Initial treatment of prostate cancer, by stage

The stage of your cancer is one of the most important factors in choosing the best way to treat it. Prostate cancer is staged based on the extent of the cancer (using T, N, and M categories) and the PSA level and Gleason score at the time of diagnosis.

But other factors, such as your age, overall health, life expectancy, and personal preferences should also be taken into account when looking at treatment options. In fact, many doctors determine a man’s possible treatment options based not just on the stage, but on the risk of cancer coming back (recurrence) after the initial treatment and on the man’s life expectancy.

You might want to ask your doctor what factors he or she is considering when discussing your treatment options. Some doctors might recommend options that are different from those listed here.

Stage I

These prostate cancers are small (T1 or T2a) and have not grown outside the prostate. They have low Gleason scores (6 or less) and low PSA levels (less than 10). They usually grow very slowly and may never cause any symptoms or other health problems.

For men without any prostate cancer symptoms who are elderly and/or have other serious health problems that may limit their lifespan, watchful waiting or active surveillance is often recommended. For men who wish to start treatment, radiation therapy (external beam or brachytherapy) or radical prostatectomy may be options.

Men who are younger and healthy may consider active surveillance (knowing that they may need to be treated later on), radical prostatectomy, or radiation therapy (external beam or brachytherapy).

Stage II

Stage II cancers have not yet grown outside of the prostate, but are larger, have higher Gleason scores, and/or have higher PSA levels than stage I cancers. Stage II cancers that are not treated with surgery or radiation are more likely than stage I cancers to eventually spread beyond the prostate and cause symptoms.

As with stage I cancers, active surveillance is often a good option for men whose cancer is not causing any symptoms and who are elderly and/or have other serious health problems. Radical prostatectomy and radiation therapy (external beam or brachytherapy) may also be appropriate options.

Treatment options for men who are younger and otherwise healthy might include:

• Radical prostatectomy (often with removal of the pelvic lymph nodes). This may be followed by external beam radiation if your cancer is found to have spread beyond the prostate at the time of surgery, or if the PSA level is still detectable a few months after surgery.
• External beam radiation only*
• Brachytherapy only*
• Brachytherapy and external beam radiation combined*
• Taking part in a clinical trial of newer treatments

*All of the radiation options may be combined with several months of hormone therapy if there is a greater chance of cancer recurrence based on PSA level and/or Gleason score.

Stage III

Stage III cancers have grown outside the prostate but have not reached the bladder or rectum (T3). They have not spread to lymph nodes or distant organs. These cancers are more likely to come back after treatment than earlier stage tumors.

Treatment options at this stage may include:

• External beam radiation plus hormone therapy
• External beam radiation plus brachytherapy, possibly with a short course of hormone therapy
• Radical prostatectomy in selected cases (often with removal of the pelvic lymph nodes). This may be followed by radiation therapy.

Men who are older or who have other medical problems may choose less aggressive treatment such as hormone therapy (by itself) or even active surveillance.

Taking part in a clinical trial of newer treatments is also an option for many men with stage III prostate cancer.

Stage IV

Stage IVcancers have already spread to nearby areas such as the bladder or rectum (T4), to nearby lymph nodes, or to distant organs such as the bones. A small portion of T4 cancers may be curable using some of the same treatments for stage III cancers. Most stage IV cancers can’t be cured, but are treatable. The goals of treatment are to keep the cancer under control for as long as possible and to improve a man’s quality of life.

Initial treatment options may include:

• Hormone therapy, possibly along with chemotherapy
• External beam radiation (sometimes combined with brachytherapy), plus hormone therapy
• Radical prostatectomy in selected patients whose cancer has not spread to the lymph nodes or other parts of the body. This might be followed by external radiation therapy.
• Surgery (TURP) to relieve symptoms such as bleeding or urinary obstruction
• Treatments aimed at bone metastases, such as denosumab (Xgeva), a bisphosphonate like zoledronic acid (Zometa), external radiation aimed at bones, or a radiopharmaceutical such as strontium-89, samarium-153 or radium-223
• Active surveillance (for those who are older or have other serious health issues and do not have major symptoms from the cancer)
• Taking part in a clinical trial of newer treatments

Treatment of stage IV prostate cancer may also include treatments to help prevent or relieve symptoms such as pain.

The options above are for the initial treatment of prostate cancer at different stages. But if these treatments aren’t working (the cancer continues to grow and spread) or if the cancer comes back, other treatments might be used (see Treating prostate cancer that doesn’t go away or comes back after treatment).