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.
Expert Review And References
- American Cancer Society. Treating Prostate Cancer. 2019: .
- American Society of Clinical Oncology. Prostate Cancer. 2020: .
- Tracy, CR. Prostate Cancer. eMedicine/Medscape 2020: .
- PDQ® Adult Treatment Editorial Board. Prostate Cancer Treatment Patient Version. Bethesda, MD: National Cancer Institute 2020: .
- PDQ® Adult Treatment Editorial Board. Prostate Cancer Treatment Health Professional Version. Bethesda, MD: National Cancer Institute 2020: .
- National Comprehensive Cancer Network . NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer . 2020 .
- Zelefsky MJ, Morris MJ, Eastham JA. Cancer of the prostate. DeVita VT Jr., Lawrence TS, Rosenberg SA, eds.. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Philadelphia, PA: Wolters Kluwer 2019: 70: 1087-1136.
- Parker C, Castro E, Fizazi K et al . Prostate cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up . Annals of Oncology . 2020 : 31: 1119-1134 .
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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A Biopsy Is Done To Diagnose Prostate Cancer And Find Out The Grade Of The Cancer
A transrectal biopsy is used to diagnose prostate cancer. A transrectal biopsy is the removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure may be done using transrectal ultrasound or transrectal MRI to help guide where samples of tissue are taken from. A pathologist views the tissue under a microscope to look for cancer cells.
Sometimes a biopsy is done using a sample of tissue that was removed during a transurethral resection of the prostate to treat benign prostatic hyperplasia.
If cancer is found, the pathologist will give the cancer a grade. The grade of the cancer describes how abnormal the cancer cells look under a microscope and how quickly the cancer is likely to grow and spread. The grade of the cancer is called the Gleason score.
To give the cancer a grade, the pathologist checks the prostate tissue samples to see how much the tumor tissue is like the normal prostate tissue and to find the two main cell patterns. The primary pattern describes the most common tissue pattern, and the secondary pattern describes the next most common pattern. Each pattern is given a grade from 3 to 5, with grade 3 looking the most like normal prostate tissue and grade 5 looking the most abnormal. The two grades are then added to get a Gleason score.
Prostate Cancer Survival Rates
Answering the question of how curable is prostate cancer? first requires understanding what doctors mean when they refer to curability. Regardless of the type of cancer, doctors consider cancer cured when a patient remains cancer-free for a specified period after treatment. The higher the number of patients who stay cancer-free for five years or longer, the higher the curability of that particular disease.
Prostate cancer, therefore, has one of the highest curability rates of all types of cancer, thanks in large part to early detection standards and advances in treatment, such as the stereotactic body radiation therapy offered by Pasadena CyberKnife. When the cancer is detected in the early local or regional stages that is, before the cancer has spread or when it has only spread to limited areas in the pelvic regions the five-year survival rate is nearly 100 percent.
Survival rates decline significantly when cancer is detected at later stages however, the good news is that only about five percent of men are diagnosed after the cancer has become widespread throughout the body. In short, more than 90 percent of men who are diagnosed with prostate cancer live for five years or longer after treatment, making it one of the most curable forms of cancer.
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Questions To Ask Your Doctor Or Nurse
You may find it helpful to keep a note of any questions you have to take to your next appointment. If youre choosing a treatment, you might find it helpful to ask your doctor or nurse some of these questions.
- What treatments are suitable for me?
- How quickly do I need to make a decision?
- What are the advantages and disadvantages of each treatment? What are their side effects?
- How effective is my treatment likely to be?
- Can I see the results of treatments youve carried out?
- Is the aim to keep my prostate cancer under control, or to get rid of it completely?
- If the aim of my treatment is to get rid of the cancer, what is the risk of my cancer coming back after treatment?
- If the aim of my treatment is to keep the cancer under control, how long might it keep it under control for?
- What treatments and support are available to help manage side effects?
- Are all of the treatments available at my local hospital? If not, how could I have them?
- After treatment, how often will I have check-ups and what will this involve? How will we know if my cancer starts to grow again?
- If my treatment doesnt work, what other treatments are available?
- Can I join any clinical trials?
- If I have any questions or get any new symptoms, who should I contact?
Clinical Trials For Prostate Cancer
Major pharmaceutical companies continually research and develop medications and treatments, which must be shown to be safe and effective before the FDA approves them and doctors can prescribe them to patients. Through prostate cancerclinical trials, researchers test the effects of new medications on a group of volunteers with prostate cancer. Following a strict protocol and using carefully controlled conditions, researchers evaluate the drugs under development and measure how well they treat prostate cancer, their safety, and any possible side effects.
Some people with prostate cancer are reluctant to join clinical trials for fear of getting no treatment at all. This is not true. Youâll get the most effective therapy available for your condition, or you might receive prostate cancer treatments that are being evaluated for future use. These drugs may be even more effective than the current treatment.
These websites offer information and services to help you find a prostate cancer clinical trial that is right for you:
TrialCheck. This website, developed by the nonprofit Coalition of Cancer Cooperative Groups, is an unbiased cancer clinical trial matching and navigation service that lets you search for cancer trials based on disease and location.
National Cancer Institute. This website lists more than 6,000 cancer clinical trials and explains what to do when you find one that you think is right for you.
Show Sources
CDC: “How is prostate cancer treated?”
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How Is Advanced Prostate Cancer Treated
There are a variety of treatment options available for men with advanced prostate cancer. Some approaches aim to slow the cancer’s growth or lessen the symptoms. Others are used to treat aggressive forms of cancer that don’t respond to prostatectomy or radiation therapy.
Our prostate cancer specialists will work closely with you to guide you through your options and help you decide what treatment, or combination of treatments, will provide the best outcome for you.
Some of the treatments of early stage prostate cancer may be part of the regimen your doctor recommends for you.
Other options that are typically used for late stage prostate cancer include:
Access The Right Treatments At The Right Time
When it comes to treating prostate cancer, it is important to have access to the best expertise possible so you can receive the right treatments at the right time. The University of Maryland Cancer Network gives you the opportunity to connect with the best treatment options available.
Led by the University of Maryland Greenebaum Comprehensive Cancer Center , the UM Cancer Network provides you access to nationally renowned experts, the latest treatments, and promising clinical trials close to home. When you work with a UM Cancer Network cancer center, your community hospital will work in partnership with UMGCCC to help you beat cancer.
Find out more about prostate cancer treatments.
Find an UMMS cancer center near you.
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Active Surveillance And Watchful Waiting
If prostate cancer is in an early stage, is growing slowly, and treating the cancer would cause more problems than the disease itself, a doctor may recommend active surveillance or watchful waiting.
Active surveillance. Prostate cancer treatments may seriously affect a person’s quality of life. These treatments can cause side effects, such as erectile dysfunction, which is when someone is unable to get and maintain an erection, and incontinence, which is when a person cannot control their urine flow or bowel function. In addition, many prostate cancers grow slowly and cause no symptoms or problems. For this reason, many people may consider delaying cancer treatment rather than starting treatment right away. This is called active surveillance. During active surveillance, the cancer is closely monitored for signs that it is worsening. If the cancer is found to be worsening, treatment will begin.
ASCO encourages the following testing schedule for active surveillance:
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A PSA test every 3 to 6 months
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A DRE at least once every year
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Another prostate biopsy within 6 to 12 months, then a biopsy at least every 2 to 5 years
Treatment should begin if the results of the tests done during active surveillance show signs of the cancer becoming more aggressive or spreading, if the cancer causes pain, or if the cancer blocks the urinary tract.
Low Dose Rate Brachytherapy
LDR brachytherapy is a treatment option for low-risk localized PCa. Good parameters of micturition are a precondition for LDR brachytherapy.
High dose rate brachytherapy
In HDR-BT, temporary needles are inserted into the prostate under spinal or general anesthesia. The radioactive source is then placed through the needles into the prostate in an afterloading technique. In contrast to LDR-BT, the radioactive source as well as the needles are removed again after the procedure. HDR-BT is characterized by a very steep dose drop-off in adjacent tissues, meaning that high individual doses can be given. As a rule HDR-BT is accompanied by percutaneous RT . No large randomized comparative studies have taken place . One randomized study compared HDR-BT and percutaneous RT with percutaneous RT alone, but the total dose was too small . Furthermore, there are numerous retrospective comparative studies that demonstrate the value of HDR-BT as a primary treatment option in the intermediate- and high-risk groups . The spectrum of adverse effects resembles that for percutaneous RT. Due to the lack of long-term prospective randomized studies comparing percutaneous RT with HDR-BT, however, no conclusion can be drawn as to superiority or inferiority. Brachytherapy of any kind should be carried out at an experienced center .
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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.
Surgery For Prostate Cancer
Many different approaches are used, each with its own risks and benefits. As with any surgery, the outcome depends in large measure on the expertise of the surgeon. Itâs crucial to find a surgeon with extensive experience in performing the type of surgery you choose.
Open radical retropubic prostatectomy involves removing the prostate through a cut made in the lower abdomen. This technique allows surgeons to remove not only the prostate but also any nearby lymph nodes that have become cancerous. Nerve-sparing techniques are now widely used to preserve urinary control and sexual function. The operation typically requires two or three days in the hospital. Most men need a urinary catheter in place for one two weeks after the surgery. For cancers confined to the prostate, radical prostatectomy remains the most effective way to remove cancer.
Radical perineal prostatectomy involves removing the prostate through a cut made in the perineum, the area between the and scrotum. This approach typically causes less bleeding, but surgeons are unable to remove nearby lymph nodes, making it useful only when the cancer is confined to the prostate.
Laparoscopic prostatectomy involves your surgeon making four or five very small cuts — about a half inch each — in the abdomen. The surgeon inserts tiny cameras and surgical tools through the cuts to remove the cancerous tissue.
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Future Directions In Care
Coupled with advances in imaging and genomic testing, the emergence of new therapeutic options for mCRPC suggests the potential for optimizing outcomes and survival. However, increasing patient access to these therapies remains a challenge, Gomella observed. Cost is one potential barrier, as he noted, Men are living longer, and many of these newer regimens can run $8000 to $10,000 or more a month, a financial burden for most. We are going to have to deal with these practical challenges. Also, it can be difficult to provide patients with appropriate treatment when also navigating challenges associated with insurance coverage and prior authorization. Insurance coverage is one of those unforeseen problems with these advances made over the last 10 years, Gomella said. The costs of developing novel agents are very significant, as well.
References
1. Lowrance WT, Breau RH, Chou R, et al. Advanced prostate cancer: AUA/ASTRO/SUO guideline part I. J Urol. 2021 205:14- 21. doi:10.1097/JU.0000000000001375
2. Cancer stat facts: prostate cancer. National Cancer Institute/ Surveillance, Epidemiology, and End Results Program. Accessed June 22, 2021. https://seer.cancer.gov/statfacts/html/prost.html
3. Rice MA, Malhotra SV, Stoyanova T. Second-generation antiandrogens: from discovery to standard of care in castration resistant prostate cancer. Front Oncol. 2019 9:801. doi:10.3389/ fonc.2019.00801
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What Is Advanced Prostate Cancer
Most prostate cancers are slow growing. However, during the illness, prostate cancer may progress. When PSA starts to rise in the months or years following surgery or radiation therapy for localized prostate cancer, it means that cancer cells remain in the body and there may be a recurrence of the disease. This is called advanced prostate cancer. At this time, advanced prostate cancer is generally not curable, although a variety of treatments can control the cancer, reduce symptoms, and improve and maintain quality of life.
Locally advanced prostate cancer is cancer that has grown through the outer wall of the prostate gland and into neighboring tissue and has returned after attempts at local treatment. Locally advanced prostate cancer has not spread into lymph nodes or to other organs.
Metastatic prostate cancer is prostate cancer that has spread to other parts of the body, particularly the bones or lymph nodes.
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