Treating Localised Prostate Cancer

Localised prostate cancer is cancer that is still contained within the prostate. Because many of these cancers grow slowly, there is often no need to rush, and there is usually more than one reasonable option. The right choice depends on the cancer’s risk category, your age and general health, and your own priorities — particularly how you weigh cancer control against the possible effects on urinary, bowel and sexual function. This is a shared decision, and taking time over it is entirely appropriate.

For low-risk and some favourable intermediate-risk cancers, the safest choice is often not to treat straight away, but to monitor the cancer closely and treat only if it shows signs of becoming more aggressive. This is called active surveillance, and it is a deliberate strategy — not a decision to do nothing.

Monitoring typically involves regular PSA blood tests, periodic MRI scans, and repeat biopsies when needed. The great advantage is that it avoids or delays the side effects of treatment for men whose cancer may never cause them harm. If monitoring shows the cancer is progressing, treatment can still be given with the intent to cure.

There is a small chance that, over time, the cancer grows towards the nerves that run alongside the prostate (the neurovascular bundle, which controls erections). If that happens, it can affect whether those nerves can be spared at surgery, and therefore erections afterwards. The risk of the cancer spreading to other parts of the body while on active surveillance is uncommon.

Surgery to remove the whole prostate is called a radical prostatectomy. It is most commonly performed using robot-assisted keyhole surgery, which allows precise movements through small incisions — meaning less blood loss and a quicker recovery than open surgery. Where the cancer allows, nerve-sparing techniques aim to preserve the nerves responsible for erections. Techniques such as bladder neck preservation and maximising urethral length help with the recovery of urinary control, and a surgical approach called Retzius-sparing prostatectomy can help continence return sooner.

Surgery removes the cancer in one operation and provides precise information about the cancer from the tissue that is removed. The main early trade-off is a period of urinary leakage. Some men are pad-free within a few weeks, and most by six weeks to six months, though this depends on patient factors (age, weight, prostate size, urethral length) and on the cancer (whether the bladder neck can be preserved and urethral length maintained). Erection quality after surgery is generally not as good as before, and depends on your function beforehand, your age, and whether the nerves can be preserved without compromising cancer control.

Radiation treats the cancer without removing the prostate, and is an equally valid curative option for many men. External beam radiotherapy directs carefully shaped radiation at the prostate from outside the body, over a number of sessions.

For intermediate- and high-risk disease, radiation is often combined with a period of hormone therapy to improve its effectiveness. Radiation avoids an operation and tends to have less early effect on urinary control, but can cause urinary, bowel or sexual side effects that may worsen over time. Other effects can include scar-tissue formation and a less stretchy bladder, which may cause urinary frequency, urgency, passing small amounts of urine, and, occasionally, significant blood in the urine.

Hormone therapy uses drugs to block testosterone. Its side effects can include hot flushes, erectile difficulties, fatigue, some effect on memory and concentration, reduced sex drive, and a small increase in cardiovascular events.

Focal therapy treats only the part of the prostate that contains the cancer, rather than the whole gland, using energy such as heat, cold or electrical pulses to destroy the tumour. Because it spares much of the normal prostate, it aims to reduce the effect on urinary and sexual function.

Focal ablation is suitable only for carefully selected men — typically those with a single, well-defined area of intermediate-risk cancer — and requires close monitoring afterwards, because cancer can occasionally remain or return elsewhere in the prostate. It is a developing field, and your suitability is assessed individually.

For many men with localised prostate cancer, surveillance, surgery and radiation offer broadly similar long-term cancer control, so the decision often comes down to the differing side-effect profiles and your personal preferences. It is reasonable to ask to discuss your case with both a surgeon and a radiation oncologist before deciding.

The table is a general guide only; your own situation may differ.