In cancer care, different types of doctors—including medical oncologists, surgeons, and radiation oncologists—often work together to create an overall treatment plan that may combine different type of treatments to treat the cancer. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as palliative care experts, physician assistants, advanced nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, physical therapists, and others.
Descriptions of the most common treatment options for prostate cancer are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Take time to learn about your treatment options and be sure to ask questions if something is unclear. Talk with your doctor about the goals of each treatment, the likelihood that the treatment will work, what you can expect while receiving the treatment, and the possible urinary, bowel, sexual, and hormone-related side effects of treatment. Men should also discuss with their doctor how the various treatment options affect recurrence, survival, and quality of life. In addition, the success of any treatment often depends on the skill and expertise of the physician or surgeon, so it is important to find doctors who have experience treating prostate cancer. These types of talks with your doctor are called shared decision making. Shared decision making is when doctors and people with cancer work together to choose treatments that fit their goals of care. Shared decision making is particularly important for prostate cancer because there are many treatment options.
Because most prostate cancers are found in the early stages when they are growing slowly, you usually do not have to rush to make treatment decisions. During this time, it is important to talk with your doctor about the risks and benefits of all your treatment options and when treatment should begin. This discussion should also address the current state of the cancer, such as:
Whether PSA levels are rising or steady
Whether the cancer has spread to the bones
Your health history
Any other medical conditions you may have
Although your treatment recommendations will depend on these factors, there are some general steps for treating early-stage and locally advanced prostate cancer. Treatment options for advanced and metastatic prostate cancer are described later in this section.
Early-stage prostate cancer (stages I and II). Early-stage prostate cancer usually grows very slowly and may take years to cause any symptoms or other health problems, if it ever does at all. As a result, active surveillance may be recommended. Radiation therapy (external-beam or brachytherapy) or surgery may also be suggested, as well as clinical trials. For men with a higher Gleason score, the cancer may be faster growing, so radical prostatectomy (see “Surgery” below) and radiation therapy are often appropriate. Your doctor will consider your age and general health before recommending a treatment option.
ASCO, the American Urological Association, American Society of Radiation Oncology, and the Society of Urologic Oncology recommend that men with high-risk early-stage prostate cancer that has not spread to other areas of the body should receive radical prostatectomy or radiation therapy with androgen-deprivation therapy (ADT) as standard treatment options. Radical prostatectomy, radiation therapy, and ADT are described in detail below.
Locally advanced prostate cancer (stage III). Men with locally advanced prostate cancer who choose not to have surgery should not have systemic therapy with either ADT or chemotherapy before surgery. Men with locally advanced prostate cancer who choose radiation therapy should receive ADT as the standard of care.
ADT given for 24 months is widely accepted as the least amount of time needed to control the disease, but 18 months may also be enough. Adjuvant or salvage radiation therapy is treatment that is given after radical prostatectomy. It is a standard of care for men with extraprostatic extension (pT3a or pT3b), regardless of Gleason score and margin status (positive or negative). Having positive margins means that cancer cells were found in margins of the tissue removed during surgery that surrounded the prostate. Having positive margins does not necessarily mean that cancer was left behind during surgery. The significance of this finding needs to be discussed with your doctor. The role of adjuvant radiation therapy for men who have microscopic cancer in their lymph nodes is still being studied.
For older men who are not expected to live for a long time and whose cancer is not causing symptoms, or for those who have another, more serious illness, watchful waiting may be considered.
Active surveillance and watchful waiting
If prostate cancer is in an early stage, is growing slowly, and treating the cancer would cause more problems than the disease itself, a doctor may recommend active surveillance or watchful waiting.
Active surveillance. Prostate cancer treatments can cause side effects, such as erectile dysfunction, which is the inability to get and maintain an erection, and incontinence, which is the inability to control urine flow or bowel function. These treatments for prostate cancer may seriously affect a man’s quality of life. In addition, many prostate cancers grow slowly and cause no symptoms or problems. For this reason, many men may consider delaying cancer treatment rather than starting treatment immediately. This is called active surveillance. During active surveillance, the cancer is closely monitored for signs that it is worsening. If the cancer is found to be worsening, treatment will begin.
Active surveillance is usually preferred for men with low-risk prostate cancer that can be treated with surgery or radiation therapy if it shows signs of getting worse. ASCO endorses recommendations from CancerCare Ontario concerning active surveillance, which recommend active surveillance for most patients with a Gleason score of 6 or below, with cancer that has not spread beyond the prostate. Sometimes, active surveillance may be an option for men with a Gleason score of 7. There is also growing use of genomic testing to help determine whether active surveillance is the best choice for a man with prostate cancer.
ASCO encourages the following testing schedule for active surveillance:
A PSA test every 3 to 6 months
A DRE at least once every year
Another prostate biopsy within 6 to 12 months, then a biopsy at least every 2 to 5 years
A patient should receive treatment if the results of the tests done during active surveillance show signs of the cancer becoming more aggressive or spreading, causes pain, or blocks the urinary tract.
Watchful waiting. Watchful waiting may be an option for much older men and those with other serious or life-threatening illnesses who are expected to live less than 5 years. With watchful waiting, routine PSA tests, DRE, and biopsies are not usually performed. If a patient develops symptoms from the prostate cancer, such as pain or blockage of the urinary tract, then treatment may be recommended to relieve those symptoms. This may include ADT (see “Systemic treatments” below). Men who start on active surveillance who later have a shorter life expectancy may switch to watchful waiting at some point to avoid repeated tests and biopsies.
Doctors must be cautious in judging the disease. In other words, doctors must collect as much information as possible about the patient’s other illnesses and life expectancy to determine whether active surveillance or watchful waiting is appropriate for each patient. In addition, many doctors recommend a repeat biopsy shortly after diagnosis to confirm that the cancer is in an early stage and growing slowly before considering active surveillance for an otherwise healthy man. New information is becoming available all the time, and it is important for men to discuss these issues with their doctor to make the best decisions about treatment.
Local treatments get rid of cancer from a specific, limited area of the body. Such treatments include surgery and radiation therapy. For men diagnosed with early-stage prostate cancer, local treatments may get rid of the cancer completely. If the cancer has spread outside the prostate gland, other types of treatment called systemic treatments (see “Systemic treatments” below) may be needed to destroy cancer cells located in other parts of the body.
Surgery involves the removal of the prostate and some surrounding healthy tissue during an operation. A surgical oncologist is a doctor who specializes in treating cancer using surgery. For prostate cancer, a urologist or urologic oncologist is the surgical oncologist involved in treatment. The type of surgery depends on the stage of the disease, the man’s overall health, and other factors.
Surgical options include:
Radical (open) prostatectomy. A radical prostatectomy is the surgical removal of the entire prostate and the seminal vesicles. Lymph nodes in the pelvic area may also be removed. This operation has the risk of affecting sexual function. Nerve-sparing surgery, when possible, increases the chance that a man can maintain his sexual function after surgery by avoiding surgical damage to the nerves that allow erections and orgasm to occur. Orgasm can occur even if some nerves are cut because these are 2 separate processes. Urinary incontinence is also a possible side effect of radical prostatectomy. To help resume normal sexual function, men can receive drugs, penile implants, or injections. Sometimes, another surgery can fix urinary incontinence.
Robotic or laparoscopic prostatectomy. This type of surgery is possibly much less invasive than a radical prostatectomy and may shorten recovery time. A camera and instruments are inserted through small keyhole incisions in the patient’s abdomen. The surgeon then directs the robotic instruments to remove the prostate gland and some surrounding healthy tissue. In general, robotic prostatectomy causes less bleeding and less pain, but the sexual and urinary side effects can be similar to those of a radical (open) prostatectomy. Talk with your doctor about whether your treatment center offers this procedure and how it compares with the results of the radical (open) prostatectomy.
Bilateral orchiectomy. Bilateral orchiectomy is the surgical removal of both testicles. It is described in detail in “Systemic treatments” below.
Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Typically, younger or healthier men may benefit more from a prostatectomy. Younger men are also less likely to develop permanent erectile dysfunction and urinary incontinence after a prostatectomy than older men.
Radiation therapy (Updated 10/2018)
Radiation therapy is the use of high-energy rays to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
The types of radiation therapy used to treat prostate cancer include:
External-beam radiation therapy. External-beam radiation therapy is the most common type of radiation treatment. The radiation oncologist uses a machine located outside the body to focus a beam of x-rays on the area with the cancer. Some cancer centers use conformal radiation therapy (CRT), in which computers help precisely map the location and shape of the cancer. CRT reduces radiation damage to healthy tissues and organs around the tumor by directing the radiation therapy beam from different directions to focus the dose on the tumor.
One method of EBRT used to treat prostate cancer is called hypofractionated radiation therapy. This is when a person receives a higher daily dose of radiation therapy given over a shorter period instead of lower doses given over a longer period.
According to recommendations from ASCO, American Society for Radiation Oncology, and American Urological Association, hypofractionated radiation therapy may be an option for the following people with early-stage prostate cancer that has not spread to other parts of the body:
Men with low-risk prostate cancer who need or prefer treatment instead of active surveillance.
Men with intermediate or high-risk prostate cancer receiving EBRT to the prostate, but not including the pelvic lymph nodes.
People who receive hypofractionated radiation therapy may have a slightly higher risk of some short-term side effects after treatment compared with those who receive regular EBRT. This can include gastrointestinal side effects. Based on current research, people who receive hypofractionated radiation therapy are not at a higher risk of side effects in the long term. Talk with your health care team if you have questions about your risk for side effects.
Brachytherapy. Brachytherapy, or internal radiation therapy, is the insertion of radioactive sources directly into the prostate. These sources, called seeds, give off radiation just around the area where they are inserted and may be left for a short time (high-dose rate) or for a longer time (low-dose rate). Low-dose-rate seeds are left in the prostate permanently and work for up to 1 year after they are inserted. However, how long they work depends on the source of radiation. High-dose-rate brachytherapy is usually left in the body for less than 30 minutes, but it may need to be given more than once.
Brachytherapy may be used with other treatments, such as external-beam radiation therapy and/or ADT. ASCO recommends the following brachytherapy options:
Men with low-risk prostate cancer who need or choose an active treatment may consider low-dose-rate brachytherapy. Other options include external-beam radiation therapy or a radical prostatectomy.
Men with intermediate-risk prostate cancer who choose external-beam radiation therapy (with or without ADT) should be offered either a low-dose-rate or high-dose-rate brachytherapy boost. For a brachytherapy boost, a lower dose of radiation is given for a shorter period of time. Some men with intermediate-risk prostate cancer may be able to receive only brachytherapy without external-beam radiation therapy or ADT.
Men with high-risk prostate cancer who are receiving external-beam radiation therapy and ADT should be offered a low-dose-rate or high-dose-rate brachytherapy boost.
Intensity-modulated radiation therapy (IMRT). IMRT is a type of external-beam radiation therapy that uses CT scans to form a 3D picture of the prostate before treatment. A computer uses this information about the size, shape, and location of the prostate cancer to determine how much radiation is needed to destroy it. With IMRT, high doses of radiation can be directed at the prostate without increasing the risk of damaging nearby organs.
Proton therapy. Proton therapy, also called proton beam therapy, is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. Current research has not shown that proton therapy provides any more benefit to men with prostate cancer than traditional radiation therapy. It is also more expensive.
Radiation therapy may cause side effects during treatment, including increased urinary urge or frequency; problems with sexual function; problems with bowel function, including diarrhea, rectal discomfort or rectal bleeding; and fatigue. Most of these side effects usually go away after treatment.
To help resume normal sexual function, men can receive drugs, penile implants, or injections. While uncommon, some side effects of radiation therapy may not show up until years after treatment.
Focal therapies are less-invasive treatments that destroy small prostate tumors without treating the rest of the prostate gland. These treatments use heat, cold, and other methods to treat cancer, primarily for men with low-risk or intermediate-risk prostate cancer. They are being studied and most have not been endorsed as standard treatment options. Focal therapies are usually done as part of clinical trials.
Cryosurgery, also called cryotherapy or cryoablation, is a type of focal therapy. It is the freezing of cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that contains the testicles. It is not an established therapy or standard of care for men newly diagnosed with prostate cancer. Cryosurgery has not been compared with radical prostatectomy or radiation therapy, so doctors do not know if it is a comparable treatment option. Its effects on urinary and sexual function are also not well known.
High-intensity focused ultrasound (HIFU) is a heat-based type of focal therapy. During HIFU treatment, an ultrasound probe is inserted into the rectum and then sound waves are directed at cancerous parts of the prostate gland. This treatment is designed to destroy cancer cells while limiting damage to the rest of the prostate gland. The FDA approved HIFU for the treatment of prostate tissue in 2015. HIFU may be an attractive option for some patients, but knowing who may benefit most from this treatment is still unknown. Similarly, HIFU should only be performed by a specialist with extensive expertise. You will need to carefully discuss with your doctor if HIFU is the best treatment for you.
Doctors use treatments such as ADT, chemotherapy, and novel agents to reach cancer cells throughout the body. This is called systemic treatment.
Androgen deprivation therapy (ADT)
Because prostate cancer growth is driven by male sex hormones called androgens, lowering levels of these hormones can help slow the growth of the cancer. The most common androgen is testosterone. Testosterone levels in the body can be lowered either by surgically removing the testicles, known as surgical castration, or by taking drugs that turn off the function of the testicles, called medical castration. Which ADT method is used is less important than the main goal of lowering testosterone levels.
ADT is used to treat prostate cancer in different situations, including locally advanced, recurrent prostate cancer, and metastatic prostate cancer. Some of the situations in which ADT may be used include:
Men with NCCN-based intermediate-risk and high-risk prostate cancer who are having definitive therapy with radiation therapy are candidates for ADT. Definitive therapy is a treatment given with the intent to cure the cancer. Men with intermediate-risk prostate cancer should receive ADT for at least 4 to 6 months. Those with high-risk prostate cancer should receive ADT for 24 to 36 months.
ADT may also be given to men who have had surgery and microscopic cancer cells were found in the removed lymph nodes. ADT is done to eliminate any remaining cancer cells and reduce the chance the cancer will return. This is known as adjuvant therapy. Although the use of adjuvant ADT is controversial, some specific patients appear to benefit from this approach.
Specific types of ADT
Bilateral orchiectomy. Bilateral orchiectomy is the surgical removal of both testicles. It was the first treatment used for metastatic prostate cancer more than 70 years ago. Even though this is an operation, it is considered an ADT because it removes the main source of testosterone production, the testicles. The effects of this surgery are permanent and cannot be reversed.
LHRH agonists. LHRH stands for luteinizing hormone-releasing hormone. Medications known as LHRH agonists prevent the testicles from receiving messages sent by the body to make testosterone. By blocking these signals, LHRH agonists reduce a man’s testosterone level just as well as removing his testicles. Unlike surgical castration, the effects of LHRH agonists are often reversible, so testosterone production usually begins again once a patient stops treatment. However, testosterone recovery can take any time from 6 months to 24 months, and for a small proportion of patients, testosterone production does not return.
LHRH agonists are injected or placed as small implants under the skin. Depending on the drug used, they may be given once a month or once a year. When LHRH agonists are first given, testosterone levels briefly increase before falling to very low levels. This effect is known as a “flare.” Flares occur because the testicles temporarily release more testosterone in response to the way LHRH agonists work in the body. This flare may increase the activity of prostate cancer cells and cause symptoms and side effects, such as bone pain in men with cancer that has spread to the bone.
LHRH antagonist. This class of drugs, also called a gonadotropin-releasing hormone (GnRH) antagonist, stops the testicles from producing testosterone like LHRH agonists, but they reduce testosterone levels more quickly and do not cause a flare. The FDA has approved degarelix (Firmagon), given by monthly injection, to treat advanced prostate cancer. One side effect of this drug is that it may cause a severe allergic reaction.
Anti-androgens. While LHRH agonists and antagonists lower testosterone levels in the blood, anti-androgens block testosterone from binding to so-called “androgen receptors,” which are chemical structures in cancer cells that allow testosterone and other male hormones to enter the cells. These drugs include bicalutamide (Casodex), flutamide (Eulexin), and nilutamide (Nilandron) and are taken as pills. Anti-androgens are usually given to men who have “hormone-sensitive” prostate cancer, which means that the prostate cancer still responds to testosterone suppression therapy. Anti-androgens are not usually used by themselves to treat prostate cancer.
Combined androgen blockade. Sometimes anti-androgens are combined with bilateral orchiectomy or LHRH agonist treatment to maximize the blockade of male hormones. This is because even after the testicles are no longer producing hormones, the adrenal glands still make small amounts of androgens. Many doctors also feel that this combined approach is the safest way to start ADT, as it prevents the possible flare that sometimes happens in response to LHRH agonist treatment. Some, but not all, research has shown that combined androgen blockade can help patients live longer than treatment with just ADT, surgery, or LHRH agonists or antagonists. Therefore, some doctors prefer to give combined drug treatment, while others may only give the combination early in the treatment to prevent the flare.
Intermittent ADT. Traditionally, ADT was given for the patient’s lifetime or until it stopped controlling the cancer, and then other treatment options were considered. During the past 2 decades, researchers have studied the use of intermittent ADT, which is ADT that is given for specific times (most commonly 6 months) and then stopped temporarily to allow for testosterone levels to recover. For these patients, ADT is restarted when the PSA begins to rise again. When to restart therapy (that is, at which PSA levels) remains controversial. Using ADT in this way may lower the side effects related to the lack of testosterone and improve a patient’s quality of life. This approach most benefits patients who have no evidence of metastases. Intermittent ADT has not been shown to be as effective as or better than lifelong ADT in men with metastatic disease.
Side effects of ADT
ADT will cause side effects that generally go away after treatment has finished, except in men who have had an orchiectomy. General side effects of ADT include:
Loss of sexual desire
Hot flashes with sweating
Gynecomastia, which is growth of breast tissue that sometimes can lead to discomfort
Cognitive dysfunction and memory loss
Loss of muscle mass
Osteopenia or osteoporosis, which is thinning of bones
Although testosterone levels may recover after stopping ADT, some men who have had medical castration with LHRH agonists for many years may continue to have hormonal effects, even if they are no longer taking these drugs.
Another serious side effect of ADT is the risk of developing metabolic syndrome. Metabolic syndrome is a set of conditions, such as obesity, high levels of blood cholesterol, and high blood pressure that increases a person’s risk of heart disease, stroke, and diabetes. Currently, it is not certain how often this happens or exactly why it happens, but it is quite clear that patients who receive a surgical or medical castration with ADT have an increased risk of developing metabolic syndrome. The risk is increased even if the medical castration is temporary.
The risks and benefits of castration should be carefully discussed with your doctor. For men with metastatic prostate cancer, especially if it is advanced and causing symptoms, most doctors believe that the benefits of castration far outweigh the risks of side effects. Aggressive management of side effects is very important for patients receiving ADT. These include getting regular exercise, quitting smoking, eating a balanced diet, making sure to get enough vitamin D and calcium, and receiving aggressive, preventive cardiovascular follow-up care.
Chemotherapy is the use of drugs to destroy cancer cells, usually by ending their ability to grow and divide. Chemotherapy is usually given by a medical oncologist, a doctor who specializes in treating cancer with medication.
Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Chemotherapy for prostate cancer is given through an intravenous (IV) tube placed into a vein using a needle. It may help patients with advanced or castration-resistant prostate cancer. A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time.
There are several standard drugs used for prostate cancer. In general, standard chemotherapy begins with docetaxel (Docefrez, Taxotere) combined with a steroid called prednisone (multiple brand names).
The FDA has also approved another drug, cabazitaxel (Jevtana), based on research that showed it improved survival when compared with mitoxantrone for patients whose disease progressed after having docetaxel. In clinical trials, cabazitaxel was compared with docetaxel in patients who had not received chemotherapy. In these patients, treatment with cabazitaxel was not better than treatment with the standard docetaxel. Another study compared the standard dose with a lower dose of cabazitaxel in people whose tumors grew after treatment with docetaxel. In addition of fewer side effects, this study also found that the lower dose also helped patients live longer.
Recent research shows that adding chemotherapy after the completion of 2 years of ADT for men with high-risk prostate cancer who are having definitive radiation therapy is an effective approach to reduce recurrence and improve survival. Although these results are interesting, further study is needed to see if this treatment helps people with prostate cancer.
In general, the side effects of chemotherapy depend on the individual, the type of chemotherapy received, the dose used, and the length of treatment, but they can include fatigue, sores in the mouth and throat, 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. The side effects of chemotherapy usually go away after treatment has finished. However, some side effects may continue, come back, or develop later. Ask your doctor which side effects you may experience, based on your treatment plan. Your health care team will work with you to manage or prevent many of these side effects.
Advanced prostate cancer (stage IV)
If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. High-risk or locally advanced prostate cancers pose a higher chance of becoming metastatic cancer. If prostate cancer has a high risk of becoming metastatic or is already metastatic, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials might be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.
For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
There is no cure for metastatic prostate cancer, but it is often treatable for quite some time. Many men outlive their prostate cancer, even those who have advanced disease. Often, the prostate cancer grows slowly, and there are now effective treatment options that extend life even further. In this way, it can be like living with a chronic disease like heart disease or diabetes, requiring ongoing treatment to minimize symptoms and maintain well-being.
Many men treated with surgery or radiation therapy are cured. However, some will develop a biochemical recurrence (BCR). The primary signs of BCR are rising PSA levels and no metastases in scans. This is why BCR is also called “rising PSA syndrome.” The exact definition of BCR depends on the initial treatment a patient has received.
For men who receive a radical prostatectomy, BCR is defined as a rising PSA level that reaches a value of 0.2 ng/mL or more. Radiation therapy may be a treatment option for certain patients with BCR after surgery; this treatment option is called “salvage radiation therapy.” Several factors are considered when deciding who can be treated with salvage radiation therapy, including Gleason score, pathologic stage, how long it took for BCR to occur, PSA value after surgery, and changes in PSA over time, also known as “PSA doubling time.” Men who receive radiation therapy to treat BCR should receive systemic treatment as well. There are currently 2 options:
2 years of hormonal therapy with an androgen receptor blocker called bicalutamide (Casodex)
6 months of testosterone suppression with standard ADT
For men who received radiation therapy as the main local definitive treatment for prostate cancer, BCR is defined as a normal testosterone level (for men who received ADT) and a PSA value more than 2.0 ng/mL plus the lowest PSA value achieved after the treatment with radiation therapy (this is called “nadir PSA”). Treating BCR after radiation therapy is more difficult. Treatment options for these men can include surgery, called “salvage radical prostatectomy,” or cryosurgery, called “salvage cryotherapy” (see “Focal therapies” above). Patients are encouraged to discuss treatment options with their health care team.
BCR is considered advanced cancer, so treatment with ADT may be recommended, especially if other local treatments are not options. ADT remains the most important treatment strategy for men with advanced prostate cancer. For men with BCR, there is still no exact recommendation for which type of ADT to use, when to start it, and for how long to give it.
Metastatic hormone-sensitive prostate cancer
Prostate cancer that has spread to other parts of the body and still responds to ADT is called metastatic hormone-sensitive prostate cancer. ASCO recommends that men with this type of cancer consider receiving ADT plus 1 of the 2 following options. The best option for each man depends on his health and the extent of the cancer. It is important for men to talk with their health care team about the risks and benefits of these treatment options.
Docetaxel. Chemotherapy with the drug docetaxel is an option, along with ADT for men newly diagnosed with widespread metastatic hormone-sensitive prostate cancer. Docetaxel is given by IV every 3 weeks for a total of 6 doses. The side effects of docetaxel may include low levels of blood cells, infection, nausea and vomiting, muscle aches, and hair and nail changes. It may also cause peripheral neuropathy, which is a type of nerve damage that causes a tingling or burning feeling in the hands and/or feet.
Abiraterone acetate (Zytiga) plus prednisone. Abiraterone acetate is an option, along with ADT for men who are newly diagnosed with metastatic hormone-sensitive prostate cancer. Although the testicles are the main producers of testosterone, other cells in the body can still make small amounts of androgens that may drive cancer growth. Abiraterone acetate prevents certain cells from making hormones that are known to help prostate cancer grow. Abiraterone acetate is taken each day as 4 pills along with a small dose of prednisone. Prednisone is used to help prevent some of the side effects of abiraterone.
Abiraterone acetate may cause serious side effects, such as high blood pressure, low blood potassium levels, fatigue, and fluid retention. Other possible side effects include weakness, joint swelling or pain, swelling in the legs or feet, hot flushes, diarrhea, vomiting, shortness of breath, and anemia.
In addition to the above treatment options, treatment to relieve a patient’s symptoms and side effects continues to be an important part of the overall treatment plan.
Non-metastatic castration-resistant prostate cancer (updated 07/2018)
Prostate cancer that is no longer stopped by low testosterone levels (less than 50 ng/mL) is called “castration resistant.” Castration-resistant prostate cancer is defined by a rising PSA level and/or worsening symptoms and/or growing cancer verified by scans. If the cancer has not spread to other parts of the body, it is called “non-metastatic castration-resistant prostate cancer.”
ASCO recommends that men who develop castration-resistant prostate cancer should continue treatment that lowers testosterone levels. This may include a permanent treatment, such as surgery to remove the testicles (called orchiectomy), or it may include continuing treatment with medicines that lower hormone levels.
Apalutamide (Erleada) in an anti-androgen medication called a nonsteroidal anti-androgen (NSAA). It is approved by the FDA for the treatment of non-metastatic castration-resistant prostate cancer. In the SPARTAN research study, apalutamide prevented metastasis that could be found with imaging scans for a median of over 2 years. The median is the midpoint, so this means that half of the men who received apalutamide had metastasis delayed for less than 2 years, and the other half had metastasis delayed for more than 2 years.
In the PROSPER study, enzalutamide (Xtandi) was given to men with non-metastatic castration-resistant prostate cancer. Treatment with enzalutamide was found to delay metastasis for a median of about 36 months compared with nearly 15 months for men who received ADT alone with a placebo. The median is the midpoint. The FDA approved enzalutamide for the treatment of non-metastatic castration-resistant prostate cancer in July 2018.
Second-line ADT may be an option for men who have not already received chemotherapy and who have a high risk of developing metastatic prostate cancer. It is not recommended for men who have not had chemotherapy and have a low risk of developing metastatic disease. Talk with your doctor about your personal risk level.
PSA testing and/or imaging tests may be done periodically to check whether the cancer has worsened or spread. For men with a low risk of developing metastatic disease, ASCO recommends PSA testing every 4 to 6 months. For men with a high risk of metastatic disease, ASCO recommends PSA testing every 3 months. Imaging tests, such as a bone scan, CT scan, or MRI, may be done if a man has symptoms or signs that the cancer is worsening.
Metastatic castration-resistant prostate cancer
If the cancer is no longer stopped by low testosterone levels (less than 50 ng/mL) and has spread to other parts of the body, it is called “metastatic castration-resistant prostate cancer.” Castration-resistant prostate cancer is defined by a rising PSA level and/or worsening symptoms and/or growing cancer verified by scans. For men with metastatic castration-resistant prostate cancer, ASCO recommends PSA testing every 3 months. Imaging tests may also be done.
Metastatic castration-resistant prostate cancer can be difficult to treat. ASCO recommends that men with metastatic castration-resistant prostate cancer continue treatment that lowers androgen levels.
Treatment options for metastatic castration-resistant prostate cancer are listed below. Treatment in a clinical trial may also be an option.
Abiraterone acetate (Zytiga) plus prednisone. Abiraterone acetate is a drug that blocks an enzyme called CYP17 and prevents these cells from making certain hormones, including adrenal androgens. Although the testicles are the main producers of testosterone, other cells in the body can still make small amounts of testosterone that may drive cancer growth. These include the adrenal glands and some prostate cancer cells themselves. Abiraterone acetate is taken in the form of a pill. Men take 4 pills per day along with prednisone twice a day. Abiraterone acetate has been approved by the FDA as a treatment for progressive, metastatic castration-resistant prostate cancer.
Abiraterone acetate may cause serious side effects, such as high blood pressure, low blood potassium levels, and fluid retention. Other common side effects include weakness, joint swelling or pain, swelling in the legs or feet, hot flushes, diarrhea, vomiting, shortness of breath, and anemia.
Enzalutamide (Xtandi). Enzalutamide is a nonsteroidal anti-androgen that is approved by the FDA for men who have metastatic castration-resistant prostate cancer. Several large clinical trials (called the STRIVE, TERRAIN, and PREVAIL studies) have shown that enzalutamide helped men live longer than treatment with other drugs.
Enzalutamide may cause serious side effects, such as headaches, confusion, loss of vision, and seizures. Other common side effects include weakness, back pain, decreased appetite, constipation, joint pain, diarrhea, hot flashes, upper respiratory tract infection, swelling, weight loss, high blood pressure, dizziness, and vertigo.
Chemotherapy. Doctors may recommend chemotherapy for patients with this type of prostate cancer, especially those with bone pain or cancer-related symptoms. Research studies of chemotherapy treatment plans that include docetaxel have been shown to lengthen life by several months. Cabazitaxel can be used after docetaxel stops working.
Immunotherapy. For some men with castration-resistant metastatic prostate cancer who have no or very few cancer symptoms and generally have not had chemotherapy, vaccine therapy with sipuleucel-T (Provenge) may be an option. Sipuleucel-T is an immunotherapy. Immunotherapy is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
Sipuleucel-T is adapted for each patient. Before treatment, blood is removed from the patient in a process called leukapheresis. Special immune cells are separated from the patient’s blood, modified in the laboratory, and then put back into the patient. At this point, the patient’s immune system may recognize and destroy prostate cancer cells. When this treatment is used, it is difficult to know if the treatment is working to treat the cancer because treatment with sipuleucel-T does not lead to PSA reductions, shrinking of the tumor, or keeping the cancer from getting worse. However, results from clinical trials have shown that treatment with sipuleucel-T can increase survival by about 4 months in men with metastatic castration-resistant prostate cancer with few or no symptoms.
Different types of immunotherapy can cause different side effects. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.
Radiopharmaceuticals. Radium-223 (Xofigo) is a radioactive substance used to treat men with castration-resistant prostate cancer that has spread to the bone. Radium-223 is an alpha-emitter radionucleotide that mimics calcium and targets areas in the bone where destruction and remodeling has occurred (this is often seen when prostate cancer spreads to bone). This treatment delivers radiation particles directly to tumors found in the bone, limiting damage to healthy tissue, including the bone marrow, where normal blood cells are made. Radium-223 is given by intravenous injection (IV) once a month for 6 months. This treatment is given by a radiation oncologist or a nuclear medicine doctor. Your medical oncologist should continue to follow your progress during this treatment to make sure you are benefiting from treatment and that any potential side effects are managed in a timely manner. Treatment with radium-233 has small effects on PSA, so patients should not expect to see big decreases in PSA levels during treatment.
Some people should not receive this treatment, especially those who need fast treatment of symptoms and men with prostate cancer that has spread to the liver and/or lungs. Discuss with your doctor whether this medication is best for your situation.
Palliative/supportive care. Treatment to relieve a patient’s symptoms and avoid side effects continues to be an important part of the overall treatment plan. This can include ways to help patients cope with stress, anxiety, and depression. Relieving pain as much as possible is very important in the management of metastatic prostate cancer. Psychosocial support and discussion of goals can be another important part of this care. Early involvement with a palliative care team has been shown to help prevent some symptoms of prostate cancer, leading to better quality of life in patients.
Getting care for symptoms and side effects
Cancer and its treatment often cause side effects. In addition to treatments intended to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his physical, emotional, and social needs.
Palliative or supportive care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the cancer at the same time that they receive treatment to ease side effects. In fact, patients who receive both at the same time often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.
Transurethral resection of the prostate (TURP). TURP is most often used to relieve symptoms of a urinary blockage, not to treat prostate cancer. In this procedure, with the patient under full anesthesia, which is medication to block the awareness of pain, a surgeon inserts a narrow tube with a cutting device called a cystoscope into the urethra and then into the prostate to remove prostate tissue.
Bone pain and weakness
Strontium and samarium. These radioactive substances (beta-emitters) are given by injection and absorbed near the area of bone pain. The radiation that is released helps relieve the pain, probably by causing the tumor in the bone to shrink. Neither substance helps patients live longer.
Radium-223. This treatment is used to relieve bone pain in men with castration-resistant prostate cancer that has spread to the bone. Read more in “Treatments for metastatic castration-resistant prostate cancer” above.
Bone-modifying drugs. Bone health is an important aspect in the life of men with prostate cancer. Osteopenia and osteoporosis are bone conditions that can be caused by low testosterone. Therefore, preventing bone loss in men receiving ADT is important because it lowers the risk of bone loss. Bone-modifying drugs like denosumab (Prolia, Xgeva) and zoledronic acid (Reclast, Zometa) can be given to prevent bone loss. Both of these drugs have unique side effects, so patients should discuss with their doctor when to take the medication and which drug would be best, based on their situation.
In metastatic castration-resistant prostate cancer, bone-modifying drugs have been shown to reduce the risk of skeletal-related events. Skeletal-related events are complications caused by prostate cancer that has spread to the bone, such as fractures and spinal cord compression. They are treated with orthopedic surgery and palliative radiation therapy for pain control.
Bone-modifying drugs have not been shown to help in the treatment of non-metastatic castration-resistant prostate cancer.
A possible condition associated with bone-modifying drugs is osteonecrosis of the jaw. It is an uncommon but serious condition. The symptoms of osteonecrosis of the jaw include pain, swelling, and infection of the jaw; loose teeth; and exposed bone. It is important for all dental work to be finished before starting these drugs. If a patient taking these drugs needs dental work, treatment should be stopped until the dental work is completed and the patient has healed.
Palliative treatment for metastatic cancer
As mentioned above and in Coping with Treatment, palliative care is important to help relieve symptoms and side effects. This includes people with metastatic prostate cancer. Palliative care options include:
TURP to manage symptoms such as bleeding or urinary obstruction.
Bone-modifying drugs, such as denosumab or zoledronic acid, may be used to strengthen bones and reduce the risk of skeletal-related events for men with prostate cancer that has spread to the bone.
Intravenous radiation therapy with radium-223, strontium, and samarium can also help relieve bone pain.
Palliative radiation therapy to specific bone areas can be used to reduce bone pain when medications don’t help.
Before treatment begins, talk with your health care team, including your dentist, about the possible side effects of your specific treatment plan and palliative care options. During and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as ADT and radiation therapy, which are described above, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate a person’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer does return after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate (called a local recurrence), in the tissues or lymph nodes near the prostate (a regional recurrence), or in another part of the body, such as the bones, lungs, or liver (a distant or metastatic recurrence). Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA-only or biochemical recurrence.
After this testing is done, you and your doctor will talk about your treatment options. The choice of treatment plan is based on the type of recurrence and the treatment(s) you have already received and may include the treatments described above, such as radiation therapy, prostatectomy for men first treated with radiation therapy, or ADT. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer.
Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects. Palliative care usually includes pain medication, external-beam radiation therapy, brachytherapy with radium-223, strontium, or samarium, or other treatments to reduce bone pain.
People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope.
If treatment doesn’t work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for many people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.
Patients who have advanced cancer and who are expected to live less than 6 months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families.