Diagnosed with prostate cancer? Know your treatment options

For those facing a prostate cancer diagnosis, it can be confusing to know which treatment path to follow. Should you get surgery to remove your prostate? What about radiation or chemotherapy?

Although prostate cancer is the most common non-skin cancer in men, it’s often slow-growing and doesn’t require treatment if it’s caught early. And for those who need surgery or radiation, treatment is usually successful. The overall five-year survival rate is 90 percent.

“Our understanding of prostate cancer has improved over the past few decades,” says Patrick Murray, MD, a urologist for MultiCare Health System. “We used to routinely perform surgery on low-risk prostate cancer, but now we know it can be monitored safely without an invasive procedure.”

Research has shown that overtreating in the early stages of the disease can unnecessarily lead to urinary issues and sexual dysfunction.

That’s why it’s key to work with your doctor or other health care provider and learn what options are available based on risk, age and overall health — and together decide which treatment is right for you.

Determining risk of spread

If prostate cancer has been diagnosed, urologists use a standard grading system called the Gleason score to determine the risk of the cancer spreading to other parts of the body. Low-risk is 6 or below; medium-risk is about 7; and high-risk is 8 or above.

In addition to the Gleason score, the prostate-specific antigen (PSA) test and cancer stage are also important factors in determining risk of spread. A PSA below 10 is considered low-risk, 10-20 is medium-risk and greater than 20 is high-risk.

Cancer stages are an assessment of the amount of cancer in the body. Like all other types of cancer, prostate cancer has four stages. Stage 1 means the cancer is confined to the prostate; stages 2 and 3 indicate prostate cancer has moved outside the prostate gland but is confined to the pelvis; and stage 4 means it has spread throughout the body.

Low-risk prostate cancer

Those with low-risk prostate cancer are ideal candidates for “active surveillance” — where patients work closely with their provider to monitor the cancer and hold off on treatment unless it progresses. This watch-and-wait method has become increasingly common, especially in the last five to 10 years. In fact, a recent study shows the percentage of patients who choose active surveillance increased from about 30 percent in 2014 to nearly 60 percent in 2021.

“Although we are postponing surgery for most low-risk prostate cancers now, it remains important to diagnose it early so we can monitor it closely and proceed to treatment if the cancer progresses,” says Dr. Murray.

Intermediate and high-risk prostate cancer

If the Gleason score is 7 or higher and/or the PSA is above 10, the cancer has a greater chance of growing or spreading. At this stage, surgery or radiation is typically recommended. Chemotherapy is not needed unless the cancer is in a late stage.

MultiCare urologist Richard N. Greene Jr., MD, says surgery is usually reserved for healthier, more active patients, and radiation for older, less healthy ones.

However, he adds, “It is important to have a shared decision-making visit with your urologist to determine which treatment is best for you.”

If surgery to remove the prostate is recommended, robotic-assisted surgery is a minimally invasive approach that has become the standard of care — approximately 98 percent of all prostate surgeries are performed this way. The techniques used in robotic-assisted prostate cancer surgery allow urologists to remove the cancer while bypassing nerves linked to sexual function and bladder control. This reduces the chances of problems during sex and/or urinary incontinence after your procedure.

Genetics are a risk factor

Prostate cancer is rare in younger men — about 60 percent of cases occur in men over the age of 65. However, because having a family history of prostate cancer increases the risk of developing the disease, it’s important to encourage brothers, sons or grandsons of patients who have prostate cancer to have a conversation with their doctor or other health care provider about when to start screening. In addition, African Americans have a higher risk of developing prostate cancer.

“There is also an increasing role for genetic screening in families with a history of breast cancer with BRCA 2 gene mutation, as well as multiple men in the family who have had prostate cancer,” explains Dr. Greene. “Earlier screening and treatment may be required for some men with these inherited conditions.”

Based on risk, here are guidelines for when to start screening for prostate cancer:

• If you are at average risk and between the ages of 55-70: Talk to your primary care physician about PSA screening.
• If you are high-risk (African American or have a close relative who has had prostate cancer): Start the conversation as early as 40.
• If you are older than 70: Talk to your provider about whether screening is necessary. Prostate cancer is generally so slow-growing that PSA screening for older men may not be useful.

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