Men living with metastatic prostate cancer now have more options available than ever before.
Each year, over 180,000 American men are diagnosed with cancer of the prostate gland. Other than skin cancer, it is the most common cancer affecting men, occurring primarily in men aged 65 or older.
When prostate cancer is diagnosed and treated, most often the tumor is still confined to the gland. But prostate cancer can spread to other parts of the body (metastasize).
In cases of metastatic prostate cancer, there are treatments available that can stop cancer growth, control pain and other symptoms, and extend survival.
Hormonal therapy, also called androgen deprivation therapy, remains the mainstay for treating metastatic prostate cancer. This type of treatment is aimed at reducing the levels of male hormones (androgens) in the body, or stopping them from affecting prostate cancer cells. The main androgens are testosterone and DHT; they act like a fuel, encouraging prostate cancer to grow. (Most androgens are made by the testes, but a small amount is made by the adrenal glands, which sit above the kidneys and produce a number of important hormones.) Without androgens, prostate cancer goes into remission, often for many years. Remission is when all signs and symptoms of cancer disappear.
There are several approaches to hormonal therapy:
- Medications called GnRH agonists. These drugs lower the amount of testosterone made by the testicles. They are either injected or placed as small implants under the skin. GnRH agonists available in the United States are triptorelin (Trelstar), leuprolide (Eligard, Lupron, and others), goserelin (Zoladex), and histrelin (Vantas).
- Combining GnRH agonists with antiandrogens. When the signals between the brain and the testes have been blocked by GnRH agonists, men with metastatic prostate cancer may experience a surge of testosterone. This can stimulate the growth of the cancer or cause symptoms, so doctors sometimes add antiandrogens to GnRH agonists. The antiandrogens prevent testosterone in the bloodstream from attaching to tumor cells and making them grow. Types of antiandrogens include flutamide (Eulexin and others), bicalutamide (Casodex and others), nilutamide (Nilandron), and enzalutamide (Xtandi). These medications are taken daily as pills.
- Degarelix, a GnRH antagonist. Degarelix (Firmagon) blocks signals from the brain to the testes. With these medications, the testes no longer receive “instructions” from the brain to make androgens, and production of the hormones is shut down. This drug lowers testosterone more quickly than do GnRH agonists, and doesn’t cause the surge of testosterone that can be seen with the use of agonists. Degarelix is given as an injection.
- Combining hormonal therapy with chemotherapy. Depending on the man’s individual circumstances, the chemotherapy drug docetaxel (Taxotere) might be given in conjunction with hormone therapy as a first line approach. Studies have shown that it may be possible to slow the growth of cancer cells by combining docetaxel with hormonal therapy (rather than prescribing it sequentially).
If a specific androgen deprivation drug does not have the desired result, your doctor may suggest a different drug, or a different form of hormonal therapy.
Because one of the liver’s important jobs is to break down toxins and medications in the body, your liver function must be checked with periodic blood tests, especially if you are taking antiandrogens. Tell your doctor immediately if you experience nausea, vomiting, stomach pain, extreme tiredness, loss of appetite, flu-like symptoms, dark yellow or brown urine, and/or yellowing of the skin or eyes. It’s crucial to remember that herbal remedies, megadoses of vitamins, and excessive amounts of alcohol should be avoided, as they can prevent the liver from breaking down antiandrogens.
Metastatic prostate cancer usually responds to hormonal therapy and goes into remission, but cancer cells can sometimes resist treatments. Prostate cancer cells can “learn” how to grow, even without male hormones. Doctors call this condition hormone-resistant prostate cancer. In some cases of hormone-resistant prostate cancer, simply stopping antiandrogen treatment causes a man’s PSA level to go down and his prostate cancer to shrink or disappear. (PSA— prostate-specific antigen—is a substance produced by the prostate gland which may indicate the presence of cancer.) In other cases, doctors may prescribe different antiandrogen drugs to try to slow cancer growth.
Surgery as a Form of Hormone Therapy
Another way to stop the testicles from producing male hormones is an orchiectomy, a surgical procedure in which the testicles are removed. (This surgery is, in effect, a form of hormone therapy.) The removal of the testicles causes most prostate cancers to stop growing or to shrink. In an orchiectomy, the scrotum (the pouch of skin that holds the testicles) and penis are left intact.
An orchiectomy is done as an outpatient procedure. While it is probably the simplest form of hormone therapy, some men have trouble accepting the change to their anatomy. However, the insertion of artificial testicles (made of silicone) into the scrotum is an option to discuss with the surgeon who is performing the procedure.
Chemotherapy and Other Treatments
Doctors sometimes recommend chemotherapy as a treatment for hormone-resistant prostate cancer, usually for men who fall into one of three groups:
- Those with fast-rising PSA levels. When the PSA level begins doubling or tripling so quickly that hormone treatments can’t control it, chemotherapy may be an option.
- Those who are developing symptoms. Chemotherapy should be considered if a man with metastatic prostate cancer is losing weight, looking pale, or experiencing physical distress.
- Those who have metastatic cancer that is growing quickly. These men are sometimes treated with radiation aimed at multiple tumor sites. However, radiation treatments to the bone can reduce the number of red blood cells in the bone marrow and lead to anemia. (In anemia, a lowered level of red blood cells may result in fatigue and other symptoms such as dizziness or headache.) Using chemotherapy may reduce the need for radiation.
In the treatment of metastatic prostate cancer, one chemotherapy drug is usually given, rather than multiple drugs being given in combination. Some of the drugs used are docetaxel (Taxotere), cabazitaxel (Jevtana), mitoxantrone (Novantrone) and estramustine (Emyct).
In most cases, the first chemotherapy drug given is docetaxel, combined with the steroid drug prednisone. If this drug does not work (or stops working), other chemotherapy options may be tried. Doctors give chemotherapy in cycles; each cycle typically lasts a few weeks. A period of treatment is followed by a period of rest, which allows the body time to recover.
Chemotherapy is very unlikely to cure prostate cancer, but it may slow the cancer’s growth and reduce symptoms.
A number of other types of drugs have been approved by the Food and Drug Administration (FDA) for metastatic prostate cancer that no longer responds to hormone treatments or chemotherapy. These drugs include:
- Sipuleucel-T (Provenge). This medication works by using the body’s own specialized white blood cells (which are important parts of the body’s immune system), to destroy prostate cancer cells. Sipuleucel-T, an immunotherapy, is given as a series of three infusions into a vein, with about two weeks between each infusion. A few days before each treatment, some of the patient’s white blood cells are removed from the blood. The white blood cells are exposed to a protein that trains them to target and destroy prostate tumor cells. These newly trained white blood cells become a personalized dose of sipuleucel-T, which is then returned to the man’s bloodstream.
- Abiraterone (Zytiga). LHRH antagonists can stop the production of androgens by the testes, but other cells in the body can still produce small amounts. Abiraterone blocks an enzyme called CYP17, helping to stop the production of androgens by these cells. Used with prednisone, this hormone therapy can be given before or after chemotherapy. Abiraterone is a tablet, usually taken once a day.
- Enzalutamide (Xtandi). This drug blocks male hormones from attaching to prostate cancer cells and helping them grow. As a result, enzalutamide slows the growth of prostate tumors and destroys them. Right now, this drug is approved for use only in men who have previously received docetaxel.
- Radium Ra 223 (Xofigo). Radium Ra 223 is a drug that contains a small amount of radiation and is injected into the bloodstream. The radiation seeks out prostate cancer cells that have spread to the bone and that may cause pain. Radium Ra 223 was approved by the FDA for men whose cancer has spread to bones but not to other organs, and has not responded to other treatments.
All cancer treatments can cause side effects. It’s important that you report any side effects you experience to your health care team so they can help you manage them. Report them right away—don’t wait for your next appointment. Doing so will improve your quality of life and allow you to stick with your treatment plan. It’s important to remember that not all patients experience side effects, and patients may experience side effects not listed here.
Side Effects of Hormone Therapy
- Hot flushes. In most men treated with hormonal therapy for metastatic prostate cancer, hot flushes are fairly limited. If you are especially troubled by hot flushes, ask your doctor about medications that can help, such as low doses of female hormones (estrogen or progesterone) or antidepressants such as venlafaxine (Effexor and others) or sertraline (Zoloft and others).
- Osteoporosis (increased risk of bone fractures). Lowered testosterone levels lead to a loss of calcium, which may cause osteoporosis (thinning, brittle bones). Treatment with bisphosphonates, such as zoledronic acid (Zometa, Reclast) or denosumab (Xgeva) can help reverse the effects of osteoporosis, reducing pain and lowering the risk of fractures.
- Weight gain. When men’s testosterone levels go down, their metabolism can change, causing them to retain fluid and gain weight. Hormone treatments can result in a loss of muscle mass. Stay active by walking, doing chores, and engaging in physical activities you enjoy. Weight training can also help build and maintain muscle strength and structure. Be sure to consult with your health care team before beginning any exercise program.
Side Effects of Chemotherapy
The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are used, and can include:
- Hair loss
- Increased risk of infection (from having too few white blood cells)
- Easy bruising or bleeding
- Changes in memory or thinking
- Peripheral neuropathy (numbness or tingling in hands and feet)
Mouth sores are also a side effect of chemotherapy. Your doctor may recommend treatments such as:
- Coating agents. These medications coat the entire lining of your mouth, forming a film to protect the sores and minimize pain.
- Topical painkillers. These are medications that can be applied directly to your mouth sores.
- Over-the-counter treatments. These include rinsing with baking soda or salt water, or “magic mouthwash,” a term given to a solution used to treat mouth sores. Magic mouthwash usually contains at least three of these ingredients: an antibiotic, an antihistamine or local anesthetic, an antifungal, a corticosteroid, and/or an antacid.
Chemotherapy can cause changes in the way food and liquids taste, including causing an unpleasant metallic taste in the mouth. Many people find that switching to plastic utensils helps. It may also help to avoid eating or drinking anything that comes in a can, and to use enamel-coated pots and pans for food preparation.
Other Side Effects
Bone pain. Prostate cancer that spreads to the bone can lead to pain. Medications such as bisphosphonates help relieve some of this pain. In addition, radiation is often used to manage bone pain. If given, men with metastatic prostate cancer typically receive 10 radiation treatments over the course of two weeks. It can take a week or longer before the pain and discomfort begin to ease.
Loss of erections (erectile dysfunction). Men can sometimes experience erectile dysfunction when being treated for prostate cancer. If you are experiencing this side effect, discuss your concerns with your doctor. He or she can recommend a number of possible treatments. Approaches used to manage this side effect include:
- A drug such as sildenafil (Revatio, Viagra, and others), vardenafil (Levitra, Staxyn, and others) or tadalafil (Adcirca, Cialis) can improve erectile function for some men.
- A penile implant that makes it possible to have and keep an erection. This approach involves surgery.
- Urethral suppositories or injections of alprostadil (Caverject, Edex) to promote erections.
- Vacuum devices that draw blood into the penis for an erection.
Loss of bladder control (incontinence). After radiation treatment, incontinence can occur, but not necessarily right away; it could begin as long as 18 months after the treatment ends. Talk with your doctor about what you can expect after treatment and the best way to cope with this side effect. Some ways to manage incontinence include:
- Medications such as solifenacin (VESIcare) or tolterodine (Detrol) that can calm the bladder and relieve symptoms.
- Special exercises called Kegel exercises (squeezing specific muscles in the pelvis).
- Drugs such as duloxetine (Cymbalta) that improve the function of the sphincter muscle, which controls the flow of urine.
- In some cases, surgical procedures can benefit men with incontinence. An artificial urinary sphincter has been used successfully since 1980.
Managing Digestive Tract Symptoms
Many cancer treatments can cause digestive tract problems; adjustments to eating habits may be of help:
Nausea and vomiting
- Avoid food with strong odors, as well as overly sweet, greasy, fried, or highly seasoned food.
- Eat meals cold or at room temperature, which often makes food more easily tolerated.
- Nibble on dry crackers or toast. These bland foods are easy on the stomach.
- Having something in your stomach when you take medication may help ease nausea.
- Drink plenty of water. Ask your doctor about using drinks such as Gatorade which provide electrolytes as well as liquid. Electrolytes are body salts that must stay in balance for cells to work properly.
- Over-the-counter medicines such as loperamide (Imodium A-D and others) and prescription drugs are available for diarrhea but should be used only if necessary. If the diarrhea is bad enough that you need medicine, discuss it with your doctor or nurse.
- Avoid sweetened foods and alcohol.
- Choose fiber-dense foods such as whole grains, fruits, and vegetables. These foods help form stools.
Managing loss of appetite
- Because it’s important to maintain your weight, eat small meals throughout the day. That’s an easy way to take in more calories and protein.
- To keep from feeling full early, avoid liquids with meals or take only small sips (unless you need liquids to help swallow). Drink most of your liquids between meals.
- Be as physically active as you can. Sometimes taking a short walk an hour or so before meals can help you feel hungry.
- Keep high-calorie, high-protein snacks on hand such as hard-boiled eggs, peanut butter, cheese, ice cream, granola bars, liquid nutritional supplements, puddings, nuts, canned tuna, or trail mix.
- Eat your favorite foods any time of the day. For example, if you like breakfast foods, eat them for dinner.
As you manage your prostate cancer, it’s important to remember that you are a consumer of health care. The best way to make decisions about health care is to educate yourself about your diagnosis and about the members of your health care team, including nurses, social workers, and patient navigators.
In addition to creating a treatment summary, here are some tips for improving communication with your health care team:
Start a health care journal. Having a health care journal or notebook will allow you to keep all of your health information in one place. You may want to write down the names and contact information of the members of your health care team, as well as any questions for your doctor. Keep a diary of your daily experiences with your cancer and its treatment. You can separate your journal or notebook into different sections to help keep it organized.
Prepare a list of questions. In advance of each medical appointment, write down your questions and concerns. Because your doctor may have limited time, you should ask your most important questions first, and be as specific and brief as possible.
Bring someone with you to your appointments. Even if you have a journal and a prepared list of questions or concerns, it’s always helpful to have support when you go to your appointments. The person who accompanies you can serve as a second set of ears. He or she may also think of questions to ask your doctor or remember details about your symptoms or treatment that you may have forgotten.
Write down your doctor’s answers. Taking notes will help you remember your doctor’s responses, advice and instructions. If you cannot write down the answers, ask the person who accompanies you to do that for you. If you have a mobile device, ask if you can use it to take notes. Writing notes will help you review the information later.
Record your visit if your doctor allows it. Recording the conversation with your doctor gives you a chance to hear specific information again or share it with family members or friends.
Incorporate other health care professionals into your team. Your medical oncologist is an essential member of your health care team, but there are other health care professionals who can help you manage your diagnosis and treatment:
- Your primary care physician should be kept updated about your prostate cancer treatment and any test results.
- Your local pharmacist is a great source of knowledge about the medications you are taking. Have all of your prescriptions filled at the same pharmacy to avoid the possibility of harmful drug interactions.
- Make sure your oncologist knows of any other medical conditions you have, or any pain you are experiencing, so that he or she can consult with your primary care physician or your specialist if needed.
Because prostate cancer can return after treatment, many men with this diagnosis find themselves coping with it over the long term. That’s why it’s especially important to maintain a relationship with your entire health care team.
Frequently Asked Questions
Q. When prostate cancer metastasizes, does the PSA level go up?
A. In general, higher-than-normal PSA levels signal that something has changed in the prostate gland. If a man has been treated for prostate cancer with surgical removal of the gland, most physicians believe that PSA levels should be very low—that is, less than 0.2 nanograms per milliliter (ng/mL) of blood. If the PSA level goes up during two consecutive readings after surgery, it may mean that prostate cancer has returned or spread from its original site to other organs. In men who have been treated with radiation, three consecutive rises in the PSA level may indicate a return or spread of the cancer. Your doctor may also order other tests to further evaluate the situation.
Q. Can I continue to do exercise, like brisk walking, when I am being treated for metastatic prostate cancer?
A. It’s a good idea to engage in as much physical activity as is comfortable. Exercise helps promote heart health and can relieve stress and fatigue. In general, activities like walking or swimming are preferable to high-impact activities, such as jogging. Men who are having a difficult time finding an exercise routine that works for them should seek the help of a physical therapist or rehabilitation specialist.
Q. Is it appropriate to have radiation treatment for metastatic prostate cancer even though I was already treated with radiation before the cancer spread?
A. If you have already received radiation to the pelvis near the prostate gland, more radiation to that area would generally not be recommended. But if you develop a problem such as pain in the bones of the arms, legs, or spine and those areas have not previously been exposed to radiation, you most likely could be treated with radiation to those areas.
Q. Can radiation therapy harm those I come in contact with?
A. There are no safety concerns for those around you associated with your being treated with external beam radiation (radiation delivered from outside the body). If a radioactive source is placed within the body, there are established safety precautions for your sexual partner, but there is no danger to those around you (you will not become “radioactive”).
Q. Is prostate cancer associated with genetic factors?
A. While prostate cancer does appear to run in families, as of yet no specific genetic mutations associated with prostate cancer have been identified. This is an area of ongoing research.