Prostate Cancer, Advanced or Metastatic

Topic Overview

Is this topic for you?

This topic is about prostate cancer that has spread or come back after treatment. For information on early cancer of the prostate gland, see the topic Prostate Cancer.

What is prostate cancer?

Prostate cancer is a group of cells that grows faster than normal in a man's prostate gland. It can spread into other areas and kill normal tissue.

The prostate gland sits just below a man's bladder. It makes part of the fluid for semen. In young men, the prostate is about the size of a walnut. It usually grows larger as you grow older.

The cancer may be one of these types:

• Locally advanced prostate cancer. This is cancer that has grown through the outer rim of the prostate and into nearby tissue.
• Metastatic prostate cancer. This is cancer that has spread, or metastasized, to the lymph nodes or other parts of the body.
• Recurrent prostate cancer. This is cancer that has come back after it was treated. The cancer can come back in the prostate, near the prostate, or in another part of the body. If it comes back in another part of the body-often the bones-it is still called prostate cancer, because it started in the prostate.

What causes prostate cancer?

Experts don't know what causes prostate cancer. But they believe that getting older and having a family history of prostate cancer raise your chance of getting it.

What are the symptoms?

Sometimes there are no symptoms of either locally advanced or metastatic prostate cancer.

When they do appear, symptoms of locally advanced prostate cancer include:

• Waking up many times during the night to urinate.
• Having trouble starting your urine stream, having a weaker-than-normal stream, or not being able to urinate at all.
• Having pain or a burning feeling when you urinate.
• Having blood in your urine.
• Having a deep pain or stiffness in your lower back, upper thighs, or hips.

Symptoms of metastatic prostate cancer may include:

• Bone pain.
• Weight loss.
• Swelling in your legs and feet.

How is prostate cancer diagnosed?

Your doctor will do a digital rectal exam, in which he or she puts a gloved, lubricated finger in your rectum to feel your prostate. You may also have a blood test called a prostate-specific antigen (PSA) test. These tests will help find out if you have prostate cancer or if your prostate cancer has come back.

Your doctor also may do a biopsy. In this test, your doctor takes a sample of tissue from your prostate gland or from the area where the cancer may have spread and sends the sample to a lab for testing. A biopsy is the only way to know for sure that you have prostate cancer.

If you have had prostate cancer before, your doctor may also order a bone scan, CT scan, or MRI to see if it has come back or spread.

Finding out that you have cancer can be scary. It may help to talk with your doctor or with other people who have had cancer. Your local American Cancer Society chapter can help you find a support group.

How is it treated?

Choosing treatment for prostate cancer can be confusing. Your choices depend on your overall health, how fast the cancer is growing, and how far it has spread.

Locally advanced prostate cancer may be treated with surgery, radiation therapy, or hormone therapy.

Treatment of metastatic cancer focuses on slowing the spread of the cancer and relieving symptoms, such as bone pain. It also can help you feel better and live longer. Treatment may include hormone therapy, radiation therapy, or chemotherapy.

Frequently Asked Questions

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Cause

The exact cause of prostate cancer is not known, but experts believe your age and family history may have something to do with your chances of getting the disease. Prostate cancer is very common and is an older man's disease. Most men who get it are older than 65.

Symptoms

Prostate cancer may not cause noticeable symptoms. Possible symptoms of locally advanced prostate cancer are:

• Having difficulty starting your urine stream. This is called hesitancy.
• Having a weaker-than-normal urine stream.
• Not being able to urinate at all.
• Having to urinate often.
• Feeling that your bladder is not emptying completely when you urinate.
• Having to get up at night to urinate. This is called nocturia.
• Having pain or a burning feeling when you urinate. This is called dysuria.
• Having blood in your urine. This is called hematuria.
• Having a deep pain in your lower back, abdomen, hip, or pelvis.
• Having blood in your semen. This is called hematospermia or hemospermia.

These symptoms also may be caused by:

• Benign prostatic hyperplasia (BPH), which is an enlarged prostate. This is very common in older men. The prostate usually grows larger with age. When it gets large enough, it can press against the urethra and cause urination problems.
• Prostatitis, an infection in the prostate.
• Urinary tract infection, an infection in any of the organs and tubes that process and carry urine out of the body.

Symptoms that may indicate the cancer has spread to other parts of the body, or metastasized, include:

• Weight loss.
• Bone pain.
• Swelling in the legs and feet.

What Happens

Prostate cancer is so common that some experts believe every man would get it if he lived long enough. Studies of autopsies show that most men older than 85 who die of other causes have tumors in their prostates.¹

It usually is a very slow-growing cancer that takes years to grow large enough to cause any symptoms. In some men, it never does cause problems. Sometimes, though, it grows quickly and may cause complications or death.

When prostate cancer grows large enough, it begins to fill the prostate and often can be felt by your doctor during a digital rectal exam. As it continues to grow, it breaks through the outer rim of the prostate and into nearby tissues, such as the seminal vesicles. At this point, the disease is called locally advanced prostate cancer.

After the cancer has broken through the prostate, it may move into nearby lymph nodes. From the lymph node system, the cancer can spread to other areas of the body. Most often, prostate cancer spreads to the bones. It also may spread to the lungs or other organs. When it has spread to the lymph nodes , the disease is called metastatic prostate cancer.

Metastatic prostate cancer is not curable. But a number of treatments are available to help you live longer and make you feel better. While most men live 1 to 3 years after this diagnosis, some men may live many years longer.

What Increases Your Risk

A risk is anything that makes you more likely to get a particular disease. Being older than 50 is the main risk for prostate cancer. At least 6 out of 10 new prostate cancers are diagnosed in men who are 65 and older.²

Your chances of getting the disease are higher if other men in your family have had it. Your risk is doubled if your father or brother developed prostate cancer. Your risk increases even more if those relatives were diagnosed before they were 55.¹ Most men who get prostate cancer have no family history of the disease.

Most men will die with prostate cancer but not from prostate cancer.³ Your chances of dying from the disease depend on:

• Your overall health.
• Your age when the cancer is diagnosed.
• Your ethnicity. African-American men and Jamaican men of African descent are more likely than Caucasian men to die from prostate cancer.⁴ Experts believe that one reason is a gene that occurs more often in African-American men that makes it more likely for them to have prostate cancer.⁵
• How large your cancer has grown and if it has spread outside the prostate. This is called the stage of your cancer.
• Whether your cancer is slow-growing or fast-growing. This is called the grade of your cancer. Faster-growing cancers are a higher grade of cancer and are more likely to reappear after treatment or to spread to other parts of the body.

If you have prostate cancer, your chances of dying from it are influenced by:

• A high-fat diet. Studies have shown that men who have prostate cancer are more likely to see their cancer advance if they have a high-fat diet.⁴
• Having a higher grade of cancer. Cancers with higher grades grow faster and are more likely to cause death.⁶
• Being obese. Studies have shown that men who have prostate cancer are more likely to die from the disease if they have a body mass index of 30 or higher.^{7, 8}

Race and prostate cancer survival

African-American men and Jamaican men of African descent have a greater chance of developing the kind of prostate cancer that grows and spreads. Researchers are not sure why there is a difference in disease and death rates among different races. Some experts think there may be a genetic link.⁵

Ethnicity and 5-year survival (percentage of men who survive for 5 years or more after prostate cancer is diagnosed)⁴

The 5-year survival rate shows the percentage of men who are still alive 5 years or longer after they are diagnosed. It is important to remember that these are only averages. Everyone's case is different, and these numbers may not show what will happen in your case.

When To Call a Doctor

Call your doctor immediately if you:

• Are completely unable to urinate.
• Have painful urination and a fever higher than 100 °F (37.78 °C), chills, or body aches.
• Have blood or pus in your urine or semen.

Call your doctor to schedule an appointment if you have unexplained:

• Weight loss.
• Dull, aching pain in your lower back, pelvis, or hips.
• Swollen lymph nodes in the groin area. These nodes are usually not tender.

Watchful Waiting

Watchful waiting means that you are not receiving treatment but you and your doctor will watch your cancer to see if your symptoms go away on their own or get worse. Watchful waiting may not be a choice when prostate cancer has spread. But some men who have metastatic prostate cancer may choose watchful waiting if their PSAlevels are rising slowly.

If you choose watchful waiting, you will still need to see your doctor regularly for digital rectal exams and PSA tests.

Who To See

Doctors who can treat locally advanced and metastatic prostate cancer include:

• Urologists.
• Radiation oncologists.
• Medical oncologists.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Locally advanced and metastatic prostate cancer are diagnosed through physical exams and tests, including:

• A digital rectal exam, in which the doctor inserts a gloved finger into your rectum to feel your prostate gland. Some prostate tumors can be found this way.
• A PSA test to measure the levels of prostate-specific antigen (PSA) in your blood. A higher level of PSA may indicate an enlargement, infection, or cancer of the prostate. A rising PSA level after treatment for prostate cancer can mean your cancer has come back.
• A urine test, in which some of your urine is sent to a lab and checked for blood or infection. Prostate cancer can cause blood in the urine.
• A prostate biopsy, in which tissue is taken from your prostate and examined under a microscope. Although the other exams and tests can give clues that you may have prostate cancer, only a prostate biopsy can tell for sure.

If you have had prostate cancer before, one or more tests will help your doctor see if your cancer has come back or spread. These may include:

• Blood tests. Different types of blood tests are used to see whether cancer has spread to your bones or liver.
• A bone scan. Radioactive material that shows up on X-rays is injected into your arm. An X-ray camera passes over your body, taking pictures as the radioactive material moves into your bones. Areas of bone damage show up in the pictures. Prostate cancer that has spread to the bones can cause this kind of damage.
• A CT scan. A CT scanner directs a series of X-ray pulses through your body. Each X-ray pulse lasts only a fraction of a second and represents a 'slice' of the organ or area being studied.
• An MRI. An MRI uses a strong magnetic field to make pictures of the prostate. This can show tissue damage or disease, such as infection or a tumor.
• ProstaScint scan. Radioactive material that is absorbed by prostate cancer cells and shows up on X-rays is injected into your vein. Four days after the injection, your body is scanned with a special camera, and lymph nodes and other areas that have been invaded by prostate cancer cells show up on the scanning image.

Follow-up checkups

If you have been treated for prostate cancer in the past, you've probably been having regular checkups that include PSA tests to check for any signs that the cancer has come back or has spread to other parts of your body. Your doctor will watch for any increases in your PSA level and the speed with which any increases occur. A higher PSA does not necessarily mean your cancer has come back, but may show the need for further tests, such as a prostate biopsy, bone scan, CT scan, or MRI.

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.

Prevention

Prostate cancer can't be prevented. But there are steps you can take to reduce your risk of developing this disease. For more information, see the topic Prostate Cancer.

Home Treatment

During medical care for any stage of prostate cancer, there are things you can do at home to help manage symptoms of prostate cancer or side effects of treatment:

• Nausea or vomiting. After vomiting has stopped for 1 hour, sip a rehydration drink to restore lost fluids and nutrients. Watch for and treat early signs of dehydration. Older adults can quickly become dehydrated from vomiting. Your doctor may also prescribe medicines to control nausea and vomiting. For more information on how to deal with these side effects, see:

  Cancer: Controlling nausea and vomiting from chemotherapy.

• Pain. For pain, talk to your doctor about using aspirin, acetaminophen (such as Tylenol), or another type of nonsteroidal anti-inflammatory drug (NSAID). Or ask about a narcotic medicine. You can also try an alternative therapy such as biofeedback. Be sure to discuss with your doctor any home treatment you use for pain.
• Diarrhea. Don't eat until you are feeling better. Take frequent, small sips of water or a rehydration drink and small bites of salty crackers. Begin eating mild foods (such as rice, dry toast or crackers, bananas, broth, and applesauce) the next day or sooner, depending on how you feel.
• Constipation. Make sure you drink enough fluids. Most adults should drink between 8 and 10 glasses of water or noncaffeinated beverages each day. Include fruits, vegetables, and fiber in your diet each day.
• Sleep problems. Often, simple measures such as having a regular bedtime, getting some exercise during the day, and avoiding caffeine late in the day can relieve sleep problems.
• Urinary problems. Home treatment for urinary incontinence includes eliminating caffeinated drinks from your diet and establishing a schedule of urinating every 3 to 4 hours, regardless of whether you feel the need. You may also try doing pelvic floor (Kegel) exercises to strengthen your pelvic muscles.

During medical treatment for prostate cancer, you may experience emotional problems. See the following tips for managing:

• Stress. Expressing your feelings to others may help you understand and cope with them. Learning relaxation techniques may also be helpful.
• Poor body image. Your feelings about your body may change after treatment for cancer. Talk openly about your concerns with your partner, and discuss your feelings with your doctor, who may also be able to refer you to groups that can offer additional support and information.

You should not have to accept pain as part of receiving cancer treatment or having cancer. For tips on pain management, see:

Cancer: Controlling cancer pain.

For more information, see the topic Cancer Pain.

Medications

Medicines may be used to slow the growth of prostate cancer and to relieve your symptoms.

Prostate cancer often needs the male hormone testosterone to grow. Hormone therapy uses special drugs to block the production or action of testosterone and may cause the cancer to shrink. This can improve your symptoms. Hormone therapy may be given before or after radiation or surgery to remove the prostate.

Chemotherapy is the use of drugs to control cancer's growth or relieve pain. Often the drugs are given through a needle in your vein, and your blood vessels carry the drugs through your body. Sometimes the drugs are available as pills you can swallow. Sometimes they are given through a shot, or injection.

Chemotherapy usually involves two or more drugs given together. This is done to lower the chances that the cancer cells will become resistant to the drugs. It is most often used when prostate cancer is hormone-resistant.

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 called hormone-resistant. This means it will no longer get better with hormone therapy. When this happens, other kinds of hormone treatment may work. If the cancer continues to grow, chemotherapy may be the next choice.

Medication Choices

Hormone therapy

• LH-RH agonists/GnRH agonists, such as leuprolide (Lupron) and goserelin (Zoladex)
• Antiandrogens, such as flutamide (Eulexin), nilutamide (Nilandron), and bicalutamide (Casodex)

Hormone therapy for prostate cancer also includes orchiectomy, which is the surgical removal of the testicles. Hormone therapy is rarely used alone. More commonly, it is used with radiation therapy.

Chemotherapy

• Docetaxel
• Mitoxantrone
• Estramustine
• Paclitaxel
• Etoposide

Having chemotherapy with docetaxel and other medicine helps men with metastatic hormone-resistant prostate cancer live longer. A study with 1,006 men found that chemotherapy with docetaxel taken along with prednisone showed longer survival and a better quality of life.¹¹

Pain-relief and appetite-stimulant drugs

Pain-relief and appetite-stimulant drugs may be used when prostate cancer has spread to other parts of the body.

• Steroids, such as hydrocortisone or prednisone, control pain and improve appetite.
• Radioactive drugs such as strontium-89 and samarium-153 are called radionuclides. They are absorbed near the area of bone pain, and the radiation that is released helps relieve the pain caused by tumors that have spread to the bone.
• Bisphosphonate drugs such as alendronate (Fosamax), pamidronate disodium (Aredia), and zoledronic acid (Zometa) may help relieve bone pain and prevent osteoporosis, which is sometimes caused by long-term hormone therapy.¹⁶

Pain medicines are made that specifically treat mild, moderate, and severe pain, as well as different types of pain such as burning and tingling. To learn more, see:

Cancer: Controlling cancer pain.

For more information, see the topic Cancer Pain.

Medicines for treating side effects

Hormone therapy can cause loss of sexual desire, hot flashes, enlarged and painful breasts, and erection problems.

• For men who have erectile problems after surgery, medicines such as sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis) may be helpful.
• Taking a temporary break from hormone therapy can make some side effects go away.
• To relieve breast pain, the anti-estrogen breast cancer medicine called tamoxifen or radiation treatment is commonly used. Tamoxifen can also help reverse breast growth. It also causes hot flashes.
• For hot flashes, taking a certain kind of antidepressant may help.¹⁷ Gabapentin or venlafaxine may also help with hot flashes. But they have different side effects, so if you are having a problem with hot flashes, talk with your doctor.

What To Think About

Antiandrogen hormone therapy also may cause diarrhea, breast tenderness, and nausea. Cases of liver problems, some serious, have been reported.

When surgery or hormone therapy reduces the body's hormones, the bones may begin to lose their mineral density. Bone mineral density refers to how many minerals-which make your bones stronger-are in your bones. Bones that become thin and brittle are more likely to break, and studies show that hormone therapy increases the likelihood of broken bones.¹⁸ Pills or shots of a medicine called bisphosphonate can help prevent bone loss during long-term hormone therapy. These medicines may also help men whose prostate cancer has spread to the bones. Regular exercise also helps. For more information, see the topic Osteoporosis.

Surgery

Surgery to treat prostate cancer is usually reserved for men in good health who are younger than 70 and who choose to have surgery. Surgery may be done to relieve symptoms and to slow the growth of cancer.

Surgery Choices

• Radical prostatectomy, the removal of the prostate and its cancer. It is not usually done if the cancer has spread to other parts of the body.
• Orchiectomy, the removal of the testicles. This may cause the cancer to shrink and may improve symptoms because prostate cancer often needs the testosterone made by the testicles to grow.
• TURP, or transurethral resection of the prostate. This operation can help to 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. This can keep the tumor from growing for a while. But TURP does not take out the whole tumor.

What To Think About

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.

Surgical removal of the testicles (orchiectomy) and hormone therapy medicines have some of the same side effects, including hot flashes, larger breasts, loss of sexual desire, and the inability to have an erection.

Other Treatment

Radiation therapy

Radiation therapy for prostate cancer may be used alone or combined with hormone treatment. In rare cases, it is used with surgery. It is most effective in treating cancers that have not spread beyond the prostate, but it can also be effective in treating cancer that is only in the tissue near the prostate (locally advanced prostate cancer). Radiation therapy also is used to relieve pain from metastatic cancer or cancer that comes back after surgery.

Radiation therapy for locally advanced prostate cancer is often combined with hormone treatment. Using both together improves your chances of being disease-free for longer and living longer.⁶

• External-beam radiation therapy uses a large machine to aim a beam of radiation at your tumor to destroy cancer cells. The radiation damages the genetic material of the cells so that they can't grow. Although radiation damages normal cells as well as cancer cells, the normal cells can repair themselves and function, while the cancer cells cannot. If cancer has spread to your bones, radiation treatment may be given to specific areas to relieve pain.

Side effects

Radiation treatment commonly has side effects, including urinary incontinence, inflammation of the bladder and colon (colitis), diarrhea, and erection problems.

Side effects are common. Some men develop long-term problems that may have a significant impact on the quality of their lives. Long-term problems that can be caused by radiation treatment include:

• An irritated rectum and an urgent need to pass a stool. This is called proctitis.
• An inflamed bladder and urination problems. This is called cystitis.
• An inflamed intestine and diarrhea. This is called enteritis.
• Being unable to have an erection. This is called impotence.
• Being unable to control urination. This is called incontinence.
• Painful urination. This is called dysuria.

Complementary therapy

Complementary therapies, such as acupuncture, herbs, biofeedback, meditation, yoga, and vitamins, are sometimes used along with medical treatment. Some people feel that they benefit from some of these therapies.

Before you try a complementary therapy, talk to your doctor about the possible value and potential side effects. Let your doctor know if you are already using any such therapies. Complementary therapies are not meant to take the place of standard medical treatment, but they may improve your quality of life and help you deal with the stress and side effects of cancer treatment.

Clinical trials

Clinical trials are ongoing to find ways to prevent, detect, diagnose, and treat prostate cancer. For example, scientists are testing vaccines that use the immune system to keep cancer from getting worse. Other studies are testing on-and-off hormone therapy for men who have advanced prostate cancer. Hormone therapy lasts until cancer growth stops, then begins again when the cancer progresses. These trials hope to prove that men can avoid some of the side effects of continuous hormone therapy and still receive treatment that will block cancer growth.¹⁹ If you are interested in taking part in this type of trial, contact the U.S. National Cancer Institute Clinical Trials Support Unit (www.ctsu.org).

Other Places To Get Help

Organizations

Related Information

• Cancer Pain
• Prostate Cancer

References

Citations

1. Gronberg H (2003). Prostate cancer epidemiology. Lancet, 361(9360): 859-864.

2. American Cancer Society (2007). Cancer Facts and Figures 2007, pp. 1-52. Atlanta: American Cancer Society. Available online: http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf.

3. Frankel S, et al. (2003). Screening for prostate cancer. Lancet, 361(9363): 1122-1128.

4. National Cancer Institute (2007). Prostate Cancer (PDQ): Prevention-Health Professional Version. Available online: http://www.nci.nih.gov/cancertopics/pdq/prevention/prostate/HealthProfessional.

5. Robbins C, et al. (2007). Confirmation study of prostate cancer risk variants at 8q24 in African Americans identifies a novel risk locus. Genome Research, 17(12): 1717-1722.

6. National Cancer Institute (2007): Prostate Cancer (PDQ): Treatment-Health Professional Version. Available online: http://www.nci.nih.gov/cancertopics/pdq/treatment/prostate/healthprofessional.

7. Calle EE, et al. (2003). Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. New England Journal of Medicine, 348(17): 1625-1638.

8. Rodriguez C, et al. (2001). Body mass index, height, and prostate cancer mortality in two large cohorts of adult men in the United States. Cancer Epidemiology, Biomarkers and Prevention, 10(4): 345-353.

9. Brada M, et al. (2007). Proton therapy in clinical practice: Current clinical evidence. Journal of Clinical Oncology, 25(8): 965-970.

10. D'Amico AV, et al. (2007). Radiation therapy for prostate cancer. In AJ Wein et al., eds., Campbell-Walsh Urology, 9th ed., vol. 3, pp. 3006-3031. Philadelphia: Saunders Elsevier.

11. Berthold DR, et al. (2008). Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer: Updated survival in the TAX 327 study. Journal of Clinical Oncology, 26(2): 242-245.

12. Tunn U (2007). The current status of intermittent androgen deprivation (IAD) therapy for prostate cancer: Putting IAD under the spotlight. British Journal of Urology International, 99(Suppl 1): 19-24.

13. McNeel DG, Malkovsky M (2005). Immune-based therapies for prostate cancer. Immunology Letters, 96(1): 3-9.

14. Bader P, et al. (2003). Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure? Journal of Urology, 169(3): 849-854.

15. Yuen KK, et al. (2006). Bisphosphonates for advanced prostate cancer. Cochrane Database of Systemic Reviews (4). Oxford: Update Software.

16. Foley KM (2005). Management of cancer pain. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 7th ed., pp. 2615-2649. Philadelphia: Lippincott Williams and Wilkins.

17. Brigitte L, et al. (2004). Nonhormonal alternatives for the treatment of hot flashes. Pharmacotherapy, 24(1): 79-93.

18. Shahinian VB, et al. (2005). Risk of fracture after androgen deprivation for prostate cancer. New England Journal of Medicine, 352(2): 154-164.

19. Hellerstedt BA, Pienta KJ (2002). The current state of hormonal therapy for prostate cancer. CA-A Cancer Journal for Clinicians, 52(3): 154-179.

Other Works Consulted

• Kantoff PW (2007). Prostate cancer. In DC Dale, DD Federman, eds., ACP Medicine, section 12, chap. 9. New York: WebMD.

• Loblaw DA, et al. (2007). Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practice guideline. Journal of Clinical Oncology, 25(12): 1596-1605.

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