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.
What Happens If My Cancer Starts To Grow Again
Your first treatment may help keep your cancer under control. But over time, the cancer may change and it may start to grow again.
You will usually stay on your first type of hormone therapy, even if its not working so well. This is because it will still help to keep the amount of testosterone in your body low. But there are other treatments that you can have alongside your usual treatment, to help control the cancer and manage any symptoms. Other treatments include:
Which treatments are suitable for me?
Which treatments are suitable for you will depend on many things, including your general health, how your cancer responds to treatment, and which treatments youve already had. Talk to your doctor or nurse about your own situation, or speak to our Specialist Nurses.
What Else Do People Living With Metastatic Prostate Cancer Need To Know About Their Treatment Options
I cannot stress enough the importance of picking the righttreatment for each individual. Side effects and the expectations for diseaseresponse should be clearly discussed and understood.
Statistically, about one-third of people with metastatic prostate cancer will live more than 5 years. Understanding where your disease is on that continuum can be important for both treatment and lifestyle decisions.
That said, I am consistently amazed by what we as a medical and scientific community can do together. The huge efforts being applied to prostate cancer research hold significant promise for new and better treatment options in the near future.
Dr. Joseph Brito provides general urologic care with a special focus on minimally invasive surgical techniques and urologic oncology. Dr. Brito received his MD from George Washington University School of Medicine and Health Sciences. Dr. Brito completed a residency in urology at Rhode Island Hospital and Alpert Medical School of Brown University and trained at Yale School of Medicine in clinical oncology. Dr. Brito is a member of the American Urological Association.
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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.
Chemotherapy For Prostate Cancer
Patients who no longer respond to hormone therapy have another option.
The chemotherapy drug docetaxel taken with or without prednisone is the standard chemotherapy regimen for patients who no longer respond to hormone therapy. Docetaxel works by preventing cancer cells from dividing and growing. Patients receive docetaxel, along with prednisone, through an injection. Side effects of docetaxel are similar to most chemotherapy drugs and include nausea, hair loss, and bone marrow suppression . Patients may also experience neuropathy and fluid retention.
Docetaxell, when used with or without prednisone, was the first chemotherapy drug proven to help patients live longer with advanced prostate cancer. The average survival was improved by about 2.5 months when compared to mitoxantrone with or without prednisone. Docetaxel has the best results when given every three weeks as compared to weekly dosing.
Cabazitaxel is another chemotherapy drug, used in combination with the steroid prednisone, to treat men with prostate cancer. Cabazitaxel is used in men with advanced prostate cancer that has progressed during, or after, treatment with docetaxelâââââââ .
Side effects in those treated with cabazitaxel included significant decrease in infection-fighting white blood cells , anemia, low level of platelets in the blood , diarrhea, fatigue, nausea, vomiting, constipation, weakness, and renal failure.
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Finding Small Amounts Of Prostate Cancer Using Imaging And Psma
NCI-supported researchers are developing new imaging techniques to improve the diagnosis of recurrent prostate cancer. A protein called prostate-specific membrane antigen is found in large amountsand almost exclusivelyon prostate cells. By fusing a molecule that binds to PSMA to a compound used in PET scan imaging, scientists have been able to see tiny deposits of prostate cancer that are too small to be detected by regular imaging. The Food and Drug Administration has approved two such compounds for use in PET imaging of men with prostate cancer.
This type of test is still experimental. But the ability to detect very small amounts of metastatic prostate cancer could help doctors and patients make better-informed treatment decisions. For example, if metastatic cancer is found when a man is first diagnosed, he may choose an alternative to surgery because the cancer has already spread. Or doctors may be able to treat cancer recurrenceeither in the prostate or metastatic diseaseearlier, which may lead to better survival.
As part of the Cancer Moonshot, NCI researchers are testing whether PSMA-PET imaging can also identify men who are at high risk of their cancer recurring. Such imaging may eventually be able to help predict who needs more aggressive treatmentsuch as radiation therapy in addition to surgeryafter diagnosis.
Adverse Effects Of Androgen Suppression
Surgical and medical castration lead to a number of adverse effects, including the following, that can have a significant impact on a mans quality of life:
- Psychological changes
In addition, in men with prostate cancer receiving ADT, lean body mass decreases significantly after 12-36 months of treatment.
Uncertainty remains about the impact of androgen ablation on cardiovascular morbidity and mortality. However, the combination of weight gain and anemia in men with asymptomatic cardiovascular disease could adversely affect survival in some cases.
The FDA has advised that manufacturers of gonadotropin-releasing hormone agonists, which are approved for palliative treatment of advanced prostate cancer, must add safety warnings about the increased risk of diabetes and certain cardiovascular diseases in men receiving these medications. The FDA notes that although the risk for these complications appears to be low, physicians should evaluate patients for risk factors for these diseases before prescribing these agents.
Patients receiving GnRH agonists should be actively monitored for diabetes and cardiovascular disease and treated when possible. Periodic measurement of fasting glucose, cholesterol, triglycerides, and blood counts should be performed. In addition, the package inserts for all LHRH medications recommend periodically measuring serum testosterone, because levels above 50 ng/dL do occur and may adversely affect long-term survival.
Acute kidney injury
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Treatments To Help Manage Symptoms
Advanced prostate cancer can cause symptoms, such as bone pain. Speak to your doctor or nurse if you have symptoms there are treatments available to help manage them. The treatments above may help to delay or relieve some symptoms. There are also specific treatments to help manage symptoms you may hear these called palliative treatments. They include:
This is the team of health professionals involved in your care. It is likely to include:
- a specialist nurse
- a therapeutic radiographer
- other health professionals, such as a dietitian or physiotherapist.
Your MDT will meet to discuss your diagnosis and treatment options. You might not meet all the health professionals straight away.
Your main point of contact might be called your key worker. This is usually your clinical nurse specialist , but might be someone else. The key worker will co-ordinate your care and help you get information and support. You may also have close contact with your GP and the practice nurses at your GP surgery.
New Ways To Detect And Destroy Prostate Cancer
Of course, before prostate cancer can be treated, it must first be detected, and the earlier the better. New imaging technology is making a difference here as well.
When prostate cancer is suspected, a biopsy is required to confirm it. A needle guided by an ultrasound machine extracts the tissue sample.
Lau is excited about the magnetic resonance imaging -fusion system using a parametric magnetic resonance imaging machine , and grafting those images onto the picture generated by the ultrasound. This method does a much better job pinpointing spots where a biopsy should be taken.
It gives us a roadmap, said Lau, and it decreases the chance of repeated biopsies.
And what if you could detect AND destroy prostate cancer with the same system?
Thats the promise of a new field called theranostics.
Theranostics is simply a mashup of the words therapeutics and diagnostics, explained nuclear pharmacist Kofi Poku, Pharm.D. In other words, You see it you treat it.
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Chemotherapy For Metastatic Prostate Cancer
Chemotherapy may be used for patients with metastatic prostate cancer, with the aim of slowing any further spread of cancer and improving quality of life.
The most commonly used chemotherapy medications, typically given via an intravenous line, are docetaxel combined with prednisone. However, there are several chemotherapy drugs available, so ask your doctor which types may be most appropriate for your treatment.
In some cases, these treatments are considered palliative, intended to relieve difficult symptoms and improve quality of life.
Prostate cancer treatment: The care you need is one call away
Your multidisciplinary team will work with you to develop a personalized plan to treat your prostate cancer in a way that fits your individual needs and goals.
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Treatments For Prostate Cancer Spread To Bones
If prostate cancer spreads to other parts of the body, it nearly always goes to the bones first. Bone metastasis can be painful and can cause other problems, such as fractures , spinal cord compression , or high blood calcium levels, which can be dangerous or even life threatening.
If the cancer has grown outside the prostate, preventing or slowing the spread of the cancer to the bones is a major goal of treatment. If the cancer has already reached the bones, controlling or relieving pain and other complications is also a very important part of treatment.
Treatments such as hormone therapy, chemotherapy, and vaccines may help with this, but other treatments specifically target bone metastasis and the problems it may cause.
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Phase I Study Of Niraparib In Combination With Radium
*Corresponding Authors:*Corresponding Authors:Corresponding Authors:
Clin Cancer Res 2022 XX:XXXX
Clin Cancer Res
Zachary Quinn, Benjamin Leiby, Guru Sonpavde, Atish D. Choudhury, Christopher Sweeney, David Einstein, Russell Szmulewitz, Oliver Sartor, Karen Knudsen, Eddy Shih-Hsin Yang, Wm. Kevin Kelly Phase I Study of Niraparib in Combination with Radium-223 for the Treatment of Metastatic Castrate-Resistant Prostate Cancer. Clin Cancer Res 2022
Treatment Of Local Events
Both the disease and its treatment can give rise to troublesome and serious consequences it is important to take these into account and to inform the patient about them early on.
Skeletal pain can be treated with palliative radiation therapy, steroids and opiates. An MRI examination should be performed promptly upon suspicion of impending spinal cord injury. If confirmed, treatment consists of immediate administration of high dose steroids combined with surgery and/or radiation therapy .
Skeletal-related events may be prevented with zoledronic acid or denosumab . Dosing intervals and when to initiate treatment are poorly defined, but common practice is to administer treatment every three months, beginning when symptomatic skeletal metastases are present. The patient should be examined by a dentist prior to use of zoledronic acid or denosumab, as there is a risk of osteonecrosis in the jaw bone . Calcium and vitamin D supplements should be taken during treatment .
Obstruction of the urinary tract or bowel may be relieved by palliative surgery, drainage or radiation therapy. Surgery, radiation therapy or embolisation may be appropriate in the event of haemorrhage.
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If Treatment Does Not Work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for some people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
Are There Any Lifestyle Changes I Should Consider While In Treatment For Metastatic Prostate Cancer
The most important thing you can do is to stay physically active and strong. This includes following a heart-healthy diet and exercising.
Cardiovascular exercise is the most important. The degree, or intensity and duration, of cardio exercise depends on the individual person.
Several studies have pointed to a link between obesity and aggressive prostate cancer, although the mechanism is still being worked out.
Weight loss is generally encouraged if youre overweight, but excessive or unintentional weight loss can be a sign of disease progression and should be discussed with your doctor.
Finally, if youre a smoker, stop! If youre finding it hard to quit, ask your doctor about products and medications that might help you.
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Car T Therapy For Solid Tumors
The idea of training the bodys own immune system to fight cancer has percolated throughout the cancer landscape for years now. Dorff is especially excited about the promise of CAR T treatment: taking a patients immune, or T cells, reengineering them to recognize specific tumor-associated antigens and then reintroducing them as supercharged cancer killers.
Dorff calls the progress in CAR T therapy profound and revolutionary. The Food and Drug Administration has approved two CAR T products for blood cancers.
But solid tumors, including prostate cancer, present special challenges.
Unlike say, leukemia cells, which are fairly uniform, solid tumors are packed with a wide variety of different cells, which means a one-size-fits-all CAR T cell targeting one specific protein cant mount much of an attack. Also, tumors often display an immunosuppressant microenvironment which can counter the punch of a CAR T onslaught. Finally, theres the problem of toxicity. Some of the proteins targeted by CAR T cells also exist in healthy tissue.
Dorff is heavily immersed in research and clinical trials to address all these concerns.
We need to find a way to get the CAR T cells into the tumor with the right amount and find a way to kill tumor cells with different expressions, she said. And we need to reduce toxicity and the immunosuppressant response.
Drug Sequencing For Androgen
The availability of the above new agents presents a challenge for physicians and patients, who must decide on the best sequence and timing for each of them. So far, no studies have been done to determine the best approach. Studies in progress are likely to result in some change to the sequencing of these drugs.
As of October 2012, and excluding cost considerations, men with asymptomatic or minimally symptomatic progressive disease can start with immunotherapy using sipuleucel-T. Since no objective responses are expected, patients can then be given abiraterone acetate.
On September 11, 2014 the FDA expanded the approved use of enzalutamide for the treatment of men with late-stage , castrate-resistant prostate cancer prior to receiving chemotherapy. The expanded indication was based on a study in which patients who received enzalutamide reduced the risk of radiographic progression or death by 83% versus placebo, while significantly reducing the risk of death by 29%.
Without formal studies to guide recommendations, either drug may be used next, although enzalutamide does not require prednisone, and for that reason it may be most suitable. Hopefully, studies will be done to determine whether men are better off receiving either enzalutamide or abiraterone first or second. Men showing progression on those drugs should then be offered docetaxel followed by cabazitaxel.
For full discussion, see Metastatic and Advanced Prostate Cancer.
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