Metastatic Prostate Cancer: Investigators Ponder New Path To Improve Survival
I am convinced that treating early and hard is better than late and less, said urologic oncologist Judd W. Moul, MD, the James H. Semans Distinguished Professor of Urologic Surgery at Duke University School of Medicine in Durham, North Carolina, who has been extensively involved with clinical trials of prostate cancer therapies. Some doctors still hold the good stuff in their back pocket and avoid or delay the most effective options up front.
Starting multiple therapies earlier in the disease course seems to provide the most benefit, said prostate cancer investigator Jonathan E. Shoag, MD, Associate Professor of Urology at University Hospitals Cleveland Medical Center and Case Western Reserve University, both in Cleveland, Ohio.
Despite all of the scientific advancements, metastatic prostate cancer is still a bad disease, Dr Shoag said. The goal should be preventing cancer from becoming metastatic in the first place. We can do this by screening, diagnosing, and intervening in the disease course earlier.
Advanced molecular imaging, such as positron emission tomography , should be used to identify metastasis as early as possible, before it spreads to distant anatomic sites, according to investigators. Potent treatments should be considered at this stage. Physicians also should try to delay development of both metastasis and castration-resistant prostate cancer , which clinical trial data suggest is possible.
The Expanding Armamentarium
Prolonged Survival
Symptoms Of Prostate Cancer Spread To The Bones
The most common place for prostate cancer to spread to is the bones. This can include the:
The most common symptom if cancer has spread to the bone is bone pain. It is usually there most of the time and can wake you up at night. The pain can be a dull ache or stabbing pain.
Your bones might also become weaker and more likely to break .
When prostate cancer spreads to the spine, it can put pressure on the spinal cord and cause spinal cord compression. This stops the nerves from being able to work properly. Back pain is usually the first symptom of spinal cord compression.
Spinal cord compression is an emergency. You should contact your treatment team immediately if you are worried you might have spinal cord compression.
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Bone Protection In Patients Receiving Androgen Blockade
Two drugs, the bisphosphonate zoledronic acid and the RANKL inhibitor denosumab, have been approved to treat osteoporosis secondary to androgen deprivation. Zoledronic acid is administered as an intravenous infusion. Denosumab is administered subcutaneously. These drugs are given along with supplemental vitamin D and calcium. Patients should be monitored regularly for hypocalcemia. Both agents are associated with a low incidence of osteonecrosis of the jaw. Both drugs delay the risk of skeletally-related events by relieving bone pain, preventing fractures, decreasing the need for surgery and radiation to the bones, and lowering the risk of spinal cord compression.
A double-blind, placebo-controlled, multicenter study in men with primary or hypogonadism-associated osteoporosis found that over a 14-month period, treatment with zoledronic acid reduced the risk of vertebral fractures by 67%. New morphometric vertebral fracture occurred in 1.6% of men taking zoledronic acid and in 4.9% taking placebo. Patients receiving zoledronic acid had significantly higher bone mineral density and lower bone-turnover markers. However, the rate of myocardial infarction was higher in the treatment group .
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Surgery For Metastatic Prostate Cancer
Unlike with localized prostate cancer, surgery isnt usually used to treat metastatic cancer. However, it may be used in some cases if it can help improve a patients quality of life, often to resolve urinary problems or stop bleeding.
If prostate cancer is locally advanced and hasnt spread far, a radical prostatectomy may still be an option. A radical prostatectomy is a surgical procedure in which the prostate is removed, along with any nearby tissue that contains prostate cancer cells.
Receiving Prostate Cancer Treatment At Moffitt Cancer Center
At Moffitt Cancer Center, we treat patients with all stages of prostate cancer. The multispecialty team within our Urologic Oncology Program includes medical oncologists, radiation oncologists, urologists, uropathologists and many other medical professionals who collaborate as a tumor board to ensure each patient receives an individualized treatment plan tailored to his needs. Moffitt patients also have access to many supportive care professionals at the same location where they receive treatment to help them address the emotional and physical challenges involved with undergoing treatment for metastatic prostate cancer.
If you would like to learn more about receiving metastatic prostate cancer treatment at Moffitt, call or fill out a new patient registration form. No referral is necessary to schedule an appointment.
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Traditional Biopsy Can Miss 30% Or More Of Cancers
More traditional prostate biopsy procedures, like a transrectal ultrasound guided biopsy, take a poke and hope approach poke the prostate multiple times and hope to hit the right area of the gland. With a TRUS biopsy, cores are taken with much less clear views of the prostate which often can lead to missing tumors at the front of the gland and under-sampling the area furthest from the bladder. Because of this, a TRUS biopsy can miss 30% or more of cancers, potentially leading to inaccurate diagnoses.
Personalized Prostate Cancer Care With Genetic Testing
Much like the prostate specific antigen that is used inPSA testing, there are other biomarkers that may help your physician diagnose prostate cancer. HALO Dx works with ExosomeDx and is proud to offer the ExoDx Prostate Test, a urine-based test that is used similarly to a PSA test before biopsy. The test analyzes three cancer-specific biomarkers found in the urine that are associated with aggressive prostate cancer. These biomarkers or genes in this case are: ERG, PCA and SPDEF. This simple non-invasive test can help assess your risk of having clinically significant high-grade prostate cancer and help you and your doctor determine whether to proceed with or defer a prostate biopsy.
Along with traditional pathology of the biopsy results, HALO Dx offers genomic tests on the same tissue sample to help identify the appropriate treatment option and help determine the metastatic potential of the tumor through the . We have seen impressive results over the years and have demonstrated that the Decipher test can be used to help predict response to Laser Focal Therapy.
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Treatment To Lower Testicular Androgen Levels
Androgen deprivation therapy, also called ADT, uses surgery or medicines to lower the levels of androgens made by the testicles.
Orchiectomy
Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where most of the androgens are made. This causes most prostate cancers to stop growing or shrink for a time.
This is done as an outpatient procedure. It is probably the least expensive and simplest form of hormone therapy. But unlike some of the other treatments, it is permanent, and many men have trouble accepting the removal of their testicles. Because of this, they may choose treatment with drugs that lower hormone levels instead.
Some men having this surgery are concerned about how it will look afterward. If wanted, artificial testicles that look much like normal ones can be inserted into the scrotum.
LHRH agonists
Luteinizing hormone-releasing hormone agonists are drugs that lower the amount of testosterone made by the testicles. Treatment with these drugs is sometimes called medical castration because they lower androgen levels just as well as orchiectomy.
With these drugs, the testicles stay in place, but they will shrink over time, and they may even become too small to feel.
- Leuprolide mesylate
LHRH antagonists
Possible side effects
Many side effects of hormone therapy can be prevented or treated. For example:
Watchful Waiting And Active Surveillance
Watchful waiting is an adequate approach in patients who are at low risk of death from prostate cancer because of their limited life expectancy due to severe comorbidities., Watchful waiting resulted in similar overall survival when compared with radical prostatectomy, but disease-specific survival was better in patients who had undergone surgery. For some patients it turns out to be hard to persist on a watchful waiting policy, and many men drop out and seek active treatment within several years, mostly when PSA elevation is noted.
Active surveillance is a novel and fascinating approach to distinguish between patients who are at higher risk and need active therapy and patients who are at low risk for disease progression., This approach avoids the risks of therapy while allowing early detection of those patients who are prone to progress. In these high-risk individuals, delayed active treatment is offered. Periodic monitoring of the PSA serum level, digital rectal exam, and repeated prostate biopsies are performed in patients who are on active surveillance, and active therapy is started when predefined threshold values are reached. This concept makes it possible to offer curative treatment to individuals who are at high risk for disease progression as indicated by active surveillance parameters.
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Just One Weapon Against Cancer
Before treatment with PLUVICTOTM is recommended, patients undergo a 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.
Questions To Ask Your Doctor Or Nurse
- What type of hormone therapy are you offering me and why?
- Are there other treatments I can have?
- What are the advantages and disadvantages of my treatment?
- What treatments and support are available to help manage side effects?
- Are there any lifestyle changes that might help me manage my cancer, symptoms, or side effects?
- How often will I have check-ups and what will this involve?
- How will we know if my cancer starts to grow again?
- What other treatments are available if that happens?
- Can I join any clinical trials?
- If I have any questions or get any new symptoms, who should I contact?
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Metastatic Prostate Cancer Treatment
If a patient has been diagnosed with prostate cancer and he or she is concerned about prostate cancer metastasis, they should talk with a doctor about the risk of prostate cancer metastasis and corresponding treatment options.
Treatments for stage 4 prostate cancer may depend on where in the body the disease has spread. Options include:
Secondary Cancer In The Bones
After the lymph nodes, the most common place for prostate cancer to spread to is the bones. Prostate cancer may spread to bones, such as the:
It may affect different areas of the bones rather than only one area.
- Pain
The first sign of a secondary cancer in the bones is usually an ache in the bone. This is often in the hips or in the back. A secondary cancer in the bone may gradually make the bone weaker. Bones that are very weak may break more easily. There are treatments you can have to help strengthen the bones and reduce pain.
- Spinal cord compression
If the bones in the spine have cancer in them, the cancer may press on the spinal cord. This is called Malignant spinal cord compression . It usually affects your legs and may cause:
- numbness or tingling in your legs.
Spinal cord compression is not common. But if you notice these symptoms, you should contact your doctors straight away even at the weekend or during a holiday period. If you cannot contact your GP or cancer doctor, you should go to the nearest emergency department .
Prostate cancer can sometimes spread from the bone to the bone marrow. Bone marrow is the spongy material in the middle of our bones where our blood cells are made. This includes red blood cells, which carry oxygen around the body.
If the bone marrow cannot produce enough red blood cells, you may become anaemic. This can make you feel very tired and breathless, and you may look very pale.
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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.
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.
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Good Prostate Cancer Care
Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.
You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.
You should also be told about any clinical trials you may be eligible for.
If you have side effects from treatment, you should be referred to specialist services to help stop or ease these side effects.
Metastatic Liver Cancer Life Expectancy
When liver cancer metastasizes, it most commonly spreads to the lungs and bones. The five-year survival rate for a patient whose liver cancer has spread to surrounding tissue, organs and/or lymph nodes is estimated at 11 percent. The five-year survival rate for a patient whose liver cancer has spread to distant tissue, organs and/or lymph nodes is estimated at 3 percent.
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Side Effects Of Chemotherapy
All chemotherapy drugs work in slightly different ways, making it challenging to predict side effects for individual patients. Dosages, drug combinations and drug responses will vary from patient to patient.
The American Cancer Society lists the following as the most common side effects of chemotherapy:
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Increased risk of infections
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Easy bruising or bleeding
How Prostate Cancer Is Treated
In cancer care, different types of doctorsincluding medical oncologists, surgeons, and radiation oncologistsoften work together to create an overall treatment plan that may combine different types of treatments to treat the cancer. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as palliative care experts, physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, physical therapists, and others.
The common types of treatments used for prostate cancer are described below. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patients preferences and overall health.
Cancer treatment can affect older adults in different ways. More information on the specific effects of surgery, chemotherapy, and radiation therapy on older patients can be found another section of this website.
Because most prostate cancers are found in the early stages when they are growing slowly, you usually do not have to rush to make treatment decisions. During this time, it is important to talk with your doctor about the risks and benefits of all your treatment options and when treatment should begin. This discussion should also address the current state of the cancer:
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Innovative Immunotherapy For Every Patient
Your immune system is the first and last line of defense against any disease, which is why bolstering it is acriticalpart of treatment. Immunotherapy could be the missing link in your existing treatment plan, as the immune system isoften overlooked in standard of care. However, at Envita, we include various levels of personalized immunotherapies ineach patients treatment plan because we understand that a strong and healthy immune system can keep diseases at bay.