Prostate Cancer

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Treating Prostate Cancer TOPICS

Prostate cancer that remains or recurs after treatment

If the prostate-specific antigen (PSA) level shows that the prostate cancer has not been cured or has come back (recurred) after an initial attempt to cure it, further treatment may be an option. Follow-up therapy will depend on where the cancer is thought to be located and what treatment(s) you have already had. Imaging tests such as CT, MRI, or bone scans may be done to get a better idea about where the cancer may be.

Cancer that is still in or around the prostate

If the cancer is still thought to be localized to the area of the prostate, a second attempt to try to cure the cancer may be possible. If you've had a radical prostatectomy, radiation therapy may be an option, sometimes along with hormone therapy.

If your first treatment was radiation, treatment options may include cryosurgery or radical prostatectomy, but when radical prostatectomy is done after radiation, it does carry a higher risk for side effects such as incontinence. Repeating radiation therapy is usually not an option because of the increased potential for serious side effects, although in some cases brachytherapy maybe an option as a second treatment.

Cancer that has spread

If the cancer has spread outside the prostate gland, it will most likely go first to nearby lymph nodes, and then to the bones. Much less often the cancer will spread to the liver or other organs.

When prostate cancer has spread to other parts of the body (including the bones), hormone therapy is probably the most effective treatment, but it isn’t likely to cure the cancer and at some point it will stop working. Usually the first treatment is a luteinizing hormone-releasing hormone (LHRH) analog or antagonist (or orchiectomy). If this stops working, an anti-androgen may be added. Other treatments aimed at bone metastases may be used as well.

Keep in mind that prostate cancer is usually slow growing, so even if it does come back, it may not cause problems for many years. In a Johns Hopkins University study of men whose PSA level began to rise after surgery for low-grade prostate cancer, there was an average of about 8 years before there were signs the cancer had spread to distant parts of the body. Of course, these signs appeared earlier in some men and later in others.

How quickly the PSA goes up can help predict how soon the cancer will show up in distant sites and cause problems. If the PSA is going up very quickly, some doctors may recommend that you begin treatment with hormone therapy even before the cancer can be seen on tests or causes problems.

Castrate-resistant and hormone-refractory prostate cancer

Hormone therapy is often very effective at shrinking or slowing the growth of prostate cancer that has spread, but it nearly always loses its effectiveness over time. Doctors use different terms to describe cancers that are no longer responding to hormones.

  • Castrate-resistant prostate cancer (CRPC) is cancer that is still growing despite the fact that hormone therapy (either an orchiectomy or an LHRH agonist or antagonist) is keeping the testosterone in the body at very low, "castrate" levels. The cancer may still respond to other forms of hormone therapy, though.
  • Hormone-refractory prostate cancer (HRPC) is cancer that is no longer helped by any form of hormone therapy.

Men whose prostate cancer is still growing despite initial hormone therapy now have many more treatment options than they had even a few years ago.

If an anti-androgen drug has not been tried as part of the initial hormone therapy, it is often added at this time. If a man is already getting an anti-androgen but the cancer is still growing, stopping the anti-androgen (while continuing other hormone treatments) actually seems to help in some cases.

Other forms of hormone therapy may also be helpful for a time, especially if the cancer is causing few or no symptoms. These include abiraterone (Zytiga), enzalutamide (Xtandi), ketoconazole, estrogens (female hormones), and corticosteroids.

Another option for men whose cancer is causing few or no symptoms is the prostate cancer vaccine sipuleucel-T (Provenge). This may not lower PSA levels, but can help men live longer.

For cancers that are no longer responding to initial hormone therapy and are causing symptoms, several options may be available. Chemotherapy with the drug docetaxel (Taxotere) is often the first choice because it has been shown to help men live longer, as well as reduce any pain they are having.

If docetaxel does not work or stops working, cabazitaxel (Jevtana) or other chemo drugs may help. Another option may be a different type of hormone therapy, such as abiraterone or enzalutamide (if they haven’t been tried yet).

Bisphosphonates or the newer drug denosumab appear to be helpful for many men whose cancer has spread to the bones. These drugs can reduce pain and even slow cancer growth in many cases. There are also other medicines and methods to keep pain and other symptoms under control. External radiation therapy can help treat bone pain if it is only in a few spots. A radiopharmaceutical such as strontium, samarium, or radium may reduce pain if it is more widespread, and may also slow the growth of the cancer.

If you are having pain from your prostate cancer, make sure your doctor and entire care team know about this. There are many very effective drugs that can relieve pain. But for this to happen, you must make it clear to your doctor that you have pain. For more information, see our document Advanced Cancer.

There are several promising new medicines now being tested against prostate cancer, including vaccines, monoclonal antibodies, and other types of targeted drugs. Because our ability to treat hormone-refractory prostate cancer is still not good enough, men are encouraged to explore new options by taking part in clinical trials.

Last Medical Review: 08/26/2013
Last Revised: 09/12/2014