Prostate Cancer, Advanced or Metastatic

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

Is this topic for you?

This topic covers prostate cancer that has spread or come back after treatment. For information on early cancer that is confined to the prostate gland (localized), see the topic Prostate Cancer.

What is prostate cancer?

Prostate cancer is the abnormal growth of cells in a man's prostate gland . The prostate sits just below the 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.

• Locally advanced prostate cancer is cancer that has grown through the outer rim of the prostate and into nearby tissue.
• Metastatic prostate cancer is cancer that has spread, or metastasized, to the lymph nodes or other areas of the body.
• Recurrent prostate cancer is cancer that has come back after previous treatment. The cancer can reappear in the prostate, near the prostate, or in another part of the body. If it reappears in another part of the body—often the bones—it is still called prostate cancer because it started in the prostate.

What causes prostate cancer?

Experts don't know what causes prostate cancer, but they believe that your age, family history, and race affect your chances of getting it.

What are the symptoms?

Sometimes there are no symptoms of either locally advanced or metastatic prostate cancer.

When they do appear, symptoms of locally advanced prostate cancer include:

• Waking frequently at night to urinate.
• Having difficulty starting your urine stream.
• Not being able to urinate.
• Having pain or a burning feeling when you urinate.
• Having a weaker-than-normal urine stream.
• Having blood in your urine.
• Having a deep pain or stiffness in your lower back, upper thighs, or hips.

Symptoms of metastatic prostate cancer may include bone pain, weight loss, or swelling in your legs and feet.

How is prostate cancer diagnosed?

The results of a digital rectal exam and a blood test called a prostate-specific antigen (PSA) test can mean that you have prostate cancer or that your prostate cancer has come back. A biopsy, in which your doctor takes a sample of tissue from your prostate gland or from the area where the cancer may have spread, is the only way to know for sure.

If you have had prostate cancer before, your doctor may order a bone scan, CT scan, or MRI to see if it has come back or spread.

How is it treated?

Locally advanced prostate cancer may be treated by surgery, radiation therapy, or hormone therapy.

Treatment of metastatic cancer focuses on slowing the spread of the cancer and relieving symptoms, such as bone pain, to make you feel better and live longer. Treatment may include hormone therapy, radiation therapy, or chemotherapy.

Frequently Asked Questions

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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:

• Having difficulty starting your urine stream. This is called hesitancy.
• Having a weaker-than-normal urine stream.
• Not being able to urinate at all.
• Having to urinate often.
• Feeling that your bladder is not emptying completely when you urinate.
• Having to get up at night to urinate. This is called nocturia.
• Having pain or a burning feeling when you urinate. This is called dysuria.
• Having blood in your urine. This is called hematuria.
• Having a deep pain in your lower back, abdomen, hip, or pelvis.
• Having blood in your semen. This is called hematospermia or hemospermia.

These symptoms also may be caused by:

• Benign prostatic hyperplasia (BPH), which is an enlarged prostate. This is very common in older men. The prostate usually grows larger with age. When it gets large enough, it can press against the urethra and cause urination problems.
• Prostatitis, an infection in the prostate.
• Urinary tract infection, an infection in any of the organs and tubes that process and carry urine out of the body.

Symptoms that may indicate the cancer has spread to other parts of the body, or metastasized, include:

• Weight loss.
• Bone pain.
• Swelling in the legs and feet.

Prostate cancer is so common that some experts believe every man would get it if he lived long enough. Studies of autopsies show that most men older than 85 who die of other causes have tumors in their prostates.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.

When prostate 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 the seminal vesicles. At this point, the disease is called locally advanced prostate cancer.

After the 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 cells spread 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. While most men live 1 to 3 years after this diagnosis, some men may live many years longer.

Being older than 50 is the main risk for prostate cancer. A risk is anything that makes you more likely to get a particular disease. More than 70% of new prostate cancers are diagnosed in men who are older than 65.²

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 increases even more if those relatives were diagnosed before they were 55.¹ Most men who get prostate cancer have no family history of the disease.

Most men will die with prostate cancer but not of prostate cancer.³ Your chances of dying from the disease depend on:

• Your overall health.
• Your age when the cancer is diagnosed.
• Your ethnicity. Blacks are more likely than whites to die from prostate cancer.⁴ Experts say that this could be because of genetics, diet, where people live, and/or access to health care.⁵
• How large your cancer has grown. This is called the stage of your cancer.
• Whether your cancer is slow-growing or fast-growing. This is called the grade of your cancer. Faster-growing cancers are a higher grade of cancer and are more likely to reappear after treatment or to spread to other parts of the body.

If you have prostate cancer, your chances of dying from it are influenced by:

• A high-fat diet. Studies have shown that men who have prostate cancer are more likely to see their cancer advance if they have a high-fat diet.⁴
• Having a higher grade of cancer. Cancers with higher grades grow faster and are more likely to cause death.⁶
• Being obese. Studies have shown that men who have prostate cancer are more likely to die from the disease if they have a body mass index of 30 or higher.^{7, 8}

You have a greater chance of developing metastatic prostate cancer if you have had prostate cancer before.

Race and prostate cancer survival

Black men have a bigger chance of getting 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. Some research suggests that access to health care may play a role in survival rates.⁹

Ethnicity and 5-year survival (percentage of men who survive for 5 years or more after prostate cancer is diagnosed)⁴

The 5-year survival rate shows the percentage of men who are still alive 5 years or longer after they are diagnosed. It is important to remember that these are only averages. Everyone’s case is different, and these numbers do not show what will happen in your case.

Call your doctor immediately if you:

• Are completely unable to urinate.
• Have painful urination and a fever higher than 100° (37.78°), chills, or body aches.
• Have blood or pus in your urine or semen.

Call your doctor to schedule an appointment if you have unexplained:

• Weight loss.
• Dull, aching pain in your lower back, pelvis, or hips.
• Swollen lymph nodes.

Watchful Waiting

Watchful waiting means that you and your doctor will watch your cancer to see if your symptoms go away on their own or get worse, but you are not receiving treatment. This step may not be a choice when prostate cancer has spread. However, some men who have metastatic prostate cancer may choose watchful waiting if their PSA levels are rising slowly.

Who To See

Doctors who can treat locally advanced and metastatic prostate cancer include:

• Urologists.
• Radiation oncologists.
• Medical oncologists.

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:

• A digital rectal exam, in which the doctor inserts a gloved finger into your rectum to feel your prostate gland. Some prostate tumors can be found this way.
• A PSA test to measure the levels of prostate-specific antigen (PSA) in your blood. A higher level of PSA may indicate an enlargement, infection, or cancer of the prostate. A rising PSA level after treatment for prostate cancer can mean your cancer has come back.
• A urine test, in which some of your urine is sent to a lab and checked for blood or infection. Prostate cancer can cause blood in the urine.
• A prostate biopsy, in which tissue is taken from your prostate and examined under a microscope. Although the other exams and tests can give clues that you may have prostate cancer, only a prostate biopsy can tell for sure.

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 include:

• Blood tests. Different types of blood tests are used to see whether cancer has spread to your bones or liver.
• A bone scan. Radioactive material that shows up on X-rays is injected into your arm. An X-ray camera passes over your body, taking pictures as the radioactive material moves into your bones. Areas of bone damage show up in the pictures. Prostate cancer that has spread to the bones can cause this kind of damage.
• A CT scan. A CT scanner directs a series of X-ray pulses through your body. Each X-ray pulse lasts only a fraction of a second and represents a “slice” of the organ or area being studied.
• An MRI. An MRI uses a strong magnetic field to make pictures of the prostate. This can show tissue damage or disease, such as infection or a tumor.
• ProstaScint scan. Radioactive material that is absorbed by prostate cancer cells and shows up on X-rays is injected into your vein. Four days after the injection, your body is scanned with a special camera, and lymph nodes and other areas that have been invaded by prostate cancer cells show up on the scanning image.

Follow-up checkups

If 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 may show the need for further tests, such as a prostate biopsy, bone scan, CT scan, or MRI.

Choosing treatment for prostate cancer can be confusing. Not all men are treated the same way. Any treatment probably will cause serious side effects. It's important to learn all you can about your choices and talk to your doctor about them.

Your decision depends on:

• Your age, overall health, and life expectancy.
• Your PSA level.
• What kind of cancer cells you have. This is called the grade or Gleason score of your cancer. Some prostate cancer cells grow more quickly than others.
• How far your cancer has spread. This is called the stage of your cancer.
• The side effects of treatment.
• Your personal feelings and concerns.

Treatment for locally advanced or metastatic prostate cancer may include hormone therapy, surgery, radiation therapy, chemotherapy, and pain medicine. You may want to talk with your doctor about entering a clinical trial of new cancer treatment options.

You may experience a wide variety of emotions after being diagnosed. Most men feel some denial, anger, and grief. Others may have fewer emotions. There is no "normal" way to react. There are many things you can do to help with your emotional reaction to prostate cancer. You may find that talking with family and friends helps you with your emotions. Some men find that spending time alone is what they need.

If your reaction is interfering with your ability to make decisions about your health, it is important to talk with your doctor. Your cancer treatment center may offer psychological or financial services. You may also contact your local chapter of the American Cancer Society to help you find a support group. Talking with other men who have had similar feelings can be very helpful.

Prostate cancer and its treatment may cause nausea, pain, or other side effects. You can manage some side effects at home. If you experience nausea, wait for 1 hour after vomiting has stopped and then sip a rehydration drink to restore lost fluids and nutrients. Constipation and diarrhea may be eased if you drink enough fluids. Pain does not have to be an accepted part of treatment for prostate cancer. For tips on handling pain, see:

Controlling cancer pain.

For more information, see the topic Cancer Pain.

Localized prostate cancer is cancer that is small and has not spread outside the prostate. For more information on treatment of localized prostate cancer, see the topic Prostate Cancer.

Treatment for locally advanced prostate cancer

Prostate cancer that has spread to tissues around the prostate may be treated with:

• Hormone therapy. Prostate cancer often needs your body's male hormones to survive. Hormone therapy decreases the amount of testosterone and other male hormones in your body. This often causes tumors to shrink. Shrinking the tumors also can ease severe bone pain caused by the spread of cancer to the bones. Hormone therapy usually is combined with radiation therapy. The most common drugs are:
  • LH-RH agonists and GnRH agonists. These drugs stop the body from making testosterone.
  • Antiandrogens. These often are used along with LH-RH agonists. Antiandrogens help block the body's supply of testosterone.
• Radiation therapy. This treatment uses high-energy rays, such as X-rays, to destroy the cancer. It usually is combined with hormone therapy.
• Prostatectomy. This operation takes out your prostate gland and the cancer in and around it. Surgery can be successful if the tumor has not spread beyond the outside of your prostate and is easily removed.

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

Treatment for metastatic prostate cancer

Treatment for prostate cancer that has spread to the bones and/or other organs in the body is aimed at relieving symptoms and slowing the cancer's growth. Treatment may include:

• Hormone therapy to slow cancer growth and relieve pain by shrinking the tumors. Hormone therapy can also improve urinary symptoms. It may be used alone or in combination with radiation therapy.
• Radiation therapy to shrink tumors and ease pain. External-beam radiation, which uses a large machine to aim a beam of radiation at your tumor, usually is combined with hormone therapy.
• Drugs to stop the growth of cancer cells. Use of these kinds of drugs is called chemotherapy.
• Surgery to remove blockages that are causing problems (TURP) or to remove the testicles to reduce the supply of testosterone to the cancer (orchiectomy).

Orchiectomy and hormone therapy both make testosterone levels drop, causing the same side effects. These include larger breasts, hot flashes, loss of sexual desire, and the inability to have an erection. Treatment options for these problems include:

• Taking a temporary break from hormone therapy. This can make some side effects go away. (Side effects after orchiectomy are permanent.)
• Radiation treatment of the breasts to prevent breast growth. This is done before starting hormone therapy.
• Radiation treatment or the anti-estrogen breast cancer medicine called tamoxifen to relieve breast pain. Tamoxifen can also help reverse breast growth. It also causes hot flashes.
• Taking a certain kind of antidepressant to improve hot flashes.¹⁰

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

For more information about specific treatments, see the following topics:

• Prostate Cancer — Health Professional Information [NCI PDQ]
• Prostate Cancer — Patient Information [NCI PDQ]

What to think about

Vaccines to keep prostate cancer from coming back after it has been treated are being tested. This type of treatment encourages the body's immune system to destroy cancer cells that remain after prostate cancer surgery. Early results suggest that vaccines may be able to help slow the growth of prostate cancer.¹¹

A study suggests that advanced prostate cancer can sometimes be cured if the cancer has spread to only a few lymph nodes and great care is used to completely remove the lymph nodes during prostatectomy.¹² Radiation and hormone treatment may be used afterwards to destroy any remaining cancer cells.

Long-term hormone therapy can also lead to osteoporosis, which causes bones to become brittle and more likely to break. Drugs are available to help prevent this side effect. For more information, see the topic Osteoporosis.

There are many studies (clinical trials) focusing on finding ways to prevent, detect, diagnose, and treat prostate cancer in all stages. Talk to your doctor about whether entering a clinical trial is a good option for you to explore.

Having a healthy weight may help you survive this disease. Studies have shown that men who have prostate cancer are more likely to die from the disease if they have a body mass index of 30 or higher.^{7, 8}

Palliative care

If your cancer gets worse, look into your options for palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different than care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

Locally advanced or metastatic prostate cancer often cannot be cured. You may wish to discuss health care and other legal issues that arise near the end of life with your family and your doctor. You may find it helpful and comforting to state your health care choices in writing—with an advance directive or living will—while you are still able to make and communicate these decisions. Think about your treatment options and which kind of treatment will be best for you. You may want to choose a health care agent to make and carry out decisions about your care if you should become unable to speak for yourself. For more information, see the topic Care at the End of Life.

A time may come when your goals or the goals of your loved ones change from treating or curing your illness to maintaining your comfort and dignity. Your doctor will be able to address questions or concerns about maintaining comfort when cure is no longer an option.

Hospice care provides medical services, emotional support, and spiritual resources for people who are at the end of life. Hospice care also helps family members manage the practical details and emotional challenges of caring for a dying loved one. For more information, see the topic Hospice Care.

Prostate cancer can't be prevented. However, there are steps you can take to reduce your risk of developing this disease. For more information, see the topic Prostate Cancer.

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:

• Nausea or vomiting. After vomiting has stopped for 1 hour, sip a rehydration drink to restore lost fluids and nutrients. Watch for and treat early signs of dehydration. Older adults can quickly become dehydrated from vomiting. For more information on how to deal with these side effects, see:

  Controlling nausea and vomiting caused by chemotherapy.

• Pain. For pain, talk to your doctor about using aspirin or another type of nonsteroidal anti-inflammatory drug (NSAID). You can also try an alternative therapy such as biofeedback. Be sure to discuss any home treatment you use for pain with your doctor.
• Diarrhea. Don't eat until you are feeling better. Take frequent, small sips of water or a rehydration drink and small bites of salty crackers. Begin eating mild foods (such as rice, dry toast or crackers, bananas, broth, and applesauce) the next day or sooner, depending on how you feel.
• Constipation. Make sure you drink enough fluids. Most adults should drink between 8 and 10 glasses of water, noncaffeinated beverages, or fruit juice each day. Include fruits, vegetables, and fiber in your diet each day.
• Sleep problems. Often, simple measures such as having a regular bedtime, getting some exercise during the day, and avoiding naps can relieve sleep problems.
• Urinary problems. Home treatment for urinary incontinence includes eliminating caffeinated drinks from your diet and establishing a schedule of urinating every 3 to 4 hours, regardless of whether you feel the need. You may also try doing pelvic floor (Kegel) exercises to strengthen your pelvic muscles.

During medical treatment for prostate cancer, you may experience emotional problems. See the following tips for managing:

• Stress. Expressing your feelings to others may help you understand and cope with them. Learning relaxation techniques may also be helpful.
• Poor body image. Your feelings about your body may change after treatment for cancer. Talk openly about your concerns with your partner, and discuss your feelings with your doctor, who may also be able to refer you to groups that can offer additional support and information.

You should not have to accept pain as part of receiving cancer treatment or having cancer. For tips on pain management, see:

Controlling cancer pain.

For more information, see the topic Cancer Pain.

Medications may be used to slow the growth of prostate cancer and to relieve your symptoms.

Prostate cancer often 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 radiation or surgery to remove the prostate.

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.

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 may be the next choice.

Chemotherapy usually involves two or more drugs given together. This is done to lower the chances that the cancer cells will become resistant to the drugs. It is most often used when prostate cancer is hormone-resistant.

Medication Choices

Hormone therapy

• LH-RH agonists/GnRH agonists, such as leuprolide (Lupron) and goserelin (Zoladex)
• Antiandrogens, such as flutamide (Eulexin), nilutamide (Nilandron), and bicalutamide (Casodex)

Chemotherapy

• Docetaxel
• Mitoxantrone
• Estramustine
• Paclitaxel
• Etoposide

Pain-relief and appetite-stimulant drugs

Pain-relief and appetite-stimulant drugs may be used when prostate cancer has spread to other parts of the body.

• Steroids, such as hydrocortisone or prednisone, control pain and improve appetite.
• Radioactive drugs such as strontium-89 and samarium are called radionuclides. They are absorbed near the area of bone pain, and the radiation that is released helps relieve the pain, probably by causing the tumor to shrink.
• Bisphosphonate drugs such as alendronate (Fosamax), pamidronate disodium (Aredia), and zoledronic acid (Zometa) may help relieve bone pain and prevent osteoporosis, which is sometimes caused by long-term hormone therapy.¹³

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:

Controlling cancer pain.

For more information, see the topic Cancer Pain.

Medicines for treating side effects

Hormone therapy can cause loss of sexual desire, hot flashes, enlarged and painful breasts, and erection problems.

• Taking a temporary break from hormone therapy can make some side effects go away.
• To relieve breast pain, the anti-estrogen breast