What are the treatments for prostate cancer ?

Treatment for prostate cancer depends on several factors such as clinical examination, PSA level, MRI results, number of positive biopsies, cancer classification, and stage.

There are several treatment options available which will be discussed by the medical team during a Multidisciplinary Team Meeting (MCM).

The team typically includes a radiotherapist, an oncologist, and a urological surgeon. These options will be presented to the patient by the doctor during a specific consultation known as an announcement consultation. If different treatments are proposed, it can be challenging for a patient to make a choice.

The patient may want to discuss this with trusted individuals or talk to other patients who have been treated for prostate cancer. However, each person's case and experience are different.

It may also be beneficial to seek a second medical opinion before deciding between the various treatment options.

Different types of monitoring

Active surveillance

Le premier mode de traitement consiste à ne pas faire de traitement curatif mais à faire une surveillance active du patient. En effet, dans le cas d’un cancer localisé, la maladie se développe très lentement et il est peu probable qu’elle mette en danger la vie du patient. Cette surveillance active s’adressera donc aux patients à faible risque d’évolution rapide de la maladie.

The selection criteria for patients eligible for active surveillance have been extensively studied and vary somewhat based on these studies. Similarly, the modalities of active surveillance may vary from one study to another.

They typically include regular PSA monitoring every 3 to 6 months and a digital rectal examination every 6 to 12 months. Initial follow-up biopsies are scheduled within 6 to 12 months after diagnosis and should be preceded by an MRI.

The frequency of subsequent biopsies should be adapted to each patient's risk profile. This active surveillance continues until evidence of disease progression is observed.

Watchful waiting

Another mode of surveillance without curative treatment is called "watchful waiting”.This approach is suitable for patients with initially localized cancer and a limited life expectancy due to other health issues. Palliative treatment will be offered to these patients if the disease manifests with clinical signs or becomes metastatic.

Different treatments

Radical prostatectomy

Radical prostatectomy is a standard treatment for localized or locally advanced prostate cancer. The goal of this surgery is the complete removal of the prostate and seminal vesicles while preserving structures responsible for continence and erectile function. It may be combined with the removal of lymph nodes in the pelvic area (lower abdomen).

Radiotherapy

The second curative treatment for prostate cancer is radiotherapy. This can be administered in four different modalities : external beam radiotherapy, brachytherapy, a combination of external beam and brachytherapy, or systemic radiotherapy.

External beam radiotherapy or brachytherapy is used as initial treatment for prostate cancer, to treat cancer at high risk of recurrence after surgery, or to manage recurrence after surgery. Radiotherapy can also be used for pain relief or to control symptoms of advanced-stage prostate cancer (palliative treatment).

External beam radiotherapy

External beam radiotherapy involves using a machine to emit radiation through the skin towards the tumor and surrounding tissue. The radiation gradually destroys cancer cells. Radiation oncologists administer the radiation to the smallest possible area to minimize the risk of side effects.

The pelvic lymph nodes can also be treated with external beam radiotherapy.

Brachytherapy

Brachytherapy is an internal radiation therapy where radioactive materials are implanted into or near the tumor. Brachytherapy can involve a permanent implant that emits low doses of radiation over several weeks or months (low-dose rate brachytherapy or LDR).

LDR brachytherapy is commonly used to treat early-stage prostate cancer that grows slowly and has a low risk of recurrence after treatment.

Brachytherapy can also involve a temporary implant that delivers a high dose of radiation over 1 to 4 treatments given over 2 days (high-dose rate brachytherapy or HDR). HDR brachytherapy is typically used for early-stage prostate cancer that grows rapidly and is more likely to spread.

Systemic radiotherapy

Systemic radiotherapy is another form of internal radiotherapy that uses a radioactive substance circulating in the body, targeting prostate cancer cells preferentially.

This type of radiotherapy can be used to treat cancer that recurs or does not respond to hormone therapy. It may also be used to treat metastatic cancer.

Hormone therapy

The third treatment for prostate cancer is hormone therapy. Male hormones (androgens), especially testosterone produced by the testicles, stimulate the growth of tumor cells, and hormone therapy reduces this growth by blocking these hormones.

Hormone therapy can be used to :

• Treat locally advanced or metastatic prostate cancer
• Reduce the size of a tumor before other treatments such as surgery or radiotherapy, which doctors call neoadjuvant treatment
• Treat prostate cancer after radiotherapy when there is a high risk of recurrence
• Treat prostate cancer that has recurred after treatment (recurrent cancer)

Different types of hormone therapy

The first type of hormone therapy includes drugs that mimic luteinizing hormone-releasing hormone (LHRH) and are called LHRH agonists.

This hormone is produced by the hypothalamus, located at the base of the brain. It stimulates the production of testosterone by the testicles. The first time an LHRH agonist is used, testosterone levels increase for about a week.

Therefore, the doctor will also prescribe another hormone therapy against male hormones concurrently with the LHRH agonist. After this temporary increase in testosterone levels, they will decrease because the body naturally blocks testosterone production when there is overstimulation by an LHRH agonist.

The second type of hormone therapy involves drugs that directly block LHRH, thereby blocking testosterone production (LHRH antagonists).

The third type of hormone therapy (anti-androgens) includes drugs that block the synthesis of male hormones or block the receptors for androgens. These anti-androgens prevent male hormones from acting on cancer cells that have these receptors.

The fourth type of hormone therapy involves surgically removing the testicles (orchidectomy). It is rarely used. Single hormone therapy or combinations of these therapies may be administered.

Management in case of metastatic disease

In cases of metastatic disease, chemotherapy that targets rapidly multiplying cells may be combined with hormone therapy.

Surgery, external beam radiotherapy, brachytherapy, systemic radiotherapy, hormone therapy, chemotherapy—there are numerous treatment options available for patients with prostate cancer, tailored to each individual case.

Exploring new medications…

Interestingly, new medications, novel treatment combinations, or new treatment modalities are being extensively studied in clinical trials. New hormone therapies, different chemotherapy agents, and immunotherapies are under investigation.

Among the emerging treatment modalities in clinical trials are the use of cold (cryotherapy), light-activated agents (phototherapy), laser therapy, or ultrasound to destroy cancerous tissue.

...and personalized care

Ultimately, advancements in prostate cancer treatments mean that today, these treatments are increasingly tailored to each patient. They are therefore considered "personalized" treatments. By participating in the selection of his therapeutic journey, from early detection to treatment, the prostate cancer patient has truly become an active participant in his illness.