelvic wall. The prostate-specific antigen can be any level and the Grade Group is 1, 2, 3, or 4.

In stage IIIB, cancer:

• has spread from the prostate to the seminal vesicles or to nearby tissue or organs, such as the rectum, bladder, or pelvic wall. The PSA can be any level and the Grade Group is 1, 2, 3, or 4.

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Stage IIIC prostate cancer. Cancer is found in one or both sides of the prostate and may have spread to the seminal vesicles or to nearby tissue or organs, such as the rectum, bladder, or pelvic wall. The prostate-specific antigen can be any level and the Grade Group is 5.

In stage IIIC, cancer:

• is found in one or both sides of the prostate and may have spread to the seminal vesicles or to nearby tissue or organs, such as the rectum, bladder, or pelvic wall. The PSA can be any level and the Grade Group is 5.

Stage IV

Stage IV is divided into stages IVA and IVB.

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Stage IVA prostate cancer. Cancer is found in one or both sides of the prostate and may have spread to the seminal vesicles or to nearby tissue or organs, such as the rectum, bladder, or pelvic wall. Cancer has spread to nearby lymph nodes. The prostate-specific antigen can be any level and the Grade Group is 1, 2, 3, 4, or 5.

In stage IVA, cancer:

• is found in one or both sides of the prostate and may have spread to the seminal vesicles or to nearby tissue or organs, such as the rectum, bladder, or pelvic wall. Cancer has spread to nearby lymph nodes. The PSA can be any level and the Grade Group is 1, 2, 3, 4, or 5.

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Stage IVB prostate cancer. Cancer has spread to other parts of the body, such as the bones or distant lymph nodes.

In stage IVB, cancer:

• has spread to other parts of the body, such as the bones or distant lymph nodes. Prostate cancer often spreads to the bones.

Prostate cancer may recur (come back) after it has been treated.

The cancer may come back in the prostate or in other parts of the body.

There are different types of treatment for people with prostate cancer.

Different types of treatment are available for patients with prostate cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

The following types of treatment are used:

There are treatments for bone pain caused by bone metastases or hormone therapy.

Prostate cancer that has spread to the bone and certain types of hormone therapy can weaken bones and lead to bone pain. Treatments for bone pain include:

• Pain medicine.
• External radiation therapy.
• Strontium-89 (a radioisotope).
• Targeted therapy with a monoclonal antibody, such as denosumab.
• Bisphosphonate therapy.
• Corticosteroids.

For more information, see Cancer Pain.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI website.

Treatment for prostate cancer may cause side effects.

For information about side effects caused by treatment for cancer, visit our Side Effects page.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCI’s clinical trials search webpage. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.

Follow-up care may be needed.

As you go through treatment, you will have follow-up tests or check-ups. Some tests that were done to diagnose or stage the cancer may be repeated to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back).

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