Prostate Cancer Treatment Options: From Active Surveillance to Surgery and Radiation

Jump To Section

• Active Surveillance for Prostate Cancer
• MRI in Prostate Cancer Monitoring
• Radical Prostatectomy Surgery
• Prostate Cancer Radiotherapy
• Proton Beam Therapy for Prostate
• Focal Therapy for Prostate Cancer
• Choosing a Prostate Cancer Treatment

Active Surveillance for Prostate Cancer

Active surveillance represents a fundamental shift in prostate cancer treatment philosophy. Dr. Mark Emberton, MD, describes this approach as "Delayed Selective Intervention," where the primary goal is to identify and treat only those men whose cancer shows signs of progression. This strategy avoids unnecessary treatment for patients whose prostate cancer is unlikely to cause detriment to quality of life or limit life expectancy. The decision to pursue surveillance relies on careful monitoring with PSA tests and increasingly with multiparametric MRI, which provides reliable data for long-term observation.

Dr. Mark Emberton, MD, emphasizes that active surveillance has proven very safe over a 10 to 15-year timeframe. Most prostate cancers remain stable for extended periods, with progression typically measured in years rather than weeks or months. This conservative approach spares patients from the potential side effects of more aggressive treatments when they are not medically necessary.

MRI in Prostate Cancer Monitoring

Multiparametric MRI has revolutionized prostate cancer monitoring by providing a reliable and consistent method for tracking disease over time. Dr. Mark Emberton, MD, explains that unlike traditional transrectal ultrasound-guided biopsies, which offer imprecise and inconsistent sampling, MRI delivers reproducible results that allow clinicians to actually watch specific prostate cancer lesions develop. This reliability eliminates the "reclassification vs. progression dilemma" that plagued previous surveillance methods.

During his discussion with Dr. Anton Titov, MD, Dr. Emberton highlighted how MRI enables true apples-to-apples comparisons between scans. When progression does occur—which is rare—clinicians can biopsy the specific area of concern immediately and proceed with appropriate treatment. This precision monitoring means that stable cancers can be surveilled without repeated invasive biopsies.

Radical Prostatectomy Surgery

At the opposite end of the treatment spectrum from active surveillance lies radical prostatectomy, the surgical removal of the entire prostate gland. Dr. Mark Emberton, MD, outlines several surgical approaches available to patients, including open operations, laparoscopic procedures, and robot-assisted surgeries. Each technique aims to completely remove the prostate while preserving surrounding structures responsible for urinary continence and sexual function when possible.

The choice of surgical approach depends on multiple factors including tumor characteristics, surgeon expertise, and patient preference. While radical prostatectomy represents the most aggressive local treatment option, technological advances have significantly improved outcomes and reduced complications associated with this procedure.

Prostate Cancer Radiotherapy

Radiotherapy offers another whole-gland treatment approach for localized prostate cancer, with several advanced delivery systems now available. Dr. Mark Emberton, MD, describes conformal radiotherapy techniques that shape radiation beams to match the prostate's contours, minimizing exposure to surrounding healthy tissues. Image-guided radiotherapy uses fiducial markers implanted in the prostate to track organ movement and ensure precise radiation targeting.

Brachytherapy represents another radiation option, involving the placement of radioactive seeds directly into the prostate (low-dose rate) or temporary placement of a higher radiation source (high-dose rate). These techniques allow for delivery of high radiation doses to the prostate while sparing adjacent organs like the bladder and rectum.

Proton Beam Therapy for Prostate

Proton beam therapy represents the latest advancement in radiation technology for prostate cancer treatment. Dr. Mark Emberton, MD, explains that this modality uses charged particles (protons) that deposit their energy at a precise depth in tissue, potentially offering superior dose distribution compared to conventional photon radiation. This characteristic makes proton therapy particularly appealing for prostate cancer due to the proximity of critical structures like the rectum and bladder.

While the UK has recently invested in proton beam therapy facilities, Dr. Mark Emberton, MD, notes that this treatment remains very expensive and its specific benefits for prostate cancer represent ongoing research questions. Traditionally used for pediatric cancers and tumors in complex anatomical locations, proton therapy's role in prostate cancer management continues to evolve.

Focal Therapy for Prostate Cancer

Emerging approaches challenge the paradigm of whole-gland treatment for prostate cancer. Dr. Mark Emberton, MD, describes experimental focal therapy techniques where only the cancerous portion of the prostate is targeted. He mentions a surgeon in northern France who performs what Dr. Anton Titov, MD, correctly identifies as a "lumpectomy"-style procedure, removing just the tumor-containing section of the prostate.

Similarly, advanced radiotherapy techniques are being developed to concentrate radiation beams specifically on tumors while preserving healthy prostate tissue. Dr. Mark Emberton, MD, notes that this focused approach allows for higher radiation doses to the cancer itself while significantly reducing exposure to the bladder and rectum, potentially minimizing treatment side effects.

Choosing a Prostate Cancer Treatment

The decision between active surveillance, surgery, or radiotherapy depends on multiple clinical and personal factors. Dr. Mark Emberton, MD, emphasizes that treatment selection must be individualized based on cancer characteristics, patient age, overall health, and personal preferences regarding potential side effects versus cancer control. Multiparametric MRI plays an increasingly crucial role in this decision-making process by providing detailed information about tumor location, size, and aggressiveness.

During his conversation with Dr. Anton Titov, MD, Dr. Emberton stressed that most prostate cancers grow slowly and may never require treatment. The development of more precise monitoring and treatment techniques continues to shift prostate cancer care toward more personalized approaches that maximize quality of life while ensuring appropriate cancer control.

Full Transcript

Dr. Anton Titov, MD: Prostate cancer treatment guidelines are behind precision medicine advances. The best treatment for prostate cancer in early stages may be observation. Choose prostate cancer therapy wisely.

Dr. Mark Emberton, MD: Let’s go back to localized prostate cancer, back into the prostate. The first treatment decision that we make when discussing with the patient is whether to treat or not to treat, whether to keep the cancer under surveillance. Because we don't feel that, if left alone, the prostate cancer is likely to progress.

We sometimes feel that prostate cancer will not cause a detriment to quality of life or limit life expectancy. And that is done with PSA and increasingly with prostate multiparametric MRI. We have talked about it.

Prostate MRI is particularly useful because it is reliable. We can watch the prostate over time. We are going to hear a lot more about how good MRI is at detecting prostate change when change in prostate cancer occurs.

Surveillance is an interesting form of prostate cancer care. Surveillance is to identify men with prostate cancer who progress. Those men who have prostate cancer progress then get treatment.

So it's delayed selective intervention. You avoid treating those men who don't need prostate cancer treatment. And what we do know now is that over a 10 to 15 year timeframe, active surveillance is very, very safe.

Dr. Anton Titov, MD: We are talking about years of progression between the subsequent prostate MRI scans. It's not weeks, months, but it's years?

Dr. Mark Emberton, MD: Most prostate cancer stays stable. The challenge is to identify those prostate cancers that progress. Now, with MRI we are going to enter a new era.

Before multiparametric MRI was available, we were using transrectal guided prostate biopsy. We've already discussed that was an imprecise way of assessment of prostate cancer. When you repeat prostate biopsy, it's also imprecise.

Dr. Anton Titov, MD: Because you could be sampling different areas of prostate tumor or healthy tissue.

Dr. Mark Emberton, MD: Correct! And so we never really knew whether the tumor has progressed, or whether we were just sampling a new part of the disease.

Dr. Anton Titov, MD: This is not comparing apples to apples, but apples to oranges.

Dr. Mark Emberton, MD: Correct! It was the reclassification vs. progression dilemma. Prostate MRI is reliable. If I do an MRI three times today, it will come up with the same result.

We can actually watch a prostate cancer lesion over time. We have learned, we've been doing MRIs here for a long time, that most prostate cancer lesions remain very stable.

Now, clearly, cancers grow. But prostate cancers have little spurts of growth and then achieve stability. Maybe prostate cancers undergo a genetic mutation and then grow some more.

So we have seen prostate cancer progressors. But they are rare. And when we do see progressive prostate cancer, we obviously treat them or biopsy them immediately.

Dr. Anton Titov, MD: And before you see any cancer growth progress on MRI, you might not even do biopsy?

Dr. Mark Emberton, MD: Correct. So just keep surveilling. If you see the progress on MRI, tumor growth, you biopsy the tumor. You proceed with local prostate cancer treatment or with a whole-gland cancer treatment.

That's exactly right. So that's the most conservative approach that we have. That's called active surveillance.

In terms of localized prostate cancer, the most aggressive approach is the opposite. It's removing the whole prostate or irradiating the whole prostate. There are various ways to do both of those.

Prostate removal can be done through an open operation, or laparoscopic operation. It can be done with the assistance of a robot. Radiotherapy can be given with various types of administration.

People will have heard of conformal radiotherapy. We try and shape the radiation beam. We have prostate cancer image-guided radiotherapy.

We put some markers inside the prostate and we can watch the prostate move with time, and the beam follows those markers.

Dr. Anton Titov, MD: Those markers are called fiducial markers.

Dr. Mark Emberton, MD: We can put the radiation source inside the prostate with iodine-seed brachytherapy, or high-dose rate brachytherapy. Proton beam therapy for prostate cancer.

The UK has just invested in proton beam therapy. It is very expensive. Protons are particles that are used for radiation.

Proton beam therapy typically was used in children. It was used for therapy of cancer in the back of the skull, and in head and neck. Proton beam therapy is also used in sarcoma, because of their ability to penetrate and deliver the energy in a precise point in space.

But, obviously, in the prostate, there may be some utility for proton beam therapy, given the proximity of the rectum and the bladder. But these are research questions going forward.

So there's lots of different types of radiation prostate cancer therapy. Currently, all of them, except in a very, very few centers, aim at the whole prostate. And surgery is aimed at the whole prostate, I think in nearly all centers.

I can think of one medical center which aims to treat the whole prostate. There's one surgeon in the north of France who is removing surgically prostate cancer that is accessible to the surgeon.

He does it by cutting out like a slice of cake from the prostate, if that slice contains the tumor.

Dr. Anton Titov, MD: Sounds like a lumpectomy?

Dr. Mark Emberton, MD: Correct. Exactly right. But just a few of those prostate cancer cases have been done to date.

In prostate cancer radiotherapy, there are a few groups around the world who are now using the modern techniques to try and focus down the beam onto the tumor, and to try and preserve the prostate.

If you do that, you can give additional dose to the tumor, which makes prostate cancer radiotherapy more effective. It also reduces the radiation dose to the bladder and rectum.