Prostate Cancer, Advanced or Metastatic

Your treatment options for prostate cancer that has spread will depend on:

• What kind of cancer cells you have. This is called the Reference grade or Reference Gleason score Opens New Window of your cancer. Some prostate cancer cells grow more quickly than others.
• Your age.
• Any serious health problems you might have, including urinary, bowel, or sexual function problems.
• Your Reference PSA level.

Treatment for Reference locally advanced Opens New Window or Reference metastatic Opens New Window prostate cancer may include hormone therapy, surgery, radiation therapy, chemotherapy, or immunotherapy. Or if you aren't having symptoms, it may include active surveillance or watchful waiting.

You may want to talk with your doctor about entering a Reference clinical trial Opens New Window of new cancer treatment options. A treatment being studied in clinical trials for advanced prostate cancer is high-intensity-focused ultrasound (HIFU). For metastatic prostate cancer, treatments in clinical trials include new forms of chemotherapy and immunotherapy, including vaccines.

Prostate cancer and its treatment may cause nausea, pain, or other side effects. You can manage some side effects Reference at home. If you experience Reference nausea, wait for 1 hour after vomiting has stopped and then sip a Reference rehydration drink Opens New Window to restore lost fluids and nutrients. Your doctor also may prescribe Reference medicines to control nausea and vomiting. Reference Constipation and Reference diarrhea may be eased if you drink enough fluids.

Pain from cancer that has spread to the bones can be managed. If pain becomes a problem, talk to your doctor about seeing a Reference pain management specialist Opens New Window. For tips on handling pain, see:

Reference Reference Cancer: Controlling Cancer Pain.

For more information, see the topic Reference Cancer Pain.

Treatment for locally advanced prostate cancer

Prostate cancer that has spread to tissue around the prostate may be treated with radiation therapy, surgery, or hormone therapy. Sometimes two of these treatments are combined.

Radiation therapy

Reference Radiation therapy uses high-energy X-rays or protons to destroy the cancer. This treatment has improved with newer technologies, so there are fewer side effects and complications than in the past. Radiation therapy usually is combined with hormone therapy.

External beam radiotherapy, or EBRT, uses high-energy rays, such as X-rays, to destroy the cancer. It is usually given in multiple doses over several weeks. Radiation destroys tissue, so it may damage the nerves along the side of the prostate that affect your ability to have an erection. If you already have bowel problems, external radiation may cause your symptoms to get worse.

Three common forms of external radiation are:

• Conformal radiotherapy (3D-CRT). This uses a three-dimensional planning system to target a strong dose of radiation to the prostate cancer. This helps to protect healthy tissue from radiation.
• Intensity modulated radiation therapy (IMRT). This uses newer 3D-CRT technology to target the cancer.
• Proton beam therapy. This is radiation therapy that uses a different type of energy (protons) rather than X-rays. This allows a higher amount of specifically directed radiation, which protects nearby healthy tissues (especially the rectum). Sometimes proton beam therapy is combined with X-ray therapy. (It is available only at big medical centers.)

Surgery

The two most common surgeries are:

• Reference Radical prostatectomy. This operation takes out your prostate gland and the cancer in and around it.
• Reference Transurethral resection of the prostate (TURP) Opens New Window. This surgery can help relieve bladder problems, because it removes part of the tumor that may be blocking the Reference urethra Opens New Window, the tube that carries urine from your bladder through your penis. The procedure is done under Reference general anesthesia Opens New Window. This can keep the tumor from growing for a while. But TURP does not take out the whole tumor.

Hormone therapy

Reference Hormone therapy is also called androgen deprivation therapy (ADT). Prostate cancer needs male hormones (Reference testosterone Opens New Window) in order to survive. Hormone therapy decreases the amount of testosterone and other male hormones in your body. This often causes tumors to shrink. Shrinking the tumors can ease severe bone pain caused by the spread of cancer to the bones. Hormone therapy usually is combined with radiation therapy.

The most common methods are:

• Reference LH-RH agonists and GnRH agonists. These drugs, such as goserelin (Zoladex), leuprolide (Lupron), and triptorelin (Trelstar), stop the body from making testosterone.
• GnRH antagonists. These drugs stop the body from making testosterone. They work right away and avoid the flare caused by GnRH agonists that can make symptoms worse for several weeks. One GnRH antagonist is degarelix (Firmagon).
• Reference Antiandrogens. These drugs, such as bicalutamide (Casodex), often are used along with LH-RH agonists. Antiandrogens help block the body's supply of testosterone.
• Reference Orchiectomy. This is surgery to remove the testicles, which produce more than 90% of the body's male hormones (Reference androgens Opens New Window), including testosterone.

Combination treatments

In some cases, men will have radiation therapy after a prostatectomy, especially if the tumor could not be completely removed by surgery.

Some men choose to start hormone therapy only after they have symptoms. But many doctors recommend starting hormone therapy right away if cancer is found in the Reference lymph nodes Opens New Window Reference Opens New Window during surgery to remove the prostate. Early treatment may allow men to live a little longer. Other doctors say to wait, because waiting delays the bothersome and serious side effects of hormone therapy.

Treatment for metastatic prostate cancer

Treatment for prostate cancer that has spread to the bones and/or other organs in the body is aimed at relieving symptoms and slowing the cancer's growth. Treatment may include:

• Reference Hormone therapy to slow cancer growth.
• Reference Radiation therapy to shrink tumors and ease pain.
• Reference Chemotherapy Opens New Window to stop the growth of cancer cells.
• Surgery to remove blockages that are causing problems (Reference TURP).
• Reference Immunotherapy Opens New Window to help a man's own immune system to fight the cancer.

Hormone therapy works by decreasing the amount of testosterone in your body. This can be done with medicine or with surgery to remove the testicles (Reference orchiectomy). Hormone therapy can also relieve pain by shrinking tumors and easing urinary problems.

Sometimes androgen deprivation (orchiectomy or an LH-RH agonist) and an antiandrogen are used together. This is called a combined androgen blockade (CAB). But the slight benefit of CAB may be offset by side effects.

Both orchiectomy and hormone therapy medicine make testosterone levels drop, causing some of the same side effects. These include Reference larger breasts, Reference hot flashes Opens New Window, loss of sexual desire, and the inability to have an erection. Treatment options for these problems include:

• Taking a temporary break from hormone therapy. This can make some side effects go away. (Side effects after orchiectomy are permanent.)
• Radiation treatment of the breasts to prevent breast growth. This is done before starting hormone therapy.
• Radiation treatment or the anti-estrogen breast cancer medicine called tamoxifen to relieve breast pain. Tamoxifen can also help reverse breast growth. It also causes hot flashes.
• Taking medicines to control hot flashes, such as paroxetine or venlafaxine. If these don't work, sometimes estrogen or megestrol may help reduce hot flashes. But all of these medicines have different side effects, so if you are having a problem with hot flashes, talk with your doctor.

Other serious side effects of hormone therapy may include thin or brittle bones (osteoporosis), reduced muscle mass, increased body mass (BMI), low red blood cell counts (anemia), fatigue, cognitive impairment (trouble thinking clearly), depression, and an increased risk for diabetes and heart disease.

Hormone therapy usually works well at first to stop cancer growth. But in most cases the cancer returns in a few years. At this point, the cancer is described as hormone-resistant, meaning it is not responding to standard hormone therapy. When this happens, other kinds of hormone treatment may be tried. If the cancer continues to grow, chemotherapy or immunotherapy may be recommended.

Some men choose to start hormone therapy only after they have symptoms. But some doctors recommend starting hormone therapy right away if cancer is found in the Reference lymph nodes Opens New Window Reference Opens New Window during surgery to remove the prostate. Other doctors say to wait, because waiting delays the bothersome and serious side effects of hormone therapy.

With intermittent androgen deprivation, known as IAD, men take cycles of hormone therapy medicines. Taking breaks between hormone therapy cycles gives men the chance to recover their ability to function sexually. It also gives relief from the other side effects of hormone therapy, including hot flashes, the loss of energy, and the loss of bone and muscle mass.

Treatment for pain

Pain is one of the main concerns of people who have metastatic cancer. But cancer pain can almost always be controlled. You and your doctor have several options to help your pain, including pain-relieving medicines and radiation, such as external beam radiation therapy and bone-targeted radioisotopes.

Additional information about prostate cancer is provided by the National Cancer Institute at www.cancer.gov/cancertopics/types/prostate.

Palliative care

Palliative care is a kind of medical care for people who have serious and chronic illnesses. It is different from trying to cure your illness. Palliative care focuses on improving your quality of life—not just in your body but also in your mind and spirit. Some people combine palliative care with curative care.

With prostate cancer, palliative care may involve treatments to reduce tumors or bone pain, such as Reference chemotherapy Opens New Window, Reference radiation therapy Opens New Window, radionuclides (medicine used in external radiation) for bone metastasis, and Reference bisphosphonates, which slow the breakdown of bone and help relieve bone pain. Surgery to relieve bladder problems (Reference transurethral resection of the prostate, or TURP Opens New Window) is also an option.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Reference Palliative Care.

End-of-life issues

You may wish to discuss health care and other legal issues that arise near the end of life with your family and your doctor. You may find it helpful and comforting to state your health care choices in writing—with an Reference advance directive or living will—while you are still able to make and communicate these decisions.

You may want to choose a Reference health care agent to make and carry out decisions about your care if you should become unable to speak for yourself. Be sure to share your wishes with your family or close friends. You can get forms from Caring Connections (www.caringinfo.org or 1-800-658-8898) or Aging With Dignity (www.agingwithdignity.org or 1-888-594-7437).

For more information, see the topic Reference Care at the End of Life.

Hospice care provides medical services, emotional support, and spiritual resources for people who are at the end of life. Hospice care also helps family members manage the practical details and emotional challenges of caring for a dying loved one. For more information, see the topic Reference Hospice Care.

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