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This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options.
In cancer care, different types of doctors often work together to create an overall treatment plan that combines different type of treatments. This is called a multidisciplinary team.
Descriptions of the most common treatment options for prostate cancer are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health.
It is important to discuss the goals and possible side effects of treatment with your doctor before treatment begins, including the likelihood that the treatment will work, the possible side effects(including urinary, bowel, sexual, and hormone-related side effects), and the patient’s preferences. Men should talk with their doctor about how the various treatments affect recurrence, survival, and quality of life. In addition, the success of any treatment often depends on the skill and expertise of the physician or surgeon, so it is important to find doctors who have experience treating prostate cancer.
Active surveillance for early-stage cancer
If a prostate cancer is in an early stage, growing slowly, and treating the cancer would cause more discomfort than the disease, a doctor may recommend active surveillance. During active surveillance, the cancer is monitored closely with periodic PSA tests, DRE tests, and watching for symptoms. Treatment would begin only if the tumor shows signs of becoming more aggressive or spreading, causes pain, or blocks the urinary tract. This approach may be used for much older patients, those with other serious or life-threatening illnesses, those who wish to delay active treatment because of possible side effects, or for patients with tumors that have a low risk of growing and spreading (small tumor size, low Gleason score, low PSA level). However, real caution must be taken not to make errors of judgment about the disease. In other words, doctors must collect as much information as possible about the patient’s other illnesses and life expectancy, so they don’t miss the chance to detect an early, aggressive prostate cancer. For this reason, many doctors recommend a repeat biopsy shortly after diagnosis to confirm that the cancer is in an early stage and growing slowly before considering active surveillance for an otherwise healthy man. New information is becoming available all the time, and it is important for men to discuss these issues with their doctor to make the best decisions about treatment.
Surgery is the removal of the tumor and surrounding tissue during an operation. It is used to try to cure cancer before it has spread outside the prostate. A surgical oncologist is a doctor who specializes in treating cancer using surgery. For prostate cancer, a urologist or urologic oncologist is the surgical oncologist involved in treatment. The type of surgery depends on the stage of the disease, the man’s general health, and other factors. Surgical options include:
Radical (open) prostatectomy. A radical prostatectomy is the surgical removal of the whole prostate and seminal vesicles; lymph nodes in the pelvic area may also be removed. This operation has the risk of interfering with sexual function. Nerve-sparing surgery, when possible, increases the chance that a man can maintain his sexual function after surgery by avoiding surgical damage to the nerves that allow erections and orgasm to occur. Orgasm can occur even if some nerves are cut since these are two separate processes. Urinary incontinence (inability to control urine flow) is also a possible side effect of prostatectomy. To help resume normal sexual function, men can receive drugs, penile implants, or injections. Sometimes, another surgery can fix urinary incontinence.
Robotic or laparoscopic prostatectomy. This type of surgery is possibly much less invasive than an open radical prostatectomy and may shorten recovery time. A camera and instruments are inserted through small, keyhole incisions in the patient’s abdomen. The surgeon then directs the robotic instruments to remove the prostate gland and surrounding tissue. In general, robotic prostatectomy has less bleeding and less pain, but sexual and urinary side effects can be similar to an open radical prostatectomy. This procedure has not been available for as long as open radical prostatectomy, so longer-term follow-up information, including permanent cure rates, are not yet certain. Talk with your doctor about whether your treatment center offers this procedure and how it compares with the results of the conventional open radical prostatectomy.
Transurethral resection of the prostate (TURP). TURP is most often used to relieve symptoms of a urinary blockage, not to cure cancer. In this procedure, with the patient under a full anesthetic, a surgeon inserts a cystoscope (a narrow tube with a cutting device) into the urethra and into the prostate to remove prostate tissue. This is rarely used to treat prostate cancer.
Cryosurgery. Cryosurgery (also called cryotherapy or cryoablation) is the freezing of cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that contains the testicles. Cryosurgery may be useful for early-stage cancer and for men who cannot have a radical prostatectomy. However, it has not been compared with radical prostatectomy or radiation therapy, so doctors do not know if this would be a better treatment option. A common side effect of cryosurgery is impotence, so this approach is not recommended for men who desire to preserve their sexual function. Another side effect may be the development of fistulae (holes between the prostate and the bowel), although this appears to be much less common with newer cryosurgery techniques.
Radiation therapy is the use of high-energy rays to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.
External-beam radiation therapy. External-beam radiation therapy focuses a beam of radiation on the area with the cancer. Some cancer centers use conformal radiation therapy (CRT), in which computers help precisely map the location and shape of the cancer. CRT reduces radiation damage to healthy tissues and organs around the tumor by directing the radiation therapy beam from different directions to focus the dose on the tumor. External-beam radiation therapy is usually given with a high-energy x-ray beam. It can also be given with proton therapy (also called proton beam therapy), which uses protons rather than x-rays. At high energy, protons can destroy cancer cells.
Intensity-modulated radiation therapy (IMRT). IMRT is a type of three-dimensional (3-D) CRT. CRT uses CT scans to form a 3-D picture of the prostate before treatment. With IMRT, high doses of radiation can be directed at the prostate without increasing the risk of damaging nearby organs.
Brachytherapy. Brachytherapy is the insertion of radioactive sources directly into the prostate. These sources (called seeds) give off radiation just around the area in which they are inserted and may be used for hours (high-dose rate) or for weeks (low-dose rate). Low-dose rate seeds are left in the prostate permanently, even after all the radioactive material has been used up. It is not usually used as the only treatment for a man with a high-risk cancer.
Radiation therapy may cause immediate side effects such as diarrhea or other problems with bowel function; increased urinary urge or frequency; fatigue; impotence (erectile dysfunction); and rectal discomfort, burning, or pain. Most of these side effects usually go away after treatment, but erectile dysfunction is usually permanent. Many side effects of radiation therapy may not show up until months or years after treatment.
Because prostate cancer growth is driven by male sex hormones called androgens, lowering levels of these hormones can help slow the growth of the cancer. Hormone treatment is also called androgen ablation or androgen-deprivation therapy. The most common androgen is testosterone. Testosterone levels in the body can be lowered either surgically, with surgical castration (removal of the testicles), or with drugs that turn off the function of the testicles (see below).
Hormone therapy is used to treat prostate cancer in different situations, including cancers that have come back after surgery and radiation therapy, or if it has spread throughout the body at any time.
Recent research has shown that hormone therapy can help lengthen lives when used with radiation therapy for a prostate cancer that is more likely to recur. For some men, hormone therapy will be used first to shrink a tumor before radiation therapy or surgery. In some men with prostate cancer that has spread locally, called locally advanced or high-risk prostate cancer, hormone therapy is given before, during, and after radiation therapy for three years. Hormone therapy should also be considered for men who have prostate cancer that has spread to the lymph nodes (found after radical prostatectomy) as adjuvant therapy (treatment that is given after the first treatment). It may also be given for up to three years for men with intermediate-risk or high-risk cancer.
Traditionally, hormone therapy was used until it stopped controlling the cancer. Then the cancer was called hormone refractory (meaning that the hormone therapy has stopped working), and other treatment options were considered. Recently, researchers have begun studying intermittent hormone therapy, which is hormone therapy that is given for certain periods and then stopped temporarily according to a schedule. Giving hormones in this way appears to lower the symptoms of this therapy.
One important side effect of hormone therapy is the risk of developing metabolic syndrome. Metabolic syndrome is a set of conditions, such as obesity, high levels of blood cholesterol and high blood pressure that increases a person’s risk of heart disease, stroke, and diabetes. Currently, it is not certain how often this happens or exactly why it happens, but it is quite clear that patients who receive a surgical or medical castration (even a temporary medical castration) with hormone therapy have an increased risk of developing metabolic syndrome. The risks and benefits of castration should be carefully discussed with your doctor. For men with metastatic prostate cancer, especially if it is advanced and causing symptoms, most doctors believe that the benefits of castration far outweigh the risks of metabolic syndrome.
Types of hormone therapy
Bilateral orchiectomy. Bilateral orchiectomy is the surgical removal of both testicles. Even though this is surgery, it is called a hormone treatment because it removes the main source of testosterone production, the testicles. This surgery is permanent and cannot be reversed.
LHRH agonists. LHRH stands for luteinizing hormone-releasing hormone. LHRH agonists are drugs that reduce the body's production of testosterone by interfering with hormonal control mechanisms within the brain, which control the functioning of the testicles.
LHRH antagonist. This type of drug, also called a gonadotropin-releasing hormone (GnRH) antagonist, stops the testicles from producing testosterone by inhibiting LHRH. The FDA has approved one drug, degarelix (Firmagon), given by injection, to treat advanced prostate cancer. One side effect of this drug is that it may cause a severe allergic reaction.
Anti-androgens. While LHRH agonists lower testosterone levels in the blood, anti-androgens block testosterone from binding to so-called “androgen receptors,” chemical structures in the cancer cells that allow testosterone and other male hormones to enter the cells.
Combined androgen blockade. Sometimes, LHRH agonists are used in combination with peripheral-blocking drugs, such as anti-androgens, to more completely block male hormones. Many doctors feel that this combined approach is the safest way to start hormone treatment, as this prevents a possible flare-up or increase in activity of the prostate cancer cells that sometimes happens because of a temporary surge in testosterone production by the testicles (in response to the LHRH agonists). Some, but not all, research has shown about a six months difference in long-term survival from the use of combined androgen blockade; therefore, some doctors prefer to give combined drug treatment while others may give the combination early in the treatment to prevent the flare-up.
CYP-17 inhibitors. CYP-17 inhibitors are a type of hormone therapy that prevents androgen from being made by the body. Abiraterone (Zytiga) is a CYP-17 inhibitor that has been approved by the FDA as a treatment for castration-resistant prostate cancer that has spread when chemotherapy with docetaxel (Docefrez, Taxotere) has not worked (see Metastatic prostate cancer, below). Research studies have shown that abiraterone increased survival for men with this type of cancer.
Hormone therapy may cause significant side effects. Side effects generally go away after hormone treatment is finished, except in men who have had an orchiectomy. Patients may experience impotence, loss of libido (sexual desire), hot flashes, gynecomastia (enlarged breasts), and osteoporosis (weakening bones). Although testosterone levels may recover after stopping hormone therapy, some men who have taken LHRH agonists for many years may continue to have hormonal effects, even if the drugs are no longer given.
Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.
Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible.
Recurrent prostate cancer
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. Treatments that help prevent a recurrence include androgen deprivation therapy and radiation therapy (see above).
A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return.
If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Also, an increasing PSA level may be a sign of prostate cancer recurrence even if no tumor can be found.
When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. The choice of treatment plan is based on the cancer’s stage and may include the therapies described above (such as surgery, radiation therapy, and hormone therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.
People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope.
Metastatic (advanced) prostate cancer
If cancer has spread to another location in the body, it is called metastatic cancer. The standard treatment for metastatic prostate cancer is hormone therapy (see above). Generally, prostate cancer will develop the ability to grow without using male sex hormones. This is called castration-resistant prostate cancer.
Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Although there is no cure for advanced prostate cancer, it is often treatable. Many men outlive their prostate cancer, even those with advanced disease. Often, the prostate cancer grows slowly, and there are now effective treatment options that extend life even further.
Your health care team may recommend a treatment plan that includes vaccine therapy with sipuleucel-T (Provenge), chemotherapy with docetaxel, or clinical trials. These treatment options are discussed in more detail below. If you have pain, radiation therapy may also be recommended.
Vaccine therapy. Sipuleucel-T (Provenge) is a form of immunotherapy (also called biologic therapy) which is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to bolster, target, or restore immune system function.
In 2010, the FDA approved sipuleucel-T for men with castration-resistant metastatic prostate cancer with few or no symptoms, because in research studies it increased survival by about four months compared to placebo (inactive treatment). Sipuleucel-T is adapted for each patient. Before treatment, blood is removed from the patient in a process called leukapheresis. Special immune cells are separated from the patient’s blood, modified in the laboratory, and then put back in the patient. At this point, the patient’s immune system may recognize and kill the prostate cancer cells. It is difficult to find out if this treatment is working to treat the cancer for a specific patient, because it has not been shown to shrink the cancer, lower the PSA level, or keep the cancer from worsening.
Chemotherapy. Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.
Chemotherapy for prostate cancer is given intravenously (injected into a vein), and it may help patients with advanced or hormone-refractory prostate cancer. There are several standard drugs used for prostate cancer. The first drug used is often docetaxel given with a steroid called prednisone (multiple brand names). This combination has been shown to help men with advanced prostate cancer live longer than another chemotherapy, mitoxantrone (Novantrone), which is most useful for controlling pain from the cancer.
The FDA has approved the drugs mitoxantrone, docetaxel, and cabazitaxel (Jevtana) for use in men with prostate cancer in specific situations, such as prostate cancer that is resistant to hormone therapy. Cabazitaxel is similar to docetaxel, but research studies have shown that it can be effective for prostate cancer that is resistant to docetaxel. The side effects are similar to docetaxel and include low white blood cell counts, increased risk of infections, allergic reactions, nausea, vomiting, diarrhea, and kidney and liver problems.
In general, the side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.
Supportive care will also be important to help relieve symptoms and side effects. A few drugs can help treat the symptoms of advanced cancer to enhance the quality of the patient’s life.
Strontium and samarium. Given by injection, these radioactive substances are absorbed near the area of bone pain. The radiation that is released helps relieve the pain, probably by causing the tumor in the bone to shrink.
Bone-modifying drugs. Hormone therapy for prostate cancer or prostate cancer that has spread to the bones can weaken a patient’s bones and lead to bone pain and an increased risk of fractures (breaks). The following bone-modifying drugs may be used to strengthen bone and reduce pain and fractures for men with prostate cancer.
Zoledronic acid (Zometa). Given by injection, zoledronic acid reduces the level of calcium in the blood and causes fewer bone complications (such as pain, fracture, and need for surgery) from metastases. A high calcium level is called hypercalcemia and is sometimes found in men with advanced prostate cancer.
Denosumab (Prolia). Recent research has looked at the use of denosumab to help slow the damage to bone from metastases and reduce bone side effects for men with castration-resistant prostate cancer. Results indicate that denosumab may be more effective at protecting the bones than zoledronic acid.
A possible condition associated with bone-modifying drugs is osteonecrosis of the jaw. It is an uncommon but serious condition. The symptoms of osteonecrosis of the jaw include pain, swelling, and infection of the jaw; loose teeth; and exposed bone.
Hormone therapy. Some types of hormone therapy may be used to treat advanced cancer. Recent research has looked at the use of the drug abiraterone along with hormone therapy. Abiraterone blocks the production of testosterone, which means that this drug combined with hormone therapy may be more effective to stop prostate cancer growth. In addition, the drug enzalutamide (XTANDI Capsules) was recently approved for men with metastatic castration-resistant prostate cancer who previously received docetaxel.
For many patients, a diagnosis of metastatic cancer can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
If treatment fails
Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.
This diagnosis is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.
Palliative care given toward the end of a person’s life is called hospice care. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.
Doctors and scientists are always looking for better ways to treat patients with prostate cancer. To make scientific advances, doctors create research studies involving people, called clinical trials.
Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. If they do not receive the new treatment being studied, patients will still receive the current standard treatment.
There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating prostate cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future men with prostate cancer.
Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants.
To join a clinical trial, patients participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, the schedule of treatment, and the costs they may need to pay.
Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trials before it ends.
Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.
Common side effects from each treatment option for prostate cancer are described in detail within the Treatment section. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.
Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with prostate cancer.
In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies.
During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care.
After treatment for prostate cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.
Men recovering from prostate cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level.
Doctors are working to learn more about prostate cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.
Finding causes of prostate cancer. Researchers continue to explore the link between nutrition and lifestyle factors in the development of prostate cancer.
Early detection. Researchers are developing a better PSA test, either a more specific and precise test or another test altogether. Researchers are also looking at a urine test to find a substance called prostate cancer gene 3 (PCA3) to help find prostate cancer. Because PCA3 is made by the body in larger amounts when a man has prostate cancer, doctors could use the test to decide if a man needs a prostate biopsy. With improved testing, more healthy men could be screened for prostate cancer, so more prostate cancers can be found and treated early.
Improved surgical techniques. Better techniques for nerve-sparing surgery can improve the likelihood that men who need radical prostatectomy keep their urinary continence and sexual function after surgery.
Shorter radiation therapy schedules. With better, more precise external-beam radiation therapy, researchers are exploring much shorter and more convenient treatment schedules. Instead of 40 treatments, researchers are evaluating 28, 12, or only five treatments.
High-intensity focused ultrasound (HIFU). This procedure, which is still being researched in the United States, uses transrectal ultrasound to heat and destroy cancer cells.
Tests that evaluate the success of treatment. Circulating tumor cells (cells that have broken free of the tumor) can be used to monitor the effectiveness of treatment; this test uses a patient’s blood sample to collect the circulating tumor cells.
Improved therapy for advanced prostate cancer. Researchers are exploring different treatment options for advanced prostate cancer through a series of clinical trials including special targeted drugs, chemotherapy, hormone therapy, and immunotherapy options are being tested in clinical trials.
Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current prostate cancer treatments in order to improve patients’ comfort and quality of life.