Prostate Cancer

There are several approaches to prostate cancer treatment. At Siteman Cancer Center, our WashU Medicine physicians build a custom treatment plan for each patient. These plans draw upon the latest research and the most advanced therapies available. 

Sometimes, our experts determine that careful monitoring is preferable to immediate treatment. This approach, known as active surveillance, allows patients to maintain their normal quality of life while physicians closely track any signs of cancer progression through regular tests. 

Treatments We Offer 

The standard treatments for prostate cancer our physicians at Siteman Cancer Center offer include: 

• Active surveillance 
• Watch and wait 
• Focal therapy 
• Surgery 
• Systemic therapy 
• Radiation therapy 
• Theranostics 

Active Surveillance

Active surveillance means watching a low-grade and non-aggressive prostate cancer instead of pursuing treatment right away. Doctors can safely watch many prostate cancers that they catch early with PSA screening. With careful monitoring, they will not cause the patient any pain or impact his quality of life. 

In other words, what this means is that the patient has prostate cancer but is not issued a treatment plan, sparing the patient the harsh side effects of cancer therapies without reducing their lifespan. 

Before choosing active surveillance, it’s crucial that you undergo testing to ensure that your cancer is safe to track. Research led by WashU Medicine urologists at Siteman has shown that active surveillance is safe for many patients with low-risk prostate cancer. 

If you and your physician decide that active surveillance is right for you, you’ll meet with your care team regularly to ensure your cancer hasn’t changed. Tests and procedures you may need to have done include a digital rectal exam, PSA blood test, ultrasound or MRI, or prostate biopsy. 

Watchful Waiting – or Watch and Wait

Similar to active surveillance, watchful waiting (also referred to as watch and wait) involves watching low-grade and non-aggressive prostate cancers. However, watchful waiting is a less intensive way of observation with fewer tests. A patient reporting a change in symptoms guides the determination of whether they need treatment. 

Doctors may consider watchful waiting a good option for slow-growing prostate cancers that don’t cause symptoms and remain contained to the prostate. It can be a good option for older patients who are not eligible for other treatment options or are already near the end of life. 

The goal of this approach is to keep the patient comfortable while sparing them the side effects of cancer treatment. If the cancer spreads or starts to cause symptoms down the road, the patient may then decide to pursue treatment. 

Focal Therapy

Focal therapy is an innovative approach to treating prostate cancer that destroys the tumor within the prostate. However, since researchers are still exploring this area, not all prostate cancers can be safely treated with focal therapy. 

We do know that high-quality imaging is key to reducing tumor growth. Surgeons use MRI scans or other imaging tests to first visualize tumors, then use various forms of energy to destroy them. Surgeons may order cryoablation (freezing), laser ablation, or high-intensity frequency ultrasounds (HIFU) to destroy cancer cells without harming the prostate. 

Since focal therapy can carefully remove cancer without harming the rest of the prostate gland, there is a reduced risk of urinary or sexual side effects. 

Surgery

There are two main surgical procedures that treat prostate cancer: 

• Radical prostatectomy: removal of the prostate gland 
• Transurethral resection of the prostate: removal of a portion of prostate tissue. Patients might undergo this procedure as part of a broader treatment program. 

WashU Medicine surgeons at Siteman Cancer Center only recommend surgery for prostate cancer when it’s absolutely necessary. They use minimally invasive methods whenever possible to reduce the risk of side effects. 

Our physicians also conduct clinical trials that involve using immunotherapy or advanced hormone therapy to shrink prostate tumors before proceeding to surgery. Don’t hesitate to ask your care team if there are any clinical trials available that could make surgery easier for you. 

Radical prostatectomy

During this prostate surgery, the surgeon removes the whole prostate gland, along with surrounding tissue, seminal vesicles, and sometimes nearby lymph nodes. Doctors perform this procedure when the cancer is confined to the prostate. 

Long-term data on radical prostatectomies demonstrate that this deepens remission in the majority of patients whose cancer has not spread. 

Although doctors performed this surgery in an open fashion in the past, we now perform it either laparoscopically or robotically. These minimally invasive approaches have dramatically reduced the pain and recovery time after surgery.   

What is a transurethral resection of the prostate?

Surgeons perform this prostate surgery through the urethra using a tube called a resectoscope to remove prostate tissue. Doctors usually perform it for benign prostatic hyperplasia (BPH), a non-cancerous enlarged prostate. It can also relieve symptoms caused by a cancerous tumor before or after other treatments. 

What are the side effects of prostate cancer surgery?

Many quality-of-life side effects, including changes in urinary and sexual function, are associated with prostate cancer treatment. Although the high-caliber urologic surgeons at Siteman have a lower rate of these side effects in patients they treat, every patient will, at a minimum, endure temporary changes in these domains. 

Urologists at WashU Medicine are not only experts in prostate cancer treatment, but also experts in urologic reconstruction. We have experts who can manage your urinary and sexual function side effects successfully so that your long-term quality of life will not suffer. 

Systemic Therapy for Prostate Cancer

Systemic therapies are a group of treatments that target cancer cells in the prostate. They can also eliminate cancer cells that have spread to other areas of the body, like the bones or lymph nodes. In general, systemic therapy for prostate cancer treats later-stage or metastatic disease. 

Patients might ingest systemic therapies as pills — or they can receive them through an IV or injection. 

WashU Medicine physicians at Siteman use newer drugs, such as new hormonal and immunotherapies, to fight prostate cancer. Some of these therapies stop cancer cells from spreading through new tissues or forming new blood vessels. They also pioneer studies of effective systemic therapy for patients with advanced prostate cancer. 

There are three main types of systemic therapy for prostate cancer: 

• Hormone therapy 
• Chemotherapy 
• Immunotherapy 

Given the rapidly evolving landscape of treatment for advanced prostate cancer, you are in expert hands at Siteman. Our WashU Medicine prostate cancer specialists are knowledgeable about the latest developments in systemic therapy. They are also actively investigating future advances through research studies. 

For patients looking for experimental approaches when standard therapy hasn’t been successful, Siteman also offers a range of clinical trials. 

Hormone therapy

Prostate cancer growth depends on androgens, which include the male sex hormones testosterone and dihydrotestosterone. Hormone therapy prevents prostate cancer cells from obtaining androgens, either by limiting the production of androgens or making it impossible for androgens to attach to the cancer cells. This slows or halts the progression of prostate cancer. 

For patients who have metastatic prostate cancer, or whose prostate cancer has come back after surgery and/or radiation, hormone therapy is the standard of care. 

Doctors may give hormone therapies in different combinations, depending on the stage of the cancer and the health of the patient. Researchers are always testing new combinations of therapies in clinical trials, and Siteman may offer them before many other treatment facilities gain access. 

Prostate cancer patients may receive hormone therapy in pill form or as injections. Most people tolerate it well, but some experience side effects, such as mood swings and hot flashes, which people have called “male menopause.” If necessary, your physician can prescribe extra medication to relieve these symptoms. 

Chemotherapy

Doctors will prescribe chemotherapy for some cases of advanced prostate cancer. Only two chemotherapy drugs have received approval to treat it – docetaxel (Taxotere) and cabazitaxel (Jevtena). This does not include other types of systemic therapy drugs for prostate cancer approved by the FDA.   

Immunotherapy

Doctors can use immunotherapy for patients who do not respond to chemotherapy or other types of systemic therapies. This advanced form of treatment uses the body’s immune system to destroy prostate cancer cells. 

For prostate cancer, immunotherapy is advancing for patients diagnosed with an advanced stage of the disease – and physicians and researchers at Siteman are leading those breakthroughs. 

Radiation Therapy for Prostate Cancer

Radiation oncologists may deliver radiation to the prostate with the intent of eliminating cancer. Your care team may decide to pursue this treatment instead of surgery. 

Doctors can treat some patients with low-grade disease using radiation alone, often with shorter courses and fewer appointments. They can also give it to relieve cancer symptoms. 

The radiation therapy options available to patients at Siteman include: 

• Intensity-modulated radiation therapy (IMRT) 
• Stereotactic body radiotherapy (SBRT)  
• Brachytherapy, given as low-dose-rate (LDR) or high-dose-rate (HDR) 
• Proton beam therapy 
• Radiopharmaceutical treatments including Xofigo (radium-223) and Pluvicto (Lutetia 177)  

If you receive radiation at Siteman, your doctors strive to ensure that your treatment is safe and effective. The radiation oncology team from WashU Medicine has developed new methods to target prostate cancer without harming nearby healthy tissue. 

Radiation therapy uses energy to attack prostate cancer cells. It can sometimes cure early-stage prostate cancer, sparing patients a prostatectomy. Patients may also receive radiation after surgery to prevent the cancer from recurring. It’s often delivered over multiple treatment sessions. 

As a prostate cancer patient at Siteman, you can take comfort in knowing that the internationally recognized team at WashU Medicine affiliates with your radiation oncology team. Our radiation oncology specialists are leaders in tailoring radiation therapy to each patient’s needs. 

WashU Medicine physicians use innovative, high-tech methods to target the tumor while protecting surrounding tissues. They also work to limit the number of radiation sessions, meaning that they achieve optimal results while reducing the treatment burden on their patients. 

External-beam radiation therapy treats prostate cancer with X-ray beams. The treatment is painless and only lasts for a few minutes at a time. 

WashU Medicine radiation oncologists at Siteman were among the first in the U.S. to deliver external-beam radiation using intensity-modulated radiation therapy (IMRT). This technique enhances the delivery of high doses of radiation. In addition, they also use advanced imaging methods such as MRI and PET scans – a technique known as adaptive radiation therapy (ART) – to focus treatment on the prostate. In turn, this reduces radiation exposure to the adjacent bladder and rectum. 

For patients whose cancer comes back after prior radical prostate surgery, radiation therapy can be an effective treatment. If the patient has had a prostatectomy, radiation targets the space where the prostate used to be. 

Brachytherapy

Brachytherapy is a therapy that implants a radioactive source within the body. There are two different types of brachytherapy: low-dose rate (LDR) and high-dose rate (HDR). 

Low dose rate brachytherapy

In low dose rate brachytherapy (LDR), the radiation oncologist places tiny radioactive seeds in the prostate. These seeds emit a steady dose of radiation for several weeks and then remain permanently – and harmlessly – in place. Siteman was the first medical center in the region to perform radioactive seed implantation for prostate cancer. 

High-dose-rate brachytherapy

High dose rate brachytherapy (HDR) involves temporarily placing a single radioactive source in the prostate using catheters. Radiation oncologists carefully control the time and position of the radioactive source to maximize the dose to the prostate and minimize the dose to the urethra, rectum, and bladder. 

A typical one-day procedure of HDR will go through the following phases: 

• First, the radiation oncologist inserts the catheters in the morning in the operating room with the patient under general anesthesia. 
• The CT scan shows the radiation oncologist where to target the treatment for the patient. 
• The patient takes a combination of a long-acting local anesthetic and other medications to stay comfortable until treatment delivery. 
• Later that afternoon, oncologists will deliver the targeted treatment in less than 15 minutes. 
• Finally, the radiation oncologist removes the catheters. 
• Patients go home the same day and are not radioactive. 

Doctors can use HDR brachytherapy alone to treat low-risk patients. It can also serve as a boost for higher-risk patients receiving external beam radiotherapy. Sometimes, radiation oncologists will recommend HDR brachytherapy to undo damage from LDR brachytherapy or external beam radiotherapy. 

Since opening in 2014, over 200 patients have received this treatment at Siteman Cancer Center. Ours was the first medical center in the region to perform HDR brachytherapy for prostate cancer. 

Proton beam therapy

Proton beam therapy eliminates cancer cells with protons instead of X-ray beams. The main advantage of this treatment is that doctors can adjust the proton beam to specific depths, allowing it to stop at its target instead of passing through the entire body like other radiation treatments do. 

Doctors may use proton therapy alone or in combination with other radiation therapies and/or hormone therapy. Your physician will determine if you are an appropriate candidate for proton therapy and if you are eligible for any clinical trials. 

The S. Lee Kling Proton Therapy Center at Siteman Cancer Center is the only proton therapy center located in Missouri and the surrounding region. It houses the world’s first compact proton beam accelerator. Radiation oncologists and physicists here helped evaluate the system and developed the patient protocols as well as the quality standards for this advanced technology. 

Theranostics for Prostate Cancer 

Theranostics is the combination of diagnosis and therapy using radiopharmaceuticals to image and provide radioactive targeted therapy. Theranostics is an approach used in several cancer types, including prostate cancer, neuroendocrine tumors, and differentiated thyroid cancers, among others. 

Theranostics’ targeted approach to cancer care combines:  

• high-resolution imaging from positron emission tomography (PET) or single photon emission computed tomography (SPECT) with a 
• highly specialized, radioactive, cancer-specific pharmaceutical, called a “radiopharmaceutical.”

Who is eligible for theranostics?

Theranostics works well for a few different cancer types, including advanced stages of prostate cancer. The term “theranostics” blends diagnostics and therapeutics. This cancer treatment uses radiopharmaceuticals to first image the cancer. Then, it delivers targeted therapy tailored to a person’s specific cancer growth.  

WashU Medicine physicians in the Division of Nuclear Medicine and Department of Radiation Oncology will assess whether the specific radiopharmaceutical used in theranostics is a good treatment option for a patient with prostate cancer. Unlike external beam radiation therapy, the targeted radiopharmaceutical therapy delivers short-range beta or alpha particles directly to the tumor. 

To see if a patient is eligible for theranostics, oncologists look for the presence (or absence) of a specific target on their cancer cells through specialized imaging, such as a positron emission tomography (PET) scan. If PET imaging shows enough targets on the cancer cells, then the radiopharmaceutical will be able to attach and deliver a high radiation dose to the cancerous tissue. 

What radiopharmaceuticals are used in treating prostate cancer?  

Currently, doctors are using two pharmaceuticals at different stages of prostate cancer: Pluvicto (also called Lu-177 PSMA) and Xofigo (also called Ra-223). A healthcare professional delivers both drugs through an IV. 

As part of the therapy, the medical team will image the patient using single photon emission computed tomography (SPECT) scans to confirm that the therapy has reached the cancer cells.   

Effects of Prostate Cancer Treatment 

Cancer treatment focuses on positive outcomes, such as removing cancer cells, reducing tumor size, preventing recurrence, and improving survivability. However, many of these treatments can take a toll on patients. Knowing what to expect can help you make treatment decisions and get the support you need to deal with the side effects of treatment for prostate cancer. 

What follows is not an exhaustive list but covers some of the more common side effects most patients report. It’s important to tell your physician during treatment about any unexpected symptoms that come up. Oftentimes, they have interventions they can prescribe to help you maintain comfort and your quality of life. 

Side effects of hormone therapy for prostate cancer 

• Short term: Impotence and hot flashes 
• Intermediate: Metabolic syndrome (increased cholesterol and triglycerides, higher body fat and depression) 
• Long term: Accelerated osteoporosis, increased risk of diabetes and cardiac toxicity 

Side effects of chemotherapy for prostate cancer

• Low blood counts: 70% of patients who undergo chemotherapy have lower blood counts, increasing the risk for infection or anemia. Physicians help you manage these through active surveillance. 
• Nausea and vomiting: This side effect is very rare in prostate cancer treatment. If it does appear, our prostate cancer specialists have considerable experience managing this side effect so cancer therapy can continue, and you can live your normal life. 
• Peripheral neuropathy: Chemotherapy-induced peripheral neuropathy (CIPN) is a set of symptoms that can occur following damage to the nerves that control the sensation in your arms and legs. 
• Sleep disorders: Cancer, pain or certain drugs and treatments may disturb your sleep. 

Depending on the type of chemotherapy, other side effects may apply. Your doctor should have information sheets available on the most common side effects for your specific drug. They will have recommendations on how to manage these symptoms or will prescribe medications that can help.

Cardiotoxicity 

Physicians at WashU Medicine are ready to help if patients need intervention, even though patients who undergo prostate cancer treatment experience fewer cardiac issues.

Cardio-oncology is a newer medical discipline that focuses on optimally treating any associated heart conditions in patients who have received or are currently receiving cancer treatment – also known as cardiotoxicity. These subspecialized cardiologists assess patients for the potential risk of developing certain heart conditions, especially if they are receiving certain cancer drugs known to effect the heart or following radiation treatment to the chest.

Button: Learn more about cardio-oncology at Siteman