Overview

Prostate cancer is the most commonly diagnosed cancer in U.S. men. If you have been diagnosed with advanced (stage III or stage IV) prostate cancer, you probably have many questions and concerns about treatment. This treatment summary, which is based on the NCCN Clinical Practice Guidelines in Oncology™, will help you understand the best available treatments for advanced prostate cancer. Talk to your doctor about these options so that together you can decide on the best treatment plan for you.

Background

The prostate gland lies just below the bladder and produces a fluid that forms part of the semen. Men over 65, men with a family history of prostate cancer, and men of African descent are at higher risk for prostate cancer than are other men.

Prostate cancer is often detected at a very early stage with the prostate-specific antigen (PSA) blood test and digital rectal examination (DRE). These two procedures can also detect advanced prostate cancer that has not been diagnosed earlier.

Advanced prostate cancer is a later stage cancer that has spread outside of the prostate tissue. Stage III and stage IV prostate cancer may be locally advanced (spread to areas surrounding the prostate) or metastatic (spread to other organs, frequently the bones). In addition, advanced cancer can refer to prostate cancer that has come back (recurred) after treatment.

For treatment of prostate cancer that is confined to the prostate, see Prostate Cancer - Localized.

Diagnosis

When a man has symptoms that could indicate prostate cancer, or has been previously treated for prostate cancer, a specimen of prostate tissue is removed for biopsy (examination under a microscope to see whether cancer is present).  If prostate cancer is present, it will be given a grade, which is based on how closely the cells from the tissue sample look like normal prostate cells under a microscope. The most commonly used grading system for prostate cancer is called the Gleason score, which ranges from 2 to 10. Generally, the higher the Gleason score, the more likely it is that the tumor is growing rapidly and/or has spread to other parts of the body.

Staging

A formal system called staging is used to identify how widespread your cancer is. Doctors divide prostate cancer into stages I to IV, with each stage characterizing the size of the tumor and whether and how much it has spread to other parts of the body. Imaging tests, such as magnetic resonance imaging (MRI), computed tomography (CT) scan, or bone scan, may be conducted to determine whether and where the cancer has spread beyond the prostate. Advanced prostate cancer is either stage III or stage IV; disease that has spread beyond the prostate to surrounding tissues or distant organs.

For a more detailed discussion of staging, see the Cancer Staging Guide.

Treatment

Before deciding on treatment, you and your doctor must consider:

• The risk (likelihood) of the cancer recurring (coming back) or progressing after treatment, which is predicted by stage, Gleason score, and PSA level; locally advanced prostate cancer (it has spread to the lymph nodes but not to distant organs) typically has a high risk of coming back; metastatic prostate cancer (it has spread to distant organs, often bones) is not curable, but can be treated to give you a longer, higher quality life.
• Your general health, including other diseases you may have that could make certain treatments risky or unnecessary
• The potential side effects of treatment
• Your personal preferences

Your doctor should provide you with a written care plan explaining what treatments you will have, when they will occur (and how often, if you are receiving radiation), and what type of side effects you may experience.  Some of the side effects can be anticipated and you can get pretreatment to minimize them.  You will be asked to sign an informed consent indicating that you have been told about your treatment and what to expect.  It is very important that you ask your doctor or nurse every question you have.  Cancer and its treatment are complicated, and most patients have questions.

Treatment for advanced prostate cancer can include a number of options, including external beam radiation therapy, androgen-deprivation therapy, and chemotherapy.

External Beam Radiation Therapy (EBRT)

In EBRT, high-energy rays are used to kill the prostate cancer cells and shrink the tumor.  This is appropriate for men with locally advanced prostate cancer.  The equipment used is similar to an X-ray machine and the treatment is usually performed on an outpatient basis. EBRT is usually given in combination with androgen-deprivation therapy (ADT; see next section) for patients with advanced prostate cancer that has not spread to a distant organ. Radiation therapy is also used to help control bone metastases. 

With EBRT, the risks for bladder obstruction and bladder control problems are low.  In the short term, the risk of erectile dysfunction (impotence) is also low, but problems with impotence may occur later.  In addition, other side effects can happen long after treatment is completed and last for an undetermined amount of time.  These may include urinary or bowel problems involving frequency, urgency, or pain.

Androgen Deprivation Therapy (ADT or Hormone Therapy)

Prostate cancer cells need male hormones, called androgens (e.g., testosterone), to grow. Blocking the hormones with androgen deprivation therapy (also known as ADT or hormone therapy) can slow tumor growth or shrink the tumor. This is usually accomplished with drugs called luteinizing hormone-releasing hormone (LHRH) agonists, which prevent the testicles from making more testosterone. ADT controls tumor growth for variable amounts of time in different patients.  Although it has significant side effects, ADT is the principal treatment for advanced prostate cancer.  Testosterone can also be blocked by removal of the testicles (a surgical procedure called orchiectomy).

ADT may be given for a short time (4 to 6 months) or long term (2 to 3 years). ADT, usually in combination with EBRT, is the treatment of choice for patients with high risk of recurrence or locally advanced disease. Long-term ADT alone is often given to patients with metastatic cancer. 

If long-term ADT is recommended for you, your doctor may speak with you about the possibility of intermittent ADT.  If this is right for you, you will receive between 6 and 18 months of ADT, stopping when your PSA is less than 4 and starting again when your PSA rises to more than 10, 20, or 40.  While you are receiving this treatment, your doctor will monitor you every 3 to 6 months.  Evidence from studies suggests that patients live as long when ADT is given intermittently as when it is given continuously.  Of course, if you develop symptoms between scheduled doctor visits, you should let your doctor know immediately.

Drugs called antiandrogens, which block the effect of male hormones in the body, are sometimes used with LHRH agonists. Their effectiveness, however, has not been proven, so get more information from your doctor about this treatment if it is recommended.

ADT can help slow tumor growth for a limited amount of time, but it does not cure the disease and causes impotence. Some doctors use the intermittent or “on-off” approach described above to try to manage impotence. There are also other ways to manage and live well with impotence, so it is important to talk to your doctor about them. ADT also has other potential side effects such as increased risk of osteoporosis, diabetes, and cardiovascular disease. Be sure to talk to your doctor about these risks before starting treatment.

Chemotherapy

Drugs that limit the growth and survival of cancer cells may be used when the cells continue to spread to distant organs (such as the bones) despite use of ADT. Common chemotherapy drugs given (usually in combinations) include docetaxel, prednisone, estramustine, and mitoxantrone. Your doctor can find a listing of the chemotherapy regimens in the Prostate Cancer NCCN Clinical Practice Guidelines in Oncology™.

If your cancer responds to chemotherapy, it may extend the length of your life.  However, chemotherapy also produces significant side effects that can worsen the quality of your life.  Because many of these side effects can be anticipated and reduced with other treatments, you should always speak with your doctor or nurse about side effects you may be experiencing.

Life After Treatment

Because prostate cancer can come back even after treatment, follow-up care is very important. Make sure to see your doctor for an exam and PSA testing at regular, agreed-upon intervals, typically every 3 to 6 months. If you have metastatic cancer (disease that has spread to other parts of the body), you may need to see the doctor more frequently.

Prognosis

In determining a prognosis (the likely course or outcome of a disease and its treatment), a doctor may look at cancer survival statistics taken from studies of large groups of patients. However, these statistics:

• Are estimates only
• Can vary widely with each cancer stage
• Are sometimes based on older data that do not reflect recent advances in early detection and treatment
• Cannot be used to precisely predict your survival

Your individual prognosis will be affected by many factors, including:

• Your age
• Your overall health
• The type, stage, grade, and other characteristics of your cancer
• Your response to the treatment(s) being used

New therapies and combinations of therapies are enabling people with cancer to live longer, better quality lives than ever before. Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life. You may want to find out whether you are eligible to participate in a clinical trial in which new and experimental therapies are compared against standard treatments.