Editing Prostate cancer (section)

=== Localized disease ===
[[File:External beam radiotherapy NCI.jpg|thumb|alt=A person lays on a table under a large machine.|Setup for radiation therapy. The person lies flat while a radiation beam is focused on the tumor site.]]
Men diagnosed with low-risk cases of prostate cancer often defer treatment and are monitored regularly for cancer progression by [[active surveillance of prostate cancer|active surveillance]], which involves testing for tumor growth at fixed intervals by PSA tests (around every six months), digital rectal exam (annually), and MRI or repeat biopsies (every one to three years).<ref>{{cite web |url=https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html |accessdate=16 April 2024 |title=Observation or Active Surveillance for Prostate Cancer |publisher=American Cancer Society |date=22 November 2023 |archive-date=16 April 2024 |archive-url=https://web.archive.org/web/20240416172559/https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html |url-status=live }}</ref> This program continues until increases in PSA levels, Gleason grade, or tumor size indicate a higher-risk tumor that may require intervention.{{sfn|Liu|Patel|Haney|Epstein|2021|loc="Reclassification and progression"}} At least half of men remain on active surveillance, never requiring more direct treatment for their prostate tumors.{{sfn|Liu|Patel|Haney|Epstein|2021|loc="Abstract"}}

Those who elect to have therapy receive [[radiation therapy]] or a [[prostatectomy]]; these have similar rates of cancer control, but different side effects.{{sfn|Rebello|Oing|Knudsen|Loeb|2021|loc="Localized Disease"}}{{sfn|Scher|Eastham|2022|loc="Clinically localized prostate cancer"}} Radiation can be delivered by [[Radiation therapy#Intensity-modulated radiation therapy (IMRT)|intensity-modulated radiation therapy]] (IMRT), which allows for high doses (greater than 80 [[Gray (unit)|Gy]]) to be delivered to the prostate with relatively little radiation to other organs, or by [[brachytherapy]], where a radioactive source is surgically inserted into the prostate.{{sfn|Scher|Eastham|2022|loc="External beam radiation therapy"}}{{sfn|Scher|Eastham|2022|loc="Brachytherapy"}} IMRT is given over several sessions, with treatments repeated five days per week for several weeks. Brachytherapy is typically performed in a single session, with the radioactive source permanently implanted into the prostate, where it expends its radioactivity within the next few months.<ref>{{cite web |url=https://www.cancer.org/cancer/types/prostate-cancer/treating/radiation-therapy.html |accessdate=5 December 2023 |title=Radiation Therapy for Prostate Cancer |publisher=American Cancer Society |date=13 February 2023 |archive-date=5 December 2023 |archive-url=https://web.archive.org/web/20231205211228/https://www.cancer.org/cancer/types/prostate-cancer/treating/radiation-therapy.html |url-status=live }}</ref> With either technique, radiation damage to nearby organs can increase the risk of subsequent [[bladder cancer]] and cause [[erectile dysfunction]], [[infertility]], [[Radiation-induced lumbar plexopathy|irreversible lumbar plexopathy]]<ref>{{cite journal |last1=Brejt |first1=Nick |last2=Berry |first2=Jonathan |last3=Nisbet |first3=Angus |last4=Bloomfield |first4=David |last5=Burkill |first5=Guy |title=Pelvic radiculopathies, lumbosacral plexopathies, and neuropathies in oncologic disease: a multidisciplinary approach to a diagnostic challenge |journal=Cancer Imaging |date=December 30, 2013 |volume=13 |issue=4 |pages=591–601 |doi=10.1102/1470-7330.2013.0052 |pmid=24433993 |pmc=3893894}}</ref> and [[radiation proctitis]] – damage to the rectum that can cause [[diarrhea]], [[blood in stool|bloody stools]], [[fecal incontinence]], and pain.{{sfn|Brawley|Mohan|Nein|2018|loc="Radiation therapy"}}

[[File:Surgeon performing robot-assisted surgery.jpg|thumb|alt=A surgeon sits with his face surrounded by a computer terminal|A surgeon performs robot-assisted surgery.]]
Radical prostatectomy aims to surgically remove the cancerous part of the prostate, along with the seminal vesicles, and the end of the [[vas deferens]] (the duct that delivers sperm from the testes).{{sfn|Dall'Era|2023|loc="Radical prostatectomy"}} In wealthier countries, this is typically done by [[robot-assisted surgery]], where robotic tools inserted through small holes in the abdomen allow a surgeon to make small and exact movements during surgery.{{sfn|Costello|2020|loc="The rise of robotic surgery"}} This method results in shorter hospital stays, less blood loss, and fewer complications than traditional open surgery.{{sfn|Costello|2020|loc="The rise of robotic surgery"}} In places where robot-assisted surgery is unavailable, prostatectomy can be performed [[laparoscopy|laparoscopically]] (using a camera and hand tools through small holes in the abdomen), or through traditional open surgery with an incision above the penis (retropubic approach) or below the scrotum (perineal approach).{{sfn|Scher|Eastham|2022|loc="Radical prostatectomy"}}{{sfn|Costello|2020|loc="The rise of robotic surgery"}} The four approaches result in similar rates of cancer control.{{sfn|Scher|Eastham|2022|loc="Radical prostatectomy"}} Damage to nearby tissue during surgery can result in erectile dysfunction and [[urinary incontinence]]. Erectile dysfunction is more likely in those who are older or had previous erectile issues.{{sfn|Scher|Eastham|2022|loc="Radical prostatectomy"}} Incontinence is more common in those who are older and have shorter [[urethra]]s.{{sfn|Scher|Eastham|2022|loc="Radical prostatectomy"}} Both for cancer progression outcomes and surgical side effects, the skill and experience of the individual surgeon doing the procedure are among the greatest determinants of success.{{sfn|Scher|Eastham|2022|loc="Radical prostatectomy"}}

After prostatectomy, PSA levels drop rapidly, reaching very low or undetectable levels within two months. Radiotherapy also substantially reduces PSA levels, but more slowly and less completely, with PSA levels reaching their nadir two years after radiotherapy.<ref>{{cite web |url=https://www.cancer.org/cancer/types/prostate-cancer/treating/psa-levels-after-treatment.html |accessdate=5 December 2023 |title=Following PSA Levels During and After Prostate Cancer Treatment |publisher=American Cancer Society |date=1 August 2019 |archive-date=7 December 2023 |archive-url=https://web.archive.org/web/20231207065408/https://www.cancer.org/cancer/types/prostate-cancer/treating/psa-levels-after-treatment.html |url-status=live }}</ref> After either treatment, PSA levels are  monitored regularly. Up to half of those treated will eventually have a rise in PSA levels, suggesting the tumor or small metastases are growing again.{{sfn|Rebello|Oing|Knudsen|Loeb|2021|loc="Biochemical recurrence and residual disease"}} People with high or rising PSA levels are often offered another round of radiation therapy directed at the former tumor site. This reduces risk for further progression by 75%.{{sfn|Rebello|Oing|Knudsen|Loeb|2021|loc="Biocehmical recurrence and residual disease"}} Those suspected of metastases can undergo PET scanning with sensitive [[PET radiotracer|radiotracers]] C-11 choline, F-18 fluciclovine, and F-18 or Ga-68 attached to a PSMA-targeting drug, each of which is able to detect small metastases more sensitively than alternative imaging methods.{{sfn|Scher|Eastham|2022|loc="Rising PSA after definitive local therapy"}}{{sfn|Rebello|Oing|Knudsen|Loeb|2021|loc="Biocehmical recurrence and residual disease"}}