Stage I Prostate Cancer

Prostate cancer is referred to as Stage I if the cancer is confined to the prostate and involves a limited amount of the prostate, and the Gleason score and PSA level are relatively low.

A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

The following is a general overview of the treatment of Stage I prostate cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.

Prostate cancer is typically a disease of aging. It may persist undetected for many years without causing symptoms. In fact, most men die with prostate cancer, not from prostate cancer. Management or treatment of early-stage prostate cancer is one of the most difficult and perplexing dilemmas for both patients and physicians. Patients with Stage I prostate cancer are curable and have a number of treatment options, including surgical removal of the cancer, radiation therapy or “watchful waiting” without immediate treatment. It is important for patients to obtain as much information as possible about the results of each treatment modality and to obtain more than one opinion on the matter, especially when deciding on surgery versus radiation therapy.

If prostate cancer is truly confined to the prostate, it is curable with surgery or radiation. However, in order to benefit from curative treatment, a patient’s life expectancy may need to be 10-15 years. Patients may ask themselves: If cure is possible, is it necessary? Treatment of prostate cancer is a very personal decision and some patients will choose to undergo aggressive treatment, while others will not.

Patients diagnosed with early-stage prostate cancer must choose between “watchful waiting”, more aggressive treatment with radiation or surgery (radical prostatectomy), or participation in a clinical study. Unfortunately, well-controlled clinical studies comparing these treatment approaches have not been performed. Before deciding on receiving treatment, patients should ensure they understand the answers to 3 questions:

• What is my life expectancy and risk of cancer progression without treatment?
• How will my prognosis be improved with treatment?
• What are the risks of the various treatment alternatives?

Before making treatment recommendations, physicians who treat prostate cancer consider a number of aspects about the patient’s disease that help predict whether the cancer is confined to the prostate (potentially curative) and how fast the cancer will grow. These aspects include the clinical stage of the cancer, the prostate-specific antigen (PSA) level, and the appearance of the prostate cancer cells under the microscope (the Gleason score). Patients with early-stage cancer, lower PSA levels and a low Gleason score have more treatment options available and a better chance of long-term survival.

Some physicians and patients choose a strategy of delaying any treatment of prostate cancer until symptoms from the cancer appear. This delayed approach is referred to as “watchful waiting” or “conservative management” of prostate cancer. Because treatment with radiation or surgery may be associated with temporary (and some permanent) side effects, in addition to inconvenience, electing not to receive immediate treatment may be appropriate for selected patients. In fact, doctors in many European countries use a strategy of watchful waiting and do not treat early-stage prostate cancer with radiation or surgery.

A recent study reported on 450 men who received watchful waiting for clinically localized prostate cancer. Thirty percent of the men were eventually offered definitive treatment (surgery, hormonal therapy, and/or radiation therapy) because of cancer progression or patient preference. Overall, the men had a low rate of death from prostate cancer; after 10 years, the risk of dying from something other than prostate cancer was more than 18 times higher than the risk of dying from prostate cancer.[1] 

Decisions about the appropriateness of watchful waiting are often based on the patient’s prostate cancer characteristics, age, and health. 

Radical prostatectomy involves surgical removal of the prostate gland and seminal vesicles, along with a small amount of surrounding tissue. Nearby lymph nodes may also be removed.

The health of the patient is an important factor when considering prostatectomy. Patients must generally be in good health in order to undergo the procedure.

Radical prostatectomy is a very effective therapy if the cancer has not spread beyond the prostate. Some patients, however, will experience a cancer recurrence after surgery. This is because patients may have undetectable areas of cancer (micrometastases) outside of the prostate at the time of surgery. These micrometastases are not eliminated by local treatments such as surgery or radiation therapy.

For more information about radical prostatectomy and its side effects, visit Surgery for Prostate Cancer.

Radiation therapy is treatment with high energy x-rays that have the ability to kill cancer cells. Standard radiation therapy utilizes either external beam radiation (EBRT) consisting of daily treatments on an outpatient basis for approximately 6 to 8 weeks or interstitial brachytherapy which involves permanent placement of radioactive seeds directly into the prostate gland. Radioactive implants are increasingly being used instead of radical prostatectomy or EBRT. Unfortunately, clinical studies directly comparing EBRT to implants have not been performed. Early results with implants suggest good control of disease with limited side effects. Long-term results are not widely available, but early results are promising, especially in patients with low risk disease.

Because radiation implants focus the radiation closely around the prostate, this form of radiation works best in patients with early-stage prostate cancer. If the PSA level or Gleason score is high, another form of treatment may be better suited for the patient. Patients with a large prostate gland, prior history of prostate infections or recent transurethral resection of the prostate (TURP) may not be able to undergo the implantation procedure for brachytherapy. To learn more about the risks and benefits of EBRT and implants, select Radiation Therapy.

The decision to undergo radical prostatectomy, EBRT or radiation seed implantation is difficult. This is because these treatment strategies have not been directly compared in well-designed clinical studies. The choice of radiation versus prostatectomy is often based on weighing the possible complications of treatment and the relative inconvenience of the treatments. It is important to be seen by more than one physician to determine the likely treatment outcome associated with the various options available in your community. Questions you may wish to ask your physicians include:

• What are the chances of this treatment curing the cancer?
• What is the risk of impotence and incontinence?
• What are the other possible complications from this treatment?

The progress that has been made in the treatment of prostate cancer has resulted from improved development of radiation treatments and surgical techniques. Despite improvements in treatment, patients still succumb to the complications of prostate cancer. Surgery and radiation are local therapies directed at treating cancer in and around the prostate gland. Future progress in the treatment of prostate cancer will result from continued participation in appropriate clinical studies designed to improve local and systemic treatment of prostate cancer. Currently, there are several areas of active exploration aimed at improving the treatment of Stage I prostate cancer.

Strategies to Improve Local Treatment: Several strategies to improve local treatment of prostate cancer are under evaluation. These strategies only treat cancer confined to the prostate. They do not treat cancer cells beyond the radiation or surgical field.

Cryotherapy: Cryotherapy kills cancer cells by freezing them. Hollow rods are inserted into the prostate and filled with liquid nitrogen or argon gas. This procedure may be used as an alternative to radical prostatectomy or radiation therapy among men with cancer that is confined to the prostate. Limited information is available, however, about the relative effectiveness of this approach.[2]

Newer Radiation Techniques: EBRT can be delivered more precisely to the prostate gland by using a special CT scan and targeting computer. One exciting technique is the use of three-dimensional (3-D) computer targeting systems to precisely aim the radiation beam at the prostate gland. Through sophisticated software, a 3-D image or “beam’s-eye view” of the cancer is generated. Many thin beams of intense X-rays are then aimed at different angles to intersect at all cross-sections of the cancer. This method delivers a concentrated dose directly to the cancer, while the individual beams leave normal, healthy tissue relatively unscathed. This 3-D conformal radiation therapy technique appears to reduce side effects to the surrounding organs, thereby allowing higher radiation doses.

Newer Radiation Machines: Most EBRT uses high energy x-rays to kill cancer cells. Some radiation oncology centers use different types of radiation that require special machines to generate. These different types of radiation, such as protons or neutrons, appear to kill more cancer cells with the same dose. Combining protons or neutrons with conventional x-rays is one method of radiation therapy being evaluated in clinical trials.

Newer Imaging Techniques: The ability of current imaging technology to detect small areas of cancer within and around the prostate gland and elsewhere in the body is limited. Magnetic resonance imaging, or MRI, provides better images of the prostate gland and is able to locate small growths of cancer. The MRI can be used to guide interstitial seed placement or determine which patients are best suited for radical prostatectomy.

Strategies to Improve Systemic Therapy: Surgery and radiation are local therapies directed at treating cancer in and around the prostate gland. Treatment administered before or after surgical removal of the cancer is referred to as adjuvant or neoadjuvant therapy. Over the past several years, many new anti-cancer drugs and biologic agents have been discovered that are more active at destroying cancer cells. It may be that these newer anti-cancer agents administered before or after surgical removal of Stage I prostate cancer will be beneficial. These newer anti-cancer agents are currently being evaluated in patients at high risk of cancer recurrence.