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:
Why Was This Study Done
- Prostate cancer is the most common cancer in males.
- Radiotherapy to the prostate is widely used as a radical treatment for nonmetastatic prostate cancer.
- A comparison was added to the STAMPEDE protocol to assess whether RT to the prostate would also be helpful for males with metastatic prostate cancer. A benefit in survival was targeted.
- The trial previously reported a clinically relevant, statistically significant overall survival benefit for patients with a low metastatic burden but not for men with a high metastatic burden.
- This long-term analysis assesses survival with substantially longer follow-up and more events and looked also at complications of local disease.
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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Radiotherapy For Advanced Prostate Cancer
This page has information for people having radiotherapy for advanced prostate cancer.
We explain how radiotherapy can be used to treat advanced prostate cancer, what treatment involves, and the advantages and disadvantages of having radiotherapy for advanced prostate cancer.
If you’ve been diagnosed with localised prostate cancer that hasn’t spread outside the prostate, read our information on external beam radiotherapy for localised or locally advanced prostate cancer instead.
Physical Emotional And Social Effects Of Cancer
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.
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Radiopharmaceuticals That Target Psma
Prostate-specific membrane antigen is a protein that is often found in large amounts on prostate cancer cells.
Lutetium Lu 177 vipivotide tetraxetan is a radiopharmaceutical that attaches to PSMA, bringing radiation directly to the prostate cancer cells.
This drug can be used to treat prostate cancer that has spread and that has already been treated with hormone therapy and chemotherapy. The cancer cells must also have the PSMA protein. Your doctor will order a PSMA PET scan before you get this drug to make sure the cancer cells have PSMA.
This drug is given as an injection or infusion into a vein , typically once every 6 weeks for up to 6 doses.
Possible side effects
Some of the more common side effects of this drug include:
This drug can lower blood cell counts:
- A low red blood cell count can cause tiredness, weakness, pale skin, or shortness of breath.
- A low blood platelet count can lead to bleeding or bruising more easily than normal, or bleeding that is hard to stop.
- A low white blood cell count can lead to an increased risk of infections, which might show as a fever, chills, sore throat, or mouth sores.
This drug might damage the kidneys. Your doctor or nurse will likely advise you to drink plenty of fluids and to urinate often before and after getting this drug, to help protect the kidneys. Tell your doctor or nurse if you start to pass less urine than is normal for you.
How Does Radiotherapy Treat Advanced Prostate Cancer
Radiotherapy can be used in different ways to treat prostate cancer that has spread from the prostate to other parts of the body :
- as part of your first treatment for advanced prostate cancer
- to improve symptoms in areas where the cancer has spread
- to help some men with bone pain live longer and to treat bone pain.
All types of radiotherapy aim to destroy cancer cells.
If youre offered radiotherapy as part of your first treatment for advanced prostate cancer, youll have a type of radiotherapy called external beam radiotherapy.
If youre having radiotherapy to improve symptoms in areas where the cancer has spread, you may have external beam radiotherapy to the part of the body where the cancer is causing problems.
If your cancer is causing bone pain, you may be offered a type of internal radiotherapy called radium-223 to help you live longer and to treat the bone pain.
A clinical oncologist or radiographer will plan your radiotherapy with you. They will tell you if radiotherapy can help you and explain which type of radiotherapy you will have, how long the treatment could take and the possible side effects. This could depend on where your cancer has spread to, any symptoms youre having, and your general health and fitness. They can also tell you about any clinical trials that might be suitable.
A team of radiographers will give you the treatment. They will also give you support and information during your treatment.
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Prostate Radiotherapy For Metastatic Hormone Sensitive Prostate Cancermyth Or Reality
Cem Onal
Baskent University Faculty of Medicine , , Turkey
Correspondence to:
Submitted May 07, 2019. Accepted for publication May 10, 2019.
doi: 10.21037/tcr.2019.05.11
Previously, local radiotherapy was only limited to palliate local symptoms, including bleeding or obstructive symptoms in metastatic prostate cancer patients. However, a population-based database and retrospective studies suggested that the local treatment of the prostate could improve survival in metastatic hormone-naïve prostate cancer with a small metastatic burden, oligometastatic state . Recently two randomized trials demonstrated the efficacy of local RT to prostate in metastatic prostate cancer patients .
In STAMPEDE trial comparing hormonotherapy ± docetaxel with RT to prostate, 2,061 newly diagnosed metastatic prostate cancer patients were analyzed . Although overall survival was not improved with local RT , a significant improvement in failure-free survival was observed with prostate RT compared to standard of care alone . However, in subgroup analysis according to metastatic burden defined in CHAARTED study , an OS and FFS benefit was observed in patients with a low metastatic burden. However, patients with a high metastatic burden did not benefit from radiotherapy in terms of OS and FFS. The authors concluded that RT to primary tumor should be an option for newly diagnosed metastatic prostate cancer patients with low metastatic burden.
Radioactive Injections For Metastatic Prostate Cancer
Radioactive injections can help with symptoms of prostate cancer that has spread to the bones. They can shrink any areas of cancer in the bone by killing the cancer cells, which can relieve pain and improve your overall prognosis. Radioactive injections will not lower your PSA. Examples of radioactive injections are strontium 89 and radium-223 .
Getting your treatmentYou will normally have the injection every month in the radiotherapy department as an outpatient, so you shouldnt need to stay in hospital overnight.
Will I get side-effects?Side-effects are mild and may include diarrhoea and sickness, and sometimes reduced levels of blood cells. Bone pain may get a little worse before it gets better.
Will I be radioactive?After the injection, a small amount of radiation remains in your urine, poo and blood. It is best to use flush toilets instead of urinals afterwards. This will reduce the risk of others being exposed to the radiation. Do flush the toilet a couple of times after passing urine as well. Be careful of any spills of urine or blood, but it is quite safe to be around people and pets. The radiation usually lasts about 7 days. Your doctor or nurse will discuss any special precautions with you before you go home.
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Having External Beam Radiotherapy
At the start of the session, the radiographer will make sure you are in the correct position on the couch and that you are comfortable. Radiotherapy is not painful. But you must lie still during the treatment. You may want to take your painkillers before you have it.
When everything is ready, the radiographer leaves the room so you can have the radiotherapy. The treatment only takes a few minutes. You can talk to the radiographers through an intercom or signal to them during the treatment. They can see and hear you from the next room.
Your cancer doctor, nurse or radiographer will explain your treatment and its possible side effects. They can give you advice on what you can do to manage any side effects. They can also help answer any questions you may have.
Biology Of Circulating Tumor Cells
Circulating tumor cells in prostate cancer patients. Early metastatic features within PCa cells can be induced under stress conditions e.g. hypoxia, immune attack, or therapeutic pressure. In response to TGF-, Wnt or IL-6 PCa cells undergo EMT to gain motility and invasiveness. PCa cells intravasate into blood vessels either passively throughout leaky vessel walls or actively via trans-endothelial migration. Prostate CTCs circulate either as single cells, CTC cluster, or coated with platelets, neutrophils or macrophages shielding immune attack and reducing shear stress. CD45-EpCAM+ CTCs are a heterogeneous population differing in, e.g. the expression of androgen receptor splice variants, TMPRSS2-ERG status or loss of tumor suppressors PTEN, RB1, and TP53 recapitulating local tumor heterogeneity, influencing metastatic capacity and indicating therapy response.
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Radiation Therapy Side Effects
Radiation not only kills or slows the growth of cancer cells, it can also affect nearby healthy cells. Damage to healthy cells can cause side effects.
Many people who get radiation therapy have fatigue. Fatigue is feeling exhausted and worn out. It can happen all at once or come on slowly. People feel fatigue in different ways and you may feel more or less fatigue than someone else who is getting the same amount of radiation therapy to the same part of the body.
Other radiation therapy side effects you may have depend on the part of the body that is treated. To see which side effects you might expect, find the part of your body being treated in the following chart. Many of the side effects in the list link to more information in the Side Effects section. Discuss this chart with your doctor or nurse. Ask them about your chances of getting each side effect.
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Radioisotope Treatment For Prostate Cancer
One of the most common causes of morbidity and mortality among patients who progress to mPCA is the development of bone metastases. Though EBRT has long been used for palliation of symptomatic bone lesions, it lacks tumor specificity and often results in increased irradiation to normal surrounding tissues and organs at risk.
Radium-223 is an alpha emitter that has been shown to target bone metastases by selectively binding to areas of high cell turnover . The advantage of alpha emitters is that, because of high linear energy transfer, they are able to deposit more energy at shorter ranges . The proposed mechanism of action involves forming complexes with hydroxyapatite in areas of high cell turnover using high-energy RT, leading to irreparable DNA damage . The ALSYMPCA trial, in which patients with mCRPC and symptomatic bone lesions were randomized to receive either placebo or radium-223, showed that radium-223 prolonged time to symptomatic bone events, reduced the risk of suffering an event by 34%, and decreased use of EBRT for bone management of bone metastases .
Another agent presently under study is actinium-225 . This alpha emitter has been shown in a small case series to cause PSA decline and has a good toxicity profile . Another therapeutic radioisotope is 177-Lu-J591, which is a radiolabeled humanized MAB. Early phase trials have shown PSA response rates limited by reversible myelosuppression however, more information is needed with regards to efficacy and safety.
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Primary And Secondary Outcomes
The primary efficacy outcome measure was OS, defined as time from randomisation to death from any cause. Secondary outcomes for this long-term efficacy analysis included local interventionfree survival consisting of time from randomisation to the first report on case report forms of TURP, ureteric stent, surgery for bowel obstruction, urinary catheter, nephrostomy, colostomy, death from prostate cancerand symptomatic local event-free survival , comprising any of these LIFS events or acute kidney injury, urinary tract infection, or urinary tract obstruction. Cause of death was determined by the site investigator, with some cases reclassified as prostate cancer death according to predefined criteria which suggested this to be the likely cause. Patients without the event of interest were censored at the time last known to be event free. QoL analyses focused on Global QoL % and QLQ-30 Summary Score %, as derived from patient reports at scheduled assessment time points in the first 2 years after randomisation .
When Is Brachytherapy Alone The Right Choice
For some patients with disease that is confined to the prostate and not too aggressive , brachytherapy alone is a good option. It is also convenient for the patient as it is done in an outpatient setting and most people can get back to work within a few days.
But brachytherapy is not right for everyone. For some patients with less-aggressive disease, a watch-and-wait approach would be preferred. At MSK, our philosophy is that when the disease is caught very early, it is very appropriate to do active surveillance and hold off on treatment.
This philosophy applies to patients with a low PSA level, or nonaggressive disease as reflected by a Gleason score of 6 with evidence of cancer in only a few of the biopsy samples and no evidence from the MRI of a significant amount of disease. There are also very select patients with Gleason 7 disease who may be candidates for active surveillance.
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The Tumor Immune Microenvironment Of Pca
Induction of immune tolerance is a key process throughout tumor development to metastasis. Basically, tumor antigens, neo or not, must be processed and presented by antigen-presenting cells such as dendritic cells . They then migrate to secondary lymphoid organs to activate specific T lymphocyte cells. Conventional CD8+ DCs appear to be critical APCs for cross-presentation of neoantigens for tumor rejection by T cells . Activation of APCs occurs in coordination with other innate immune cells, including natural killer cells, natural killer T cells and T cells in response to damage-associated molecular patterns .
Immunologically, tumors are classified as hot and cold tumors according to their immune infiltrate. Features of hot tumors include increased T cell and cytotoxic T lymphocyte infiltration, primarily due to a high tumor mutational burden , and increased proteins that activate checkpoint proteins. In contrast, features of cold tumors include exhausted cTL cells in the tumor or their absence at the tumor margins, the presence of tumor-associated macrophages polarized to an M2-like phenotype , a low mutational load and poor antigen presentation. PCa can be considered as an immunologically cold tumor .