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Diagnosis and treatment.
Have you recently been diagnosed with prostate cancer? This video is for you! When it comes to cancer, it pays to know the facts. Let’s take a closer look.

Overview

Depending on your type of prostate cancer (grade, stage, PSA rate), your age, your health status, your medical and family history, you may be able to choose your treatment from among several treatment options. It will then be important to have all the information on each option available to make an informed decision.

There are a number of treatments for prostate cancer available. Some treatments are standard (the currently used treatment), and some are still being tested in clinical trials.

Primary standard treatments

Active surveillance – Involves closely monitoring small, low-risk, slow-growing prostate cancer.

Radical prostatectomy (open, laparoscopic, robotic) – Surgery that completely removes the prostate gland, as well as part of the urethra within the prostate and the seminal vesicles.

Radiation therapy (external beam, brachytherapy) – Radiation therapy uses radiation to shrink tumours and kill cancer cells.

Brachytherapy – Brachytherapy irradiates the prostate from an internal source to shrink tumours and kill cancer cells.

Hormone therapy – Hormone therapy deprives cancer cells of the male hormones (e.g., testosterone) they need in order to grow.

Chemotherapy – Drugs that treat aggressive cancer. These drugs affect both cancer cells and healthy cells. Healthy cells tend to regenerate whereas cancer cells struggle to do so.

There are also several approaches and strategies for preventing or treating bone metastases, treat them or to relieve symptoms and bone pain.

Clinical trials

One way to access new treatments before they become widely available is to participate in clinical trials. A clinical trial is a research study that uses volunteers, called participants, to test new ways of preventing, detecting, treating, or managing prostate cancer or other illnesses. Some clinical trials help determine whether or not a new drug or device is effective and safe.

Participating in a clinical trial is a valuable contribution to research as clinical trials answer important questions that can lead to better health outcomes. Participation can be a good way for participants to access free and new treatments and to be closely monitored by healthcare workers. To learn more about clinical trials, speak with your healthcare team.

Finding a clinical trial can be a difficult and tedious process. To address this issue, our partner Q-CROC developed Onco+, a free support service available to anyone looking for an oncology clinical trial in Quebec.

If you would like to learn more about oncology clinical trials in Quebec and consider whether participating in a clinical trial might be an option for you, please visit the website of our partner Q-CROC.

Additional clinical trial sites:

• Clinical Trials: www.clinicaltrials.gov
• Canadian Cancer Trials: canadiancancertrials.ca

Alternative medicine

Complementary and alternative treatments include a wide range of approaches and therapies. It is important to understand the differences between conventional medicine, complementary therapies, and alternative therapies.

Traditional medicine – Medical or surgical treatments that are accepted and practiced within the Canadian healthcare system. The best available research has shown these treatments to be effective and safe. Radiation therapy is an example of conventional medicine.

Complementary therapies – Therapies used with or alongside conventional medicine, often to help people cope with cancer, treatment, or side effects. More research is needed to find out if they are safe and effective. An example of a complementary therapy is using meditation to help with stress or anxiety during treatment.

Alternative therapies – Therapies used instead of conventional medicine. Alternative therapies have not been scientifically proven to be safe and effective. Following a special diet to treat prostate cancer instead of conventional treatments is an example of alternative therapy. Delaying or refusing conventional therapies in preference of using alternative therapies can have serious health consequences.

Discuss all treatment decisions with your healthcare team.

Your type of cancer

The diagnosis of prostate cancer greatly influences the choice of treatment. In fact, the results of the biopsy and the various tests determine two key indicators, namely the grade (Gleason score) and the stage of prostate cancer. The grade specifies the degree of aggressiveness of cancer while the stage indicates its degree of spread. These two indicators make it possible to determine the level of evolution of prostate cancer: localized, locally advanced, or metastatic. Our diagnostic page deals in detail with the type and risk of progression.

Once prostate cancer has been diagnosed, it is usually urologists and radiation oncologists who treat your cancer. If metastases are present, especially when using chemotherapy, a medical oncologist will often consult other health professionals.

Your healthcare team—consisting of your family doctor, radiation oncologist technicians, and volunteers—is there for support and comfort.

Factors to consider

Prostate cancer is a complex disease. Many personal or cancer-related factors may influence the choice of treatment in a given patient. It is important that you learn as much as you can about your cancer and the treatment options available to you, including potential side effects. This will allow you to have an informed discussion with your doctor and establish a treatment plan that is right for you. Decisions about your treatment are normally based on:

Your treatment options

Choosing treatment can be difficult

Be sure to take the time to think about what is good for you and to get all the information you need. You will have an informed discussion with your doctor and choose the treatment option that is right for you.

You should also be aware that research is now providing increasingly precise treatments that target specific forms of cancer. In addition, treatment protocols now include many strategies to treat advanced disease.

Active surveillance

Active surveillance refers to close monitoring of your prostate cancer. Depending on your age and state of health, this option may be right for you if your tumor is small, detected at an early stage with a low risk of progression, and does not put your life at risk.

Regular checkups are scheduled every 3 to 6 months and usually include a digital rectal exam (DRE), prostate‑specific antigen (PSA) test, and repeat prostate biopsies.

Radical surgery 

Radical prostatectomy is a surgical procedure that involves the complete removal of your prostate and seminal vesicles for the purpose of curing cancer. Surgery is suitable for patients who are otherwise healthy and whose disease is thought to be confined to the prostate. If your cancer is at high risk of progression, the surgeon will remove your lymph nodes near your prostate (in the pelvis).

Transurethral resection of the prostate (TURP) 

This procedure is normally used to relieve urinary obstruction symptoms caused by an increase in the volume of your prostate exerting pressure on your urethra. This surgery is used for men with advanced prostate cancer or for men who are not healthy enough to undergo a radical prostatectomy. This surgery does not cure cancer.

External beam radiotherapy 

The use of external beam radiotherapy is to eradicate cancer cells in the prostate from a device (linear accelerator) placed close to your body. It is given for the purpose of curing cancer when it is confined to the prostate. Radiation therapy is usually combined with hormone therapy for cases of high-risk prostate cancer.

Brachytherapy 

Brachytherapy is the use of radioactive material placed directly in the prostate to destroy cancer cells. There are two types of brachytherapy: low dose rate brachytherapy requires the implantation of permanent radioactive seeds in the prostate. This is usually only an option if the cancer is at a relatively early stage and slow-growing (such as low-grade tumors).

High dose rate brachytherapy involves temporarily inserting a radioactive source directly into the prostate using catheters connected to a radiation source. In cancer at higher risk of progression, brachytherapy may be associated with external beam radiotherapy.

Hormone therapy 

Hormone therapy involves removing, suppressing, or blocking your male hormones, such as testosterone, which hinders the growth and spread of your cancer. Hormone therapy treats your entire body rather than just targeting your prostate. It is used to treat cancer that has spread beyond the prostate. It can be administered “intermittently” or “continuously”.

The main hormonal therapy modalities for prostate cancer are in the form of injections or implants to stop your testosterone production or tablets to block the effects of testosterone.

Standard hormone therapy has been used for many years in the treatment of prostate cancer. However, in recent years, multiple new therapies commonly grouped as second-line hormone therapy (new generation) have been approved in Canada.

Thus, cancer – which no longer responds to standard hormone with nos metastasis – could be treated with new-generation hormone therapy in the form of tablets – apalutamide (Erleada), enzalutamide (Xtandi) or darolutamide (Nubeqa). If your cancer progresses despite these treatments, your doctor may recommend a combination of treatments approved by Health Canada or available through clinical trials.

Chemotherapy

Chemotherapy can destroy cancer cells that have spread to other parts of the body. It can be used at diagnosis of metastatic prostate cancer or when hormone therapy is no longer effective (castration-resistant prostate cancer). It can also be used to relieve the pain and symptoms of generalized (metastatic) prostate cancer. Chemotherapy can be used in combination with other therapies.

The main modalities for prostate cancer are in the form of injections (infusion) in a hospital, with one to three treatments every three weeks lasting about 30 minutes per treatment.

Next-generation hormone therapy – apalutamide (Erleada), enzalutamide (Xtandi), and abiraterone acetate (Zytiga) – are also new agents in the therapeutic arsenal for the treatment of metastatic cancer, according to medical indications approved by Health Canada.

Treatment of bone metastasis

When prostate cancer spreads to other parts of the body, it spreads mostly to the bones. Your doctor can use a variety of treatments to help prevent the spread of cancer to the bones or to treat metastases (as mentioned above), to strengthen the bones and to alleviate the pain and discomfort caused by bone metastases. Treatment to relieve symptoms and improve quality of life will be implemented.

Follow-up after treatment

Regular follow-up visits are important, especially during the first 5 years after treatment.

Understanding your choices

Talk to your doctor

Men recently diagnosed with prostate cancer experience significant psychological distress filled with anxiety and fear, which can make it difficult to process information. This makes it very difficult to make an informed decision, especially when it could be one of the most important decisions of your life. This is why your doctor-patient relationship is crucial.

Here are a few points to make your doctor’s visit as efficient as possible:

• Don’t be afraid to ask questions about your disease, treatments, and side effects.
• Keep a running list of your questions as they come to mind.
• Take a relative or friend with you.
• Taking a second appointment may be a good option for thinking and compiling questions.

If your doctor is giving you too much information at one time, let him or her know. There is nothing wrong with letting your doctor know how much information you can absorb in a single visit.

The right doctor for me

It is very likely that you will meet many people who are good resources and can help you. However, once you have been diagnosed with prostate cancer, your primary doctor will be your urologist. Your family doctor will also be informed of your diagnosis in order to monitor your overall health. Your urologist is probably the one you will speak to most. If necessary, you may be referred to a radiation oncologist, medical oncologist, or doctor specializing in palliative care.

How to know?

Once you have picked a urologist, there are a number of questions you can ask if you are waiting for your diagnosis or if you have received a prostate cancer diagnosis.

General

• What percentage of your practice treats prostate cancer?
• What is the grade and stage of my cancer now?
• What are my treatment options?
• What are the advantages and disadvantages of each?
• What are the risks that my cancer will be cured / will relapse after treatment?

Radical prostatectomy

• How many radical prostatectomies do you do a year?
• Do you do laparoscopic prostatectomies? Am I a good candidate?
• What is the likelihood that I will have problems with bladder control after I undergo a radical prostatectomy?
• What is the likelihood that I will experience problems obtaining or maintaining an erection if I undergo a radical prostatectomy?

Radiation therapy / Brachytherapy

• Do you do external radiation therapy or brachytherapy?
• What are the requirements to be a good candidate for brachytherapy? Am I a good candidate?
• What is the likelihood that I will experience problems with bladder control after I undergo radiation therapy or brachytherapy?
• What is the likelihood that I will experience problems obtaining or maintaining an erection after I undergo radiation therapy or brachytherapy?

Hormone therapy

• What is hormone therapy?
• What are the side effects?

Chemotherapy

• What kind of chemotherapy is used to treat prostate cancer?
• What are the side effects?

Please also see our Your team and questions section

Help manage your treatment

It is important that you have enough information to really understand your situation. This will help you feel more in control of your life and help you make decisions.

If, for whatever reason, you are not comfortable with your doctor, ask for a second opinion. Doing so does not mean you are questioning your doctor’s competency. Certain elements of the doctor/patient relationship may encourage you to consult another specialist.

In addition, each doctor may have a different way of approaching the situation. It is important to develop a relationship of trust with your urologist. Ask yourself the following questions:

• Does my doctor spend enough time with me?
• Are all my questions being answered?
• Is the language my doctor is using clear or is it too technical or medical?
• Is there a language barrier?
• Is my doctor’s office too far away from my home?

Perhaps you and your family need more reassurance about the possible treatment options and what would be the best approach to treat your cancer.

Seeking a second opinion is perfectly acceptable if you feel the need. Just let your urologist know—they may be able to suggest someone or give you information on how to get a copy of your chart.