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Prostate Cancer - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Prostate Cancer. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

Cancer begins when normal cells in the prostate change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

About the prostate gland

The prostate is a walnut-sized gland located behind the base of a man’s penis, in front of the rectum, and below the bladder. It surrounds the urethra, the tube-like channel that carries urine and semen through the penis. The prostate's main function is to make seminal fluid, the liquid in semen that protects, supports, and helps transport sperm.

Types of prostate cancer

Prostate cancer is a malignant tumor that begins in the prostate gland. Some prostate cancers grow very slowly and may not cause symptoms or problems for years. However, most prostate cancer cells make excessive amounts of a protein called prostate specific antigen (PSA). PSA is also found in higher-than-normal levels in men other various prostate conditions, such as benign prostatic hyperplasia (BPH, an enlarged prostate) and prostatitis (inflammation or infection of the prostate), in addition to prostate cancer (see the Risk Factors and Prevention section).

Prostate cancer is somewhat unusual, compared with other types of cancer, because many tumors do not spread from the prostate. And often, even metastatic prostate cancer can be successfully treated, allowing men with prostate cancer to live with good health for several years. However, if the cancer does metastasize (spread) to other parts of the body and cannot be well controlled with treatment, it can cause pain, fatigue, and other symptoms.

More than 95% of prostate cancers are a type called adenocarcinomas. A rare type of prostate cancer known as neuroendocrine cancer or small cell anaplastic cancer tends to spread earlier but usually does not make PSA. Read more about neuroendocrine tumors.

Many times, when a man develops prostate cancer much later in life, it is unlikely to cause symptoms or shorten the man’s life, and aggressive treatment may not be needed. For this reason, early detection for prostate cancer with prostate specific antigen (PSA) testing in men who don’t have symptoms of the disease is controversial.

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If you would like additional introductory information, explore these related items. Please note these links will take you to other sections on Cancer.Net:

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Prostate Cancer - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find information about how many men learn they have this type of cancer each year and some general survival information. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

Prostate cancer is the most common cancer among men (except for skin cancer). This year, an estimated 233,000 men in the United States will be diagnosed with prostate cancer. Most prostate cancers (93%) are found when the disease is confined to the prostate and nearby organs.

Overall, most men who develop prostate cancer (99%) are expected to live at least five years after diagnosis. Ninety-nine percent (99%) are alive after 10 years, and 94% live for at least 15 years. However, for men diagnosed with prostate cancer that has spread to other parts of the body, the five-year survival rate drops to 28%. The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases.

Prostate cancer is the second leading cause of cancer death in men in the United States. It is estimated that 29,480 deaths from this disease will occur this year. Although the number of deaths from prostate cancer continues to decline among all men, the death rate remains more than twice as high in black men than in white men. A man’s individual survival depends on the type of prostate cancer and the stage of the disease.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of men with this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a man how long he will live with prostate cancer. Because survival statistics are often measured in multi-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2014.

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Prostate Cancer - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find a basic drawing of the common body parts affected by this disease. To see other pages, use the menu on the side of your screen.

Prostate Cancer Illustration

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For medical illustrations of the different stages of prostate cancer, please visit the Stages section.

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Prostate Cancer - Risk Factors and Prevention

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find out more about what factors increase the chance of this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors can raise a man’s risk of developing prostate cancer:

Age. The risk of prostate cancer increases with age, especially after age 50. More than 80% of prostate cancers are diagnosed in men who are 65 or older.

Race/ethnicity. Black men have a higher risk of prostate cancer than white men. They are also more likely to develop prostate cancer at an earlier age and to have aggressive tumors that grow quickly. The exact reasons for these differences are not known and may involve socioeconomic and other factors. Hispanic men have a lower risk of developing prostate cancer and dying from the disease than white men. Prostate cancer occurs most often in North America and northern Europe. It also appears that prostate cancer is increasing among Asian people living in urbanized environments, such as Hong Kong, Singapore, and North American and European cities, particularly among those who have a more western lifestyle.

Family history/genetics. Prostate cancer often begins when one or more genes in a cell are mutated (changed), causing cells to multiply uncontrollably and become cancerous. Most prostate cancers (about 75%) are considered sporadic, meaning that the genetic changes occur by chance after a person is born. Prostate cancer that runs in a family, called familial prostate cancer, is less common (about 20%) and occurs because of a combination of shared genes and shared environmental or lifestyle factors. Hereditary (inherited) prostate cancer is rare (about 5%) and occurs when gene mutations are passed down within a family from one generation to the next. Hereditary prostate cancer may be suspected if a man’s family history includes any of the following characteristics:

  • Three or more first-degree relatives with prostate cancer
  • Prostate cancer in three generations on the same side of the family
  • Two or more close relatives (father, brother, son, grandfather, uncle, nephew) on the same side of the family diagnosed with prostate cancer before age 55

If a man has a first-degree relative (father, brother, son) with prostate cancer, his risk of developing prostate cancer is two to three times higher than the average risk. This risk increases with the number of relatives diagnosed with prostate cancer. 

Although researchers have identified several genes or gene mutations that are more common for men with prostate cancer, none of them have been shown to cause prostate cancer or be specific to this disease. One gene shown to increase the risk of prostate cancer, by as much as three times the average risk, is located on chromosome 17. What this gene does when it is not mutated is not known, but men who inherit the mutated version of the gene have a 44% higher prostate-specific antigen (PSA) level (see below for more information about PSA levels). Other genes that may cause an increased risk of developing prostate cancer include HPC1, HPC2, HPCX, and CAPB.

Research to identify genes associated with an increased risk of prostate cancer is ongoing, and researchers are constantly learning more about how specific genetic changes can influence prostate cancer development. Currently there are no genetic tests available to specifically determine a man's chance of developing prostate cancer.

Hereditary breast and ovarian cancer (HBOC) syndrome. HBOC is associated with mutations in the BRCA1 and/or BRCA2 genes. (BRCA stands for BReast CAncer.) HBOC is most commonly associated with an increased risk of breast and ovarian cancer in women. However, men with HBOC also have an increased risk of developing breast cancer and prostate cancer. Mutations in the BRCA1 and BRCA2 genes are thought to cause only a small percentage of familial prostate cancers. Genetic testing may only be appropriate for families with prostate cancer that may also have HBOC.

Agent Orange exposure. The U.S. Department of Veterans Affairs lists prostate cancer as a disease associated with exposure to Agent Orange, a chemical used during the Vietnam War.

Diet. No study has proven that diet and nutrition can directly cause or prevent the development of prostate cancer, but many studies that look at links between certain eating behaviors and cancer suggest there may be a connection. There is not enough information yet to make clear recommendations about the role diet plays in prostate cancer, and dietary changes may need to be made many years earlier in a man’s life to reduce the risk of developing prostate cancer. The following dietary information may be helpful:

  • A diet high in fat, especially animal fat, may increase prostate cancer risk. In fact, many doctors believe a low-fat diet may help reduce the risk of prostate cancer in addition to having other health benefits.
  • A diet high in vegetables, fruits, and legumes (beans and peas) may decrease the risk of prostate cancer. It is unclear which nutrients are directly responsible. Lycopene, found in tomatoes and other vegetables, may slow or prevent cancer growth. In any case, such a diet does not cause harm and can lower a person’s blood pressure and risk of heart disease.
  • Selenium, an element that people get in very small amounts from food and water, and vitamin E have been tested to find out if either or both of these nutrients can lower the risk of prostate cancer. However, in a clinical trial (a research study involving people) of more than 35,000 men called the Selenium and Vitamin E Cancer Prevention Trial (SELECT), researchers found that selenium and vitamin E supplements (pills), taken alone or together for an average of five years, did not prevent prostate cancer and may even cause harm in some men. Because of this risk, the National Cancer Institute has stopped the SELECT study. Men should talk with their doctor before taking selenium and vitamin E supplements to prevent prostate cancer.

It’s important to remember that specific changes to diet may not stop or slow the development of prostate cancer, and it’s possible such changes would need to begin early in life to have an effect.

Prevention

Although some risk factors for prostate cancer cannot be controlled, such as age and ethnicity, researchers continue to look into what men can do to lower their personal risk. There is no proven way to completely prevent this disease, but there may be steps you can take to lower your cancer risk. Talk with your doctor if you have concerns about your personal risk of developing this type of cancer.

Hormones and chemoprevention. High levels of testosterone (a male sex hormone) may speed up or cause the development of prostate cancer. For instance, it is very uncommon for a man whose body no longer makes testosterone to develop prostate cancer. And, stopping the body’s production of testosterone, called androgen deprivation therapy, often shrinks advanced prostate cancer (see the Treatment Options section for more information).

A class of drugs called 5-alpha-reductase inhibitors (5-ARIs), which includes finasteride (Proscar) and dutasteride (Avodart), may lower a man’s risk of prostate cancer. In clinical trials, both drugs have reduced the risk of prostate cancer. However, research has also shown that some men who receive these drugs have a higher risk of developing a more aggressive type of prostate cancer than men who do not receive them. Interestingly, according to the results of long-term follow-up study that was published in 2013, the same number of men taking finasteride were alive 15 years later as those taking a placebo (78%). These results suggest that there is no increase in the risk of death for men taking finasteride. This subject remains controversial, and these drugs have not been approved yet for prostate cancer prevention by the U.S. Food and Drug Administration (FDA).

Prostate cancer screening

Screening for prostate cancer is done to find evidence of cancer in otherwise healthy men. Two tests are commonly used to screen for prostate cancer: the PSA blood test and digital rectal examination (DRE, a test in which the doctor inserts a gloved lubricated finger into a man’s rectum and feels the surface of the prostate for any irregularities).

There is controversy about using the PSA test to look for prostate cancer in men with no symptoms of the disease. On one hand, the PSA test is useful for detecting early prostate cancer, which helps many men get the treatment they need before the cancer spreads. On the other hand, PSA screening finds conditions that are not cancer in addition to slow-growing prostate cancers that would never threaten a man’s life. Because of this, screening for prostate cancer may mean that some men have surgery and other treatments that may not ever be needed. For this reason, many men and their doctors may consider active surveillance (see the Treatment Options section) of the cancer rather than immediate treatment.

Because biopsies and treatment have significant side effects, such as impotence (inability to get and maintain an erection) and incontinence (inability to control urine flow) treating it unnecessarily may seriously affect a man’s quality of life. However, it is not easy to predict which tumors will grow and spread quickly and which will grow slowly.

According to a provisional clinical opinion on PSA screening for men with no symptoms of prostate cancer, ASCO recommends that men expected to live 10 years or less should not have PSA screening and men expected to live longer than 10 years should talk with their doctors to find out if the test is appropriate for them. Every man should discuss his situation and risk of prostate cancer and work with his doctor to make a decision.

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Prostate Cancer - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

Often, prostate cancer is found through a PSA test or DRE (see the Risk Factors and Prevention section) in men who have early-stage disease and no symptoms or signs. If prostate cancer is suspected based on a PSA test or DRE, more monitoring and testing is needed to diagnose prostate cancer (see the Diagnosis section for more information). When prostate cancer does cause symptoms or signs, it is usually diagnosed in a later stage (see the Stages section for details). These symptoms and signs may include:  

  • Frequent urination
  • Weak or interrupted urine flow or the need to strain to empty the bladder
  • Blood in the urine
  • The urge to urinate frequently at night
  • Blood in the seminal fluid
  • Pain or burning during urination (much less common)
  • Discomfort when sitting, caused by an enlarged prostate

Other noncancerous conditions cause these same symptoms. For instance, men who have a noncancerous condition called BPH or an enlarged prostate also have these symptoms. Urinary symptoms also can be caused by an infection or other conditions. In addition, sometimes men with prostate cancer do not have any of these symptoms.

If cancer has spread outside of the prostate gland, a man may experience:

  • Pain in the back, hips, thighs, shoulders, or other bones
  • Unexplained weight loss
  • Fatigue

If you are concerned about a symptom or sign on this list, please talk with your doctor. Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

The next section helps explain what tests and scans may be needed to learn more about the cause of the symptoms. Use the menu on the side of your screen to select Diagnosis, or you can select another section, to continue reading this guide.  

Prostate Cancer - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis, but this situation is rare for prostate cancer. For example, a biopsy may not be done when a patient has another medical problem that makes it difficult to do a biopsy, or when a person has a very high PSA level and a bone scan that indicates cancer. Imaging tests may be used to find out whether the cancer has spread. This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition
  • Type of cancer suspected
  • Signs and symptoms
  • Previous test results

In addition to a physical examination, the following tests may be used to diagnose prostate cancer:

PSA test. As described in the Overview and Risk Factors and Prevention section, PSA is a type of protein released by prostate tissue that is found in higher levels in a man's blood when there is abnormal activity in the prostate, including prostate cancer, BPH, or inflammation of the prostate. Doctors can look at features of the PSA value, such as absolute level, change over time, and level in relation to prostate size, to decide if a biopsy is needed. In addition, a version of the PSA test allows the doctor to measure a specific component, called the “free” PSA, which can sometimes help find out if a tumor is noncancerous or cancerous.

DRE. A doctor uses this test to find abnormal parts of the prostate by feeling the area using a finger (see the Risk Factors and Prevention section for more information). It is not very precise; therefore, most men with early prostate cancer have normal DRE test results.

If the PSA or DRE test results are abnormal, the following tests can confirm a diagnosis of cancer:

Transrectal ultrasound (TRUS). A doctor inserts a probe into the rectum that takes a picture of the prostate using sound waves that bounce off the prostate. This procedure is usually done at the same time as a biopsy (see below).

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. To get a tissue sample, a surgeon most often uses TRUS and a biopsy tool to take very small slivers of prostate tissue. The sample removed during the biopsy is then analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). A patient usually can have this procedure at the hospital or doctor’s office without needing to stay overnight. The patient is given local anesthesia beforehand to numb the area. A patient may also receive antibiotics before the procedure to prevent an infection afterwards.

To find out if cancer has spread outside of the prostate, doctors may perform the imaging tests listed below. Because prostate cancer is unlikely to have spread, many of these tests are not used when a man’s PSA level is only slightly increased. Learn more about when these tests are recommended to find out if the cancer has spread.

Bone scan. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can also be used to measure the tumor’s size. Generally, a contrast medium (a special dye) is injected into a patient’s vein or given orally (by mouth) to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein or given orally to create a clearer picture. By creating detailed pictures of the prostate, MRI scans are able to show whether the cancer has spread outside the prostate into nearby tissues or structures.

After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

The next section helps explain the different stages for this type of cancer. Use the menu on the side of your screen to select Stages, or you can select another section, to continue reading this guide.  

Prostate Cancer - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Staging for prostate cancer also involves looking at test results to find out if the cancer has spread from the prostate to other parts of the body. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

There are two types of staging for prostate cancer:

  • The clinical stage is based on the results of tests done before surgery, which includes DRE, biopsy, x-rays, CT scans, and bone scans. X-rays, bone scans, and CT scans may not always be needed. They are recommended based on the level of serum PSA, the grade and volume (size) of the cancer, and the clinical stage of the cancer.
  • The pathologic stage is based on information found during surgery, plus the laboratory results (pathology) of the prostate tissue removed during surgery (which often includes the removal of the entire prostate and some lymph nodes).

One tool that doctors use to describe the stage is the TNM system. TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

  • How large is the primary tumor and where is it located? (Tumor, T)
  • Has the tumor spread to the lymph nodes? (Node, N)
  • Has the cancer metastasized to other parts of the body? (Metastasis, M)

The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Below are more details about each part of the TNM system for prostate cancer.

Tumor. Using the TNM system, the "T" plus a number (0 to 4) is used to describe the size and location of the tumor. Some T groups are divided into smaller subgroups using the lowercase letters "a," "b," or "c" to help describe the tumor in even more detail.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of a tumor in the prostate.

T1: The tumor cannot be felt during a DRE and is not seen during imaging (any test that produces pictures of the inside of the body, such as a CT scan). It may be found when surgery is done for another reason, usually for BPH or an abnormal growth of noncancerous prostate cells.

T1a: The tumor is in 5% or less of the prostate tissue removed during surgery.

T1b: The tumor is in more than 5% of the prostate tissue removed during surgery.

T1c: The tumor is found during a needle biopsy, usually because the patient has an elevated PSA level.

T2: The tumor is found only in the prostate, not other parts of the body. It is large enough to be felt during a DRE.

T2a: The tumor has spread to one-half of one lobe (part or side) of the prostate.

T2b: The tumor has spread to more than one-half of one lobe of the prostate but not to both lobes.

T2c: The tumor has grown into both lobes of the prostate.

T3: The tumor has grown through the prostate capsule (into the tissue just outside the prostate) on one side.

T3a: The tumor has grown through the prostate capsule either on one side or on both sides of the prostate, or it has spread to the neck of the bladder.

T3b: The tumor has grown into the seminal vesicle(s), the tube(s) that carry semen.

T4: The tumor is fixed, or it is growing into nearby structures other than the seminal vesicles, such as the external sphincter (part of the muscle layer that helps to control urination), the rectum, levator muscles, and/or the pelvic wall.

Nodes. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the prostate in the pelvic region are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0: The cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to the regional lymph node(s).

Distant metastasis. The "M" in the TNM system indicates whether the prostate cancer has spread to other parts of the body, such as the lungs or the bones.

MX: Distant metastasis cannot be evaluated.

M0: The disease has not metastasized.

M1: There is distant metastasis.

M1a: The cancer has spread to nonregional, or distant, lymph node(s).

M1b: The cancer has spread to the bones.

M1c: The cancer has spread to another part of the body, with or without spread to the bone.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classification See the table below the stage descriptions for all of the TNM combinations for each stage.

Stage I: Cancer is found in the prostate only, usually during another medical procedure. It cannot be felt during the DRE or seen on imaging tests. A stage I cancer is usually made up of cells that look more like healthy cells and is likely to grow slowly.

Stage I Prostate Cancer

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Stage IIA and IIB: This stage describes a tumor that is too small to be felt or seen on imaging tests. Or, it describes a slightly larger tumor that can be felt during a DRE. The cancer has not spread outside of the prostate gland, but the cells are usually more abnormal and may tend to grow more quickly. It has not spread to lymph nodes or distant organs.

Stage IIA Prostate Cancer

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Stage IIB Prostate Cancer

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Stage III: The cancer has spread beyond the outer layer of the prostate into nearby tissues. It may also have spread to the seminal vesicles, the glands in men that help make semen.

Stage I Prostate Cancer

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Stage IV: This stage describes any tumor that has spread to other parts of the body, such as the bladder, rectum, bone, liver, lungs, or lymph nodes.

Stage IV Prostate Cancer

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Recurrent: Recurrent prostate cancer is cancer that has come back after treatment. It may come back in the prostate area again or in other parts of the body. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above

Stage Grouping Chart

Stage

T

N

M

I

T1a, T1b, or T1c

N0

M0

 

T2a

N0

M0

 

Any T1 or T2a

N0

M0

 

 

 

 

IIA

T1a, T1b, or T1c

N0

M0

 

T1a, T1b, or T1c

N0

M0

 

T2a

N0

M0

 

T2b

N0

M0

 

T2b

N0

M0

 

 

 

 

IIB

T2c

N0

M0

 

Any T1 or T2

N0

M0

 

Any T1 or T2

N0

M0

 

 

 

 

III

T3a or T3b

N0

M0

 

 

 

 

 

 

 

 

IV

T4

N0

M0

 

Any T

N1

M0

 

Any T

Any N

M1

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010), published by Springer-Verlag New York, www.cancerstaging.net

Prognostic factors

In addition to stage, doctors use other prognostic factors to help plan the best treatment and predict how successful treatment will be. Below are prognostic factors for men with prostate cancer.

PSA test. As described in the Risk Factors and Prevention section, PSA is a measurement of prostate-specific antigen levels in a man’s blood. These results are usually reported as nanograms per milliliter (ng/mL), such as 7 ng/mL for a PSA level of 7. For men already diagnosed with prostate cancer, the PSA level (and the Gleason score, described below) helps the doctor understand and predict a patient’s prognosis. This measurement gives doctors more information about the cancer to help make treatment decisions. Some prostate cancers do not cause an increased PSA level, so a normal PSA does not always mean that there is no prostate cancer.

Gleason score for grading prostate cancer. Prostate cancer is also given a grade called a Gleason score, which is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less dangerous tumors generally look more like healthy tissue, and more dangerous tumors that are likely to grow and spread to other parts of the body look less like healthy tissue.

The Gleason System is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 1 to 5. Cancer cells that look similar to healthy cells are given a low score, and cancer cells that look less like healthy cells are given a higher score. To assign the numbers, the doctor determines the main pattern of cell growth (area where the cancer is most obvious), looks for any other less common pattern of growth, and gives each one a score. The scores are added to come up with an overall score between 2 and 10.

The interpretation of the Gleason score by doctors has changed recently. Originally, doctors used a wide range of scores. Today, doctors no longer use Gleason scores of 5 or lower for cancer found with a biopsy. The lowest score used is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a high-grade cancer.

Doctors look at the Gleason score in addition to stage to help plan treatment. For example, active surveillance (see the Treatment Options section) may be an option for a patient with a small tumor, low PSA level, and a Gleason score of 6. On the other hand, patients with high Gleason score (8-10) may need more intensive treatment even if it doesn’t appear that the cancer has spread.

Gleason X: The Gleason score cannot be determined.

Gleason 6 or lower: The cells are well differentiated.

Gleason 7: The cells are moderately differentiated.

Gleason 8, 9, or 10: The cells are poorly differentiated or undifferentiated.

Information about the cancer’s stage will help the doctor recommend a treatment plan.  The next section helps explain the treatment options for this type of cancer. Use the menu on the side of your screen to select Treatment Options, or you can select another section, to continue reading this guide.  

Prostate Cancer - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will learn about the different ways doctors use to treat men with prostate cancer. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create an overall treatment plan that combines different type of treatments. This is called a multidisciplinary team.

Descriptions of the most common treatment options for prostate cancer are listed below, followed by an outline of general approaches to treatment according to stage. 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.

Take time to learn about your treatment options and be sure to ask questions about things that are unclear. Before treatment begins, 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, as well as their preferences. 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.

Learn more about making treatment decisions.

Active surveillance for early-stage cancer

If prostate cancer is found at an early stage, is growing slowly, and treating the cancer would cause more discomfort than the disease, a doctor may recommend active surveillance (also known as watchful waiting). During active surveillance, the cancer is monitored closely with periodic PSA tests, DRE tests, and watching for symptoms. Active treatment only begins if the tumor shows signs of becoming more aggressive or spreading, causes pain, or blocks the urinary tract.

This approach may be used for much older patients, those with other serious or life-threatening illnesses, those who wish to delay active treatment because of possible side effects, or for patients with tumors that have a low risk of growing and spreading (small tumor size, low Gleason score, low PSA level). However, real caution must be taken not to make errors of judgment about the disease. In other words, doctors must collect as much information as possible about the patient’s other illnesses and life expectancy so the chance to detect an early, aggressive prostate cancer is not missed. For this reason, 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

Local treatments are aimed at eliminating cancer from a specific, limited area of the body. For men diagnosed with early-stage prostate cancer, local treatments, such as surgery or radiation therapy, may get rid of the cancer completely. However, if the cancer has spread outside the prostate gland, other types of treatment may be needed to destroy cancer cells located in other parts of the body.

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. It is used to try to eliminate a tumor before it spreads outside the prostate. 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 general health, and other factors. Surgical options include:

Radical (open) prostatectomy. A radical prostatectomy is the surgical removal of the entire prostate and seminal vesicles. Lymph nodes in the pelvic area may also be removed. This operation has the risk of interfering with 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 since these are two 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 (open) 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 surrounding tissue. In general, robotic prostatectomy causes less bleeding and less pain, but the sexual and urinary side effects can be similar to a radical (open) prostatectomy. This procedure has not been available for as long as radical (open) prostatectomy, so longer-term follow-up information, including permanent cure rates, are not yet certain. Talk with your doctor about whether your treatment center offers this procedure and how it compares with the results of the conventional radical (open) prostatectomy.

Cryosurgery. Cryosurgery (also called cryotherapy or cryoablation) 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. Cryosurgery may be useful for early-stage cancer and for men who cannot have a radical prostatectomy. However, it has not been compared with radical prostatectomy or radiation therapy, so doctors do not know if this would be a better treatment option. A common side effect of cryosurgery is impotence, so this approach is not recommended for men who desire to preserve their sexual function. Another side effect may be the development of fistulae (holes between the prostate and the bowel), although this appears to be much less common with newer cryosurgery techniques. 

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 a full anesthesia (medication to block the awareness of pain), a surgeon inserts a cystoscope (a narrow tube with a cutting device) into the urethra and then into the prostate to remove prostate tissue.

Learn more about cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy rays to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

External-beam radiation therapy. External-beam radiation therapy focuses a beam of radiation 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. External-beam radiation therapy is usually given with a high-energy x-ray beam. It can also be given with proton therapy (also called proton beam therapy), which uses protons rather than x-rays. At high energy, protons can destroy cancer cells.

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 patients with prostate cancer than traditional radiation therapy.

Brachytherapy. Brachytherapy is the insertion of radioactive sources directly into the prostate. These sources (called seeds) give off radiation just around the area in which they are inserted and may be used for hours (high-dose rate) or for weeks (low-dose rate). Low-dose rate seeds are left in the prostate permanently, even after all the radioactive material has been used up. For a man with a high-risk cancer, brachytherapy is usually combined with other treatments.

Radiation therapy may cause immediate side effects such as diarrhea or other problems with bowel function, such as diarrhea, gas, bleeding, and loss of control of bowel movements; increased urinary urge or frequency; fatigue; impotence (erectile dysfunction); and rectal discomfort, burning, or pain. Most of these side effects usually go away after treatment, but erectile dysfunction is usually permanent. Many side effects of radiation therapy may not show up until months or years after treatment (see the After Treatment section).

Learn more about radiation therapy.

Systemic treatments

Doctors use treatments such as hormone therapy, chemotherapy, and vaccine therapy to reach cancer cells throughout the body. For men with later-stage prostate cancer or those considered to have a high risk of recurrence, systemic treatments may be used to shrink the cancer before surgery or radiation therapy (known as neoadjuvant therapy) or used after local treatment to eliminate any remaining cancer cells and reduce the chance the cancer will return (known as adjuvant therapy).

Hormone therapy

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. Hormone treatment is also called androgen ablation or androgen-deprivation therapy. The most common androgen is testosterone. Testosterone levels in the body can be lowered either surgically, with surgical castration (removal of the testicles), or with drugs that turn off the function of the testicles (medical castration, see below).

Hormone therapy is used to treat prostate cancer in different situations, including cancer that has come back after surgery and radiation therapy (recurrent prostate cancer) or cancer that has spread throughout the body at any time (metastatic prostate cancer).

Recent research has shown that hormone therapy can help lengthen lives when used with radiation therapy for a prostate cancer that is more likely to recur. For some men, hormone therapy will be used first to shrink a tumor before radiation therapy or surgery. In some men with prostate cancer that has spread locally, called locally advanced or high-risk prostate cancer, hormone therapy is given before, during, and after radiation therapy for three years. Hormone therapy should also be considered for men who have prostate cancer that has spread to the lymph nodes (found after radical prostatectomy) as adjuvant therapy. It may also be given for up to three years for men with intermediate-risk or high-risk cancer. 

Traditionally, hormone therapy was used until it stopped controlling the cancer. Then the cancer was called castration-resistant (meaning that the hormone therapy has stopped working), and other treatment options were considered. Recently, researchers have begun studying intermittent hormone therapy, which is hormone therapy that is given for specific periods of time and then stopped temporarily according to a schedule. Giving hormones in this way appears to lower the side effects of this therapy, but it has not been shown to be effective for all stages of prostate cancer.

Types of hormone therapy

Bilateral orchiectomy. Bilateral orchiectomy is the surgical removal of both testicles. Even though this is an operation, it is considered a hormone therapy 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. However, unlike surgical castration, the effects of LHRH agonists are reversible, so testosterone production usually begins again once a patient stops taking the medication.

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, known as a “flare,” happens because of a temporary surge in testosterone production by the testicles 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 whose cancer has spread to the bones.

LHRH antagonist. This type of drug, 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 like LHRH agonists. The FDA has approved one drug, 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, such as flutamide (Eulexin), bicalutamide (Casodex), and nilutamide (Nilandron), are taken as pills, usually by men who have “hormone sensitive” prostate cancer (prostate cancer that still responds to hormone therapy). Anti-androgens are not usually used by themselves in prostate cancer treatment.

Enzalutamide (Xtandi) is a newer type of anti-androgen that blocks signals from the androgen receptor that tell prostate cancer cells to grow and divide. Enzalutamide may be used for men with metastatic castration-resistant prostate cancer who previously received docetaxel (Docefrez, Taxotere), but it is also currently being studied to see if it can help men earlier in their treatment plan.

Combined androgen blockade. Sometimes anti-androgens are combined with bilateral orchiectomy or LHRH agonist treatment to more completely block 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 hormone treatment, as it prevents the possible flare that sometimes happens in response to LHRH agonist treatment. Some, but not all, research has shown about a six-month difference in long-term survival from the use of combined androgen blockade; therefore, some doctors prefer to give combined drug treatment while others may give the combination early in the treatment to prevent the flare.

CYP17 inhibitors. Although the testicles are the main producers of androgens, other cells in the body, including prostate cancer cells, can still make small amounts, which may drive cancer growth. Abiraterone (Zytiga) is a drug that blocks an enzyme called CYP17 and prevents these cells (but not the testicles) from making certain hormones, including androgens. Abiraterone, which is taken as a pill every day, has been approved by the FDA as a treatment for castration-resistant prostate cancer that has grown or spread while a man is having chemotherapy with docetaxel. Research studies have shown that abiraterone increased survival for men with this type of cancer. Abiraterone may also be used with prednisone (multiple brand names) before chemotherapy for men with metastatic castration-resistant prostate cancer.

Hormone therapy may cause significant side effects. Side effects generally go away after hormone treatment is finished, except in men who have had an orchiectomy. Patients may experience impotence, loss of libido (sexual desire), hot flashes with severe sweating, gynecomastia (growth of breast tissue), depression, weight gain, loss of muscle mass, and osteopenia or osteoporosis (bone thinning). Although testosterone levels may recover after stopping hormone therapy, some men who have taken LHRH agonists for many years may continue to have hormonal effects, even if they are no longer taking these drugs.

Another important side effect of hormone therapy 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 (even a temporary medical castration) with hormone therapy have an increased risk of developing metabolic syndrome. Find out more about hormone deprivation symptoms and how to manage them.

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 metabolic syndrome.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping their ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy for prostate cancer is given intravenously (injected into a vein), and it may help patients with advanced or castration-resistant prostate cancer. A medical oncologist, a doctor who specializes in treating cancer with medication, usually prescribes chemotherapy.

There are several standard drugs used for prostate cancer, and a number of new drugs are currently being studied in clinical trials. In general, standard chemotherapy begins with docetaxel combined with a steroid called prednisone. This combination has been shown to help men with advanced prostate cancer live longer than another chemotherapy drug, mitoxantrone (Novantrone), which is most useful for controlling pain from the cancer. The FDA has also approved the drugs mitoxantrone, docetaxel, and cabazitaxel (Jevtana) for use in specific situations, such as prostate cancer that is resistant to hormone therapy. Cabazitaxel is similar to docetaxel, but research studies have shown it can be effective for prostate cancer that is resistant to docetaxel.

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 once 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.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Vaccine therapy

Sipuleucel-T (Provenge) is a form of immunotherapy (also called biologic therapy), which 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 the prostate cancer cells. It is difficult to know if this treatment is working to treat the cancer for a specific patient because it has not been shown to shrink the cancer, lower the PSA level, or keep the cancer from getting worse. However, results from clinical trials have shown that treatment with sipuleucel-T can increase survival in men with castration-resistant metastatic prostate cancer with few or no symptoms.

Learn more about immunotherapy and cancer vaccines.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment 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 or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both 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, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, and radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.

Specific supportive care options used to help treat the symptoms of later-stage prostate cancer and enhance the quality of a patient’s life, include:

Strontium and samarium. Given by injection, these radioactive substances are 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.

Radium-223. Radium-223 dichloride (Xofigo) is a radioactive substance that is naturally attracted to areas of high bone turnover (areas where bone is being destroyed and replaced more than normal). Radium-223 delivers radiation directly to tumors found in the bone, limiting damage to health tissue. According to the results of a clinical trial published in 2013, treatment with radium-223 not only reduced bone-related complications, but also improved survival (see the section below about castration-resistant prostate cancer for more information).

Bone-modifying drugs. Prostate cancer that has spread to the bone or hormone therapy for prostate cancer can weaken a patient’s bones and lead to bone pain and an increased risk of fractures (breaks). Therefore, bone-modifying drugs like zoledronic acid (Zometa) or denosumab (Prolia) may be given to men diagnosed with metastatic castration-resistant prostate cancer to help reduce bone complications (such as pain, fracture, and need for surgery). Some men taking hormone therapy may also be given a bone-modifying drug less frequently and at a lower dose to promote bone health.

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.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. Learn more about palliative care.

Developing a treatment plan

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 and whether the cancer has spread to the bones), your health history, and any other medical conditions you may have. Although the treatment(s) recommended to you will depend on these factors, there are some general steps for treating prostate cancer.

Early-stage prostate cancer

Early-stage prostate cancer means that cancer cells are found only in the prostate. If the cancer has a low Gleason score (6 or less) and low PSA level (less than 10), it usually grows very slowly and may take a number of years to cause any symptoms or other health problems, if it ever does at all. As a result, active surveillance may be recommended. Alternatively, radiation therapy (external-beam or brachytherapy) or surgery may be suggested depending on your age and overall health. Clinical trials testing new types of treatment may also be an option.

For men with an early-stage cancer that has a higher Gleason score (and therefore may be faster growing), radical prostatectomy and radiation therapy (external-beam or brachytherapy) are often appropriate, but your doctor will consider your age and general health before recommending either (or both) as a treatment option.

Locally advanced prostate cancer

For some patients with a larger tumor, local treatments, like surgery and radiation therapy, are less likely to eliminate the cancer by themselves. Radical prostatectomy at this stage is not nerve sparing and is often done with removal of the pelvic lymph nodes. Some men are given hormone therapy before surgery (neoadjuvant hormone therapy) or have radiation therapy (external-beam and/or brachytherapy) afterward. Research has shown that adjuvant radiation therapy improves survival for men with locally advanced prostate cancer (pT3 disease) or those with positive margins after prostatectomy (cancer cells are found in the area of tissue surrounding the prostate that was removed during surgery).

For men who receive radiation therapy as their primary treatment, it is generally combined with several months of hormone therapy if there is a greater chance of recurrence based on disease extent, PSA level, and/or Gleason score. For older men with limited longevity and whose cancer is not causing symptoms, or for those who have another more serious illness, active surveillance may be considered.

Metastatic (advanced) prostate cancer

If cancer has spread to another location in the body, it is called metastatic cancer. At this stage, surgery to remove the prostate and pelvic lymph nodes cannot eliminate the cancer. As a result, most men with metastatic prostate cancer receive hormone therapy (see above). Read more about hormone therapy for advanced prostate cancer.

Some patients may also receive external-beam radiation therapy. If symptoms are not relieved by standard treatments and the cancer continues to grow and spread, chemotherapy may be an option, as is participating in a clinical trial.

Another important part of treating metastatic prostate cancer is relieving a patient's symptoms and/or side effects. Surgery (TURP) may be used to manage symptoms such as bleeding or urinary obstruction, while bone-modifying drugs, such as zoledronic acid or denosumab, may be used to strengthen bones, lessen pain, and reduce fractures for men with prostate cancer that has spread to the bone or for men who have received hormone therapy. Intravenous radiation therapy with strontium and samarium also helps relieve bone pain (see above).

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.

Although there is no cure for advanced prostate cancer, it is often treatable. Many men outlive their prostate cancer, even those with advanced disease. Often, the prostate cancer grows slowly, and there are now effective treatment options that extend life even further.

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.

Castration-resistant prostate cancer

Prostate cancer that no longer responds to hormone therapy, such as LHRH agonists or anti-androgens, is considered castration resistant and can be difficult to treat. Doctors may recommend chemotherapy (see above) 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 the drug docetaxel have shown they improve survival by several months. Cabazitaxel can be used after docetaxel stops working.

For some patients who have no or very few cancer symptoms and generally have not had chemotherapy, vaccine therapy with sipuleucel-T (see above) may be an option. In 2010, the FDA approved sipuleucel-T for men with castration-resistant metastatic prostate cancer with few or no symptoms because in research studies it increased survival by about four months compared to placebo.

The FDA has approved treatment with the CYP17 inhibitor abiraterone along with prednisone for men with castration-resistant prostate cancer that has grown or spread despite chemotherapy with docetaxel, and more recently, in patients who have not received docetaxel. In addition, the drug enzalutamide may be used for men with metastatic castration-resistant prostate cancer who previously received docetaxel.

In 2013, the FDA approved radium-223 dichloride as a treatment for men with metastatic castration-resistant prostate cancer that had spread to bones but not to other organs. This monthly injection is intended to be given to men whose cancer has spread only to their bones and who have already received treatment to lower their testosterone level. According to a study involving 809 men with castration-resistant prostate cancer that had spread to their bones, but not to other organs, men who received radium-223 lived an average of 14 months compared to just over 11 months for men who received a placebo injection.

Recurrent prostate cancer

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormone therapy and radiation therapy (see above), it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

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 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 recurrence.

After 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 therapies described above, such as radiation therapy, prostatectomy (for men initially treated with radiation therapy), or hormone therapy. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

Palliative care usually includes pain medication, external-beam radiation therapy, brachytherapy with strontium or samarium, or other treatments to reduce bone pain (see above).

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. Learn more about dealing with cancer recurrence.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and it 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 six 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 think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and bereavement.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.  

Prostate Cancer - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

Doctors and scientists are always looking for better ways to treat patients with prostate cancer. To make scientific advances, doctors create research studies involving volunteers, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. If they do not receive the new treatment being studied, patients will still receive the current standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating prostate cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future men with prostate cancer.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

To join a clinical trial, patients participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, the schedule of treatment, and the costs they may need to pay.

For specific topics being studied for prostate cancer, learn more in the Latest Research section.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trials before it ends.

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

The next section helps explain the areas of research going on today about this type of cancer. Use the menu on the side of your screen to select Latest Research, or you can select another section, to continue reading this guide.  

Prostate Cancer - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will read about the scientific research being done now to learn more about prostate cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about prostate cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options that are best for you.

Finding causes of prostate cancer. Researchers continue to explore the link between nutrition and lifestyle factors and the development of prostate cancer.

Early detection. Researchers are developing a better PSA test, either a more specific and precise test or another test altogether. Researchers are also developing a urine test to find a substance called prostate cancer gene 3 (PCA3) to help find prostate cancer. Because PCA3 is made by the body in larger amounts when a man has prostate cancer, doctors could use the test to decide if a man needs a prostate biopsy. With improved testing, more healthy men could be screened for prostate cancer, so more prostate cancers can be found and treated early.

Improved surgical techniques. Better techniques for nerve-sparing surgery can decrease the risk of urinary and sexual side effects for men who need a radical prostatectomy.

Shorter radiation therapy schedules. With better, more precise external-beam radiation therapy, researchers are exploring much shorter and more convenient treatment schedules. Instead of 40 treatments, researchers are evaluating 28, 12, or only five treatments.

High-intensity focused ultrasound (HIFU). This procedure, which is still being researched in the United States, uses transrectal ultrasound to heat and destroy cancer cells.

Tests that evaluate the success of treatment. Circulating tumor cells (cells that have broken free of the tumor) can be used to monitor the effectiveness of treatment; this test uses a patient’s blood sample to collect the circulating tumor cells.

Improved therapy for advanced prostate cancer. Researchers are exploring different treatment options for advanced prostate cancer, including special targeted drugs, chemotherapy, hormone therapy, and immunotherapy, through a series of clinical trials.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current prostate cancer treatments in order to improve patients’ comfort and quality of life.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding prostate cancer, explore these related items that take you outside of this guide:

The next section addresses how to cope with the symptoms of the disease or the side effects of its treatment. Use the menu on the side of your screen to select Coping with Side Effects, or you can select another section, to continue reading this guide.  

Prostate Cancer - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for prostate cancer are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. This discussion should include possible side effects involving your fertility, sexual function, and bladder function. In addition, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with prostate cancer. Learn more about caregiving.

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. Learn more about the importance of addressing such needs, including concerns about managing the cost of your cancer care

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the After Treatment section or talking with your doctor.

The next section helps explain medical tests and check-ups needed after finishing cancer treatment. Use the menu on the side of your screen to select After Treatment, or you can select another section, to continue reading this guide.  

 

Prostate Cancer - After Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will read about your medical care after cancer treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

After treatment for prostate cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is complete.

Men recovering from prostate cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes.

Learn more about coping with cancer, including important topics for men with prostate cancer, such as self-image and cancer, fertility and cancer treatment, sexual health, and talking with your spouse or partner.

The next section offers a list of questions you may want to ask. Use the menu on the side of your screen to select Questions to Ask the Doctor, or you can select another section, to continue reading this guide.  

Prostate Cancer - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care.

Before diagnosis—risk reduction and screening

  • What type of prostate cancer screening schedule do you recommend for me, based on my individual medical profile and family history?
  • Are there any changes I can make to my diet that can help me lower my risk of prostate cancer?

After a diagnosis of prostate cancer

  • What type of prostate cancer do I have?
  • What stage is my prostate cancer, and what does this mean?
  • What is the Gleason score of my prostate cancer? What does this mean?
  • Can you explain my pathology report (laboratory test results) to me?
  • What experience do you have treating this type of cancer?
  • What are my treatment options?
  • What clinical trials are open to me?
  • What treatment plan do you recommend and why?
  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?
  • Who will be part of my health care team, and what does each member do?
  • Who will be coordinating my overall treatment and follow-up care?
  • What are the possible side effects of each treatment option, both in the short term and the long term?
  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  • Will I have difficulty controlling my bladder or bowel function after treatment?
  • Could this treatment affect my sex life? If so, how and for how long?
  • Could this treatment affect my ability to have children? If so, should I talk with a fertility specialist before cancer treatment begins? Should I consider sperm banking?
  • What type of recovery should I expect following treatment?
  • What follow-up care tests will I need, and how often will I need them?
  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
  • What support services are available to me? To my family?
  • Whom should I call for questions or problems?

The next section offers some more resources that may be helpful to you. Use the menu on the side of your screen to select Additional Resources, or you can select another section, to continue reading this guide.  

Prostate Cancer - Additonal Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/2013

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Prostate Cancer. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond. Here are a few sections that may get you started in exploring the rest of Cancer.Net:

This is the end of Cancer.Net’s Guide to Prostate Cancer. Use the menu on the side of your screen to select another section, to continue reading this guide.