Advanced Prostate Cancer

Advanced prostate cancer is when cancer has spread beyond the prostate. It can also be when the cancer has not responded to hormone treatment. There are a few main groups of advanced prostate cancer.

Advanced Prostate Cancer Groups

Biochemical recurrence — If your PSA is high after initial treatment but you have no other sign of cancer, it’s called biochemical recurrence. Hormone treatment can help. This form of advanced prostate cancer has more options for treatment and has a better survival rate than the others.

Metastatic prostate cancer — Prostate cancer is found beyond the prostate in other tissues or organs. Most common places: the lymph nodes outside the pelvis, bones, lungs, liver, or brain. Men can be diagnosed with metastatic prostate cancer right away (rare), soon after treatment, or many years after.

Castration-resistant prostate cancer (CRPC) — CRPC means that cancer has grown after hormone therapy. If the cancer cells “outsmart” hormone treatment, they learn how to grow even without testosterone to fuel its growth. With this condition, your prostate-specific antigen (PSA) is high or your cancer shows other signs of growth after hormone treatment.

Metastatic castration-resistant prostate cancer (mCRPC) — If your PSA is high after hormone treatment and your cancer has spread beyond the prostate, you have mCRPC. Many of the newest treatments are for men diagnosed with mCRPC.

Generally, advanced prostate cancer is difficult to treat. When it has spread far from the prostate, it is not curable. However, if advanced prostate cancer is found in only a few pelvic lymph nodes, treatment is available, and a patient may be cured. Also, if advanced prostate cancer is “hormone naive” and not responding to hormone treatment, other options can help. It’s important to note that newer treatments are helping men diagnosed with advanced cancer feel better, longer. It helps to learn about your range of treatment options.

Symptoms

Men with advanced prostate cancer may have no symptoms at all. When men do have symptoms, they feel tired or weak, have lost weight, feel pain or have shortness of breath. Or, they have problems going to the bathroom and see blood in their urine. When prostate cancer spreads to the pelvic bones, you can feel lower back or hip pain. Symptoms depend on the size of the tumor(s) and where the cancer has spread.

Evaluation and Diagnosis

To diagnose advanced cancer, your health care provider looks for cancer outside the prostate. Blood and imaging tests may show where the cancer has spread. Your health care provider will want to know how much cancer there is and how it is affecting you. That way they can offer treatment that is best for you.

Advanced cancer may be found before, at the same time, or later than the main tumor. Most men diagnosed with advanced prostate cancer have had biopsy and treatment in the past. When a new tumor is found in someone who has been treated for cancer in the past, it is usually cancer that has spread. Rarely, tests done for other reasons may reveal prostate cancer cells.

Treatment

With advanced cancer, the goal of treatment is to relieve symptoms and help you live longer. Most aggressive prostate cancers cannot be cured, so the goal is to manage side effects. The most common treatments are:

Hormone Therapy or Androgen Deprivation Therapy (ADT)

Hormone therapy is any treatment that lowers a man’s androgen levels. Androgens are male sex hormones, like testosterone. Testosterone is the main fuel for prostate cancer cells, so blocking it may slow the cancer. This process is also called medical castration. There are several types of hormone therapy (also called androgen deprivation therapy (ADT). Some are better at treating advanced disease than others.

Hormone therapy treatment can help men whose prostate cancer has metastasized (spread) from the prostate or when prostate cancer has come back after treatment has failed. It may also be used to shrink a local tumor to make room for radiation treatment.

Unfortunately, it tends to work for only a few years. Over time, the cancer can grow in spite of the low hormone level. Hormone therapy does not cure the cancer. Other treatments are also needed to manage the cancer.

The main types of hormone therapy are:

Orchiectomy (surgery to remove the testicles) — Orchiectomy is surgery to remove the testicles. It is also called surgical castration. The testicles make most of the body’s testosterone. Orchiectomy removes the testicles to stop the body from making the male hormone that feeds prostate cancer cells. This surgery is not expensive, it’s simple and has few risks. It only needs to be performed once to work. Testosterone levels drop dramatically. There is often fast relief from cancer symptoms. Many men feel uncomfortable with this surgery because it’s permanent. The genital area will look different. Concerns about body image or self-image may lead men not to choose surgical castration. Consequently, it is rarely used as a treatment choice in the United States.

LHRH or GnRH agonists — This hormone therapy is used for recurrent cancer, whether or not it has spread. Possible agonists include:

• Lupron (Leuprolide)
• Zoladex (Goserelin)
• Trelstar (Triptorelin)
• Vantas (Histrelin)

LHRH or GnRH agonists are man-made, powerful versions of natural LHRH hormone. LHRH causes your body to make luteinizing hormone (LH), which leads your body to make testosterone. The LHRH agonist mimics normal LHRH and fills the pituitary gland receptors that hold this hormone. Because they are “fake”, they cause your body to react at first with a burst of testosterone (called a “hormone flare”). But, since the fake LHRH or GNRH remains longer than normal, they soon cause your body to stop making testosterone.

Side effects include the “flare up” from the agonist treatment. A “flare up” is when your body first makes extra LH and testosterone immediately after using an LHRH drug. About 7-10 days later, these hormones stop being produced by your body. After your testosterone levels drop to almost 100%, you are at “castration level.” It’s the same as if your testicles were gone. Once testosterone levels drop, prostate cancer cells stop growing.

LHRH or GnRH antagonists — This medicine blocks the release of natural LH. When LH isn’t released, your body stops making testosterone. The drug used is Firgmagon (Degarelix). Antagonists are injected (shot) in the buttocks every month.

It is done in the health care provider’s office. Your doctor will want to make sure you have no allergic reaction. After the first shot, a blood test is done. This is done to check testosterone levels. For both antagonists and agonists, you may also have tests to monitor your bone density. With LHRH treatment there is no need for surgery. The main down side to LHRH treatment is the cost. The injections are more expensive than a one-time surgery. Men who cannot or do not wish to have surgery are good candidates for this treatment.

Anti-androgen drugs — These drugs block testosterone from linking to the cancer cells. Drugs such as Flutamide (Eulexin), Bicalutamide (Casodex), and Nilutamide (Nilandron) are given as a daily pill.

CAB (combined androgen reducing treatment, with anti-androgens) — This method blends castration (by surgery or with the drugs described above) and anti-androgen drugs. The treatment blocks testosterone and stops it from binding to cancer cells.

Androgen synthesis inhibitors — Abiraterone acetate (Zytiga) is a drug you take as a pill. It stops your body and the cancer from making steroids (including testosterone). Because of the way it works, this drug must be taken with an oral steroid called Prednisone. Abiraterone may be used before or after chemotherapy in men with mCRPC. These drugs are often called second-generation anti-androgen and are used along with other antiandrogen therapies.

Androgen receptor binding inhibitors — Enzalutamide (Xtandi) is a drug, taken as a pill to block testosterone from binding to the prostate cancer cells. You do not need to take a steroid (prednisone) with this drug. Enzalutamide may be used in men with mCRPC before or after chemotherapy.

Chemotherapy

Chemotherapy drugs slow the growth of cancer and reduce symptoms. It may improve survival. Or, it may ease pain and symptoms by shrinking tumors. Chemotherapy is useful for men whose cancer is widespread. Or it is used when hormone therapy (alone) is no longer able to control the cancer. Docetaxel (Taxotere, Docefrez) and Cabazitaxel (Jevtana) have been shown to help.

Most chemotherapy drugs are given through a vein (intravenous, IV). During chemotherapy, the drugs move throughout the body. They kill quickly growing cancer cells and non-cancer cells. This is what causes the side effects that most people know about. They include hair loss, fatigue, nausea/ vomiting. There can be changes in your sense of taste and touch. You may be more prone to infections. You may experience neuropathy (tingling or numbness in the hands and feet).

Immunotherapy

Immunotherapy helps your immune system to fight cancer. This treatment is for men with mCRPC and doesn’t cause any major symptoms. It is given to mCRPC patients before chemotherapy. Some men get chemotherapy and immunotherapy together. To take it, you should have no or mild symptoms.

Sipuleucel-T (Provenge) is the first immunotherapy approved for advanced prostate cancer. It works by boosting your immune system, so it attacks cancer cells. This is the first drug of its kind shown to help men live longer. It may extend survival by months for some patients. Other immunotherapies are still being studied.

Side effects from Provenge (for the first 24 hours after) can include fever, chills, weakness, headache, nausea, vomiting and diarrhea. You may also have low blood pressure and rashes.

Bone-targeted Therapy

Men coping with advanced prostate cancer must protect their bones. Some men with prostate cancer have weak bones or have Skeletal Related Events (SREs).

These include weakening or breaking bones. Older men are at higher risk for bone and mineral loss. Low testosterone makes this worse.

To strengthen and protect your bones, you should take calcium or Vitamin D. You should also do weight-bearing exercises. Some drugs can help, they include Denosumab (Xgeva) and Zoledronic Acid (Zometa). Both help prevent pain and weakness from cancer growing in your bones. Radium-223 (Xofigo) is another treatment approved for men whose mCPRC has spread to their bones. This treatment is injected into your veins. It collects in the bones to stop cancer that has spread. Once in the bones, it gives off small amounts of radiation that can only travel short distances. This can target radiation to the exact areas where cancer cells are growing. Radium-223 has been shown to help men live longer. With Radium-223, your PSA level does not show how well you are responding. Although your PSA level may increase, this does not mean that the treatment is not working.

Radiation

Advanced prostate cancer often spreads to the bones. Radiation can help ease pain and other symptoms caused by tumors in bone. There are many types of radiation treatments.

Radiation may be given one time, or at a few visits. The treatment is like having an x-ray. It uses high-energy beams to kill tumors. New radiation techniques focus on saving nearby healthy tissue. Computers and new software show where the cancer is exactly. They target the radiation to pinpoint where it is needed. These methods are expected to improve the success of radiation therapy. They also cause fewer side effects.