Treatment by stage

Discussion entre un urologue et un homme sur les traitements du cancer de la prostate

Stage I

Localized prostate cancer

stade 1 cancer prostate

A tumour is localized only within the prostate. The type of treatment you are given is based on your individual needs.

Active surveillance

Surgery

  • Radical prostatectomy

Radiation therapy

  • External
  • Permanent brachytherapy (low-dose internal radiation therapy)

Watchful waiting

Stage 2

Localized prostate cancer

stade 2 cancer prostate

The size of the tumour is larger than tumours seen at stage 1, but is still confined to the prostate. The type of treatment you are given is based on your individual needs.

Surgery

  • Radical prostatectomy
  • Pelvic lymph node dissection (pelvic lymphadenectomy)

Radiation therapy

  • External beam adjuvant (after surgery)
  • External beam with (or without) hormone therapy
  • External beam with temporary brachytherapy (high dose)
  • Permanent brachytherapy (low dose)

Hormone therapy

  • Only for cases of intermediate- or high-risk cancer that cannot be treated with radiation therapy or surgery.
  • Before, during, or after radiation therapy (1 to 3 years)

Active surveillance

Watchful waiting

Clinical trials

Stage 3

Locally advanced prostate cancer

stade 3 cancer prostate

The tumour has spread beyond the prostate, but has not spread to the organs or neighbouring lymph nodes. The type of treatment you are given is based on your individual needs.

Radiation therapy

  • External beam with (or without) hormone therapy
  • External beam adjuvant (after surgery)
  • External beam with temporary brachytherapy (high dose)

Hormone therapy

  • Alone as a primary treatment for men who cannot have radiation therapy or surgery
  • Before, during, or after radiation therapy (1 to 3 years)
  • In combination with surgery, followed by radiation therapy

Surgery

  • Radical prostatectomy in combination with radiation therapy
  • Transurethral resection of the prostate (TURP)
    • To relieve urinary symptoms caused by the tumour
    • Sometimes done before starting radiation therapy or hormonal therapy

Watchful waiting

Clinical trials

Stage 4

Advanced prostate cancer

stade 4 cancer prostate

The tumour has spread to neighbouring organs, lymph nodes, or other parts of your body far from your prostate. The type of treatment you are given is based on your individual needs.

Hormone therapy – medical or surgical

  • Alone as the principal treatment for men with advanced prostate cancer or who cannot undergo radiation therapy or surgery.
  • Before, during, or after radiation therapy
  • In combination with chemotherapy (in trials)
  • Surgical removal of testicles (orchiectomy)

Chemotherapy

  • Given when the patient no longer responds to hormone therapy
  • In combination with hormone therapy (in trials)

Radiation therapy

  • External beam with (or without) hormone therapy
  • To relieve bone pain (bone metastases)

Surgery

  • Radical prostatectomy in combination with radiotherapy
  • Transurethral resection of the prostate (TURP)
    • To relieve urinary symptoms caused by the tumour
    • Sometimes done before starting radiation therapy or hormonal therapy

Biological therapy

  • Helps to prevent bone fractures
  • Helps to prevent cancer from spreading to the bones

Bisphosphonates

  • Relieves bone pain
  • Helps to prevent bone fractures in men with hormone resistant cancer

Watchful waiting

Clinical trials

Recurrent or resistant

With or without metastasis

metastase cancer prostate

A recurrence corresponds to a cancer that returns after radical prostatectomy or radiotherapy – whether or not these treatments have been associated with hormone therapy. This recurrence is considered an advanced cancer. The types of treatments administered are based on your needs only.

Hormone therapy – medical or surgical

  • Alone as the principal treatment for men with advanced prostate cancer or who cannot undergo radiation therapy or surgery.
  • Before, during, or after radiation therapy
  • In combination with chemotherapy (in trials)
  • Surgical removal of testicles (orchiectomy)

Chemotherapy

  • Given when the patient no longer responds to hormone therapy
  • In combination with hormone therapy (in trials)

Radiation therapy

  • External beam with (or without) hormone therapy
  • To relieve bone pain (bone metastases)

Surgery

  • Radical prostatectomy in combination with radiotherapy
  • Transurethral resection of the prostate (TURP)
    • To relieve urinary symptoms caused by the tumour
    • Sometimes done before starting radiation therapy or hormonal therapy

Biological therapy

  • Helps to prevent bone fractures
  • Helps to prevent cancer from spreading to the bones

Bisphosphonates

  • Relieves bone pain
  • Helps to prevent bone fractures in men with hormone resistant cancer

Watchful waiting

Clinical trials

Case studies

discussion traitement cancer prostate

Frank, 63 years old

Occupation: Retired accountant

Frank is retired and in good health. He keeps busy with leisure activities, sports, volunteer works, and his grandchildren. He has always been concerned with good nutrition and watches what he eats.

During a routine examination, his doctor detected a lump extending beyond the prostate and found his PSA level to be 23.0 ng/mL, five times higher than normal. A TRUS revealed a suspicious abnormality that appeared to extend beyond the capsule (envelope surrounding the prostate). Several biopsies were done in this area, and the pathologist determined that Frank has a grad 4+5 (score of 9) cancer. Frank underwent a lymphadenectomy of the pelvic nodes that showed the cancer had spread to his lymph nodes. The bone scan was normal.

What’s going on? Frank has fairly advanced prostate cancer that has spread to the pelvic lymph nodes (N1) but not yet to the bones (M0). It is now up to him and his doctor to choose the appropriate treatment. The chance of cure is low, but if Frank responds well to treatment he may live many years with a good quality of life.

Charles, 50 years old

Occupation: Businessman

Charles works 40 hours a week, plays golf, and jogs. During his last annual check-up, his doctor performed a digital rectal exam (DRE), and everything seemed normal. However, his PSA test results were a little high at 5.0 ng/mL.

The doctor carried out a transrectal ultrasound (TRUS), found no abnormalities, and collected some samples for biopsy. The pathologist determined that the prostate contained cancerous cells scoring 6 (grades 3 + 3) on the Gleason scale. Additional examinations came up negative.

What does it all mean? While the DRE and the TRUS showed nothing, Charles does have cancer, although it is not very advanced. After a radical prostatectomy, the pathological tissue analysis showed that the cancer remained within the prostate (T2) and had not yet spread to the pelvic lymph nodes (N0) or bones (M0).

Charles has a very good chance of being cured and will likely not require other treatment.

Louis, 64 years old

Occupation: Foreman in a paper-pulp mill

Louis’ prostate cancer scores 6 (3 + 3+) on the Gleason scale and his PSA tests 8 ng/mL. According to the Albertsen life tables analysis, there is a 68 percent risk that he will die within the next 15 years and a 23 percent chance that this will be due to prostate cancer; therefore, his chance of dying from other causes within this period is 45 percent. In other words, Louis is twice as likely to die of a cause other than prostate cancer sometime over the next 15 years.

The doctor suggests Louis opt for active surveillance instead of immediate treatment, with its possible side effects. Louis doesn’t agree, however; he cannot imagine living with the sword of Damocles hanging over his head and insists on treatment.

The doctor proposes surgery or radiation therapy, explaining the advantages and drawbacks of both. The doctor also uses the Kattan nomograms to calculate the risk of recurrence.

Larry, 67 years old

Occupation: Sales representative

Larry plans to retire next year, buy a sailboat, and travel the South Seas with his wife. Suddenly, his doctor informs him that he has localized prostate cancer, although it does not appear to be too aggressive.

The tumour is at stage T1 and scores 6 (grades 3 + 3) on the Gleason scale, and his PSA level is 5. The doctor presents the three treatment options—active surveillance, radical prostatectomy, and radiation therapy—explaining the benefits and drawbacks of each.

Larry is unsure. He takes his time to think about it, eventually deciding on active surveillance. Because it is likely that his cancer will progress slowly, he prefers to postpone treatment and enjoy his long-anticipated trip. He will see his doctor as soon as he gets back.

William, 71 years old

Occupation: Retired accountant

William is still alert and in good shape, with no known medical conditions other than localized prostate cancer that is at stage T2 and scores 7 (3 + 4) on the Gleason scale. William’s PSA level is 10.

Relating his family history, William mentions that his parents died at the ages of 98 and 99. The doctor determines that William probably has a similar life expectancy and presents the three treatment options—active surveillance, radical prostatectomy, and radiation therapy—explaining the benefits and drawbacks of each.

William opts for radical prostatectomy to maximize his chances of long-term recovery.

John, 67 years old

Occupation: Retired math teacher

John is 67 years old and divorced. The doctor informs him that he is suffering from prostate cancer with a stage T2 tumour scoring 6 (3 + 3) on the Gleason scale and PSA testing at 8 ng/mL. According to the Partin table analysis, there is a 44 percent chance the cancer has extended beyond the prostate, but only a 3 percent risk it has affected the seminal vesicles and a 2 percent chance it has spread to the pelvic nodes.

John is told that because the risk that the cancer has spread is quite high, he might need other treatments in addition to surgery. The doctor also informs him that the nodes will not be removed, since there is such a low risk that they are affected.

The Kattan nomograms are then used to calculate the risk of recurrence after five years, and John learns he has an 85 percent chance of being cured with surgery as his only treatment.

Eric, 73 years old

Occupation: Retired journalist

Eric has had a coronary bypass surgery. His cancer seems fairly aggressive at stage T2 and scoring 8 (grades 4 + 4) on the Gleason scale. His PSA level is 20. Eric wants a treatment that will help control his disease and give3 him hope for recovery.

Given his age and history of heart disease, he and his doctor choose radiation therapy rather than surgery. Adding hormone therapy to radiation for two or three years will help him control the disease better in the long term and increase his chances of survival.

Michael, 56 years old

Occupation: Mail carrier

Michael is in excellent shape. However, he recently discovered that he has relatively aggressive localized prostate cancer that is at stage T1 and scores 7 (grades 3 + 4) on the Gleason scale. His PSA level is 9.

Michael’s doctor suggests radical prostatectomy, adding that he may also need radiation therapy depending on what is discovered during the operation.

Paul doesn’t hesitate. He is about to become a grandfather for the first time, and he wants to see his grandchildren grow up. He is aware of the side effects and complications of treatment but reckons they are a small price to pay for being able to continue enjoying his family in the years to come.

Richard, 55 years old

Occupation: Electrician

Richard is married and works for a large company as an electrician. His cancer scores 8 (grades 4 + 4) on the Gleason scale. He has a stage T3 tumour and a PSA level of 15 ng/mL. Partin table analysis indicates there is only a 6 percent chance the cancer is still confined to the prostate and a 26 percent chance it has spread to the pelvic nodes.

Richard begins to think about radiation therapy. Before going any further, however, the doctor decides to perform a pelvic lymphadenectomy to analyze the nodes, since the chance they are affected is relatively high. The pathologist discovers metastasis has indeed occurred. According to the Kattan nomograms, there is an 85 percent risk the cancer will recur within the next five years.

Given the lymph nodes metastasis, radiation therapy or surgery alone are unlikely to cure the cancer. Richard and the doctor opt for hormone therapy in addition to radiation therapy to control the disease throughout the entire body.

Richard can increase his chances of survival significantly by beginning hormone therapy early, before bone metastasis takes place.

Robert, 67 years old

Occupation: Volunteer chauffeur

Robert was diagnosed with prostate cancer three years ago. At that time, the cancer had spread to his bones. He was prescribed an LH-RH analog (hormone therapy) and did well until a few months ago, with his PSA dropping from 150 at the time of diagnosis to 1. Six months ago, his PSA began to rise, and he developed intense pain in his hip and lower spine.

He received radiation therapy and zoledronic acid, and these relieved most of the pain in his hip. He then began chemotherapy with docetaxel (Taxotere) every three weeks at the outpatient oncology clinic. His PSA dropped from 50 to 2.5.

He felt much better and his pain disappeared completely. Apart from hair loss, he tolerated the chemotherapy quite well. It has now been three months since he finished his chemotherapy, and he complains of some recurrence of pain in his lower back. In addition, his PSA has gone up to 30. Otherwise, he is feeling very well.

His options were discussed with him. Since he is feeling healthy and had a good experience with previous chemotherapy, he has decided to begin cabazitaxel (Jevtana), to be administered every three weeks. He remains optimistic, continues to eat as well as possible, and stays active. He is well aware that a cure is not possible, but he is encouraged by the positive results reported with cabazitaxel. He knows that abiraterone is another option if needed in the future, as is MDV3100.

He is also aware that he could have access to new therapies by participating in ongoing clinical research. Given the new therapies available, he is optimistically looking forward to being present for his grandson’s birth in six months.

Drugs used

Treatments can be given to cure cancer or to control or relieve symptoms. You may receive a single treatment or a combination of treatments based on your individual preferences / values and depending on the grade and stage of your cancer (i.e. how far the cancer has spread and how fast it can grow).

This section provides you with information on drugs to treat prostate cancer that are currently approved by Health Canada. As new prostate cancer drugs are approved for use in Canada we will update our information in a timely manner.

Approuved by Health Canada

Drugs used in chemotherapy and radiotherapy

  • Cabazitaxel (Jevtana®)
  • Docétaxel (Taxotere®)
  • Mitoxantrone (Teva®)
  • Prednisone ou prednisolone
  • Dichlorure de radium 223 (Xofigo®)

Drugs used in hormone therapy

  • Abiraterone Acetate (Zytiga®)
  • Bicalutamide (Casodex®)
  • Buserelin Acetate (Suprefact®)
  • Cyproterone Acetate (Androcur®)
  • Degarelix Acetate (Firmagon®)
  • Enzalutamide (Xtandi®)
  • Flutamide (Euflex®)
  • Goserelin Acetate (Zoladex®)
  • Histrelin Acetate (Vantas®)
  • Leuprolide Acetate (Lupron®, Eligard®)
  • Triptorelin Pamoate (Trelstar®)

Drugs to treat bone metastases

  • Alendronate (Fosamax®)
  • Denosumab (Xgeva®)
  • Pamidronate (Aredia®)
  • Zoledronic Acid (Zometa®)

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