The first decision is whether treatment is needed. Low-grade forms found in elderly men often grow so slowly that treatment is not required. Treatment may be inappropriate if a person has other serious health problems or is not expected to live long enough for symptoms to appear. Approaches in which treatment is postponed are termed "expectant management". Expectant management is divided into two approaches: Watchful waiting, which has palliative intent (aims to treat symptoms only), and active surveillance, which has curative intent (aims to prevent the cancer from advancing). Which option is best depends on disease stage, the Gleason score, and the PSA level. Other important factors are age, general health and a person's views about potential treatments and their possible side effects. Because most treatments can have significant side effects, such as erectile dysfunction and urinary incontinence, treatment discussions often focus on balancing the goals of therapy with the risks of lifestyle alterations. A 2017 review found that more research focused on person-centered outcomes is needed to guide patients. A combination of treatment options is often recommended. Guidelines for specific clinical situations require estimation of life expectancy. As average life expectancy increases due to advances in the treatment of other diseases, more patients will live long enough for their<unk>  to express symptoms. An 18-item questionnaire was proposed to learn whether patients have adequate knowledge and understanding of their treatment options. In one 2015 study, most of those who were newly diagnosed correctly answered fewer than half of the questions. The widespread use of PSA screening in the US has resulted in diagnosis at earlier age and cancer stage, but almost all cases are still diagnosed after age 65, while about 25% are diagnosed after age 75. Though US National Comprehensive Cancer Network guidelines recommend using life expectancy to help make treatment decisions, in practice, many elderly patients are not offered curative treatment options such as radical<unk> ctomy or radiation therapy and are instead treated with hormonal therapy or watchful waiting. Surveillance Many men diagnosed with low-risk<unk>  are eligible for active surveillance. The tumor is carefully observed over time, with the intention of initiating treatment if signs of progression appear. Active surveillance is not synonymous with watchful waiting, a term which implies no treatment or specific program of monitoring, with the assumption that only palliative treatment would be used if advanced, symptomatic disease develops. Active surveillance involves monitoring the tumor for growth or symptoms, which trigger treatment. The monitoring process may involve PSA tests, digital rectal examination, or repeated biopsies every few months. The goal of active surveillance is to postpone treatment, and avoid overtreatment and its side effects, given a slow-growing or self-limited tumor that in most people is unlikely to cause problems. This approach is not used for aggressive cancers, and may cause anxiety for people who wrongly believe that all cancers are deadly or that their condition is life-threatening. Between 50 and 75% of patients die from other causes without experiencing<unk>  symptoms. In localized disease, based on long-term follow-up, radical<unk> ctomy results in significantly improved oncological outcomes when compared with watchful waiting.<unk> ctomy is associated with increased rates of urinary incontinence and erectile dysfunction, but these findings are based primarily on men diagnosed before widespread PSA screening and cannot be highly generalized. When compared to active monitoring/surveillance, on follow-up at ten years, radical<unk> ctomy probably has similar outcomes for disease-specific survival and probably reduces risk of disease progression and spreading. Urinary and sexual function are probably decreased in patients treated with radical<unk> ctomy. Active treatment Both surgical and nonsurgical treatments are available, but treatment can be difficult, and combinations can be used. Treatment by external beam radiation therapy, brachytherapy, cryosurgery, high-intensity focused ultrasound, and<unk> ctomy are, in general, offered to men whose cancer remains within the<unk> . Hormonal therapy and chemotherapy are often reserved for metastatic disease. Exceptions include local or metastasis-directed therapy with radiation may be used for advanced tumors with limited metastasis. Hormonal therapy is used for some early-stage tumors. Cryotherapy (the process of freezing the tumor), hormonal therapy, and chemotherapy may be offered if initial treatment fails and the cancer progresses. Sipuleucel-T, a cancer vaccine, was reported to offer a four-month increase in survival in metastatic<unk> , but the marketing authorisation for it was withdrawn on 19 May 2015. If radiation therapy fails, radical<unk> ctomy may be an option, though it is a technically challenging surgery. However, radiation therapy after surgical failure may have many complications. It is associated with a small increase in bladder and colon cancer. Radiotherapy and surgery appear to result in similar outcomes with respect to bowel, erectile and urinary function after five years. Nonsurgical treatment Non-surgical treatment may involve radiation therapy, chemotherapy, hormonal therapy, external beam radiation therapy, and particle therapy, high-intensity focused ultrasound, or some combination.<unk>  that persists when testosterone levels are lowered by hormonal therapy is called castrate-resistant<unk>  (CRPC). Many early-stage cancers need normal levels of testosterone to grow, but CRPC does not. Previously considered "hormone-refractory<unk> " or "androgen-independent<unk> ", the term CRPC emerged because these cancers show reliance upon hormones, particularly testosterone, for androgen receptor activation. The cancer chemotherapeutic docetaxel has been used as treatment for CRPC with a median survival benefit of 2 to 3 months. A second-line chemotherapy treatment is cabazitaxel. A combination of bevacizumab, docetaxel, thalidomide and prednisone appears effective in the treatment of CRPC. Immunotherapy treatment with sipuleucel-T in CRPC appeared to increase survival by four months. However, marketing authorisation for sipuleucel-T was withdrawn on 19 May 2015. The second line hormonal therapy abiraterone increases survival by about 4.6 months. Enzalutamide is another second line hormonal agent with a five-month survival advantage. Both abiraterone and enzalutamide are currently in clinical trials in those with CRPC who have not previously received chemotherapy. Not all patients respond to androgen signaling-blocking drugs. Certain cells with characteristics resembling stem cells remain unaffected. Therefore, the desire to improve CRPC outcomes resulted in increasing doses or combination therapy with synergistic androgen-signaling blocking agents. But even these combination will not affect stem-like cells that do not exhibit androgen signaling. For patients with metastatic<unk>  that has spread to their bones, doctors use a variety of bone-modifying agents to prevent skeletal complications and support the formation of new bone mass. Zoledronic acid (a bisphosphonate) and denosumab (a RANK-ligand-inhibitor) appear to be effective agents, but are associated with more frequent and serious adverse events. Surgery Radical<unk> ctomy is considered the mainstay of surgical treatment of<unk> , where the surgeon removes the<unk> , seminal vesicles, and surrounding lymph nodes. It can be done by an open technique (a skin incision at the lower abdomen), or laparoscopically. Radical retropubic<unk> ctomy is the most commonly used open surgical technique. Robotic-assisted<unk> ctomy has become common. Men with localized<unk> , having laparoscopic radical<unk> ctomy or robotic-assisted radical<unk> ctomy, might have shorter stays in the hospital and get fewer blood transfusions than men undergoing open radical<unk> ctomy. How these treatments compare with regards to overall survival or recurrence-free survival is unknown. Transurethral resection of the<unk>  is the standard surgical treatment for benign enlargement of the<unk> . In<unk> , this procedure can be used to relieve symptoms of urinary retention caused by a large<unk>  tumor, but it is not used to treat the cancer itself. The procedure is done under spinal anesthesia, a resectoscope is inserted inside the penis and the extra<unk> c tissue is cut to clear the way for the urine to pass. Complications The two main complications encountered after<unk> ctomy and<unk>  radiotherapy are erectile dysfunction and urinary incontinence, mainly stress-type. Most men regain continence within 6 to 12 months after the operation, so doctors usually wait at least one year before resorting to invasive treatments. Stress urinary incontinence usually happens after<unk>  surgery or radiation therapy due to factors that include damage to the urethral sphincter or surrounding tissue and nerves. The<unk>  surrounds the urethra, a muscular tube that closes the urinary bladder. Any of the mentioned reasons can lead to incompetent closure of the urethra and hence incontinence. Initial therapy includes bladder training, lifestyle changes, kegel exercises, and the use of incontinence pads. More invasive surgical treatment can include the insertion of a urethral sling or an artificial urinary sphincter, which is a mechanical device that mimics the function of the urethral sphincter, and is activated manually by the patient through a switch implanted in the scrotum. The latter is considered the gold standard in patients with moderate or severe stress urinary incontinence. Erectile dysfunction happens in different degrees in nearly all men who undergo<unk>  treatment, including radiotherapy or surgery; however, within one year, most of them will notice improvement. If nerves were damaged, this progress may not take place. Pharmacological treatment includes PDE-5 inhibitors such as viagra or cialis, or injectable intracavernous drugs injected directly into the penis (prostaglandin E1 and vasoactive drug mixtures). Other nonpharmacological therapy includes vacuum constriction devices
Prostate cancer
Benign prostatic hyperplasia
Bladder cancer
Penile cancer
Testicular cancer
Urethral cancer
Breast cancer
Kidney cancer