The prostate is a walnut-sized gland that is found behind the base of the penis, in front of the rectum, and beneath the bladder. It encircles the urethra, the tube-like canal that transports urine and sperm through the penis. The prostate’s primary purpose is to produce seminal fluid, a substance found in sperm that protects, supports, and transports sperm.
As people age, their prostates continue to expand. This can result in a disease known as benign prostatic hypertrophy (BPH), in which the urethra gets obstructed. BPH is a common disorder associated with aging, and it has not been linked to an increased risk of prostate cancer.
WHAT IS PROSTRATE CANCER?
Cancer develops when healthy cells in the prostate alter and expand out of control, resulting in the formation of a tumor. A tumor might be malignant or noncancerous. A malignant tumor is one that can grow and spread to other regions of the body. A benign tumor is one that can develop but does not spread.
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| Photo from camc.org |
When compared to other types of cancer, prostate cancer is fairly uncommon. This is due to the fact that many prostate cancers do not spread rapidly to other areas of the body. Some prostate tumors grow slowly and may not create symptoms or issues for many years, if at all. Even when prostate cancer has spread to other parts of the body, it is frequently treatable for an extended period of time. As a result, men with prostate cancer, even those with advanced disease, may enjoy good health and a high quality of life for many years. However, if the cancer is not properly controlled with current treatments, it can produce symptoms such as discomfort and exhaustion and, in some cases, death. Watching for growth over time to determine whether it is growing slowly or quickly is an important element of controlling prostate cancer. Your doctor can determine the best available treatment options and when to provide them based on the pattern of growth.
Histology is the examination of cancer cells under a microscope. Adenocarcinoma is the most prevalent histology seen in prostate cancer. Neuroendocrine prostate cancer and small cell prostate cancer are two less prevalent histologic forms of prostate cancer. These variations are more aggressive, produce far less PSA, and spread outside the prostate much sooner.
What is prostrate-specific antigen (PSA)
PSA is a protein that is produced by cells in the prostate gland and released into the circulation. PSA levels are determined using a blood test. Although there is no such thing as a “normal PSA” for anyone at any age, patients with prostate cancer have higher-than-normal PSA levels. Other non-cancerous prostate diseases, such as BPH or prostatitis, can also cause an increase in PSA levels. Prostatitis is an infection or inflammation of the prostate. Furthermore, some actions, including as ejaculation, can temporarily raise PSA levels. To avoid artificially high PSA levels, ejaculations should be avoided prior to a PSA test. Before utilizing PSA testing to check for prostate cancer, people should consider the benefits and drawbacks with their primary care doctor.
WHAT ARE THE SYMPTOMS AND SIGNS OF PROSTRATE CANCER
A symptom, such as weariness, nausea, or discomfort, is something that only the person experiencing it can identify and explain. A symptom is something that others can recognize and quantify, such as a fever, rash, or an increased pulse. Signs and symptoms, when combined, can assist describe a medical situation. While most prostate cancers do not cause any symptoms, the following are some of the symptoms and indicators of prostate cancer:
- Urination that occurs frequently.
- Urine flow that is weak or interrupted, or the need to strain to empty the bladder
- Urge to urinate frequently during the night
- Urine with blood in it
- Erectile dysfunction has manifested itself in a new way.
- Urinary pain or burning, which is far less prevalent
- An enlarged prostate that causes discomfort or agony when sitting.
Other noncancerous prostate disorders, such as BPH or an enlarged prostate, can produce similar symptoms. Alternatively, the origin of a symptom or sign could be another medical problem that is unrelated to cancer. Urinary symptoms might also be caused by a bladder infection or other illnesses.
Symptoms and indicators of prostate cancer that has progressed outside of the prostate gland may include:
- Back, hip, thigh, shoulder, or other bone pain
- Swelling or accumulation of fluid in the legs or feet
- Unknown cause of weight loss
- Fatigue
- Alteration in bowel habits
Please consult your doctor if you are concerned about any changes you are experiencing. In addition to other questions, your doctor will inquire how long and how frequently you have been experiencing the symptom(s). This is done to assist in determining the cause of the condition, which is referred to as a diagnostic.
If cancer is discovered, symptom relief is an important element of cancer care and treatment. This is known as “palliative care” or “supporting care.” It is frequently initiated shortly after diagnosis and continues throughout treatment. Make an appointment with your health care provider to discuss your symptoms, especially any new or changing symptoms.
WHAT ARE THE STAGES AND GRADES OF PROSTRATE CANCER?
Staging describes where the cancer is present, whether or not it has spread, and whether or not it is impacting other sections of the body.
Doctors utilize diagnostic tests to determine the stage of cancer, therefore staging may not be complete until all of the tests are completed. Prostate cancer staging also entails reviewing test data to see whether the cancer has progressed from the prostate to other places of the body. Knowing the stage allows the doctor to propose the best course of treatment and can assist estimate a patient’s prognosis, or possibility of recovery. Distinct forms of cancer have different stage descriptions.
There are two forms of prostate cancer staging:
- Clinical staging: This is based on DRE, PSA tests, and the Gleason score. These results will assist establish whether additional tests such as x-rays, bone scans, CT scans, or MRI are required. If scans are required, they might provide additional information to assist the clinician in determining the clinical stage.
- Pathologic staging: This is based on information discovered during surgery as well as laboratory results from prostate tissue retrieved during surgery, generally known as pathology. The entire prostate and some lymph nodes are frequently removed during surgery. Pathologic staging can be improved by inspecting the excised lymph nodes.
TNM system of staging
The TNM system is one technique that clinicians use to describe the stage. The American Joint Committee on Cancer created this system. Doctors use diagnostic test and scan results to address the following questions:
Tumor(T): What is the size of the main tumor? Where can I find it?
Node(N): Has the cancer spread to your lymph nodes? If so, where are they and how many are there?
Metastasis(M): Is the malignancy in other parts of the body? If so, where and how much?
The results are aggregated to establish each person’s cancer stage. There are five stages: stage 0 (zero), stages I through IV, and level V. (1 through 4). The stage provides a common language for doctors to describe the cancer so that they can collaborate to determine the best treatments.
Gleason score: Prostrate cancer grading
A Gleason score is also assigned to prostate cancer. This score is determined by how closely the cancer resembles healthy tissue when seen under a microscope. Less aggressive tumors resemble healthy tissue in appearance. More aggressive tumors are more likely to grow and spread to other regions of the body. They appear to be less healthy tissue.
The most often used prostate cancer grading method is the Gleason score system. The pathologist examines the arrangement of cancer cells in the prostate and assigns a score on a scale of 3 to 5 from two separate places. Cancer cells that resemble healthy cells are given a low score. Cancer cells that resemble healthy cells less or appear more aggressively are given a higher grade. To assign the numbers, the pathologist first analyzes the major pattern of cell development, which is the part of the cancer that is most visible, and then searches for another area of growth. The doctor then assigns a score of 3 to 5 to each location. The scores are totaled up to produce an overall score between 6 and 10.
Gleason scores of 5 or less are not accepted. The lowest Gleason score is 6, indicating that the cancer is of modest severity. A Gleason score of 7 indicates that the cancer is of medium severity, whereas a score of 8, 9, or 10 indicates that the cancer is of high severity. Lower-grade cancers grow more slowly and are less likely to spread than higher-grade cancers.
To help plan treatment, doctors consider the Gleason score in addition to the stage. Active monitoring, for example, may be a possibility for someone with a tiny tumor, a low PSA level, and a Gleason score of 6. Even if the cancer is not large or has not spread, people with a higher Gleason score may require more intense treatment.
- Gleason X: There is no means of determining the Gleason score.
- Gleason 6 or lower: The cells resemble healthy cells, which is referred to as well differentiated.
- Gleason 7: The cells have a moderately differentiated appearance, which means they are similar to healthy cells.
- Gleason 8, 9, or 10: The cells are poorly differentiated or undifferentiated because they appear considerably different from healthy cells.
Cancer stage grouping
Doctors determine the cancer stage by integrating the T, N, and M classifications. The PSA level and Gleason score are also included in staging.
Stage I: Cancer is normally slow developing in this stage. The tumor is not palpable and occupies one-half of one side of the prostate, if not less. PSA levels are quite low. Cancer cells resemble healthy cells.
Stage II: The tumor has only been identified in the prostate. PSA levels are moderate to low. Although stage II prostate cancer is tiny, it has a high chance of developing and spreading.
- Stage IIA: The tumor is not palpable and only affects half of one side of the prostate, if that. PSA levels are moderate, and the cancer cells are differentiated. Larger tumors discovered only in the prostate are also included in this stage, as long as the cancer cells are still well differentiated.
- Stage IIB: The tumor is only discovered within the prostate and may be large enough to be felt during DRE. The PSA level is moderate. Cancer cells have a modest level of differentiation.
- Stage IIC: The tumor is only discovered within the prostate and may be large enough to be felt during DRE. The PSA level is moderate. Cancer cells might be either moderately or poorly differentiated.
Stage III: PSA levels are elevated, the tumor is expanding, or the malignancy is of a high grade. All of these symptoms point to a locally advanced cancer that is likely to grow and spread.
- Stage IIIA: The cancer has progressed beyond the prostate’s outer layer into surrounding tissues. It could have also spread to the seminal vesicles. The PSA level is elevated.
- Stage IIIB: The tumor has spread beyond the prostate gland and may have infiltrated neighboring structures such as the bladder or rectum.
- Stage IIIC: Cancer cells throughout the tumor are poorly differentiated, which means they appear quite different from healthy cells.
Stage IV: The cancer has progressed from the prostate to other parts of the body.
- Stage IVA: The cancer has spread to the lymph nodes in the region.
- Stage IVB: The cancer has spread to distant lymph nodes, other bodily parts, or the bones.
Recurrent: Cancer that has returned after treatment is referred to as recurrent prostate cancer. It may reappear in the prostate area or elsewhere in the body. If the cancer returns, more tests will be performed to determine the degree of the recurrence. These tests and scans are frequently identical to those performed at the time of the first diagnosis.
HOW IS PROSTRATE CANCER DIAGNOSED?
Many tests are used by doctors to detect or diagnose cancer. They also perform tests to see whether the cancer has spread to another place of the body from where it began. This is referred as as metastasis. Imaging tests, for example, can reveal whether or not the cancer has spread. Images of the inside of the body are produced via imaging tests. Doctors may also conduct tests to determine which treatments are most likely to be effective.
A biopsy is the only guaranteed way for a doctor to know if a part of the body has cancer in most cases of cancer. During a biopsy, the doctor extracts a small sample of tissue for laboratory testing.
There are numerous tests available to diagnose prostate cancer. Not all of the tests outlined here are typically utilized for every individual. When selecting a diagnostic test, your doctor may take the following variables into account:
- The cancer type suspected
- Your symptoms and signs
- Your age and general well-being
- The outcomes of previous medical tests
Preliminary tests
If prostate cancer is suspected, a physical exam and the following procedures may be done to determine whether more diagnostic testing are required:
PSA test: PSA is a protein produced by prostate tissue that is present in increased concentrations in the blood. Levels can rise when there is aberrant activity in the prostate, such as prostate cancer, BPH, or prostate inflammation. Doctors can use PSA value characteristics such as absolute level, change over time (also known as “PSA velocity”), and level in proportion to prostate size to determine whether a biopsy is required.
Free PSA test: The “free” PSA is a variation of the PSA test that allows the clinician to measure a specific component. PSA that is not attached to proteins is present in the bloodstream as free PSA. A conventional PSA test examines total PSA, which includes both PSA bound to proteins and PSA that is not. The free PSA test calculates the free PSA/total PSA ratio. Knowing this ratio or percentage can sometimes aid in determining if an increased PSA level is more likely to be connected with a malignant condition such as prostate cancer.
DRE: A DRE is used by a clinician to detect abnormal portions of the prostate by feeling the area with a finger. It is not very exact, and not every doctor is trained in it; thus, DRE does not frequently detect early prostate cancer.
Biomarker tests: A biomarker is a substance discovered in the blood, urine, or body tissues of a cancer patient. It is produced by the tumor or by the body as a reaction to malignancy. A biomarker is also known as a tumor marker. The 4Kscore predicts the likelihood that someone has high-risk prostate cancer, and the Prostate Health Index (PHI) predicts the likelihood that someone has prostate cancer.
When a person is diagnosed with prostate cancer via biopsy, a genetic test, such as Oncotype Dx Prostate, Prolaris, Decipher, or ProMark, can provide extra information to help make a decision about how the prostate cancer should be managed. This includes patients who are considering active surveillance for low-risk or intermediate-risk localized prostate cancer. It may also entail employing the Decipher test to assist identify whether extra treatment should be explored in certain patients following prostatectomy, or surgical removal of the prostate. When doing a biomarker test, the results should always be compared to all other relevant information.
Discuss biomarker tests with your doctor to learn more about what they signify and how the results may or may not alter your treatment strategy.
Diagnosis
If the PSA or DRE test results are abnormal, additional tests will be performed to determine whether a person has prostate cancer. Many tests can indicate the presence of cancer, but only a biopsy can provide a definitive diagnosis.
Biopsy: A biopsy is the removal of a small sample of tissue for examination under a microscope. To get a tissue sample, a surgeon will typically employ transrectal ultrasonography (TRUS) and a biopsy tool to extract extremely small slivers of prostate tissue. Biopsy specimens will be collected from various regions of the prostate. This is done to ensure that a good sample is taken for examination. Most people will have 12 to 14 pieces of tissue removed, and the process can take 20 to 30 minutes to complete.
This operation is frequently performed in a hospital or doctor’s office without the requirement for an overnight stay. Before the procedure, the patient is given local anaesthetic to numb the area and is usually given antibiotics to avoid infection. To collect tissue samples, the ultrasound tool is inserted into the rectum, and then the biopsy needle is passed through the rectum and into the prostate gland.
Because there is a danger of infection with transrectal prostate biopsy, some doctors prefer transperineal prostate biopsy instead. TRUS is used to guide this biopsy as well, but the biopsy needle penetrates through the skin of the perineum and into the prostate gland. The gap between the scrotum and the anus is known as the perineum. This treatment reduces the danger of infection by inserting the needle through the skin rather than the rectum.
The sample(s) are next examined under a microscope by a pathologist. A pathologist is a medical professional who specializes in interpreting laboratory tests and assessing cells, tissues, and organs to identify disease.
Request a review of the pathology report results with your health care team.
Transrectal ultrasound (TRUS): A doctor inserts a probe into the rectum and uses sound waves that bounce off the prostate to take an image of the prostate. A TRUS is typically performed concurrently with a biopsy.
MRI fusion biopsy: An MRI fusion biopsy combines an MRI scan with a TRUS examination. In clinical practice, a prostate MRI scan has become a standard technique. The patient is first given an MRI scan to identify any worrisome spots of the prostate that need to be evaluated further. The patient is subsequently subjected to an ultrasound of the prostate. These photos are combined by computer software to create a 3D image that aids in the targeting of a precise spot for the biopsy. Although it does not obviate the need for additional biopsies, an MRI fusion biopsy can detect areas that are more likely to be malignant than other procedures. An MRI fusion biopsy should only be conducted by a trained professional.
Determining whether the cancer has spread
Doctors may use the imaging tests described below to determine if cancer has spread beyond the prostate. Doctors can estimate the likelihood of metastasis based on PSA levels, tumor grade, and other indicators, but an imaging test can confirm and offer information about the location of the malignancy.
Imaging examinations are not always necessary. For patients with no symptoms and low-risk, early-stage prostate cancer, as confirmed by the PSA test and biopsy, a CT scan or bone scan may not be required.
ASCO recommends that persons with advanced prostate cancer have one or more of the imaging tests listed below to learn more about the disease and plan the optimal treatment. This includes when a high-risk cancer is initially diagnosed; when metastasis is suspected or confirmed; when the cancer has returned after therapy; or when the cancer increases during the treatment period.
Whole-body bone scan: A bone scan examines the inner of the bones using a radioactive tracer (Technetium-99). The tracer contains far too little radiation to be dangerous. The tracer is injected into the vein of a patient. It gathers in places of the bone where there has been metabolic activity. Healthy bone appears lighter to the camera, but regions of harm, such as those produced by cancer, stand out. It is critical to understand that structural changes to the bone, such as arthritis or bone injuries such as fractures, can also be viewed as abnormal and should be investigated by a specialist to ensure they are not cancer.
Magnetic resonance imaging (MRI): An MRI scan produces detailed images of the body by using magnetic fields rather than x-rays. An MRI can be used to determine the size of the tumor, and the scan can be focused exclusively on the prostate or on the entire body. To provide a clearer image, a special dye called contrast medium is injected into a patient’s vein before to the scan.
Computed tomography (CT) scan: A CT scan uses x-rays captured from various angles to create images of the inside of the body. A computer combines these images to create a detailed, three-dimensional image that identifies any anomalies or malignancies. A CT scan can be performed to determine the size of the tumor. To improve image detail, a specific dye known as a contrast medium is sometimes administered before to the scan. This dye can be injected into a patient’s vein or given to them in the form of a pill or liquid to consume.
Positron emission tomography (PET) or PET-CT scan: A PET scan is frequently coupled with a CT scan, resulting in a PET-CT scan. However, your doctor may refer to this technique simply as a PET scan. A PET scan is a technique for creating images of organs and tissues within the body. A radioactive chemical is put into the patient’s body in a modest amount. This chemical is absorbed by the cells that expend the most energy or are most physiologically active. Cancer absorbs more radioactive stuff since it uses energy and is physiologically active. The amount of radiation in the material, however, is too low to be dangerous. The material is then detected by a scanner, which produces images of the inside of the body.
A PET-CT scan images fluorodeoxyglucose (FDG) for many types of cancer; however, FDG is not a helpful material for early imaging in prostate cancer and should not be used consistently. A PET scan employing gallium-68 PSMA-11 or fluorine-18 (18F)-DCFPyL may be recommended if metastasis or recurrence is suspected. The gallium-68 or fluorine-18 in this sort of scan binds to prostate-specific membrane antigen (PSMA), which is commonly found at higher levels in prostate cancer cells, and shows where the cancer has progressed.
Researchers are researching the use of several chemicals in conjunction with PET scans to detect prostate cancer. For example, because sodium fluoride is absorbed by bones, using it in a PET scan may increase the likelihood of detecting prostate cancer that has migrated to the bone. Choline acetate and fluciclovine are two other compounds being researched.
After the diagnostic tests are completed, your doctor will go through the results with you. If cancer is the diagnosis, these data will also assist the clinician in describing the cancer.
WHAT ARE THE TREATMENTS OF PROSTRATE CANCER?
In cancer care, several types of clinicians, such as medical oncologists, surgeons, and radiation oncologists, frequently collaborate to develop an overall treatment plan that may include a combination of different types of therapy to treat the cancer. This is referred to as a multidisciplinary team. Other health care professionals on cancer care teams include palliative care specialists, physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, nutritionists, physical therapists, and others.
The most frequent types of prostate cancer therapies are mentioned below. Treatment for symptoms and side effects, which is an important element of cancer care, may also be part of your treatment plan.
The type and stage of cancer, potential side effects, and the patient’s preferences and overall health all influence treatment options and recommendations. Cancer treatment can have a variety of effects on older persons.
Take the time to read about your treatment options, and don’t be afraid to ask clarifying questions. Discuss the aims of each treatment with your doctor, as well as the chance that the treatment will work, what you can expect while receiving the treatment, and the potential urinary, bowel, sexual, and hormone-related side effects of treatment. Discuss with your doctor how the various treatment options can effect recurrence, survival, and quality of life. It is also critical to inquire about your doctor’s experience treating prostate cancer. These discussions are known as “shared decision-making.” When you and your doctors collaborate to identify therapies that meet the goals of your care, this is referred to as shared decision-making. Because there are various treatment options for prostate cancer, shared decision-making is very vital.
Because most prostate cancers are discovered in their early stages, when they are growing slowly, treatment decisions are usually not rushed. During this time, it is critical to discuss with your doctor the risks and benefits of all of your treatment options, as well as when therapy should begin. This debate should also provide an update on the cancer’s current status:
Whether you experience symptoms or your PSA levels are fast climbing,
- The extent to which the cancer has progressed to the bones.
- Your medical history
- Your standard of living
- Your present sexual and urinary function
- Any other medical issues you may be suffering from
Although your treatment options will be determined by these circumstances, there are some broad guidelines for treating prostate cancer by stage.
Active surveillance and watchful waiting
Active surveillance: Treatment for prostate cancer can have a significant impact on a person’s quality of life. These therapies may result in adverse effects such as erectile dysfunction (the inability to obtain and sustain an erection) and incontinence (the inability to control one’s urine flow or bowel function). Furthermore, many prostate tumors grow slowly and generate no signs or complications. As a result, many patients may think of postponing cancer treatment rather than commencing it straight immediately. This is known as active surveillance. The malignancy is continuously checked for symptoms of worsening during active surveillance. Treatment will begin if the cancer is discovered to be worsening.
Active surveillance is usually suggested for patients with very-low-risk or low-risk prostate cancer that can be treated with surgery or radiation therapy if it shows indications of worsening. ASCO supports CancerCare Ontario’s active surveillance recommendations, which urge active surveillance for most patients with cancer that has not progressed beyond the prostate and has a Gleason score of 6 or less. Active surveillance may be an option in the case of prostate cancer with a Gleason score of 7. There is also an increase in the use of genomic testing to determine whether active monitoring is the best option for a person with prostate cancer.
For active monitoring, ASCO recommends the following testing schedule:
- A PSA test should be performed every 3 to 6 months.
- A DRE should be performed at least once a year.
- Another prostate biopsy should be performed within 6 to 12 months, followed by a biopsy every 2 to 5 years.
Treatment should begin if the results of tests performed during active surveillance show evidence of the cancer growing more aggressive or spreading, causing pain, or blocking the urinary tract.
Watchful waiting: For older persons and those with other serious or life-threatening conditions who are projected to live less than 5 years, watchful waiting may be an option. Routine PSA tests, DRE, and biopsies are not routinely performed with watchful waiting. If the prostate cancer creates symptoms such as pain or urinary tract blockage, therapy may be advised to alleviate such symptoms. Hormonal treatment may be included. Patients who begin on active surveillance but later have a decreased life expectancy may be switched to watchful waiting to prevent recurring testing and biopsies.
Doctors must gather as much information about the patient’s other ailments and life expectancy as feasible in order to evaluate whether active monitoring or watchful waiting is appropriate for each individual. Furthermore, before considering active surveillance for someone who is otherwise healthy, many clinicians request a repeat biopsy shortly after diagnosis to establish that the cancer is in an early stage and developing slowly. New information is always becoming accessible, and it is critical to discuss these topics with the doctor in order to make the best treatment options.
Local treatments
Cancer is eradicated from a specific, confined area of the body using local therapy. Surgical procedures and radiation therapy are examples of such treatments. Local therapy for early-stage prostate cancer may entirely eradicate the tumor. If the cancer has gone beyond the prostate gland, further treatments (such as drugs) may be required to eradicate cancer cells in other parts of the body.
Surgery
During a surgery, the prostate and some surrounding lymph nodes are removed. A surgical oncologist is a specialist who specializes in the surgical treatment of cancer. A urologist, often known as a urologic oncologist, is the surgical oncologist involved in the treatment of prostate cancer. The type of surgery is determined by the disease’s stage, the patient’s overall condition, and other considerations.
- Radical (open) prostatectomy: The surgical removal of the whole prostate as well as the seminal vesicles is known as a radical prostatectomy. Lymph nodes in the pelvic area may be removed as well. This procedure has the potential to impair sexual function. When possible, nerve-sparing surgery increases the likelihood that the patient will be able to preserve sexual function after surgery by avoiding surgical injury to the nerves that allow erections and orgasm to occur. Because these are independent processes, orgasm can occur even if some nerves are severed. Urinary incontinence is another potential side effect of radical prostatectomy. Drugs, penile implants, or injections may be advised to assist restore normal sexual function. Urinary incontinence can sometimes be treated with another procedure.
- Bilateral orchiectomy: The surgical removal of both testicles is known as a bilateral orchiectomy. It is discussed in length in the section “Systemic therapies” below.
- Transurethral resection of the prostate (TURP): TURP is typically performed to ease the symptoms of a urinary obstruction rather than to treat prostate cancer. In this surgery, a surgeon inserts a small tube with a cutting device called a cystoscope into the urethra and then into the prostate to remove prostate tissue while the patient is under complete anesthesia, which is medication to block pain awareness.
- Robotic or laparoscopic prostatectomy: This procedure is less invasive than a radical prostatectomy and may result in a shorter recovery time. A camera and tools are placed into the patient’s belly through small keyhole incisions. The robotic devices are then directed by the surgeon to remove the prostate gland. In general, robotic prostatectomy is less painful and causes less bleeding, but the sexual and urinary side effects are similar to those of a radical (open) prostatectomy. Discuss with your doctor whether your treatment facility offers this operation and how it compares to the results of a radical (open) prostatectomy.
Before undergoing surgery, consult with your health care team about the potential adverse effects of the procedure. Patients who are younger or healthier may benefit more from a prostatectomy. Younger patients are also less likely than older patients to experience permanent erectile dysfunction and urine incontinence after a prostatectomy.
Radiation therapy
The use of high-energy rays to eliminate cancer cells is known as radiation therapy. A radiation oncologist is a doctor who specializes in the use of radiation therapy to treat cancer. A radiation therapy regimen, or schedule, typically consists of a predetermined number of treatments administered over a predetermined time period.
External-beam radiation therapy: The most prevalent type of radiation therapy is external-beam radiation therapy. The radiation oncologist directs an x-ray beam onto the cancerous region using an equipment placed outside the body.
Hypofractionated radiation therapy is a type of external-beam radiation therapy used to treat prostate cancer. This is when a person receives a larger daily dose of radiation therapy over a shorter period of time rather than lesser doses over a longer period of time. When the complete treatment is provided in 5 or fewer treatments, this is referred to as extreme hypofraction radiation therapy. Typical moderate hypofraction radiation therapy regimens comprise 20 to 28 treatments. Stereotactic body radiation therapy (SBRT) or stereotactic ablative radiation therapy are other terms for this (SABR).
Hypofractionated radiation therapy may be an option for the following persons with early-stage prostate cancer that has not progressed to other parts of the body, according to recommendations from ASCO, the American Society for Radiation Oncology, and the American Urological Association:
- Patients with low-risk prostate cancer who require or choose therapy over active surveillance.
- Patients with intermediate or high-risk prostate cancer who are undergoing external-beam radiation therapy to the prostate and maybe the pelvic lymph nodes.
When compared to standard external-beam radiation therapy, people who undergo hypofractionated radiation therapy may have a slightly higher risk of several short-term side effects after treatment. This could include stomach issues. According to current studies, patients who get hypofractionated radiation therapy are not at a higher risk of long-term negative effects. If you have any concerns about your risk of side effects, consult with your health care team.
Intensity-modulated radiation therapy (IMRT): IMRT is a type of external-beam radiation therapy in which CT scans are used to create a 3D image of the prostate prior to treatment. A computer utilizes this information about the prostate cancer’s size, shape, and location to calculate how much radiation is required to eradicate it. High doses of radiation can be directed at the prostate with IMRT without increasing the risk of harming surrounding organs.
Proton therapy: Proton therapy, also known as proton beam therapy, is a type of external-beam radiation therapy in which protons are used instead of x-rays. Protons have the ability to destroy cancer cells at high energies. Proton treatment does not appear to be any more beneficial to persons with prostate cancer than standard radiation therapy, according to current data. It may also be more costly.
Brachytherapy: Internal radiation therapy, also known as brachytherapy, involves inserting radioactive sources directly into the prostate. These sources, known as seeds, emit radiation just around the area where they are implanted and can be left for a short period of time (high-dose rate) or for a prolonged period of time (low-dose rate) (low-dose rate). Low-dose-rate seeds are implanted permanently in the prostate and can work for up to a year after being put. The length of time they work, however, is determined by the source of radiation. High-dose-rate brachytherapy is normally administered in less than 30 minutes, however it may be necessary to administer it more than once.
Brachytherapy can be combined with other therapies including external-beam radiation therapy and/or hormone therapy. The following brachytherapy options are recommended by ASCO:
- Low-dose-rate brachytherapy may be an option for people with low-risk prostate cancer who require or want active treatment. External-beam radiation therapy or a radical prostatectomy are two other alternatives.
- People with intermediate-risk prostate cancer who select external-beam radiation therapy (with or without hormone therapy) should get either a low-dose-rate or a high-dose-rate brachytherapy boost in addition to the external-beam radiation therapy. A lower dose of radiation is delivered for a shorter period of time during a brachytherapy boost. Some individuals with intermediate-risk prostate cancer may be able to receive brachytherapy alone, without the need for external-beam radiation therapy or hormone therapy.
- Patients with high-risk prostate cancer who are receiving external-beam radiation therapy and hormone therapy should be offered a brachytherapy boost at a low or high dose rate.
Radiation therapy side effects
During treatment, radiation therapy may induce side effects such as increased need to pee or frequency of urination; sexual function problems; bowel function problems such as diarrhea, rectal discomfort, or rectal bleeding; and weariness. The majority of these side effects normally subside following treatment.
Drugs, penile implants, or injections may be advised to assist restore normal sexual function. In the Coping With Treatment area, you may learn more about coping with the sexual side effects of prostate cancer. While uncommon, some radiation therapy adverse effects may not manifest themselves for years following treatment.
Focal therapies
Focal therapies are less invasive treatments that eliminate tiny prostate cancers while leaving the remainder of the prostate gland alone. Heat, cold, and other approaches are used to treat cancer in these treatments, which are usually used to treat low-risk or intermediate-risk prostate cancer. Clinical trials are being conducted to investigate focal treatments. The majority of them have not been accepted as routine treatment choices.
Cryosurgery, also known as cryotherapy or cryoablation, involves freezing cancer cells with a metal probe introduced through a small incision in the skin sac that holds the testicles, between the rectum and the scrotum. It is not a proven therapy or standard of care for the treatment of newly diagnosed prostate cancer. Because cryosurgery has not been compared to radical prostatectomy or radiation therapy, clinicians are unsure if it is a comparable treatment choice. Its impact on urinary and sexual function is also unknown.
High-intensity focused ultrasound (HIFU) is a sort of heat-based targeted treatment. During HIFU treatment, an ultrasound probe is placed into the rectum, and sound waves are focused at cancerous areas of the prostate gland. This treatment is intended to kill cancer cells while causing minimal damage to the remainder of the prostate gland. In 2015, the FDA approved HIFU for the treatment of prostate tissue. HIFU may be appealing to some people, however it is unclear who will gain the most from this treatment. HIFU should only be performed by a highly skilled professional. If HIFU is the ideal treatment for you, you should consult with your doctor first.
Hormonal therapy
Because prostate cancer is fueled by male sex hormones known as androgens, reducing levels of these hormones can help limit the cancer’s growth. Testosterone is the most common androgen. Hormonal therapy is used to reduce testosterone levels in the body, either by surgically removing the testicles (known as surgical castration) or by taking drugs that inhibit the action of the testicles (known as medical castration). It is less crucial whatever hormonal therapy is employed than the fundamental goal of reducing testosterone levels. This treatment is also known by other names, such as androgen-deprivation therapy (ADT).
Another strategy to prevent testosterone from fueling the growth of prostate cancer is to treat it with an androgen axis inhibitor, which is a sort of drug. These medicines can either prevent the body from producing testosterone or prevent testosterone from acting. Androgen axis inhibitors include androgen receptor inhibitors as well as androgen synthesis inhibitors, which are both discussed further below.
Hormonal therapy is used to treat prostate cancer in a variety of settings, including localized, locally progressed, and metastatic prostate cancer, as well as rising PSA levels after localized prostate cancer surgery and/or radiation therapy. This therapy may be utilized in the following situations:
- People who have intermediate-risk or high-risk, localized prostate cancer who are undergoing definitive radiation therapy are candidates for hormonal therapy. Definitive therapy is a cancer treatment that is intended to cure the patient. Patients with intermediate-risk prostate cancer should be treated with hormone treatment for at least 4 to 6 months. Those at high risk of developing prostate cancer should have it for 2 to 3 years.
- Those who have undergone surgery and tiny cancer cells identified in the excised lymph nodes may also be offered hormone therapy. It is done to remove any leftover cancer cells and limit the likelihood of the cancer returning. This is referred to as adjuvant therapy. Although the use of adjuvant hormonal therapy is debatable, some patients appear to benefit from it.
Hormonal therapy types
Bilateral orchiectomy: The surgical removal of both testicles is known as a bilateral orchiectomy. More than 70 years ago, it was the first treatment for metastatic prostate cancer. Despite the fact that it is a surgical treatment, it is considered systemic, hormonal therapy since it eliminates the testicles, which are the main source of testosterone production. The consequences of this procedure are permanent and irreversible. Bilateral orchiectomy is no longer widely used.
LHRH agonists: LHRH is an abbreviation for luteinizing hormone-releasing hormone. LHRH agonists are medications that block the testicles from getting information from the body to produce testosterone. LHRH agonists lower testosterone levels exactly as effectively as removing the testicles by blocking these signals. Unlike orchiectomy, the effects of LHRH agonists are frequently reversible, therefore testosterone production normally resumes after treatment is discontinued. However, testosterone recovery can take 6 to 24 months, and testosterone production does not return in a tiny minority of patients.
LHRH agonists are injected or implanted under the skin as tiny implants. They may be given once a month or once a year, depending on the medicine. When LHRH agonists are first administered, testosterone levels rise temporarily before plummeting to extremely low levels. This is referred to as a “flare.” Flares arise as a result of the testicles momentarily releasing more testosterone in response to how LHRH agonists act in the body. This flare-up may enhance the activity of prostate cancer cells, resulting in symptoms and side effects such as bone discomfort if the cancer has migrated to the bone.
LHRH antagonist: This class of medications, also known as gonadotropin-releasing hormone (GnRH) antagonists, prevents the testicles from making testosterone in the same way that LHRH agonists do, but they reduce testosterone levels more quickly and without causing the flare that LHRH agonists do. The FDA has approved the monthly injection of degarelix (Firmagon) to treat advanced prostate cancer. One of the drug’s negative effects is that it can produce a severe allergic reaction. The FDA has also approved relugolix (Orgovyx), an oral LHRH antagonist, for the treatment of advanced prostate cancer. In patients with preexisting heart disease, Relugolix has a lower risk of causing serious heart problems. Furthermore, when relugolix treatment is discontinued, testosterone production is recovered within weeks rather than months, which may be beneficial for patients receiving intermittent hormonal therapy.
Androgen receptor (AR) inhibitors: While LHRH agonists and antagonists reduce blood testosterone levels, androgen receptor (AR) inhibitors prevent testosterone from attaching to “androgen receptors,” which are chemical structures in cancer cells that allow testosterone and other male hormones to enter the cells. AR inhibitors, in effect, prevent testosterone from working. Older AR inhibitors, such as bicalutamide (Casodex), flutamide (a generic medication), and nilutamide (Nilandron), are taken as pills. Apalutamide (Erleada), darolutamide (Nubeqa), and enzalutamide are newer AR inhibitors (Xtandi).
These drugs are also known as anti-androgens. AR inhibitors can be administered to men who have “castration-sensitive” prostate cancer, which means the cancer responds to treatments that suppress testosterone levels. AR inhibitors are rarely used alone to treat prostate cancer.
- Apalutamide: The FDA has approved apalutamide in combination with hormone therapy for the treatment of non-metastatic castration-resistant prostate cancer and metastatic castration-sensitive prostate cancer.
- Darolutamide: Darolutamide is approved for the treatment of castration-resistant non-metastatic prostate cancer.
- Enzalutamide: Enzalutamide is a nonsteroidal AR inhibitor approved for the treatment of metastatic and non-metastatic castration-resistant prostate cancer, as well as metastatic castration-sensitive prostate cancer.
Androgen synthesis inhibitors: Although the testicles create the majority of the body’s testosterone, other cells in the body can still produce trace amounts of the hormone, which may promote cancer growth. Adrenal glands and prostate cancer cells are examples of this. Androgen synthesis inhibitors work by inhibiting an enzyme called CYP17, which prevents cells from producing testosterone.
- Abiraterone acetate (Zytiga): Abiraterone acetate is administered as a tablet. Patients may use abiraterone in conjunction with prednisone (various brand names) or prednisolone (multiple brand names). Prednisone or prednisolone can help prevent some of abiraterone’s negative effects. Abiraterone can produce major adverse effects such high blood pressure, low potassium levels in the blood, tiredness, and fluid retention. Weakness, joint swelling or pain, swelling in the legs or feet, heat flushes, diarrhea, vomiting, shortness of breath, and anemia are all common adverse effects.
- Ketoconazole (Nizoral): Ketoconazole is an androgen synthesis inhibitor that is no longer often used due to numerous medication interactions. Ketoconazole, on the other hand, may be a possibility for some people.
Combined androgen blockade: Androgen receptor inhibitors are sometimes used with bilateral orchiectomy or LHRH agonist medication to optimize male hormone blocking or to avoid the flare associated with LHRH agonist treatment.
Intermittent hormonal therapy: Traditionally, hormone therapy was administered throughout the duration of the patient’s life. Researchers have explored the use of intermittent hormonal therapy over the last two decades, which is when therapy is administered for a set period of time (usually six months) and then stopped to allow testosterone levels to recover. When the PSA begins to rise again, hormone therapy is continued for these patients. When to continue therapy (i.e., at what PSA levels) is still debatable. Using hormone therapy in this manner may reduce the negative effects of low testosterone and improve a person’s quality of life. This method is solely recommended by ASCO for those who have a high risk of PSA recurrence and no indication of metastatic illness after radical prostatectomy and/or radiation therapy. However, because intermittent hormonal therapy has not been investigated in conjunction with chemotherapy or newer hormonal treatments such as abiraterone or enzalutamide, ASCO cannot endorse it.
Hormonal therapy side effects
Except for patients who have had an orchiectomy, these treatments will cause side effects that will normally go away after the treatment is completed. Among the general side effects are:
- ED (erectile dysfunction)
- Sexual desire loss
- Sweating and hot flushes
- Gynecomastia (the abnormal growth of breast tissue that can cause discomfort.
- Depression
- Memory loss and cognitive dysfunction
- Heart disease and difficulties with the heart
- Putting on weight
- Muscle mass loss
- Osteopenia, often known as osteoporosis, is a condition characterized by bone thinning.
Although testosterone levels may rebound after discontinuing treatment, some people who have been taking LHRH agonists for a long time may continue to have hormonal effects even after they stop taking the medicines.
The chance of developing metabolic syndrome is another severe side effect of these medicines. Metabolic syndrome is a group of disorders that raise a person’s risk of heart disease, stroke, and diabetes. These conditions include obesity, high levels of blood cholesterol, and high blood pressure. It is still unknown how frequently or why this occurs, although it is apparent that individuals who take hormone therapy have an increased chance of developing metabolic syndrome. Even if temporary medical castration is done, the risk is raised.
Treatment dangers and benefits should be thoroughly addressed with your doctor. Most doctors believe that the benefits of treatment much exceed the risks of side effects for persons with metastatic prostate cancer, especially if it is advanced and producing symptoms. It is strongly advised that patients undergoing hormonal therapy take precautions to manage or avoid any negative effects. Regular exercise, stopping smoking, eating a balanced diet, obtaining adequate vitamin D and calcium, and receiving comprehensive, preventive cardiovascular follow-up treatment are all examples.
Targeted therapy
Targeted therapy is a type of cancer treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This method of treatment inhibits cancer cell growth and spread while limiting damage to healthy cells.
The targets of all cancers are not the same. Your doctor may order tests to determine the genes, proteins, and other variables in your tumor in order to find the most effective treatment. This enables clinicians to provide the most effective treatment to each patient whenever possible. Furthermore, research studies are continuing to learn more about specific molecular targets and new treatments aimed at them.
Prostate cancer targeted therapy comprises the following treatments:
Olaparib (Lynparza): Olaparib is a PARP inhibitor, which is a sort of targeted therapy. It is licensed for individuals with metastatic castration-resistant prostate cancer who have had their illness grow and spread despite treatment with abiraterone and/or enzalutamide and who have DNA-repair gene abnormalities that may be hereditary or present in the tumor. Defects in DNA-repair genes make it more difficult for cancer cells to repair damaged DNA. Certain genes, including BRCA1, BRCA2, and a few others, have been related to DNA-repair gene deficiencies, and the existence of any of these can allow therapy with olaparib. The FDA has also approved two particular tests to select patients for olaparib treatment.
Rucaparib (Rubraca): Rucaparib is another PARP inhibitor that has been approved to treat metastatic castration-resistant prostate cancer in patients whose disease has not been stopped by treatment with abiraterone and/or enzalutamide and chemotherapy, and who have an inherited or tumor-derived BRCA1 or BRCA2 mutation.
To establish if a patient can receive olaparib or rucaparib, one or more tests must be performed:
- Following consultation with a genetic counselor, testing for an inherited, or germline, mutation is performed.
- Tumor tissue genomic sequencing
- The tumor DNA floating in the bloodstream was subjected to genomic sequencing.
Genomic sequencing can be done on previously obtained tissue or on tissue from a new biopsy. Germline mutation testing alone identifies around half of the patients who are candidates for this treatment. People with metastatic prostate cancer who are considering targeted therapy should discuss all three of the following tests with their doctors.
Discuss with your doctor the potential side effects of a certain medicine and how to manage them.
Chemotherapy
Chemotherapy is the use of medications to eradicate cancer cells, typically by preventing the cancer cells from growing, dividing, and proliferating.
Chemotherapy may benefit both advanced or castration-resistant prostate cancer and freshly diagnosed or castration-sensitive metastatic prostate cancer. A chemotherapy regimen, or schedule, typically consists of a predetermined number of cycles administered over a predetermined time period.
There are a number of standard medications used to treat prostate cancer. In most cases, conventional chemotherapy begins with docetaxel (Taxotere) and prednisone.
According to new research, combining docetaxel with hormone therapy in persons with newly diagnosed or castration-sensitive metastatic prostate cancer considerably extends life and prevents the illness from developing and spreading.
Cabazitaxel (Jevtana) is approved for the treatment of metastatic castration-resistant prostate cancer that has previously been treated with docetaxel. It functions as a microtubule inhibitor.
Chemotherapy side effects vary depending on the individual, the type of chemotherapy used, the dose administered, and the length of treatment, but they can include fatigue, mouth and throat sores, diarrhea, nausea and vomiting, constipation, blood disorders, nervous system effects, changes in thinking and memory, sexual and reproductive issues, appetite loss, pain, and hair loss. Chemotherapy side effects normally fade when treatment is completed. Some adverse effects, however, may persist, reappear, or emerge later. Inquire with your doctor about the potential adverse effects of your treatment plan. Many of these adverse effects will be managed or prevented in collaboration with your health care team.
Immunotherapy
Immunotherapy, also known as biologic therapy, is intended to increase the body’s natural defenses against cancer. It employs components created by the body or in a laboratory to enhance, target, or restore immune system activity.
Vaccine therapy with sipuleucel-T (Provenge) may be an option for certain persons with castration-resistant metastatic prostate cancer who have no or few disease symptoms and have not received chemotherapy.
Sipuleucel-T is tailored to each individual patient. Blood is extracted from the patient prior to therapy in a procedure known as leukapheresis. Special immune cells are extracted from the patient’s blood, changed in the laboratory, and then reintroduced. The patient’s immune system may recognize and destroy prostate cancer cells at this point. Because treatment with sipuleucel-T does not result in decreased PSA levels, tumor shrinkage, or keeping the disease from worsening, it is difficult to know if the drug is working to treat the cancer. Clinical trial data, on the other hand, reveal that treatment with sipuleucel-T can extend lives by about 4 months in persons with metastatic castration-resistant prostate cancer who have few or no symptoms.
Different forms of immunotherapy might result in a variety of adverse effects. Skin rashes, flu-like symptoms, diarrhea, and weight fluctuations are all common adverse effects. Consult your doctor about the potential adverse effects of the immunotherapy that has been prescribed for you.
Radiation therapy by infusion
Radium-223 (Xofigo): This treatment involves the use of a radioactive material to treat castration-resistant prostate cancer that has progressed to the bone. Radium-223 is a radionucleotide with an alpha emitter that mimics calcium and targets parts of the bone where cancer is generating alterations. This treatment delivers radiation particles specifically to bone cancers, limiting damage to healthy tissue, including bone marrow, which produces normal blood cells. Radium-223 is administered intravenously (IV) once a month for six months. A radiation oncologist or a nuclear medicine specialist administers this treatment. Your medical oncologist should monitor your progress throughout this treatment to ensure that the treatment is effective and that any potential side effects are handled. Because radium-233 treatment does not consistently lower PSA levels, patients should not expect to see significant declines in PSA levels during treatment; in fact, PSA levels may rise in some cases.
Some people should not undergo this treatment, particularly if they have prostate cancer that has progressed to the liver or lungs, or if they have enlarged lymph nodes (3 cm or more in diameter). Radium-223 should not be used with abiraterone or prednisone because it raises the risk of bone fractures. Consult your doctor to see if this drug is right for you.
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto): This treatment targets PSMA (prostate-specific membrane antigen), a protein that is abundantly expressed on prostate cancer cells, and hence delivers radiation directly to the cancer cells. It is licensed for the treatment of patients with metastatic castration-resistant prostate cancer who have previously received an AR inhibitor plus taxane chemotherapy, such as docetaxel. A special form of positron-emission tomography (PET) scan is required to validate that the cancer cells express the PSMA molecule before receiving this treatment. Fatigue, dry mouth, nausea, anemia, loss of appetite, and constipation are the most prevalent side effects of this medication.
Bone-modifying drugs
Bone health is a major concern in the lives of men with prostate cancer. Osteopenia and osteoporosis are bone diseases that can be induced or exacerbated by hormone therapy. Patients undergoing hormonal therapy for non-metastatic prostate cancer should have their fracture risk assessed. A dual-energy X-ray absorptiometry (DEXA) scan to test bone strength is the most common approach to determine a person’s risk. Patients who are discovered to be at high risk of fracture should be treated to reduce their risk. Denosumab (Prolia, Xgeva), zoledronic acid (Reclast, Zometa), alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and pamidronate are examples of bone-modifying medicines that can be utilized in this condition (Aredia). These medications can have adverse effects, so consult with your doctor about when to take them and which would be best for your specific circumstances.
Bone-modifying medicines have not been proved to prevent prostate cancer from spreading to the bone in people who do not currently have evidence of bone metastases.
There is always a risk of bone problems in people with prostate cancer that has gone to the bone, such as fracture, discomfort, and spinal cord compression. These are referred to as “skeletal-related occurrences.” When prostate cancer spreads to the bone and becomes resistant to regular hormonal therapy (a condition known as metastatic castration-resistant prostate cancer, see below), bone-modifying medications may be used to lower the risk of these complications. To lessen that risk, denosumab or zoledronic acid can be administered once a month.
Osteonecrosis of the jaw is a rare but dangerous side effect of bone-modifying medications. Pain, swelling, and infection of the jaw, as well as loose teeth and exposed bone, are indications of osteonecrosis of the jaw. The necessity for invasive dental work (for example, tooth extraction) in a person who is already getting a potent bone-modifying therapy such as denosumab or zoledronic acid is the most prominent risk factor for this side event. Before beginning a bone-modifying therapy, it is critical to undergo a dental evaluation to check safety and manage any issues that may arise. If a person taking these medications requires dental work, treatment should be halted until the dental work is done and the patient has healed.
Prostate cancer treatment based on stage
Depending on the stage of prostate cancer, several treatments may be prescribed. Your doctor will collaborate with you to establish a treatment plan based on the stage of the cancer and other considerations. Earlier on this page, detailed descriptions of each type of treatment are provided. Clinical trials could also be used as a therapy option at each level.
Early-stage prostate cancer (stages I and II)
Early-stage prostate cancer grows slowly and may take years to create symptoms or other health concerns, if it ever occurs. As a result, active monitoring or watchful waiting may be advised. Radiation therapy (either external-beam or brachytherapy) or surgery, as well as treatment in clinical trials, may be recommended. Cancer may grow faster in patients with a higher Gleason score, hence radical prostatectomy and radiation therapy are frequently advised. Before prescribing a treatment plan, your doctor will examine your age and overall health.
ASCO, the American Urological Association, the American Society of Radiation Oncology, and the Society of Urologic Oncology all recommend that patients with high-risk early-stage prostate cancer that has not spread to other parts of the body receive radical prostatectomy or radiation therapy with hormonal therapy as standard treatments.
Locally advanced prostate cancer (stage III)
External-beam radiation therapy plus concomitant hormone therapy, or surgery alone, can be used to treat locally advanced prostate cancer. When patients are able to undergo this method, ASCO suggests that doctors investigate hormonal therapy to suppress testosterone production, as well as abiraterone and prednisolone. If abiraterone isn’t a possibility, combined androgen blocking with an AR inhibitor may be advised. Treatments may be administered in various combinations to halt the growth and spread of cancer. Active monitoring is another approach. Early (immediate) hormonal therapy may be administered to patients who have not previously received local treatment, including surgery, and who are reluctant or unable to receive radiation therapy.
It is usually assumed that at least 24 months of hormonal therapy are required to control the condition, but 18 months may possibly suffice. Radiation therapy is administered to patients who have had a radical prostatectomy. Adjuvant radiation therapy, also known as salvage radiation therapy, is used in this situation. It is considered standard of therapy for prostate cancer with extraprostatic extension, which occurs when the tumor has progressed to locations outside of the prostate gland. Those who are at high risk of bone fractures may be given a bone-modifying medication as part of an osteoporosis therapy dose and plan.
For older persons who are not anticipated to live for a long time and whose cancer is not causing symptoms, or for those who have another, more serious condition, watchful waiting may be considered.
Advanced prostate cancer (stage IV)
Doctors refer to cancer that has spread to another place of the body from where it began as metastatic cancer. High-risk or locally advanced prostate cancers are more likely to spread to other parts of the body. If your prostate cancer has a high chance of spreading or is already spreading, it is a good idea to consult with a specialist who has experience treating it. Different doctors may have differing views on the optimal conventional treatment strategy. Clinical trials are another possibility. Learn more about getting a second opinion before beginning treatment so that you are confident in your treatment plan.
A diagnosis of advanced cancer can be extremely stressful and traumatic for many people. You and your family are encouraged to express your feelings to doctors, nurses, social workers, and other members of the health care team. Talking with other patients, such as in a support group or other peer support program, may also be beneficial.
Although there is no cure for metastatic prostate cancer, it is generally curable for a long time. Even those with advanced prostate cancer outlive their disease in a large number of cases. Prostate cancer often grows slowly, and there are currently excellent treatment alternatives that can extend one’s life even longer. In this sense, it might be compared to living with a chronic disease such as heart disease or diabetes, which necessitates continual therapy to reduce symptoms and maintain well-being.
Supportive, or palliative, care to alleviate symptoms and side effects is an important element of advanced prostate cancer treatment. Options for supportive care include:
- TURP is used to treat symptoms like as bleeding and urinary blockage.
- Bone-modifying medications may be used to strengthen bones, lower the risk of bone fractures, and lower the risk of skeletal-related events in patients with prostate cancer that has progressed to the bone.
- In addition, intravenous radiation therapy with radium-223, strontium, and samarium can help reduce bone discomfort.
- When drugs fail to relieve bone pain, palliative radiation therapy to particular bone regions can be employed.
Biochemical or PSA recurrence
Many people who have undergone surgery or radiation therapy have been cured. Some, however, will develop a biochemical recurrence (BCR). The main symptoms of BCR include growing PSA levels and scans showing no metastases. Because of this, BCR is also known as “PSA recurrence” or “increasing PSA syndrome.” The precise definition of BCR is determined by the initial treatment received by a person with prostate cancer.
BCR is defined as an increasing PSA level of 0.2 ng/mL or above in patients who have had a radical prostatectomy. After surgery, radiation therapy may be a choice for certain individuals with BCR. This is known as “salvage radiation therapy.” Gleason score, pathologic stage, how long it took for BCR to occur, PSA level after surgery, and fluctuations in PSA over time, often known as “PSA doubling time,” are all factors examined when selecting who can be treated with salvage radiation treatment.
BCR is defined for persons who received radiation therapy as the primary treatment for prostate cancer as a normal testosterone level and a PSA value more than 2.0 ng/mL plus the lowest PSA value achieved following radiation therapy (this is referred to as “nadir PSA”). It is more difficult to treat BCR following radiation therapy. Surgery, known as “salvage radical prostatectomy,” or cryosurgery, known as “salvage cryotherapy” (see “Focal treatments,” above), are two treatment possibilities. You are invited to speak with the health care team about your treatment options.
Hormonal therapy may be advised, particularly if other local therapies are ineffective. If hormone therapy is utilized to treat high-risk BCR, ASCO suggests intermittent hormonal therapy.
Metastatic castration-sensitive prostate cancer
Metastatic castration-sensitive prostate cancer is defined as prostate cancer that has spread to other areas of the body but still responds to treatment that lowers testosterone. The optimum treatment option is determined by the patient’s overall health as well as the extent of the malignancy. It is critical to discuss the risks and advantages of each option with your health care provider. The following treatment options, including radical prostatectomy or radiation therapy, can be used to treat both newly diagnosed patients and those who have already received treatment.
- Docetaxel plus hormonal therapy: Docetaxel coupled with hormone therapy may be indicated for patients with extensive illness who are able to receive chemotherapy. Docetaxel, with or without prednisolone, is administered intravenously every three weeks for a total of six doses. Docetaxel side effects may include low blood cell counts, infection, nausea and vomiting, muscle aches, and changes in hair and nails. It may also induce peripheral neuropathy, a type of nerve injury characterized by tingling or burning sensations in the hands and/or feet.
- Apalutamide plus hormonal therapy: In 2019, this combination was approved. It provides a treatment regimen that does not require long-term steroid medication or frequent laboratory testing. Regardless of the risk or volume of the disease, this treatment is indicated for patients with metastatic castration-sensitive prostate cancer.
- Abiraterone with prednisone or prednisolone plus hormonal therapy: Abiraterone in combination with prednisone or prednisolone, as well as hormonal therapy This medication is suggested for persons with newly diagnosed, high-risk metastatic castration-sensitive prostate cancer, although it can also be given to those with low-risk disease.
- Enzalutamide in combination with hormonal treatment: In late 2019, this combo was approved. It does not necessitate steroid medication or frequent laboratory testing. Regardless of the risk or volume of the disease, this treatment is indicated for patients with metastatic castration-sensitive prostate cancer.
Therapy to relieve symptoms and side effects, in addition to the foregoing treatment choices, is an important aspect of the entire treatment plan.
Non-metastatic castration-resistant prostate cancer
Castration resistant prostate cancer is defined as cancer that is resistant to low testosterone levels (less than 50 ng/mL). Castration-resistant prostate cancer is distinguished by an increase in PSA levels, increasing symptoms, and/or developing cancer as seen by scans. It is referred to as “non-metastatic castration-resistant prostate cancer” if the cancer has not progressed to other parts of the body.
The American Society of Clinical Oncology (ASCO) recommends that treatment for non-metastatic castration-resistant prostate cancer continue to focus on reducing testosterone levels. This could be a permanent treatment, such as orchiectomy, or it could be ongoing treatment with hormone-lowering drugs, such as apalutamide, darolutamide, or enzalutamide.
Additional hormone therapy may be a possibility for patients who have not had chemotherapy if there is a high chance that the disease will spread. Discuss your personal risk level with your doctor.
PSA and/or imaging tests may be performed on a regular basis to determine whether the cancer has progressed or spread. ASCO recommends PSA testing every 4 to 6 months if there is a low chance of acquiring metastatic illness. ASCO advises PSA testing every three months if there is a high risk of metastatic illness. If there are symptoms or indicators that the malignancy is worsening, imaging tests such as a bone scan, CT scan, or MRI may be performed.
Metastatic castration-resistant prostate cancer
When low testosterone levels (less than 50 ng/mL) no longer stop the cancer from spreading, it is referred to as “metastatic castration-resistant prostate cancer.” Castration-resistant prostate cancer is distinguished by an increase in PSA levels, increasing symptoms, and/or developing cancer as seen by scans. For metastatic castration-resistant prostate cancer, ASCO recommends PSA testing every 3 months. Imaging tests may also be performed.
It can be challenging to treat metastatic castration-resistant prostate cancer. For metastatic castration-resistant prostate cancer, ASCO recommends continued treatment that reduces hormone levels. ASCO offers treatment recommendations for hormone therapy for advanced cancer and for systemic treatment of metastatic castration-resistant prostate cancer.
The following are treatment options for metastatic castration-resistant prostate cancer. A clinical study may also be a possibility for treatment.
- AR inhibitors like abiraterone and enzalutamide
- Olaparib or rucaparib-based targeted therapy
- Docetaxel chemotherapy, especially if there is bone pain or other cancer-related symptoms
- If docetaxel fails to work, cabazitaxel chemotherapy is used.
- Immunotherapy using sipuleucel-T
- To treat cancer that has spread to the bones, radium-223 or a bone-modifying medication may be used.
