Cancer That Is Thought To Still Be In Or Around The Prostate
If the cancer is still thought to be just in the area of the prostate, a second attempt to cure it might be possible.
After surgery: If youve had a radical prostatectomy, radiation therapy might be an option, sometimes along with hormone therapy.
After radiation therapy: If your first treatment was radiation, treatment options might include cryotherapy or radical prostatectomy, but when these treatments are done after radiation, they carry a higher risk for side effects such as incontinence. Having radiation therapy again is usually not an option because of the increased potential for serious side effects, although in some cases brachytherapy may be an option as a second treatment after external radiation.
Sometimes it might not be clear exactly where the remaining cancer is in the body. If the only sign of cancer recurrence is a rising PSA level , another option for some men might be active surveillance instead of active treatment. Prostate cancer often grows slowly, so even if it does come back, it might not cause problems for many years, at which time further treatment could then be considered.
Factors such as how quickly the PSA is going up and the original Gleason score of the cancer can help predict how soon the cancer might show up in distant parts of the body and cause problems. If the PSA is going up very quickly, some doctors might recommend that you start treatment even before the cancer can be seen on tests or causes symptoms.
In Five Years A Major Treatment Shift
In men diagnosed with metastatic hormone-sensitive prostate cancer, the cancer is typically driven to grow and spread by androgens that are produced largely in the testes. For many years, treatments that block androgen production have been a mainstay for men initially diagnosed with metastatic prostate cancer.
Starting in 2014, that began to change after a large clinical trial showed that adding the chemotherapy drug docetaxel to ADT improved how long men with hormone-responsive disease lived. Shortly after, another clinical trial showed that adding abiraterone to ADT also improved survival in these men, although primarily in men with many metastatic tumors, known as high-volume disease.
However, docetaxel, which works by directly killing cancer cells, can have substantial side effects, and some patients arent healthy enough to tolerate it. And abirateronewhich blocks androgen production throughout the bodycan also cause side effects, including those that affect the liver. It also has to be given in combination with the steroid prednisone, which carries its own toxicity.
Doing so, Dr. Chi said during a presentation of the TITAN data at the ASCO meeting, might help stave off the typically inevitable development of hormone-resistant cancer, which is more difficult to treat and a key driver of prostate cancer deaths.
Physical Emotional And Social Effects Of Cancer
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.
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Standards Of Care In Hormone Therapy
Most doctors agree that hormone therapy is the most effective treatment available for patients with advanced prostate cancer. However, there is disagreement on exactly how and when hormone therapy should be used. Here are a few issues regarding standards of care:
Timing of Cancer Treatment
The disagreement is due to conflicting beliefs. One is that hormone therapy should begin only after symptoms from the metastases, like bone pain, occur. The counter belief is that hormone therapy should start before symptoms occur. Earlier treatment of prostate cancer is associated with a lower incidence of spinal cord compression, obstructive urinary problems, and skeletal fractures. However, survival is not different whether treatment is started early, or deferred.
The only exception to the above, is in lymph node-positive, post-prostatectomy patients, given androgen deprivation as an adjuvant immediately after surgery. In this situation, immediate therapy resulted in a significant improvement in progression free survival, prostate cancer specific survival, and overall survival.
Length of Cancer Treatment
The disagreement in this situation is between continuous androgen deprivation and intermittent androgen deprivation.
Combination vs. Single-Drug Therapy
Parp Inhibitors For Prostate Cancer
A PARP inhibitor is a substance that blocks an enzyme in cells called PARP. PARP helps repair DNA when it becomes damaged. Some prostate tumors have genetic defects that limit their ability to repair DNA damage. Such tumors may be sensitive to PARP inhibitors.
Two PARP inhibitors, olaparib and rucaparib , have been approved for some men whose prostate cancer has metastasized, and whose disease has stopped responding to standard hormone treatments.
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Treatments For Prostate Cancer
If you have prostate cancer, your healthcare team will create a treatment plan just for you. It will be based on your health and specific information about the cancer. When deciding which treatments to offer for prostate cancer, your healthcare team will consider:
- the type and stage of the cancer
- the grade or Gleason score
- prostate-specific antigen levels
- your overall health and any existing medical conditions
- your age and life expectancy
- whether you have symptoms
Prostate cancer treatments can seriously affect your quality of life and cause side effects such as erectile dysfunction and incontinence . Many prostate cancers grow slowly and cause no symptoms or problems.
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Impact On Everyday Care
Fatima Karzai, M.D., of the Genitourinary Malignancies Branch in NCIs Center for Cancer Research, called relugolix an exciting option for men with advanced prostate cancer. Its most obvious role will be in men with advanced prostate cancer who also have cardiovascular disease, Dr. Karzai said.
Although trial participants who received relugolix had a more than 50% lower risk of serious cardiac events, she said its unclear exactly why it poses less of a threat to the heart. Some studies have suggested, she noted, that the difference in how the two drugs work may also influence how they affect plaque deposits in the cardiovascular system.
Relugolix is not the first GnRH antagonist to be approved by FDA to treat men with advanced prostate cancer. Degarelix was approved more than a decade ago. However, degarelix is given as a monthly injection, and the injections can cause intense pain at the injection site, greatly limiting its use.
Dr. Karzai noted that there are still questions about using relugolix in patient care. For example, there might be problems with mens ability to take a pill every day, as opposed to only having to get an injection of leuprolide or related drugs every few months.
Dr. Morgans agreed that this could be a concern but noted that men with more advanced forms of prostate cancer also receive other drugs that are taken as pills and have been generally good about using them as prescribed.
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Studying Early Detection For Men At High Risk
Men with certain inheritedgenetic traits are at increased risk for developing prostate cancer. Examples of such traits include inherited BRCA gene mutations and Lynch syndrome. No clear guidelines exist for when or howor ifto screen men at high genetic risk for prostate cancer.
NCI researchers are using magnetic resonance imaging of the prostate in men at high risk to learn more about how often and how early these cancers occur. Theyre also testing whether regular scans in such men can detect cancers early, before they spread elsewhere in the body .
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More Options Lead To More Questions
Elisabeth Heath, M.D., director of prostate cancer research at Karmanos Cancer Institute in Detroit, agreed that the ARASENS results should have an immediate impact on how this form of the disease is treated.
Speaking at the ASCO symposium, Dr. Heath, who was not involved in the study, highlighted an important difference between ARASENS and other trials that tested androgen receptorblocking drugs in men with this form of prostate cancer. In those other trials, she explained, some participants received docetaxel prior to treatment with the androgen receptorblocking drugs rather than at the same time.
Based on the ARASENS results, Dr. Heath said, giving all three treatments simultaneously looks to be the preferred option for some patients.
Dr. Karzai noted that despite there being multiple options to treat metastatic hormone-sensitive prostate cancer, many questions remain. We don’t have guidelines on who should start with what drug and whether one drug is better than another for a patient, she said.
She also pointed out that more research is needed on how the order in which the drugs are given impact their effectiveness and the frequency of side effects.
Additionally, she said, the survival improvement in the ARASENS trial was seen in patients whose cancer had spread in multiple areas beyond the prostate .
We dont know if people with lower-volume benefit from as much as the patients with higher-volume disease do, she said.
Treatment For Metastatic Prostate Cancer
Treatment for metastatic or advanced prostate cancer can help to reduce symptoms, make you feel better and help you to live longer. Common treatments include chemotherapy and hormone therapy.
This section is about treatment for prostate cancer that has spread to another part of the body. We have separate information about treatment for cancer that hasn’t spread to another part of the body.
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Duke Cancer Center Offers New Treatment For Metastatic Prostate Cancer
Terence Wong, MD, PhD, and Stacy Wood, a Duke Health nuclear medicine technologist, provides treatment to a patient.
Men with advanced metastatic prostate cancer that has not responded to other treatments may now benefit from a new radiopharmaceutical treatment called PLUVICTOTM . Duke is one of the first cancer centers in the Southeastern region to offer PLUVICTOTM following its FDA approval in March 2022. Studies show it can extend the lives of people with this aggressive form of prostate cancer, even in the late stages, said Terence Wong MD, PhD, a nuclear radiologist at Duke Health.
Future Directions For Genetic Testing
Simmons Cancer Center offers comprehensive integrative care for all oncology patients, including the latest advances in genetic testing. One area of active research at Simmons is evaluating the utility of genetic testing to assess the hereditary risk of cancer. Several gaps in genetic testing exist today, including gender inequities, such as the ratio of women to men acquiring testing . Other gaps include African American men having a higher lifetime risk of developing prostate cancer, and lack of education among patients and referring physicians on the availability and costs of testing. Around 90% of patients who meet their insurance criteria for testing end up paying less than $100 out-of-pocket, and the cost is only $250 for patients who pay 100% out-of-pocket.
The most significant risk factors for contracting prostate cancer are age, race, and family history, and there are several key reasons to have genetic testing performed based on these risk factors. Primarily, having a first-degree relative with prostate cancer will put men in the same family at about a 30% higher risk of developing the malignancy. Additionally, outcomes for patients could be improved if they better understand their genetic risk, often allowing them to adopt lifestyle changes based on results. Lastly, genetic testing may help inform selection of specific gene therapies.
Footnotes
1. How common is prostate cancer? Cancer.org website. Updated January 8, 2020. Accessed July 28, 2020.
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Treatment By Stage Of Prostate Cancer
Different treatments may be recommended for each stage of prostate cancer. Your doctor will work with you to develop a specific treatment plan based on the cancers stage and other factors. Detailed descriptions of each type of treatment are provided earlier on this same page. Clinical trials may also be a treatment option for each stage.
Early-stage prostate cancer
Early-stage prostate cancer usually grows very slowly and may take years to cause any symptoms or other health problems, if it ever does at all. As a result, active surveillance or watchful waiting may be recommended. Radiation therapy or surgery may also be suggested, as well as treatment in clinical trials. For those with a higher Gleason score, the cancer may be faster growing, so radical prostatectomy and radiation therapy are often recommended. Your doctor will consider your age and general health before recommending a treatment plan.
ASCO, the American Urological Association, American Society of Radiation Oncology, and the Society of Urologic Oncology recommend that patients with high-risk early-stage prostate cancer that has not spread to other areas of the body should receive radical prostatectomy or radiation therapy with hormonal therapy as standard treatment options.
Locally advanced prostate cancer
Watchful waiting may be considered for older adults who are not expected to live for a long time and whose cancer is not causing symptoms or for those who have another, more serious illness.
Cancer That Clearly Has Spread
If the cancer has spread outside the prostate, it will most likely go to nearby lymph nodes first, and then to bones. Much less often the cancer will spread to the liver or other organs.
When prostate cancer has spread to other parts of the body , hormone therapy is probably the most effective treatment. But it isnt likely to cure the cancer, and at some point it might stop working. Usually the first treatment is a luteinizing hormone-releasing hormone agonist, LHRH antagonist, or orchiectomy, sometimes along with an anti-androgen drug or abiraterone. Another option might be to get chemotherapy along with the hormone therapy. Other treatments aimed at bone metastases might be used as well.
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Remission And The Chance Of Recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someone’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA recurrence or biochemical recurrence.
Improvements For Localized Cancers
There have been breakthroughs in the treatment of earlier-stage prostate cancers, too, which help to reduce the number of advanced cases in the long run. With respect to localized prostate cancer, one significant development has been the advent and expansion of active surveillance as a treatment option for men with low-risk prostate cancer, explains Dr. Haywood. For men with low-risk and very-low risk prostate cancer, this strategy avoids side effects of prostate cancer treatment while maintaining the ability to deliver definitive therapy when conditions dictate.
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Just One Weapon Against Cancer
Before treatment with PLUVICTOTM is recommended, patients undergo a PSMA-PET/CT scan to determine if their tumor contains the PSMA target. If it does not, PLUVICTOTM would not be appropriate, explained Dr. Wong. At Duke we treat you as an individual. Each case is discussed among a multidisciplinary team of surgeons, radiation oncologists, medical oncologists, radiologists, and nuclear medicine specialists. He emphasized that PLUVICTOTM is not for everyone and is just one weapon in the arsenal for fighting cancer. Our team will determine how and if this new option fits in with all the others we offer.
Duke can provide PLUVICTOTM and other novel treatments because it is a Comprehensive Cancer Center with the latest advances in diagnosing and treating prostate cancer. Duke is also recognized as a Comprehensive Radiopharmaceutical Therapy Center of Excellence, which requires strict adherence to safety and treatment criteria that ensures the best care for patients.