Confidence Scale

The confidence ratings in this guide are derived from a systematic review of the literature. The LEVEL OF CONFIDENCE is based on the overall quantity and quality of clinical evidence.

HIGH There are consistent results from good quality studies. Further research is very unlikely to change the conclusions.

MEDIUM Findings are supported, but further research could change the conclusions.

LOW There are very few studies, or existing studies are flawed.

Expectant Management

With expectant management (also known as watchful waiting or active surveillance), men have regular monitoring of their prostate cancer. Monitoring may include PSA testing, digital rectal examination, prostate ultrasound, or prostate biopsy. If the cancer progresses, an active treatment can be added.

Radical Prostatectomy

Radical prostatectomy is the most widely used surgical treatment for prostate cancer. Men who are initially treated with radical prostatectomy tend to be younger and report better health status than men initially treated with radiation therapy or hormonal therapy. They also tend to be younger and healthier than men who use expectant management. Evidence is insufficient to determine whether older men attain the same benefits from radical prostatectomy as younger men.

Risks of surgery increase with age. Treatment-related problems are also common in older men. Up to 10 percent of men 65 and older experience cardio-pulmonary complications after surgery.

Most prostatectomies involve lower abdominal incision. Nerve-sparing surgical techniques are widely used and are designed to lessen the chance of erectile dysfunction (ED). Evidence is insufficient to judge whether newer techniques, such as laparoscopic or robotic-assisted prostatectomy, are as effective as conventional surgery.

• Men who have radical prostatectomy for localized prostate cancer are less likely to die from prostate cancer than men who use expectant management. (See Figure 2.)
  LEVEL OF CONFIDENCE
• Using hormonal therapy before prostatectomy (neoadjuvant hormonal therapy) does not improve survival or cancer recurrence rates compared with prostatectomy alone.
  LEVEL OF CONFIDENCE

Figure 2

Radical Prostatectomy Versus Expectant Management. Results are from a large, randomized controlled trial of men diagnosed between 1989 and 1999. Average age at diagnosis was 65 years, average Gleason score 5–6, and average PSA 13 ng/mL. Most cancers (more...)

Radiation Therapy

Two types of radiation therapy are currently in wide use: external beam radiation therapy (EBRT) and brachytherapy (radioactive seeds implanted into the prostate). Recent modifications to EBRT include conformal EBRT and intensity-modulated radiation therapy (IMRT). These techniques focus on delivering radiation to the cancer cells while minimizing damage to healthy tissue.

• Increasing the total amount of radiation slows the rate of cancer progression (as measured by PSA levels) compared with lower doses of radiation therapy. Higher total EBRT doses do not increase urinary side effects but can increase gastrointestinal side effects.
  LEVEL OF CONFIDENCE
• Evidence is insufficient to determine whether higher doses of radiation reduce mortality compared with lower doses of radiation.
• Combining 6 months of hormonal therapy (leuprolide or goserelin, combined with flutamide) with EBRT can reduce mortality but increases side effects. One study found that 12 percent of men treated with combination therapy and 22 percent of men treated with EBRT alone had died from any cause within 5 years.
  LEVEL OF CONFIDENCE
• It is not known how the results of treatment with any type of radiation therapy compare with the results of expectant management or radical prostatectomy.
• Evidence is insufficient to determine whether the results of other radiation modalities (brachytherapy, proton beam, or IMRT) differ from the results of conventional EBRT.

Hormonal Therapy

Reducing the effects of testosterone slows the growth of prostate cancer. Hormonal therapy includes surgical orchiectomy, androgen-blocking agents (such as flutamide and bicalutamide), and hormonal agonists (such as leuprolide and goserelin).

Hormonal therapy is usually an adjuvant or salvage therapy, but it is sometimes used as sole initial therapy.

• Bicalutamide (used alone or in addition to prostatectomy or EBRT) does not reduce cancer recurrence or mortality.
  LEVEL OF CONFIDENCE
• There is insufficient evidence about the effectiveness of using other hormonal therapies to treat localized prostate cancer.

Erectile Dysfunction

Inability to achieve and maintain an erection is the most common long-term side effect and occurs with all active prostate cancer treatments.

LEVEL OF CONFIDENCE

Urinary Problems

Incontinence is more common after prostatectomy than after radiation or hormonal therapy.

LEVEL OF CONFIDENCE

Bowel Problems

Bowel problems, such as painful hemorrhoids and bowel urgency, are more common after EBRT than after other treatments.

LEVEL OF CONFIDENCE

Effects of Hormonal Therapy

Hormonal therapy can cause loss of libido, depression, memory difficulties, fatigue, hot flashes, gynecomastia, and fractures.

• Hot Flashes. About 60 percent of men have hot flashes with hormonal therapy (hormonal agonist or orchiectomy).
  LEVEL OF CONFIDENCE
• Gynecomastia. About 25 percent of men taking a hormonal agonist and 10 percent of men treated with orchiectomy have breast swelling.
  LEVEL OF CONFIDENCE
• Fractures. At 5 years after diagnosis, men treated with hormonal therapy have more fractures than men not treated with hormonal therapy (19 percent versus 13 percent). The risk of fracture increases with the total number of doses of hormonal therapy.
  LEVEL OF CONFIDENCE
• Men receiving 6 months of hormonal therapy with EBRT have more gynecomastia and ED (erections not sufficient for intercourse) than men treated with EBRT alone.
  LEVEL OF CONFIDENCE

Expectant Management Versus Active Treatments

Choosing Among Active Treatments

• Men who have radical prostatectomy generally have a lower risk of cancer progression and death than men who follow expectant management.
• It is not known whether men who undergo any type of radiation therapy have a higher risk of death than men who undergo radical prostatectomy or expectant management.
• Bicalutamide is not effective as initial treatment. There is no evidence about the effectiveness of using other hormonal therapy as sole initial treatment for localized prostate cancer.
• The long-term outcomes for many newer treatment approaches (cryotherapy, high-intensity focused ultrasound, and laparoscopic or robotic-assisted prostatectomy) are not yet known.