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.
This section tells you the treatments that are the standard of care for this type of cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn if it is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Your doctor can help you consider all your treatment options. To learn more about clinical trials, see the About Clinical Trials and Latest Research sections.
In cancer care, different types of doctors often work together to create an overall treatment plan that may combine different type of treatments. This is called a multidisciplinary team. Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.
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. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Take time to learn about your treatment options and be sure to ask questions if something is unclear. Also, talk with your doctor about the goals of each treatment, the likelihood that the treatment will work, what you can expect while receiving the treatment, and the possible urinary, bowel, sexual, and hormone-related side effects of treatment. Men should also discuss with their doctor how the various treatment options affect recurrence, survival, and quality of life. In addition, the success of any treatment often depends on the skill and expertise of the physician or surgeon, so it is important to find doctors who have experience treating prostate cancer. Learn more about making treatment decisions.
Active surveillance and watchful waiting
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 or watchful waiting.
- Active surveillance. Prostate cancer treatments can cause side effects, such as erectile dysfunction, which is the inability to get and maintain an erection, and incontinence, which is the inability to control urine flow. These treatments for prostate cancer may seriously affect a man’s quality of life. For this reason, many men with very early prostate cancer and their doctors consider postponing cancer treatment rather than starting treatment immediately. During active surveillance, the cancer is closely monitored for signs that it is worsening.
Active surveillance is usually preferred for men with a long life expectancy who may benefit from curative local therapy (see below) if the cancer shows signs of getting worse. ASCO endorses recommendations from CancerCare Ontario concerning active surveillance, which recommend active surveillance for most patients with a Gleason score of 6 or below with cancer that has not spread beyond the prostate. Sometimes, active surveillance may be an option for men with a Gleason score of 7.
ASCO encourages the following testing schedule for active surveillance:
A PSA test every 3 to 6 months
A DRE at least once every year
Another prostate biopsy within 6 to 12 months, then a biopsy at least every 2 to 5 years
A patient should receive treatment if the results of the tests done during active surveillance show signs of the cancer becoming more aggressive or spreading, causes pain, or blocks the urinary tract.
Watchful waiting. Watchful waiting may be an option for much older men and those with other serious or life-threatening illnesses who are expected to live less than 5 years. With watchful waiting, routine PSA tests, DRE, and biopsies are not usually performed. If a patient develops symptoms from the prostate cancer, such as pain or blockage of the urinary tract, then treatment may be recommended. This may include ADT (see “Systemic treatments” below). Men who start on active surveillance who later have a shorter life expectancy may switch to watchful waiting at some point to avoid repeated tests and biopsies.
Doctors must be cautious that they do not make errors in judging the disease. In other words, doctors must collect as much information as possible about the patient’s other illnesses and life expectancy to determine whether active surveillance or watchful waiting is appropriate for each patient. In addition, many doctors recommend a repeat biopsy shortly after diagnosis to confirm that the cancer is in an early stage and growing slowly before considering active surveillance for an otherwise healthy man. New information is becoming available all the time, and it is important for men to discuss these issues with their doctor to make the best decisions about treatment. Learn more about ASCO’s endorsement of recommendations for active surveillance on asco.org.
Local treatments get rid of cancer from a specific, limited area of the body. Such treatments include surgery and radiation therapy. For men diagnosed with early-stage prostate cancer, local treatments may get rid of the cancer completely. However, if the cancer has spread outside the prostate gland, other types of treatment called systemic treatments (see next section, below) may be needed to destroy cancer cells located in other parts of the body.
Surgery is the removal of the tumor and some surrounding healthy 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, an urologist or urologic oncologist is the surgical oncologist involved in treatment. The type of surgery depends on the stage of the disease, the man’s overall health, and other factors.
Surgical options include:
Radical (open) prostatectomy. A radical prostatectomy is the surgical removal of the entire prostate and the seminal vesicles. Lymph nodes in the pelvic area may also be removed. This operation has the risk of 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 because these are 2 separate processes. Urinary incontinence is also a possible side effect of radical prostatectomy. To help resume normal sexual function, men can receive drugs, penile implants, or injections. Sometimes, another surgery can fix urinary incontinence.
Robotic or laparoscopic prostatectomy. This type of surgery is possibly much less invasive than a radical prostatectomy and may shorten recovery time. A camera and instruments are inserted through small keyhole incisions in the patient’s abdomen. The surgeon then directs the robotic instruments to remove the prostate gland and some surrounding healthy tissue. In general, robotic prostatectomy causes less bleeding and less pain, but the sexual and urinary side effects can be similar to those of a radical (open) prostatectomy. Talk with your doctor about whether your treatment center offers this procedure and how it compares with the results of the conventional radical (open) prostatectomy.
Learn more about the basics of cancer surgery.
Radiation therapy is the use of high-energy rays to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.
The types of radiation therapy used to treat prostate cancer include:
External-beam radiation therapy. External-beam radiation therapy is the most common type of radiation treatment. The radiation oncologist uses a machine located outside the body to focus a beam of x-rays on the area with the cancer. Some cancer centers use conformal radiation therapy (CRT), in which computers help precisely map the location and shape of the cancer. CRT reduces radiation damage to healthy tissues and organs around the tumor by directing the radiation therapy beam from different directions to focus the dose on the tumor.
Intensity-modulated radiation therapy (IMRT). IMRT is a type of external-beam radiation therapy that uses CT scans to form a 3-dimensional (3D) picture of the prostate before treatment. A computer uses this information about the size, shape, and location of the prostate cancer to determine how much radiation is needed to destroy it. With IMRT, high doses of radiation can be directed at the prostate without increasing the risk of damaging nearby organs.
Proton therapy. Proton therapy, also called proton beam therapy, is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. Current research has not shown that proton therapy provides any more benefit to men with prostate cancer than traditional radiation therapy. It is also more expensive.
Brachytherapy. Brachytherapy, or internal radiation therapy, is the insertion of radioactive sources directly into the prostate. These sources, called seeds, give off radiation just around the area where they are inserted and may be left for a short time (high-dose rate) or for a longer time (low-dose rate). Low-dose rate seeds are left in the prostate permanently and work for up to 1 year after they are inserted. However, how long they work depends on the source of radiation used. High-dose rate brachytherapy is usually left in the body for less than 30 minutes, but may need to be given more than once.
Brachytherapy may be used with other treatments, such as external-beam radiation therapy and/or androgen deprivation therapy. ASCO recommends the following brachytherapy options:
Men with low-risk prostate cancer who need or choose an active treatment may consider low-dose rate brachytherapy. Other options include external-beam radiation therapy or a radical prostatectomy.
Men with intermediate-risk prostate cancer who choose external-beam radiation therapy (with or without androgen deprivation therapy) should be offered either a low-dose rate or high-dose rate brachytherapy boost. For a brachytherapy boost, a lower dose of radiation is given for a shorter period of time. Some men with intermediate-risk prostate cancer may be able to receive only brachytherapy without external-beam radiation therapy or androgen deprivation therapy.
Men with high-risk prostate cancer who are receiving external-beam radiation therapy and androgen deprivation therapy should be offered a low-dose rate or high-dose rate brachytherapy boost.
Read ASCO’s recommendations for brachytherapy for prostate cancer, located on ASCO’s website.
Radiation therapy may cause immediate side effects such as diarrhea or other problems with bowel function, such as gas, bleeding, and loss of control of bowel movements; increased urinary urge or frequency; fatigue; 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 Follow-up Care section for more information about long-term side effects.
Learn more about the basics of radiation therapy.
Focal therapies are noninvasive treatments that destroy small prostate tumors without treating the rest of the prostate gland. These treatments use heat, cold, and other methods to treat cancer, primarily for men with low-risk or intermediate-risk prostate cancer. They are still being studied at this time and have not been endorsed as standard treatment options. Focal therapies are done as part of clinical trials.
An example of focal therapy is cryosurgery, also called cryotherapy or cryoablation. It is the freezing of cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that contains the testicles. It is not an established therapy or standard of care for men newly diagnosed with prostate cancer. Cryosurgery has not been compared with radical prostatectomy or radiation therapy, so doctors do not know if it is a comparable treatment option. Its effects on urinary and sexual function are also not well defined.
Doctors use treatments such as ADT, chemotherapy, and novel agents to reach cancer cells throughout the body. This is called systemic treatment.
Androgen deprivation therapy (ADT)
Because prostate cancer growth is driven by male sex hormones called androgens, lowering levels of these hormones can help slow the growth of the cancer. The most common androgen is testosterone. Testosterone levels in the body can be lowered either by surgically removing the testicles, known as surgical castration, or by taking drugs that turn off the function of the testicles, called medical castration. Which ADT method is used is less important than the main goal: that testosterone levels are lowered.
ADT is used to treat prostate cancer in different situations, including locally advanced, recurrent prostate cancer, and metastatic prostate cancer. Metastatic prostate cancer is cancer that has spread to another part of the body. Some of the situations in which ADT may be used include:
Men with NCCN-based intermediate-risk and high-risk prostate cancer who are having definitive therapy with radiation therapy are candidates for ADT. Definitive therapy is a treatment given with the intent to cure the cancer. Men with intermediate-risk prostate cancer should receive ADT for at least 6 months. Those with high-risk prostate cancer should receive ADT for 24 to 36 months.
ADT may also be given to men who have had surgery and microscopic cancer cells were found in the removed lymph nodes. ADT is done to eliminate any remaining cancer cells and reduce the chance the cancer will return. This is known as adjuvant therapy. Although the use of adjuvant ADT is controversial, some specific patients appear to benefit from this approach.
ADT should also be considered as adjuvant therapy if prostate cancer has been found in the lymph nodes after a radical prostatectomy.
Specific types of ADT
Bilateral orchiectomy. Bilateral orchiectomy is the surgical removal of both testicles and was the first treatment used for metastatic prostate cancer more than 70 years ago. Even though this is an operation, it is considered an ADT because it removes the main source of testosterone production, the testicles. The effects of this surgery are permanent and cannot be reversed.
LHRH agonists. LHRH stands for luteinizing hormone-releasing hormone. Medications known as LHRH agonists prevent the testicles from receiving messages sent by the body to make testosterone. By blocking these signals, LHRH agonists reduce a man’s testosterone level just as well as removing his testicles. Unlike surgical castration, the effects of LHRH agonists are often reversible, so testosterone production usually begins again once a patient stops treatment. However, testosterone recovery can take any time from 6 months to 24 months, and for a small proportion of patients testosterone recovery does not happen.
LHRH agonists are injected or placed as small implants under the skin. Depending on the drug used, they may be given once a month or once a year. When LHRH agonists are first given, testosterone levels briefly increase before falling to very low levels. This effect is known as a “flare.” Flares occur because the testicles temporarily release more testosterone in response to the way LHRH agonists work in the body. This flare may increase the activity of prostate cancer cells and cause symptoms and side effects, such as bone pain in men with cancer that has spread to the bone.
LHRH antagonist. This class of drugs, also called a gonadotropin-releasing hormone (GnRH) antagonist, stops the testicles from producing testosterone like LHRH agonists, but they reduce testosterone levels more quickly and do not cause a flare. The FDA has approved 1 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 include bicalutamide (Casodex), flutamide (Eulexin), and nilutamide (Nilandron) and are taken as pills. Anti-androgens are usually given to men who have “hormone-sensitive” prostate cancer, which means that the prostate cancer still responds to testosterone suppression therapy. Anti-androgens are not usually used by themselves in prostate cancer treatment.
Combined androgen blockade. Sometimes anti-androgens are combined with bilateral orchiectomy or LHRH agonist treatment to maximize the blockade of male hormones. This is because even after the testicles are no longer producing hormones, the adrenal glands still make small amounts of androgens. Many doctors also feel that this combined approach is the safest way to start ADT, as it prevents the possible flare that sometimes happens in response to LHRH agonist treatment. Some, but not all, research has shown that combined androgen blockade can help patients live longer than treatment with just ADT, surgery, or LHRD agonists or antagonists. Therefore, some doctors prefer to give combined drug treatment, while others may only give the combination early in the treatment to prevent the flare.
Side effects of ADT
Traditionally, ADT was given for the patient’s lifetime or until it stopped controlling the cancer. Then the cancer was called castration-resistant, meaning that ADT has stopped working, and other treatment options were considered. During the past 2 decades, researchers have studied the use of intermittent ADT, which is ADT that is given for specific times and then stopped temporarily according to a schedule. Using ADT in this way may lower the side effects and improve a patient’s quality of life. Only patients without evidence of metastases are candidates for this approach. Intermittent ADT has not been shown to be equivalent or superior to lifelong ADT in men with metastatic disease.
ADT will cause side effects that will generally go away after treatment has finished, except in men who have had an orchiectomy. General side effects of ADT include:
Loss of sexual desire
Hot flashes with sweating
Gynecomastia, which is growth of breast tissue that sometimes can lead to discomfort
Cognitive dysfunction and memory loss
Loss of muscle mass
Osteopenia or osteoporosis, which is thinning of bones
Although testosterone levels may recover after stopping ADT, some men who have had medical castration with LHRH agonists for many years may continue to have hormonal effects, even if they are no longer taking these drugs.
Another serious side effect of ADT is the risk of developing metabolic syndrome. Metabolic syndrome is a set of conditions, such as obesity, high levels of blood cholesterol, and high blood pressure that increases a person’s risk of heart disease, stroke, and diabetes. Currently, it is not certain how often this happens or exactly why it happens, but it is quite clear that patients who receive a surgical or medical castration with ADT have an increased risk of developing metabolic syndrome. The risk is increased even if the medical castration is temporary. Find out more about the symptoms of hormone deprivation 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 side effects. Aggressive management of side effects is very important for patients receiving ADT. These include getting regular exercise, quitting smoking, following a healthy diet, supplementing vitamin D and calcium intake, and receiving aggressive, preventive cardiovascular follow-up care.
Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping their ability to grow and divide. Chemotherapy is usually given by a medical oncologist, a doctor who specializes in treating cancer with medication.
Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Chemotherapy for prostate cancer is given through an intravenous (IV) tube placed into a vein using a needle. It may help patients with advanced or castration-resistant prostate cancer. A chemotherapy regimen usually consists of a specific number of cycles given over a set period of time.
There are several standard drugs used for prostate cancer. In general, standard chemotherapy begins with docetaxel (Taxotere) combined with a steroid called prednisone (multiple brand names). This chemotherapy has been shown to help men with metastatic castration-resistant prostate cancer live longer when compared with another chemotherapy drug, mitoxantrone (Novantrone). Mitoxantrone was one of the first chemotherapies approved for metastatic castration-resistant prostate cancer, but it is not commonly used. Mitoxantrone is most useful for controlling pain from the cancer and is sometimes considered in specific situations.
The FDA has also approved another drug, cabazitaxel (Jevtana), based on research that showed it improved survival when compared with mitoxantrone for patients whose disease progressed after having docetaxel. In clinical trials, cabazitaxel was compared with docetaxel in patients who had not received chemotherapy. In these patients, treatment with cabazitaxel was not better than treatment with standard docetaxel. Another study compared the standard dose with a lower dose of cabazitaxel in people whose tumors grew after treatment with docetaxel. This study did not find that the lower dose helped patients live longer; however, they did have fewer side effects.
Recent research shows that adding chemotherapy after the completion of 2 years of ADT for men with high-risk prostate cancer who are having definitive radiation therapy is an effective approach to reduce recurrence and improve survival. Although these results are interesting, longer follow-up is required to see if this treatment helps people with prostate cancer.
In general, the side effects of chemotherapy depend on the individual, the type of chemotherapy received, the dose used, and the length of treatment, but they can include fatigue, sores in the mouth and throat, diarrhea, nausea and vomiting, constipation, blood disorders, nervous system effects, changes in thinking and memory, sexual and reproductive issues, appetite loss, pain, and hair loss. The side effects of chemotherapy usually go away 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 the basics of 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.
Chemotherapy and ADT
New research shows a role for chemotherapy and ADT in the treatment of metastatic prostate cancer. For example, 2 recent clinical trials showed that men with metastatic, hormone-sensitive prostate cancer who received docetaxel with ADT survived longer than men who received only ADT. All patients should have a thorough discussion with their doctor about the potential benefits and risks of receiving chemotherapy.
Sipuleucel-T (Provenge) is an immunotherapy. Immunotherapy is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
Sipuleucel-T is adapted for each patient. Before treatment, blood is removed from the patient in a process called leukapheresis. Special immune cells are separated from the patient’s blood, modified in the laboratory, and then put back into the patient. At this point, the patient’s immune system may recognize and destroy prostate cancer cells. When this treatment is used, it is difficult to know if the treatment is working to treat the cancer because treatment with Sipuleucel-T does not lead to PSA reductions, shrinking of the tumor, or keeping the cancer from getting worse. However, results from clinical trials have shown that treatment with sipuleucel-T can increase survival in men with castration-resistant metastatic prostate cancer with few or no symptoms.
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 physical, emotional, and social needs.
Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process.
People often receive treatment for the cancer 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, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.
Transurethral resection of the prostate (TURP). TURP is most often used to relieve symptoms of a urinary blockage, not to treat prostate cancer. In this procedure, with the patient under full anesthesia, which is medication to block the awareness of pain, a surgeon inserts a narrow tube with a cutting device called a cystoscope into the urethra and then into the prostate to remove prostate tissue.
Bone pain and weakness
Strontium and samarium. These radioactive substances (beta-emitters) are given by injection and absorbed near the area of bone pain. The radiation that is released helps relieve the pain, probably by causing the tumor in the bone to shrink. Neither substance helps patients live longer.
Radium-223. This is a different class of radioactive substance (alpha-emitter). It mimics calcium and targets areas in the bone affected by prostate cancer. A recent clinical trial in men with metastatic castration-resistant prostate cancer with disease largely in the bone demonstrated that men receiving radium-223 plus the best supportive care lived longer compared with those receiving only the best supportive care. Radium-223 is given by injection every month for 6 months. This treatment is given by a radiation oncologist or a nuclear medicine doctor. Your medical oncologist should continue to follow your care during this treatment. Some people should not receive this treatment, so discuss with your doctor whether this medication is best for your situation.
Bone-modifying drugs. Prostate cancer that has spread to the bone or ADT for prostate cancer can weaken a patient’s bones and lead to bone pain and an increased risk of breaks known as fractures. Therefore, bone-modifying drugs like denosumab (Prolia) and zoledronic acid (Zometa) may be given to men diagnosed with metastatic castration-resistant prostate cancer to help reduce bone complications. Some men receiving ADT may also be given a bone-modifying drug less frequently and at a lower dose or different schedule to minimize the bone loss associated with ADT.
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, including your dentist, about the possible side effects of your specific treatment plan and palliative 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 can be addressed as quickly as possible. Learn more about palliative care.
Developing a Treatment Plan (updated 04/2017)
Because most prostate cancers are found in the early stages when they are growing slowly, you usually do not have to rush to make treatment decisions. During this time, it is important to talk with your doctor about the risks and benefits of all your treatment options and when treatment should begin. This discussion should also address the current state of the cancer, such as:
Whether PSA levels are rising or steady
Whether the cancer has spread to the bones
Your health history
Any other medical conditions you may have
Although your treatment recommendations will depend on these factors, there are some general steps for treating 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 Gleason score of 6 or less and a 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, the cancer may be faster growing, so radical prostatectomy and radiation therapy are often appropriate. 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 is often done with removal of the pelvic lymph nodes. Some men are given neoadjuvant ADT, meaning the ADT is given before surgery, or have radiation therapy (external-beam and/or brachytherapy) afterward. Research has shown that adjuvant radiation therapy may improve survival for men with locally advanced prostate cancer or those with positive margins, extracapsular extension, or seminal vesicle invasion after prostatectomy. Having positive margins means that cancer cells were 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 ADT if there is a greater chance of recurrence based on disease extent, PSA level, and/or Gleason score. For older men who are not expected to live for a long time and whose cancer is not causing symptoms, or for those who have another, more serious illness, watchful waiting may be considered.
Non-metastatic castration-resistant prostate cancer
Prostate cancer that no longer responds to ADT, such as LHRH agonists or anti-androgens, is considered castration resistant. If it has not spread to other parts of the body, it is called non-metastatic castration-resistant prostate cancer.
The American Society of Clinical Oncology (ASCO) recommends that men who develop castration-resistant prostate cancer should continue treatment that lowers androgen levels. This may include a permanent treatment such as surgery to remove the testicles or it may include medicines that lower hormone levels (see above).
Second-line hormonal therapy may be an option for men who have not already received chemotherapy and have a high risk of developing metastatic prostate cancer. Second-line hormonal therapy is not recommended for men who have not had chemotherapy and have a low risk of developing metastatic disease. Talk with your doctor about your personal risk level.
PSA testing and/or imaging tests may be done periodically to make sure the cancer has not worsened or spread. For men with a low risk of developing metastatic disease, ASCO recommends PSA testing every 4 to 6 months. For men with a high risk of metastatic disease, ASCO recommends PSA testing every 3 months. Imaging tests, such as a bone scan, CT scan, or MRI, may be done if a man has symptoms or signs that the cancer is worsening.
Metastatic prostate cancer (updated 04/2017)
If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials might be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.
For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
Although there is no cure for metastatic prostate cancer, it is often treatable. Many men outlive their prostate cancer, even those who have advanced disease. Often, the prostate cancer grows slowly, and there are now effective treatment options that extend life even further.
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 ADT, as described above.
Metastatic castration-resistant prostate cancer
Prostate cancer that no longer responds to ADT and has spread to other parts of the body is called metastatic castration-resistant prostate cancer. This type of cancer can be difficult to treat. The American Society of Clinical Oncology (ASCO) recommends that men with metastatic castration-resistant prostate cancer continue treatment that lowers androgen levels, such as orchiectomy or hormone-lowering medicines (see above). ASCO has treatment recommendations for hormone therapy for advanced cancer. Read more about these recommendations, side effects of treatment, and questions to ask your doctor.
ASCO recommends second-line hormonal therapy for men with metastatic castration-resistant prostate cancer who have not received chemotherapy. Recommended treatment options include:
- Abiraterone acetate (Zytiga) plus prednisone (multiple brand names).Abiraterone acetate (Zytiga) is a drug that blocks an enzyme called CYP17 and prevents these cells from making certain hormones, including adrenal androgens. Although the testicles are the main producers of testosterone, other cells in the body can still make small amounts of testosterone that may drive cancer growth. These include the adrenal glands and some prostate cancer cells themselves. Abiraterone acetate is taken in the form of a pill. Men take 4 pills per day along with prednisone twice a day. Abiraterone acetate has been approved by the FDA as a treatment for progressive, metastatic castration-resistant prostate cancer.
Abiraterone acetate may cause serious side effects, such as high blood pressure, low blood potassium levels, and fluid retention. Other common side effects include weakness, joint swelling or pain, swelling in the legs or feet, hot flushes, diarrhea, vomiting, shortness of breath, and anemia.
- Enzalutamide (Xtandi). Enzalutamide is an anti-androgen that is approved by the FDA for men who have developed progressive metastatic prostate cancer despite testosterone suppression. Enzalutamide may also cause serious side effects, such as headaches, confusion, loss of vision, and seizures. Other common side effects include weakness, back pain, decreased appetite, constipation, joint pain, diarrhea, hot flashes, upper respiratory tract infection, swelling, weight loss, high blood pressure, dizziness, and vertigo.
Other treatment options for metastatic castration-resistant prostate cancer are listed below. Treatment in a clinical trial may also be an option.
Chemotherapy. Doctors may recommend chemotherapy for patients with this type of prostate cancer, especially those with bone pain or cancer-related symptoms. Research studies of chemotherapy treatment plans that include docetaxel have been shown to improve survival by several months. Cabazitaxel can be used after docetaxel stops working.
Immunotherapy. For some men with castration-resistant metastatic prostate cancer who have no or very few cancer symptoms and generally have not had chemotherapy, vaccine therapy with sipuleucel-T may be an option (see “Immunotherapy” above). In research studies, sipuleucel-T increased survival by about 4 months compared with men who did not receive it.
Radium-223 dichloride (Xofigo). Radium-223 is a radioactive substance used to treat men with castration-resistant prostate cancer that has spread to the bone. It is naturally attracted to areas of high bone turnover, which are 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 healthy tissue. According to the results of a clinical trial published in 2013, treatment with radium-223 reduced bone-related complications and improved survival.
Palliative care. Treatment to relieve a patient’s symptoms and side effects continues to be an important part of the overall treatment plan.
For men with metastatic castration-resistant prostate cancer, ASCO recommends PSA testing every 3 months. Imaging tests may also be done.
ASCO has recommendations for the treatment of metastatic castration-resistant prostate cancer. Learn more about these recommendations, the side effects, and questions to ask your doctor.
Palliative treatment for metastatic cancer
As mentioned above and in the Coping with Treatment section, palliative care is important to help relieve symptoms and side effects. This includes people with metastatic prostate cancer. Palliative care options include:
TURP to manage symptoms such as bleeding or urinary obstruction
Bone-modifying drugs, such as denosumab or zoledronic acid, may be used to strengthen bones and reduce the risk of pain progression and fractures for men with prostate cancer that has spread to the bone
Intravenous radiation therapy with strontium and samarium also helps relieve bone pain, as described above
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as ADT and radiation therapy, which are described above, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate risk of recurrence. Understanding your 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 treatments described above, such as radiation therapy, prostatectomy for men first treated with radiation therapy, or ADT. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.
Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects. Palliative care usually includes pain medication, external-beam radiation therapy, brachytherapy with strontium or samarium, or other treatments to reduce bone pain. See above for more information.
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 the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.
Patients who have advanced cancer and who are expected to live less than 6 months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to 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 loss.
The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Or, use the menu to choose another section to continue reading this guide.