Prostate Cancer, Advanced or Metastatic - Treatment Overview

Treatment Overview

Choosing treatment for prostate cancer can be confusing. Not all men are treated the same way. 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, overall health, and life expectancy.
• 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. 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:

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 tissues around the prostate may be treated with:

• Hormone therapy. Prostate cancer often needs your body's male hormones 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 also 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 drugs are:
  • LH-RH agonists and GnRH agonists. These drugs stop the body from making testosterone.
  • Antiandrogens. These often are used along with LH-RH agonists. Antiandrogens help block the body's supply of testosterone.
• Radiation therapy. This treatment uses high-energy rays, such as X-rays, to destroy the cancer. It usually is combined with hormone therapy.
• 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 is easily removed.

Some men choose to wait until they have symptoms before starting hormone therapy. But many doctors recommend starting it if cancer is found in the lymph nodes during surgery to remove the prostate.

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 to slow cancer growth and relieve pain by shrinking the tumors. Hormone therapy can also improve urinary symptoms. It may be used alone or in combination with radiation therapy.
• 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.
• Drugs to stop the growth of cancer cells. Use of these kinds of drugs is called chemotherapy.
• Surgery to remove blockages that are causing problems (TURP) or to remove the testicles to reduce the supply of testosterone to the cancer (orchiectomy).

Orchiectomy and hormone therapy both make testosterone levels drop, causing 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 a certain kind of antidepressant to improve hot flashes.¹⁰

Hormone therapy usually works well at first to stop cancer growth. However, in most cases the cancer returns in a few years. At this point, the cancer is described as hormone-resistant, meaning it will no longer respond to hormone therapy. When this happens, other kinds of hormone treatment may be tried. If the cancer continues to grow, chemotherapy may be recommended.

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.¹¹

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.¹² 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 have 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 than care to cure your illness, called curative treatment. 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.

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.