UNDERSTANDING TREATMENT OPTIONS
Involvement of patients in treatment decisions is fundamental, enabling them to understand both benefits and risks of available treatment options. Patients must be given information that is clear and understandable to ensure their preferences are based on fact and free of clinician bias.
Nurses, being patient advocates, are in a unique position to assist prostate cancer patients in making the most appropriate decision for treatment through education and clarification of the evidence supporting each option. Nurses must remain knowledgeable about the following treatment options and be prepared to educate and discuss them with their patients, to support them through their decision-making process, and to provide care during and following their treatment.
Conservative Treatment for Localized Prostate Cancer
Watchful waiting and active surveillance are conservative measures for management of low-risk, low-grade (Gleason score ≤6 and PSA ≤10), stage I and II prostate cancer. These forms of management are based on research that shows many men diagnosed with early-stage, low-grade prostate cancer need little if any immediate medical treatment, especially older men (PCF, 2021a).
It is important when discussing these forms of treatment with the patient that there is a clear understanding of how the physician defines each approach. Some consider them identical; others consider them as separate management approaches (PCUK, 2019).
WATCHFUL WAITING BENEFITS AND RISKS
Watchful waiting, often called observation, is a noninvasive approach that monitors for symptom development. When symptoms occur, treatment is directed toward slowing the disease progression or relieving its symptoms, and not to cure.
This approach is recommended for men 65 years of age and older who have significant comorbidities and those whose cancer is low-risk and slow-growing. It is also an option for patients with life expectancy of less than 5 years. Its purpose is to avoid the risks and complications associated with more aggressive forms of treatment.
The benefits of watchful waiting include avoiding aggravation of other health conditions that would be caused by the side effects of aggressive forms of treatment. Watchful waiting avoids overtreatment, maintains the patient’s quality of life, reduces the chance of complications, and treats symptoms as soon as possible.
Risks include the chance that a possibility for a cure may be missed, that characteristics of the cancer will change, and that the cancer will start to grow and metastasize. Living with untreated cancer and its frequent monitoring can also be a source of psychological stress for men (Leslie et al., 2021; Hinkle & Cheever, 2018).
ACTIVE SURVEILLANCE BENEFITS AND RISKS
Active surveillance for men with prostate cancer involves avoiding or postponing immediate treatment combined with monitoring. Definitive treatment is offered if there is evidence that the patient is at increased risk for disease progression (Richie, 2020).
Active surveillance is appropriate for men under 65 years of age with a considerable life expectancy (>10 years) and low-risk disease. It involves a monitoring protocol, with the American Society of Clinical Oncology (ASCO, 2020a) recommendations including:
- PSA test every 3 to 6 months
- DRE every 12 months
- Confirmatory prostate biopsy within 6 to 12 months
- Repeat biopsy every 2 to 5 years
- MRI if clinical or PSA changes of concern arise
Initiation of active treatment is recommended for Gleason scores ≥7 or significant increases in the volume of cancer. Terminating serial biopsies should occur when patients turn 80 years old (Sosnowski et al., 2020).
The benefits of active surveillance include avoidance of unnecessary treatment and its resultant side effects. Risks are that it can create ongoing worry about having cancer and “doing nothing” or missing the window of opportunity for curative treatment should the cancer become more aggressive (NFPCSG, 2021).
Aggressive Treatments for Prostate Cancer
High-risk prostate cancer carries an increased risk of disease recurrence and death. It is treated locally, focally, or systemically. Aggressive treatments increase the potential for definitive cure for localized prostate cancer and for cancer that has spread beyond the prostate. Hormonal therapy, targeted therapy, radiopharmaceuticals, immunotherapy, and chemotherapy are the standard treatments for cancer that has spread beyond the prostate and is no longer considered curable (Leslie et al., 2021; ASCO, 2020b).
LOCAL TREATMENTS
Local treatments affect the cancerous tumor and the area surrounding it. These include surgery and forms of radiation therapy.
Surgery
A radical prostatectomy is the complete removal of the prostate, seminal vesicles, tips of the vas deferens, and often, surrounding fat, lymph nodes, and blood vessels. An attempt is made to protect the nerves that control penile erection and the bladder from damage.
Radical prostatectomy is the treatment of choice for high-risk localized prostate cancer, offering the benefits of a significant improvement in overall survival, cancer-specific survival, and the development of distant metastases. These benefits over other therapies are not evident before 10 years after treatment and are most pronounced in men younger than 65 years at time of diagnosis (Leslie et al., 2021).
A radical retropubic prostatectomy is performed through an incision in the wall of the lower abdomen under general, spinal, or epidural anesthesia along with sedation. Postoperatively, a urinary catheter remains in place for up to 2 weeks. The operation requires a hospital stay for a few days and limited activities for several weeks.
A radical perineal prostatectomy is done through an incision in the skin of the perineum. This approach is used less often, as it is more likely to lead to erectile dysfunction and because nearby lymph nodes cannot be removed. It is useful for men with other medical conditions that make retropubic surgery difficult. This approach may result in less pain and easier recovery.
A laparoscopic radical prostatectomy (LRP) is done through several smaller incisions. Special surgical tools are used to remove the prostate, one of which has a small video camera on the end for visualization purposes. The surgeon either holds the tools directly or uses a control panel to precisely move robotic arms that hold the surgical tools. This approach has become more common. Rates of major side effects from LRP, however, appear to be about the same as for open prostatectomies. Recovery of bladder control may be slightly delayed with this approach.
Transurethral resection of the prostate (TURP), the surgery done for benign prostatic hypertrophy, may be recommended for men with advanced prostate cancer to help relieve symptoms, such as difficulty with urination. It is not used as a curative measure, however. During this procedure, under spinal or general anesthesia, the inner part of the prostate gland that surrounds the urethra is removed using a resectoscope passed through the urethra. A laser is used to cut or vaporize the tissue.
Risks of prostate surgery during or shortly after the operation can include:
- Adverse reaction to anesthesia
- Bleeding
- Blood clots in legs or lungs
- Infections at surgical site
- Damage to nearby organs
Rarely, the intestines may be injured, leading to possible abdominal infections that may require reparative surgery. Injuries are more common with laparoscopic and robotic surgery than with the open approach (Leslie et al., 2021; ACS, 2019a).
Side effects of surgery may include erectile dysfunction, which may occur immediately and improve over time, urinary incontinence, urethral strictures, and an increased risk of inguinal hernias (Leslie et al., 2021).
Radiation Therapy
Radiation therapy involves destroying cancer cells using high-energy rays or particles. Cure rates with radiation are comparable to those of radical prostatectomy. Two major forms of radiation therapy are external beam radiation (EBRT) and brachytherapy (internal radiation). External beam radiation is used as initial treatment for high-risk localized cancer, and brachytherapy is an option for patients with low- or intermediate-risk prostate cancer.
External beam radiation involves focusing high-energy beams, such as X-rays or protons, directly at the prostate from a machine outside the body, called a linear accelerator. It can be used to attempt a cure in an early-stage cancer or to help relieve symptoms, such as bone pain.
Brachytherapy is a type of radiation therapy that can be given as either high-dose-rate or low-dose-rate. With high-dose-rate brachytherapy, radioactive material is temporarily placed in the body for a short period (from a few minutes up to 20 minutes); this may be repeated once or twice a day over a number of days or weeks. Low-dose-rate seed brachytherapy involves placing 80 to 100 radioactive metallic seeds permanently inside the prostate gland. These seeds slowly deliver a high dose of radiation to the gland and seminal vesicles over several months before the radiation completely decays. Brachytherapy can be given by itself or along with external beam radiation.

Brachytherapy seeds used to treat prostate cancer. Arrow marks the beads. (Source: James Heilman, MD / Wikimedia Commons, Creative Commons License BY-SA 4.0.)
Depending on the stage of the prostate cancer and other factors, indications for radiation therapy include:
- As initial treatment for high-risk localized cancer, resulting in cure rates that are approximately the same as for radical prostatectomy
- As part of the first treatment (along with hormone therapy) for cancers that have spread into nearby tissues
- If the cancer is not removed completely or recurs in the area of the prostate post surgery
- To help keep advanced cancer under control and to prevent or relieve symptoms
Side effects of radiation include:
- Radiation proctitis, which can cause bowel dysfunction, including diarrhea, blood in the stool, rectal leakage, and rectal fistula
- Radiation cystitis, which causes frequency, burning on urination, and/or hematuria. These usually improve over time, but in some men it is permanent. The U.S. Food and Drug Administration has approved a device called a SpaceOAR that places a hydrogel between the prostate and the rectum to physically separate those two structures, thereby reducing the dose of radiation delivered to the rectum.
- Seed migration (with brachytherapy)
- Urinary incontinence, but less often than with surgery. The risk is low at first, but increases each year for several years after.
- Rarely, urethral stricture requiring further treatment
- Erectile dysfunction, including impotence
- Skin reactions
- Fatigue
- Reduced blood counts
- Pubic hair loss
The benefits of having brachytherapy include avoiding the risks of major surgery, and because brachytherapy is delivered with a high degree of accuracy, it has minimal side effects, especially sexual dysfunction. Preserving sexual function for as long as possible is what men may value the most. Opting for radiation rather than surgery may help avoid erection problems (ACS, 2021d; UM, 2021; Hall et al., 2021).
FOCAL TREATMENTS
Focal treatments are noninvasive techniques using heat or cold to target small low- or intermediate-risk tumors inside the prostate. The goal of the treatment is to ablate, or destroy, the tumor and a safety margin within the prostate while leaving the remainder of the gland intact. Focal treatments can also be an option for men whose cancer has returned after other treatments.
Cryotherapy
Cryotherapy, also called cryosurgery or cryoablation, is a focal treatment that uses very cold temperatures to freeze and kill prostate cancer cells as well as most of the prostate gland. Compared to surgery or radiation therapy, long-term effectiveness of cryotherapy is not well known.
Cryotherapy treatment is indicated for a cancer that has recurred following other forms of treatment such as radiation therapy. It is an option for men with large prostate glands, for treating low-risk early-stage prostate cancer, or for a man who is not a candidate for surgery or radiation. In most cases, cryotherapy is not used as the initial treatment for prostate cancer.
Cryotherapy is done under spinal, epidural, or general anesthesia, and for most patients, it is a same-day procedure. During this treatment, a transrectal ultrasound (TRUS) is used to guide several hollow needles through the skin of the perineum, and very cold gases are then passed through the needles to freeze and destroy the prostate. Warm saltwater is passed through a catheter placed in the urethra during the procedure to keep it from freezing. This catheter remains in place for several weeks during recovery.
Side effects tend to be worse in men who have already had radiation therapy compared to those who have it as initial treatment, and may include:
- Hematuria for a day or two following the procedure
- Soreness in the needle insertion sites
- Swelling of the penis or scrotum
- Pain or burning sensation in the bladder and rectum
- Bladder and bowel frequency (most individuals recover normal function over time)
- Damage to nerves near the prostate that control erections (erectile dysfunction is more common following cryotherapy than after radical prostatectomy)
- Urinary incontinence (rare for those who have cryotherapy as initial treatment but more common in those who have already had radiation therapy)
- Development of a fistula between rectum and bladder (a rare [<1%] but serious occurrence that allows urine to leak into the rectum, often requiring surgical repair)
(ACS, 2021e)
Cryotherapy has several benefits over other forms of treatment, including:
- Performed on an outpatient basis, with half of all patients going home the same day and half the next day
- Less blood loss
- Reported success rates similar to surgery and brachytherapy
- Quick patient recovery, return to normal activities in about 10 days
- Minimal pain, which can be treated with anti-inflammatory medications for several days; narcotic pain medications not needed
- Lower risk over surgery and radiation of incontinence, irritable bladder, and bowel problems
- Can be repeated if prostate cancer recurs
(SHS, 2021)
High-Intensity Focused Ultrasound
High-intensity focused ultrasound (HIFU) is a heat-based type of focal therapy in which sound waves are directed at cancerous parts of the prostate gland via a probe inserted into the rectum. HIFU causes the temperature of the tissue to rise, and the heat destroys the targeted tissue area. It is an alternative to active surveillance for patients with early-stage prostate cancer and an alternative or follow-up to radiation, surgery, or other failed treatment for tumors that are small and localized.
Benefits include:
- Requires no surgical incisions and does not use radiation
- Can target cancer cell tissue, leaving nontargeted tissue unharmed
- Is an outpatient procedure with short recovery time (within 24 hours)
- Reduces (but does not eliminate) the risk of urinary incontinence and erectile dysfunction compared to surgery or radiation therapy
HIFU is associated with fewer side effects compared to more aggressive therapies and may include:
- Erectile dysfunction, ejaculation problems, and sexual impotence
- Urinary tract infections, incontinence, frequency, burning sensation, urinary retention
- Rectal wall injury, rectal incontinence, burning and bleeding from the probe
- Prostate infection
- Return of prostate cancer
(Cleveland Clinic, 2021)
SYSTEMIC TREATMENTS
Systemic treatments are standard for disease that has spread beyond the prostate and is no longer considered curable. These include:
- Hormone therapy
- Immunotherapy
- Targeted therapy
- Chemotherapy
- Radiopharmaceuticals
Hormone Therapy
Androgen deprivation therapy (ADT) (also sometimes referred to as antihormone therapy)—through pharmaceuticals (antiandrogens/chemical castration) or surgery (orchiectomy/medical castration)—is standard care for advanced and metastatic prostate cancer.
Androgen hormones such as testosterone are the main fuel for prostate cancer cell growth and the target of hormone therapy. Its purpose is either to stop testosterone from being produced or to directly block it from fueling prostate cancer cell growth. Without androgens, prostate cancer goes into remission, often for many years. Hormone therapy alone, however, does not cure prostate cancer (CancerCare, 2021).
While hormone therapy is generally effective at controlling cancer growth, in many men some cells gain the ability to grow in the low-testosterone environment. As they grow, the therapy has less and less effect over time on the growth of the cancer. This is referred to as castration-resistant prostate cancer (CRPC).
Orchiectomy (the surgical removal of the testicles) is an effective method for drastically reducing testosterone release. The procedure is most often done on an outpatient basis, and recovery tends to be quick, with no further hormone-therapy required. Although orchiectomy does not cause the side effects associated with other hormonal therapies, it is associated with considerable emotional impact. For some men who are concerned about cosmetic appearance following orchiectomy, artificial testicles that look like normal ones can be inserted into the scrotum. Because orchiectomy is permanent and irreversible, most men opt for drug-based therapy instead.
Drug-based hormone therapy involves the use of medications (luteinizing hormone-releasing hormone [LHRH] agonists and antagonists) to block the release of LHRH. Drugs are also available that block the formation of androgens made in other parts of the body, such as the adrenal glands and the prostate glands themselves, which can still produce male hormones.
There are many side effects for androgen deprivation therapy, including:
- Decreased libido
- Erectile dysfunction
- Shrinkage of the testicles and penis
- Hot flashes
- Anemia
- Osteoporosis leading to fractures
- Decreased mental sharpness, especially in memory
- Loss of muscle mass and physical strength
- Insulin resistance
- Weight gain
- Mood swings and depression
- Fatigue
- Gynecomastia and mastodynia
(ACS, 2020a; PCF, 202b)
Immunotherapy
In recent years, immunotherapy has made a major impact on the treatment of metastatic cancer and has altered the standard of care for many tumor types. Immunotherapy uses the power of the body’s immune system to prevent, control, and eliminate cancer, and it is effective on many different types of cancer. Immunotherapy has become a treatment for patients with certain types of cancer that are resistant to chemotherapy and radiation treatment. The ability of immunotherapy to recognize and target cancer cells makes it a universal response to cancer (CRI, 2021).
There are two FDA-approved types of immunotherapies for prostate cancer. Sipuleucel-T (Provenge) is a vaccine created by collecting immune cells from the patient’s blood and incubating them with a prostate cancer–associated antigen intended to stimulate and direct them against prostate cancer. Ultimately, the engineered product is reinfused into the patient over three treatments, two weeks apart.
The most common side effects seen in those receiving sipuleucel-T are:
- Fevers
- Chills
- Headache
- Influenza-like illness
- Myalgias
- Hypertension
- Hyperhidrosis
- Groin pain
These side effects are associated with the infusion period and usually last only for a few days (Fay & Graff, 2020; Zero, 2021a; Johns Hopkins, 2021a).
Pembrolizumab is a type of immune checkpoint inhibitor that blocks signals that mask cancer cells and activates tumor-killing immune cells. It is approved for treatment of all solid tumors with specific genetic characteristics. Patients who qualify for this treatment must have progressed on prior treatment and have no satisfactory alternative treatment options.
This therapy is delivered intravenously once every 3 weeks, and the most common side effects include:
- Fatigue
- Cough
- Shortness of breath
- Nausea
- Constipation
- Itching
- Rash
- Decreased appetite
There are also rare but serious side effects related to overactive immune responses, which are treated by discontinuing the drug. In some instances, steroid medications must be used to suppress the immune reactions (PCF, 2021c; CRI, 2020).
Two other medications, abiraterone acetate (Zytiga) and cabazitaxel (Jevtana injection), are treatment options for patients requiring care for management of metastatic castration-resistant prostate cancer that does not respond to sipuleucel-T or the usual treatment options (Hinkle & Cheever, 2018).
Although immunotherapy for prostate cancer does not lower PSA, treat symptoms, or delay disease progression, it has been shown to increase survival in patients with metastatic castration-resistant cancer who show few or no symptoms. There are ongoing studies attempting to clarify exactly how this treatment works (PCF, 2021c).
Targeted Therapy
Targeted therapy uses drugs or other substances to precisely identify and attack the specific genes, proteins, or the tissue environment that contribute to cancer growth and survival while causing limited damage to healthy cells.
Such drugs used in the treatment of prostate cancer include the poly (ADP-ribose) polymerase (PARP) inhibitors rucaparib (Rubraca) and olaparib (Lynparza). These target PARP, which is an enzyme involved in the normal pathway to repair damaged cellular DNA. By blocking this pathway, these drugs make it difficult for tumor cells with an abnormal gene to repair damaged DNA, leading to the death of these cells. Tests of saliva and tumor are done to be certain the patient has the genetic mutation before starting treatment with this drug.
PARP inhibitors have been shown to improve cancer patient outcomes when used alone or in combination with treatments such as chemotherapy and radiation, both of which damage DNA.
Enzalutamide (XTANDI), approved for metastatic castration-sensitive prostate cancer (mCSPC), is an androgen receptor-signaling inhibitor that interferes with androgen receptor nuclear translocation, DNA finding, and coactivator mobilization, leading to cellular death and decreased prostate tumor volume.
Targeted therapy is often used along with chemotherapy and other treatments. These drugs may cause side effects including nausea, vomiting, weakness, changes in blood counts, as well as skin, hair, nail, and/or eye problems (ASCO, 2021b; FDA, 2019).
Chemotherapy
Chemotherapy is recommended for treatment of hormone-resistant prostate cancer, usually for men who fall into one of three groups:
- Those with fast-rising PSA levels
- Those who are developing metastatic cancer symptoms
- Those with metastatic cancer that is rapidly growing
Chemotherapy can extend life, reduce pain, and improve quality of life, but it does not cure prostate cancer. Many men experience symptomatic improvement after starting chemotherapy.
Taxane chemotherapy given along with prednisone is the standard of care for metastatic prostate cancer that is spreading and progressing despite hormone therapy. Approved taxane chemotherapy agents include docetaxel (Taxotere) and cabazitaxel (Jevtana) (PCF, 2021d).
Chemotherapy targets cells that grow and divide quickly, as cancer cells do. These drugs work by inhibiting mitosis and inducing apoptosis (death) in cells undergoing the division process. The main benefit of chemotherapy is its potential to destroy cancer cells. It is the most potent tool for fighting cancer, and the potential benefit depends on the type of cancer, how advanced it is, and the patient’s goals in receiving the treatment.
While chemotherapy may kill rapidly growing cancer cells, the risk is that it may also damage fast-growing healthy cells throughout the body. These include blood-forming cells in the bone marrow, hair follicles, and cells lining the mouth, digestive tract, and reproductive system. Chemotherapy can also cause damage to nerves.
Chemotherapy is given in cycles, each lasting a few weeks, followed by a period of rest. Many patients experience some side effects, both short- and long-term, but others experience very few. Each person’s experience with chemotherapy is unique.
More common short-term side effects may include:
- Fatigue (the most common side effect)
- Alopecia
- Anemia
- Nausea and vomiting
- Appetite changes
- Constipation
- Diarrhea
- Mouth, tongue, and throat sores (mucositis)
- Urine and bladder changes
- Mood changes
Long-term side effects are less common and may include:
- Peripheral neuropathy
- Skin and nail changes
- Increased risk of dental problems
- Increased risk for cardiac problems
- Lung damage in those who also received radiation, smoke, or have a history of lung disease
- Weight changes
- Changes in libido and sexual function
- Fertility issues
(ACS, 2020b)
Most types of pain improve or disappear between treatments, but nerve damage often worsens with each dose of chemotherapy. It can take months or years for nerve damage to improve or disappear, and in some people, it never completely disappears (ASCO, 2019).
Systemic Radiopharmaceuticals
Systemic radiopharmaceuticals, or radionuclides, are liquid drugs administered orally or intravenously. They travel throughout the body and collect in places where cancer cells are located. This allows for delivery of radiation doses exactly to the tumor or cancer cells.
One such drug, radium Ra 223 dichloride (Xofigo), is approved by the FDA for men whose prostate cancer has metastasized to bones but not to other organs and that has not responded to other treatments. Xofigo has been found to improve pain-related quality of life and to reduce the risk for or delay the time before it becomes necessary to use opioids and before the first skeletal event.
Adverse reactions to Xofigo can include:
- Pancytopenia due to bone marrow suppression
- Nausea
- Diarrhea
- Vomiting
- Peripheral edema
- Renal impairment and failure
- Increased risk of bleeding or infection
(ACS, 2019b; Weaver, 2021)