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This topic is about
prostate cancer that has spread or come back after treatment. For information on prostate cancer that has not spread outside the prostate (localized prostate cancer), see the topic Prostate Cancer.
Prostate cancer is a group of cells that grows faster than normal in a
man's prostate gland. It can spread into other areas and kill normal
prostate gland sits just below a man's bladder. It makes part of the fluid for
semen. In young men, the prostate is about the size of
a walnut. It usually grows larger as you grow older.
may be one of these types:
Experts don't know what causes prostate cancer. But they believe that
getting older and having a family history of prostate cancer raise your chance
of getting it.
Sometimes there are no symptoms of either locally
advanced or metastatic prostate cancer.
When they do appear,
symptoms of locally advanced prostate cancer include:
Symptoms of metastatic prostate cancer may include:
Your doctor will do a
digital rectal exam, in which he or she puts a gloved,
lubricated finger in your rectum to feel your prostate. You may also have a
blood test called a
prostate-specific antigen (PSA) test. These tests will
help find out if you have prostate cancer or if your prostate cancer has come
Your doctor also may do a
biopsy. In this test, your doctor takes samples of
tissue from your prostate gland or from the area where the cancer may have
spread and sends the samples to a lab for testing. A biopsy is the only way to
know for sure that you have prostate cancer.
If you have had
prostate cancer before, your doctor may also order a
CT scan, or
MRI to see if it has come back or spread.
Learning that you have cancer that has spread or come back can be very hard. Some people find that it helps to talk about their feelings with their family and friends. You may also want to talk with your doctor or with other people who have had this kind of cancer. Your local American Cancer Society chapter can help you find a support group.
Your treatment choices depend on your overall health,
how fast the cancer is growing, and how far it has spread.
Locally advanced prostate cancer may be treated with surgery, radiation
therapy, hormone therapy, or a combination of these.
Treatment of metastatic cancer
focuses on slowing the spread of the cancer and relieving symptoms, such as
bone pain. It also can help you feel better and live longer. Treatment may
include hormone therapy, radiation therapy, chemotherapy, or immunotherapy.
In some cases, men may be able to wait before starting treatment (active surveillance). But older men with other serious health problems may decide not to have treatment except for what is needed to treat any symptoms (watchful waiting).
Learning about prostate cancer:
Living with prostate cancer:
Health Tools help you make wise health decisions or take action to improve your health.
The exact cause of
prostate cancer is not known, but experts believe your
age and family history may have something to do with your chances of getting
the disease. Prostate cancer is very common and is an older man's disease. Most
men who get it are older than 65.
Prostate cancer may not cause noticeable
symptoms. Possible symptoms of
locally advanced prostate cancer are:
These symptoms also may be caused by:
Symptoms that may mean the cancer has spread to other
parts of the body, or metastasized, include:
Prostate cancer is a common cancer affecting older
men. About 16 out of 100 men in the United States will get prostate cancer, but only 3 will die because of it. That means about 97 out of 100 men will die of something other than prostate cancer.1
It usually is a very
slow-growing cancer that takes years to grow large enough to cause any
symptoms. In some men, it never does cause problems. Sometimes, though, it
grows quickly and may cause complications or death.
cancer grows large enough, it begins to fill the prostate and often can be felt
by your doctor during a
digital rectal exam. As it continues to grow, it
breaks through the outer rim of the prostate and into nearby tissues, such as
seminal vesicles. At this point, the disease is called
locally advanced prostate cancer.
Locally advanced prostate cancer is usually not curable. But there are treatments that can help you live longer and feel better. Most men live up to 5 years after this diagnosis, but some men may
cancer has broken through the prostate, it may move into nearby lymph nodes.
From the lymph node system, the cancer can spread to other areas of the body.
Most often, prostate cancer spreads to the bones. It also may spread to the
lungs or other organs. When it has spread to the
lymph nodes, the disease is called metastatic prostate cancer.
Metastatic prostate cancer is not curable. But a
number of treatments are available to help you live longer and make you feel
better. Most men live 1 to 3 years after this diagnosis, but some men may
live many years longer.2
A risk is anything that makes
you more likely to get a particular disease. Being older than 50 is the main
prostate cancer. About 6 out of 10 new prostate
cancers are diagnosed in men who are 65 and older.3
Your chances of getting the disease are higher
if other men in your family have had it. Your risk is doubled if your father or
brother developed prostate cancer. Your risk also depends on the age at which your relative was diagnosed. Most
men who get prostate cancer have no family history of the disease.
men and Jamaican men of African descent have a greater chance of developing the
kind of prostate cancer that grows and spreads. Researchers are not sure why
there is a difference in disease and death rates among different races. Some
experts think there may be a genetic link.4
Call your doctor immediately if you:
Call your doctor to schedule an appointment if you have
Active surveillance means a man will be watched closely by his doctor and have regular checkups and tests, including prostate biopsies. If the cancer starts to grow more quickly, he will have other treatment.
Active surveillance is an option for men with low-risk cancer who expect to live more than 10 years and don't have other chronic health problems. It may be an option for some men with intermediate-risk prostate cancer. But active surveillance usually is not a choice when prostate cancer has spread.
Sometimes men who have PSA levels that are rising slowly after having treatment may not start hormone treatments right away but be monitored with active surveillance.
Watchful waiting means a man will be watched closely by his doctor but not have treatments that try to get rid of the cancer. If an older man has serious health problems and isn't expected to live more than 10 years, he may not be able to handle treatments or even want to have treatments except those needed to keep him comfortable (palliative care).
Doctors who can treat locally advanced and metastatic
prostate cancer include:
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Locally advanced and
metastatic prostate cancer are diagnosed through
physical exams and tests, including:
If you have had prostate cancer before, one or more tests
will help your doctor see if your cancer has come back or spread. These may
you have been treated for prostate cancer in the past, you've probably been
having regular checkups that include
PSA tests to check for any signs that the cancer has
come back or has spread to other parts of your body. Your doctor will watch for
any increases in your PSA level and the speed with which any increases occur. A
higher PSA does not necessarily mean your cancer has come back. But it may mean that you need further tests, such as a prostate biopsy, bone scan, CT scan, or
Your treatment options for prostate cancer that has spread will depend on:
locally advanced or
metastatic prostate cancer may include hormone
therapy, surgery, radiation therapy, chemotherapy, or immunotherapy. Or if you aren't having symptoms, it may include active surveillance or watchful waiting.
want to talk with your doctor about entering a
clinical trial of new cancer treatment options. A treatment being studied in clinical trials for advanced prostate cancer is high-intensity-focused ultrasound (HIFU). For metastatic prostate cancer, treatments in clinical trials include new forms of chemotherapy and immunotherapy, including vaccines.
Prostate cancer and its treatment may cause nausea, pain, or other side
effects. You can manage some side effects
at home. If you experience
nausea, wait for 1 hour after vomiting has stopped and
then sip a
rehydration drink to restore lost fluids and
nutrients. Your doctor also may prescribe
medicines to control nausea and vomiting.
diarrhea may be eased if you drink enough fluids.
Pain from cancer that has spread to the bones can be managed. If pain becomes a problem, talk to your doctor about seeing a pain management specialist. For tips on handling pain, see:
For more information, see the topic
Prostate cancer that has spread to
tissue around the prostate may be treated with radiation therapy, surgery, or hormone therapy. Sometimes two of these treatments are combined.
Radiation therapy uses high-energy
X-rays or protons to destroy the cancer. This treatment has improved with newer technologies, so there
are fewer side effects and complications than in the past. Radiation therapy
usually is combined with hormone therapy.
External beam radiotherapy, or EBRT, uses high-energy rays,
such as X-rays, to destroy the cancer. It is usually given in multiple doses
over several weeks. Radiation destroys tissue, so it may damage the
nerves along the side of the prostate that affect your ability to have an
erection. If you already have bowel problems, external radiation may cause your
symptoms to get worse.
Three common forms of external radiation are:
The two most common surgeries are:
Hormone therapy is also called androgen deprivation therapy (ADT). Prostate cancer needs male
hormones (testosterone) in order to survive. Hormone therapy
decreases the amount of testosterone and other male hormones in your body. This
often causes tumors to shrink. Shrinking the tumors can ease severe bone pain
caused by the spread of cancer to the bones. Hormone therapy usually is
combined with radiation therapy.
The most common methods are:
In some cases, men will have radiation therapy after a
prostatectomy, especially if the tumor could not be completely removed by
Some men choose to start hormone therapy only after they
have symptoms. But many doctors recommend starting hormone therapy right away
if cancer is found in the
lymph nodes during surgery to remove the prostate. Early treatment may allow
men to live a little longer. Other doctors say to wait, because waiting delays
the bothersome and serious side effects of hormone therapy.
prostate cancer that has spread to the bones and/or
other organs in the body is aimed at relieving symptoms and slowing the
cancer's growth. Treatment may include:
Hormone therapy works by decreasing the amount of testosterone in your body. This can be done with medicine or with surgery to remove the testicles (orchiectomy). Hormone therapy can also relieve pain by shrinking tumors and easing urinary
androgen deprivation (orchiectomy or an LH-RH agonist) and an antiandrogen are
used together. This is called a combined androgen blockade (CAB). But the slight benefit of CAB may be offset by side effects.
Both orchiectomy and hormone therapy medicine make
testosterone levels drop, causing some of the same side effects. These include
hot flashes, loss of sexual desire, and the inability
to have an erection. Treatment options for these problems include:
Other serious side effects of hormone therapy may include thin or brittle bones (osteoporosis), reduced muscle mass, increased body mass (BMI), low red blood cell counts (anemia), fatigue, cognitive impairment (trouble thinking clearly), depression, and an increased risk for diabetes and heart disease.
Hormone therapy usually works well at first to stop
cancer growth. But in most cases the cancer returns in a few years. At this
point, the cancer is described as hormone-resistant,
meaning it is not responding to standard hormone therapy. When this happens,
other kinds of hormone treatment may be tried. If the cancer continues to grow,
chemotherapy or immunotherapy may be recommended.
Some men choose
to start hormone therapy only after they have symptoms. But some doctors
recommend starting hormone therapy right away if cancer is found in the
lymph nodes during surgery to remove the prostate. Other doctors say to wait, because waiting delays
the bothersome and serious side effects of hormone therapy.
With intermittent androgen deprivation, known as IAD,
men take cycles of hormone therapy medicines. Taking breaks between
hormone therapy cycles gives men the chance to recover their ability to
function sexually. It also gives relief from the other side effects of hormone
therapy, including hot
flashes, the loss of energy, and the loss of bone and muscle mass.
Pain is one of the main concerns of people who have metastatic cancer. But cancer pain can almost always be controlled. You and your doctor have several options to help your pain, including pain-relieving medicines and radiation, such as external beam radiation therapy and bone-targeted radioisotopes.
Additional information about prostate cancer is provided by the National Cancer Institute at www.cancer.gov/cancertopics/types/prostate.
Palliative care is a kind of medical care for people who have serious and chronic illnesses. It
is different from trying to cure your illness. Palliative care focuses on
improving your quality of life—not just in your body but also in your mind and
spirit. Some people combine palliative care with curative care.
With prostate cancer, palliative care may involve treatments to reduce
tumors or bone pain, such as
radiation therapy, radionuclides (medicine used in
external radiation) for bone metastasis, and
bisphosphonates, which slow the breakdown of bone and
help relieve bone pain. Surgery to relieve bladder problems (transurethral resection of the prostate, or TURP) is
also an option.
Palliative care may help you manage symptoms or side effects from
treatment. It could also help you cope with your feelings about living with a
long-term illness, make future plans around your medical care, or help your
family better understand your illness and how to support you.
you are interested in palliative care, talk to your doctor. He or she may be
able to manage your care or refer you to a doctor who specializes in this type
For more information, see the topic
You may wish to
discuss health care and other legal issues that arise near the end of life with
your family and your doctor. You may find it helpful and comforting to state
your health care choices in writing—with an
advance directive or living will—while you are still
able to make and communicate these decisions.
You may want to
health care agent to make and carry out decisions
about your care if you should become unable to speak for yourself. Be sure to share your wishes with your family or close friends.
You can get forms from Caring Connections (www.caringinfo.org or 1-800-658-8898) or Aging With Dignity (www.agingwithdignity.org or 1-888-594-7437).
information, see the topic
Care at the End of Life.
Hospice care provides medical services,
emotional support, and spiritual resources for people who are at the end of
life. Hospice care also helps family members manage the practical details and
emotional challenges of caring for a dying loved one. For more information, see
can't be prevented. But there are steps you can take to reduce your risk for this disease. For more information, see the topic
During medical care for any stage of
prostate cancer, there are things you can do at home
to help manage symptoms of prostate cancer or side effects of treatment:
During medical treatment for prostate cancer, you may
experience emotional problems. See the following tips for managing:
Having cancer can change your life in many ways. For help with managing these changes, see the topic: Getting Support When You Have Cancer.
Medicines may be used to slow the growth of
prostate cancer and to relieve your symptoms.
Prostate cancer needs the male hormone
testosterone to grow. Hormone therapy uses special
drugs to block the production or action of testosterone and may cause the
cancer to shrink. This can improve your symptoms. Hormone therapy may be given
before or after
surgery to remove the prostate.
Hormone therapy usually works well at
first to stop cancer growth. But in most cases the cancer returns in a few
years. At this point, the cancer is called hormone-resistant. This means it will no longer get better
with hormone therapy. When this happens, other kinds of hormone treatment may
work. If the cancer continues to grow, chemotherapy or immunotherapy may be the next choice.
Chemotherapy is the use of drugs to control cancer's
growth or relieve pain. Often the drugs are given through a needle in your
vein, and your blood vessels carry the drugs through your body. Sometimes the
drugs are available as pills you can swallow. Sometimes they are given through
a shot, or injection.
Chemotherapy usually involves two or more
drugs given together. Combinations may work better than a single medicine. That's because each drug can attack the cancer cells in a different way. This is most often used when prostate cancer
Immunotherapy is treatment that uses the body's
immune system to destroy the cancer cells. This is used for prostate cancer that is hormone-resistant.
Hormone therapy is commonly used with radiation therapy. It may be used alone with metastatic cancer.
Chemotherapy may be helpful when prostate cancer no longer responds to hormone therapy.
Vaccines such as sipuleucel-T (Provenge) use cells from
a man's own body to stimulate his immune system. This can slow the growth of cancer cells.
Pain-relief and appetite-stimulant drugs may be used when prostate cancer
has spread to other parts of the body.
Pain medicines are made that specifically treat mild,
moderate, and severe pain, as well as different types of pain such as burning
and tingling. To learn more, see:
For more information, see the topic
therapy can cause loss of sexual desire,
hot flashes, enlarged and painful breasts, and
Antiandrogen hormone therapy also
may cause diarrhea, breast tenderness, and nausea. Cases of liver problems,
some serious, have been reported.
Hormone therapy can also affect the bones, making them thin and brittle and more likely to break. Medicines such as bisphosphonates and denosumab may help prevent bone loss during long-term hormone therapy.
Surgery to treat
prostate cancer is usually reserved for men in good
health who are younger than 70 and who choose to have surgery. Surgery may be
done to relieve symptoms and to slow the growth of cancer.
removal of the testicles (orchiectomy) and hormone therapy medicines have some
of the same side effects, including hot flashes, larger breasts, loss of sexual
desire, and the inability to have an erection.
Radiation therapy for
prostate cancer may be used alone or combined with
hormone treatment. Radiation therapy also is used to relieve
pain from metastatic cancer or cancer that comes back after surgery.
Radiation therapy for locally advanced prostate cancer is often combined
with hormone treatment. Using both together may improve your chances of being
disease-free for longer and living longer.2
External-beam radiation therapy uses a large machine
to aim a beam of radiation at your tumor to destroy cancer cells. The radiation
damages the genetic material of the cells so that they can't grow. Although
radiation damages normal cells as well as cancer cells, the normal cells can
repair themselves and function, while the cancer cells cannot. If cancer has
spread to your bones, radiation treatment may be given to specific areas to
People sometimes use complementary therapies along with medical treatment to help relieve symptoms and side effects of cancer treatments. Some of the complementary therapies that may be helpful include:
Mind-body treatments like those mentioned above may help you feel better and cope better with treatment. These treatments also may reduce chronic low back pain, joint pain, headaches, and pain from cancer treatments.
Before you try a complementary therapy, talk to your doctor about
the possible value and potential side effects. Let your doctor know if you are
already using any such therapies. Complementary therapies are not meant to take
the place of standard medical treatment, but they may improve your quality of
life and help you deal with the stress and side effects of cancer treatment.
may be interested in taking part in research studies called clinical trials. Clinical trials are designed to
find better ways to treat prostate cancer patients and are based on the most up-to-date information. People who do not want standard treatments or are not cured by standard treatments may want to take part in
Check with your doctor to see whether clinical trials are in your area and whether you might be eligible.
The American Cancer Society (ACS) conducts educational
programs and offers many services to people with cancer and to their families.
Staff at the toll-free number have information about services and activities
in local areas and can provide referrals to local ACS divisions.
The Centers for Disease Control and Prevention (CDC) is
an agency of the U.S. Department of Health and Human Services. The CDC works
with state and local health officials and the public to achieve better health
for all people. The CDC creates the expertise, information, and tools that
people and communities need to protect their health—by promoting health,
preventing disease, injury, and disability, and being prepared for new health
The National Cancer Institute (NCI) is a U.S. government
agency that provides up-to-date information about the prevention, detection,
and treatment of cancer. NCI also offers supportive care to people who have cancer
and to their families. NCI information is also available to doctors, nurses,
and other health professionals. NCI provides the latest information about
clinical trials. The Cancer Information Service, a service of NCI, has trained
staff members available to answer questions and send free publications.
Spanish-speaking staff members are also available.
Zelefsky MJ, et al. (2011). Cancer of the prostate. In VT DeVita Jr et al., eds., DeVita, Hellman and Rosenberg's Cancer: Principles and Practice of Oncology, 9th ed., pp. 1220–1271. Philadelphia: Lippincott Williams and Wilkins.
National Cancer Institute (2012). Prostate Cancer Treatment (PDQ)—Health Professional Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/prostate/HealthProfessional.
American Cancer Society (2012). Cancer Facts and Figures 2012. Atlanta: American Cancer Society. Available online: http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2012.
Robbins C, et al. (2007). Confirmation study of
prostate cancer risk variants at 8q24 in African Americans identifies a novel
risk locus. Genome Research, 17(12):
Other Works Consulted
Abernathy A, Foley KM (2011). Management of cancer pain. In VT DeVita Jr et al., eds., DeVita, Hellman and Rosenberg's Cancer: Principles and Practice of Oncology, 9th ed., pp. 2426–2447. Philadelphia: Lippincott Williams and Wilkins.
Loblaw DA, et al. (2007). Initial hormonal management
of androgen-sensitive metastatic, recurrent, or progressive prostate cancer:
2007 update of an American Society of Clinical Oncology practice guideline.
Journal of Clinical Oncology, 25(12):
National Cancer Institute (2011). Prostate Cancer Treatment (PDQ)—Patient Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/prostate/patient.
National Comprehensive Cancer Network (2012). Prostate cancer. NCCN Clinical Practice Guidelines in Oncology, version 2.2012. Available online: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Nelson JB (2012). Hormone therapy for prostate cancer. In AJ Wein et al., eds., Campbell-Walsh Urology, 10th ed., vol. 3, pp. 2934–2953. Philadelphia: Saunders.
Rosenberg JE, Kantoff PW (2011). Prostate cancer. In EG Nabel, ed., ACP Medicine, section 12, chap. 9. Hamilton, ON: BC Decker.
October 22, 2012
E. Gregory Thompson, MD - Internal Medicine & Christopher G. Wood, MD, FACS - Urology, Oncology
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