Prostate Cancer, Advanced Or Metastatic: Treatment Overview

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Treatment Overview

Choosing treatment for prostate cancer can be confusing. Any treatment probably will cause serious side effects. It's important to learn all you can about your choices and talk to your doctor about them.

Your decision depends on:

• Your age.
• Any serious health problems you might have, including urinary, bowel, or sexual function problems.
• Your PSA level.
• What kind of cancer cells you have. This is called the grade or Gleason score of your cancer. Some prostate cancer cells grow more quickly than others.
• How far your cancer has spread. This is called the stage of your cancer.
• The side effects of treatment.
• Your personal feelings and concerns.

Treatment for locally advanced or metastatic prostate cancer may include hormone therapy, surgery, radiation therapy, chemotherapy, and pain medicine. You may want to talk with your doctor about entering a clinical trial of new cancer treatment options.

You may experience a wide variety of emotions after being diagnosed. Most men feel some denial, anger, and grief. Others may have fewer emotions. There is no "normal" way to react. There are many things you can do to help with your emotional reaction to prostate cancer. You may find that talking with family and friends helps you with your emotions. Some men find that spending time alone is what they need.

If your reaction is interfering with your ability to make decisions about your health, it is important to talk with your doctor. Your cancer treatment center may offer psychological or financial services. You may also contact your local chapter of the American Cancer Society to help you find a support group. Talking with other men who have had similar feelings can be very helpful.

Prostate cancer and its treatment may cause nausea, pain, or other side effects. You can manage some side effects at home. If you experience nausea, wait for 1 hour after vomiting has stopped and then sip a rehydration drink to restore lost fluids and nutrients. Your doctor also may prescribe medicines to control nausea and vomiting. Constipation and diarrhea may be eased if you drink enough fluids. Pain does not have to be an accepted part of treatment for prostate cancer. For tips on handling pain, see:

Cancer: Controlling cancer pain.

For more information, see the topic Cancer Pain.

Localized prostate cancer is cancer that is small and has not spread outside the prostate. For more information on treatment of localized prostate cancer, see the topic Prostate Cancer.

Treatment for locally advanced prostate cancer

Prostate cancer that has spread to tissue around the prostate may be treated with:

• Radiation therapy. This treatment uses high-energy X-rays or protons to destroy the cancer. Radiation treatments, both external and internal radiation, have been improved with newer technologies, so there are fewer side effects and complications than in the past. Radiation therapy usually is combined with hormone therapy.
  • External radiation. Also called external beam radiotherapy, or EBRT, radiation therapy uses high-energy rays, such as X-rays, to destroy the cancer. It is usually given in multiple doses over several weeks. For men with locally advanced cancers, ERBT may be given along with brachytherapy. Radiation destroys tissue, so it may damage the nerves along the side of the prostate that affect your ability to have an erection. If you already have bowel problems, external radiation may cause your symptoms to get worse. The three most common forms of external radiation are listed below:
    • Conformal radiotherapy (3D-CRT) uses a three-dimensional planning system to target a strong dose of radiation to the prostate cancer. This helps to protect healthy tissue from radiation.
    • Intensity modulated radiation therapy (IMRT) uses a carefully adjusted amount of radiation. This protects healthy tissue more than conformal radiotherapy does.
    • Proton therapy uses a different type of energy (protons) rather than X-rays. This allows a higher amount of specifically directed radiation, which protects nearby healthy tissue the most, especially the rectum.⁹ Sometimes proton therapy is combined with X-ray therapy.
  • Internal radiation (brachytherapy). Brachytherapy is a one-time radiation treatment that uses tiny radioactive seeds. After you are given anesthesia, a needle is used to inject the seeds into your prostate, where they slowly release radiation directly into the cancer. Sometimes external radiation or hormone therapy is added to brachytherapy. If you already have urinary problems, brachytherapy may make your symptoms worse.
    • High-dose rate brachytherapy (HDR brachytherapy). This is another form of brachytherapy where radioactive material is placed into the prostate for a very brief period of time (seconds to minutes) and then removed. The radiation is delivered this way several times.¹⁰
• Surgery.
  • Radical prostatectomy. This operation takes out your prostate gland and the cancer in and around it. Surgery can be successful if the tumor has not spread beyond the outside of your prostate and if it is easily removed.
  • Transurethral resection of the prostate (TURP). This surgery can help relieve bladder problems because it removes part of the tumor that may be blocking the urethra, the tube that carries urine from your bladder through your penis. The procedure is done under general anesthesia. This can keep the tumor from growing for a while. But TURP does not take out the whole tumor.
• Hormone therapy. Prostate cancer often needs male hormones (testosterone) in order to survive. Hormone therapy decreases the amount of testosterone and other male hormones in your body. This often causes tumors to shrink. Shrinking the tumors can ease severe bone pain caused by the spread of cancer to the bones. Hormone therapy usually is combined with radiation therapy. The most common methods are:
  • LH-RH agonists and GnRH agonists. These drugs, such as goserelin (Zoladex), leuprolide (Lupron), and triptorelin (Trelstar Depot), stop the body from making testosterone.
  • Antiandrogens. These drugs, such as bicalutamide (Casodex), often are used along with LH-RH agonists. Antiandrogens help block the body's supply of testosterone.
  • Orchiectomy. This is surgery to remove the testicles, which produce more than 90% of the body's male hormones (androgens), including testosterone.

In some cases, men will have radiation therapy after a prostatectomy, especially if the tumor could not be completely removed by surgery.

Some men choose to start hormone therapy only after they have symptoms. But many doctors recommend starting hormone therapy right away if cancer is found in the lymph nodes during surgery to remove the prostate. Early treatment may allow men to live a little longer. Other doctors say to wait, because waiting delays the bothersome side effects of ADT.

Treatment for metastatic prostate cancer

Treatment for prostate cancer that has spread to the bones and/or other organs in the body is aimed at relieving symptoms and slowing the cancer's growth. Treatment may include:

• Hormone therapy with medicines or with surgery to remove the testicles (orchiectomy). This slows cancer growth and relieves pain by shrinking the tumors. Hormone therapy can also improve urinary symptoms. It may be used alone or combined with radiation therapy. Sometimes androgen deprivation (orchiectomy or an LH-RH agonist) and an antiandrogen are used together. This is called a combined androgen blockade (CAB). But the slight benefit of CAB may be offset by side effects.
• Radiation therapy to shrink tumors and ease pain. External-beam radiation, which uses a large machine to aim a beam of radiation at your tumor, usually is combined with hormone therapy.
• Medicines to stop the growth of cancer cells. Use of these kinds of medicines is called chemotherapy. One study found that chemotherapy with docetaxel and prednisone was associated with a longer survival rate than mitoxantrone and prednisone.¹¹
• Surgery to remove blockages that are causing problems (TURP).

Both orchiectomy and hormone therapy medicine make testosterone levels drop, causing some of the same side effects. These include larger breasts, hot flashes, loss of sexual desire, and the inability to have an erection. Treatment options for these problems include:

• Taking a temporary break from hormone therapy. This can make some side effects go away. (Side effects after orchiectomy are permanent.)
• Radiation treatment of the breasts to prevent breast growth. This is done before starting hormone therapy.
• Radiation treatment or the anti-estrogen breast cancer medicine called tamoxifen to relieve breast pain. Tamoxifen can also help reverse breast growth. It also causes hot flashes.
• Taking medicines to control hot flashes, such as venlafaxine, paroxetine, and gabapentin. If these don't work, sometimes estrogen or megestrol may help reduce hot flashes. But all of these medicines have different side effects, so if you are having a problem with hot flashes, talk with your doctor.

Hormone therapy usually works well at first to stop cancer growth. But in most cases the cancer returns in a few years. At this point, the cancer is described as hormone-resistant, meaning it is not responding to standard hormone therapy. When this happens, other kinds of hormone treatment may be tried. If the cancer continues to grow, chemotherapy may be recommended.

Other hormone therapies may include the use of medicines such as megestrol acetate, estrogen, ketoconazole, aminoglutethimide combined with hydrocortisone, and corticosteroids (prednisone, dexamethasone, and hydrocortisone).

Some men choose to start hormone therapy only after they have symptoms. But many doctors recommend starting hormone therapy right away if cancer is found in the lymph nodes during surgery to remove the prostate. Early treatment may allow men to live a little longer. Other doctors say to wait, because waiting delays the bothersome side effects of ADT.

Alternatives to conventional hormone therapy include intermittent ADT, known as IAD, where men take cycles of hormone therapy medicines. Taking breaks between hormone therapy cycles gives men the chance to recover their ability to function sexually. It also gives relief from the other side effects of hormone therapy, including the loss of energy, loss of bone and muscle mass, and hot flashes. The long-term survival outcome of IAD compared to conventional ADT is not yet known, but from early studies, it looks like they both work about the same.¹²

For more information about specific treatments, see the following topics:

• Prostate Cancer — Health Professional Information [NCI PDQ]
• Prostate Cancer — Patient Information [NCI PDQ]

What to think about

Vaccines to keep prostate cancer from coming back after it has been treated are being tested. This type of treatment encourages the body's immune system to destroy cancer cells that remain after prostate cancer surgery. Early results suggest that vaccines may be able to help slow the growth of prostate cancer.¹³

A study suggests that advanced prostate cancer can sometimes be cured if the cancer has spread to only a few lymph nodes and great care is used to completely remove the lymph nodes during prostatectomy.¹⁴ Radiation and hormone treatment may be used afterwards to destroy any remaining cancer cells.

Long-term hormone therapy can also lead to osteoporosis, which causes bones to become brittle and more likely to break. Drugs are available to help prevent this side effect. For more information, see the topic Osteoporosis.

There are many studies (clinical trials) focusing on finding ways to prevent, detect, diagnose, and treat prostate cancer in all stages. Talk to your doctor about whether entering a clinical trial is a good option for you to explore.

Having a healthy weight may help you survive this disease. Studies have shown that men who have prostate cancer are more likely to die from the disease if they are obese, as defined by a body mass index of 30 or higher.^{7 8}

Palliative care

If your cancer gets worse, look into your options for palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different from trying to cure your illness. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

With prostate cancer, palliative care may involve treatments to reduce tumors or bone pain, such as chemotherapy, radiation therapy, radionuclides (medicine used in external radiation) for bone metastasis, and bisphosphonates, which slow the breakdown of bone and help relieve bone pain. Surgery to relieve bladder problems (transurethral resection of the prostate, or TURP) is also an option.

Studies show that men with advanced prostate cancer who took bisphosphonates had better pain relief and fewer bone problems, although they had some nausea.¹⁵

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

Locally advanced or metastatic prostate cancer often cannot be cured. You may wish to discuss health care and other legal issues that arise near the end of life with your family and your doctor. You may find it helpful and comforting to state your health care choices in writing—with an advance directive or living will—while you are still able to make and communicate these decisions. Think about your treatment options and which kind of treatment will be best for you. You may want to choose a health care agent to make and carry out decisions about your care if you should become unable to speak for yourself. For more information, see the topic Care at the End of Life.

A time may come when your goals or the goals of your loved ones change from treating or curing your illness to maintaining your comfort and dignity. Your doctor will be able to address questions or concerns about maintaining comfort when cure is no longer an option.

Hospice care provides medical services, emotional support, and spiritual resources for people who are at the end of life. Hospice care also helps family members manage the practical details and emotional challenges of caring for a dying loved one. For more information, see the topic Hospice Care.

Last updated:	July 01, 2008
Author:	Bets Davis, MFA
Reviewed By:	E. Gregory Thompson, MD - Internal Medicine, Christopher G. Wood, MD, FACS - Urology/Oncology
Editors:	Susan Van Houten, RN, BSN, MBA, Pat Truman, MATC