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.
How Can I Choose From Among The Options
In addition to talking with family and friends, you will need a team of physicians to help advise you. It is advisable that you meet with all of the specialists involved in your cancer treatment planning prior to making a decision regarding treatment, including:
- your primary care physician as well as a urologist to discuss surgery
- a radiation oncologist to discuss radiation therapy.
Once you have met with these doctors, you will be able to make a more informed decision regarding your treatment options. If you have an early-stage cancer or moderately advanced cancer and there is no evidence of spread to other organs , the two major options for treatment are surgery or radiation therapy .
If your cancer is advanced and you require hormonal suppression therapy or chemotherapy, then you will also need a medical oncologist, who administers these drugs. Hormone-ablation therapy, which is often used to treat more advanced prostate cancer by suppressing your androgen hormones since most prostate cancer growth is stimulated by androgen or testosterone. The androgen suppression treatment can be administered by your internist, urologist, radiation oncologist or medical oncologist. Depending on the stage of the cancer, hormone suppression therapy may be used in addition to radiation therapy to help control the cancer. Hormone suppression therapy may be administered for as little as four to six months, or for as long as two to three years.
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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At What Point Should I Consider A Clinical Trial
Clinical trials are designed to answer a wide array of clinical questions. A quick search of clinicaltrials.gov shows over 150 mCaP trials currently enrolling patients in the United States.
Its important to remember that clinical trials are often not intended to treat or cure participants, but rather to further the knowledge of the scientific community.
If youre diagnosed with mCaP and are inclined to get involved with research, discuss it with your physician or check the site above for trials in your area.
I would add that for patients very close to the end of life, time might be better spent with family and friends.
Inspection Of Important Features In Predicting Treatment Discontinuation
To find the key determinants of treatment discontinuation, we investigated the feature importance by calculating the delta-error of each feature in our random forest model , on both the full dataset and subsets . We also colored the features according to their categories defined in the previous study .
The Feature Importance Map of All 78 Features used in Our Model
The importance of all features . The top 10 important features are ALB, NA., TPRO, MG, TESTO, WBC, PHOS, MHVASC, NEU, and MHSOCIAL, which represent albumin, sodium, total protein, magnesium, testosterone, white blood cell, phosphorus, medical history of vascular disorders, neutrophils, and medical history of social circumstances, respectively. The colors of the bars represent the categories that the features belong to, and the sub-boxplot summaries the feature importance in each category. Note that there is only one feature that belongs to metastases.
Top 10 important features in different subsets of data are also presented here, where the stars represent the overlaps between them and the overall top 10 in panel A.
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Will There Ever Be A Cure For Metastatic Prostate Cancer
Thats a tough one! The research and progress in treating this disease has come so far in just the past few years.
I have to say that someday, there will likely be a treatment so successful that it will effectively cure the disease. We still have a lot of work to do.
In my opinion, current research into theranostics, which incorporates targeted drug delivery with advanced imaging techniques, offers particular promise.
I also believe the key to outsmarting the disease is to stay a step ahead. This means identifying and anticipating the progression of the tumors escape mechanisms and preempting them.
I cannot stress enough the importance of picking the right treatment for each individual. Side effects and the expectations for disease response 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.
Your Cancer Care Team
People with cancer should be cared for by a multidisciplinary team . This is a team of specialists who work together to provide the best care and treatment.
The team often consists of specialist cancer surgeons, oncologists , radiologists, pathologists, radiographers and specialist nurses.
Other members may include physiotherapists, dietitians and occupational therapists. You may also have access to clinical psychology support.
When deciding what treatment is best for you, your doctors will consider:
- the type and size of the cancer
- what grade it is
- whether the cancer has spread to other parts of your body
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Getting Help With Treatment Decisions
Making such a complex decision is often hard to do by yourself. You might find it helps to talk with your family and friends before making a decision. You might also find it helpful to speak with other men who have faced or are currently facing the same issues. The American Cancer Society and other organizations offer support programs where you can meet and discuss these and other cancer-related issues. For more information about our programs, call us toll-free at 1-800-227-2345 or see Find Support Programs and Services.
Itâs important to know that each manâs experience with prostate cancer is different. Just because someone you know had a good experience with a certain type of treatment doesnât mean the same will be true for you.
You might also want to consider getting more than one medical opinion, perhaps even from different types of doctors. For early-stage cancers, it is natural for surgical specialists, such as urologists, to favor surgery and for radiation oncologists to lean more toward radiation therapy. Doctors specializing in newer types of treatment may be more likely to recommend their therapies. Talking to each of them might give you a better perspective on your options. Your primary care doctor may also be helpful in sorting out which treatment might be right for you.
Management Of Advanced And Metastatic Disease
AUA/ASTRO/SUO guidelines on advanced prostate cancer separate management considerations into the following four disease states, which encompass the entire continuum of advanced prostate cancer :
These disease states are defined by the following:
- Primary tumor status
- Presence or absence of distant disease on imaging
- Testosterone levels
- Prior chemotherapy exposure
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Metastatic Prostate Cancer: Seeking A Fresh Chance Of Recovery
In 2012, a man in his 50s arrived at the Cleveland Clinic in Ohio with high-grade prostate cancer that had spread to a nearby lymph node. The treatment in such cases would ordinarily have been limited to drugs that block testosterone, a hormone that fuels prostate tumour growth. At the time, metastatic prostate cancer was considered uniformly fatal, and physicians were reluctant to subject someone to the side effects of surgery and radiation if these extra measures were unlikely to prolong life.
Part of Nature Outlook: Prostate cancer
But the man insisted on doing more. In addition to undergoing six months of hormonal therapy, he had his prostate and cancerous lymph node surgically removed. A tumour that was detected in his pelvic bones one year later was treated with radiation. The extra effort paid off. Hes eight years out now with no sign of cancer in his body, says Eric Klein, a urologist at the Cleveland Clinic who consulted on the case. Ever since, Ive been asking if there is a subset of patients like him who would also benefit from more aggressive treatment.
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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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.
What Are The Side Effects Of Hormone Therapy For Prostate Cancer
Because androgens affect many other organs besides the prostate, ADT can have a wide range of side effects , including:
- loss of interest in sex
Studer UE, Whelan P, Albrecht W, et al. Immediate or deferred androgen deprivation for patients with prostate cancer not suitable for local treatment with curative intent: European Organisation for Research and Treatment of Cancer Trial 30891. Journal of Clinical Oncology 2006 24:18681876.
Zelefsky MJ, Eastham JA, Sartor AO. Castration-Resistant Prostate Cancer. In: Vincent T. DeVita J, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenbergs Cancer: Principles & Practice of Oncology, 9e. Philadelphia, PA: Lippincott Williams & Wilkins 2011.
Smith MR, Saad F, Chowdhury S, et al. Apalutamide and overall survival in prostate cancer. European Urology 2021 79:150158.
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Drugs That Stop Androgens From Working
Anti-androgens
For most prostate cancer cells to grow, androgens have to attach to a protein in the prostate cancer cell called an androgen receptor. Anti-androgens are drugs that also connect to these receptors, keeping the androgens from causing tumor growth. Anti-androgens are also sometimes called androgen receptor antagonists.
Drugs of this type include:
They are taken daily as pills.
In the United States, anti-androgens are not often used by themselves:
- An anti-androgen may be added to treatment if orchiectomy or an LHRH agonist or antagonist is no longer working by itself.
- An anti-androgen is also sometimes given for a few weeks when an LHRH agonist is first started. This can help prevent a tumor flare.
- An anti-androgen can also be combined with orchiectomy or an LHRH agonist as first-line hormone therapy. This is called combined androgen blockade . There is still some debate as to whether CAB is more effective in this setting than using orchiectomy or an LHRH agonist alone. If there is a benefit, it appears to be small.
- In some men, if an anti-androgen is no longer working, simply stopping the anti-androgen can cause the cancer to stop growing for a short time. This is called the anti-androgen withdrawal effect, although it is not clear why it happens.
Newer anti-androgens
Enzalutamide , apalutamide and darolutamide are newer types of anti-androgens. They can sometimes be helpful even when older anti-androgens are not.
These drugs are taken as pills each day.
Treatment Options For Metastatic Prostate Cancer
Matthew Fowler: I want to transition and focus in on metastatic castration-resistant prostate cancer . Can you talk a little about some of the available systemic treatment options for this disease?
Oliver Sartor, MD: We have a lot, so Im going to run through some of the frontline studies and then move in sequence. The granddaddy was docetaxel chemotherapy back in 2004. Then we transitioned into having sipuleucel-T and cabazitaxel, which was indicated for patients with progressive castration-resistant disease after docetaxel administration. Very importantly, we then had abiraterone, initially starting in the postdocetaxel space and then coming predocetaxel. Enzalutamide was postdocetaxel initially, then predocetaxel. Then we had radium, which was important because it was bifurcated into postdocetaxel or predocetaxel, and the FDA approval came in for both. Im sticking with metastatic castration-resistant disease. If I went to nonmetastatic, Id bring in a couple more. But Im still concentrating on metastatic castration-resistant disease.
For each of these, theres a curative sequence in particular ways. Cabazitaxel can come after docetaxel, but not before docetaxel. Theres a little complexity, but you get the idea. Ive gone through it a bit historically, and then brought in the precursors to where we stand today.
Transcript edited for clarity.
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Side Effects Of Chemotherapy
Side effects of chemotherapy are common and may include:
- Digestive issues such as nausea, vomiting and diarrhea
While on chemotherapy, patients are also susceptible to infections because their white blood cell counts are lower. Other common side effects include bruising or bleeding due to fewer blood platelets and fatigue due to the lowered red blood cell count.
Its also possible to experience a severe allergic reaction to some of the drugs used to treat prostate cancer, especially Taxotere® and Jevtana® . The patients care team may recommend medicines before each session to help prevent a reaction.
The prostate chemotherapy drug mitoxantrone may cause leukemia later in life, but this is rare. The prostate chemotherapy drug Emcyt® may increase the risk for blood clots.
During chemotherapy, doctors may also offer supportive care services to help ease side effects. For example, naturopathic providers may suggest supplements to reduce nausea. Also, a mind-body therapist may recommend techniques to help the patient relax and feel less anxious during prostate cancer chemotherapy treatments.
Stereotactic Body Radiation Therapy Or Stereotactic Ablative Radiation Therapy
Guided by advanced imaging techniques, SBRT delivers large doses of radiation over a short period of time to a precise area. SBRT is commonly referred to by the names of the machines used to deliver the radiation. SBRT can offer some patients with localized prostate cancer the convenience of fewer treatments while maintaining treatment effectiveness and safety. SBRT may also be used to treat metastases for some patients to reduce tumor mass and potentially enhance survival.
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What Is My Outlook
If youre diagnosed with advanced prostate cancer, you may want to know how well your treatment is likely to control your cancer and for how long it will control it. This is sometimes called your outlook or prognosis. But not all men will want to know this.
While it isnt possible to cure advanced prostate cancer, treatments can help keep it under control, often for several years. Treatments will also help manage any symptoms, such as pain.
No one can tell you exactly what your outlook will be, as it will depend on many things such as where the cancer has spread to, how quickly it has spread, and how well you respond to treatment. Some men may not respond well to one treatment, but may respond better to another. And when your first treatment stops working, there are other treatments available to help keep the cancer under control for longer. Speak to your doctor about your own situation and any questions or concerns you have.