Understanding The Specifics Of Your Diagnosis
- The staging system for prostate cancer depends on several factors, including the extent of the main tumor, whether it has spread to lymph nodes, and whether it has metastasized anywhere else in the body.
- When you are diagnosed at an advanced stage, treatment will typically focus more on systemic therapies, or therapies that treat the whole body, initially.
- Treatments for advanced prostate cancer often focus on reducing or blocking male hormones. This approach is called androgen deprivation therapy (ADT). When cancer is considered “castration-sensitive,” ADT can be quite effective at slowing progression.
- ADT may be combined with other hormone therapies or chemotherapy.
- When cancer becomes “castration-resistant,” there are still several treatment options available. These include additional hormone treatments, radioligand therapy, chemotherapy, and more.
“When we’re evaluating a case for treatment options, the first thing is to determine the stage,” Dr. Edward Yen, medical oncologist at Baylor College of Medicine in Houston, tells SurvivorNet.
Read More- The extent of the main tumor (T)
- Whether it has spread to any lymph nodes (N)
- Whether it has spread (metastasized) to other parts of your body (M)
- Your PSA level at the time of diagnosis
- The grade (based on your Gleason score), which is how aggressively your cancer is likely to behave
“Those types of treatments basically focus on disease in one site, and so it’s more suitable for non-metastatic cancer or cancer that has not spread out, but once it spreads out, we usually need to use a different strategy,” he explains.
“For example, if you did surgery to the prostate in a metastatic case, or if you did radiation to the prostate in a metastatic case, those treatment options, again, are only going to treat the prostate and so treating one area where there’s other sites of disease elsewhere, it really won’t address those other metastatic sites,” Dr. Yen says.
In these cases, systemic treatments, or therapies that treat the whole body, are typically more useful.
Treating ‘Castration-Sensitive’ Cancer
“Once we’ve confirmed that they actually have stage four [prostate cancer], then we also try to figure out if the patient has castration sensitive or castration resistant prostate cancer. Our treatment options depend on the castration status and whether or not the disease is resistant,” Dr. Yen explains.
Prostate cancer cells need a specific fuel to grow, and that fuel is primarily a male hormone called testosterone. This is why treatments for advanced prostate cancer often focus on reducing or blocking this male hormone. This approach is called Androgen Deprivation Therapy (ADT).
“ADT is the backbone of prostate cancer management or treatment. It’s also otherwise known as castration, which sounds like a very aggressive word, but many, many decades ago, when we didn’t have good medications for this, basically we achieved castration by doing surgery,” Dr. Yen says. These days, treatment has evolved.
ADT can involve injections or daily pills that either stop testosterone production or block it from reaching the testosterone receptor in cancer cells. While ADT doesn’t typically cure prostate cancer, it is very effective at controlling its growth, especially when the disease is more aggressive or has spread.
Initially, most prostate cancers are hormone-sensitive, also known as castration-sensitive. This means the cancer cells still rely on testosterone to grow and respond well to ADT. At this stage, your doctor’s goal is to starve the cancer by significantly lowering your testosterone levels, typically below 50 ng/dL.
While ADT can be quite effective, your medical team may also consider adding additional hormone therapies or chemotherapies to the treatment plan, Dr. Yen says.
Treating ‘Castration-Resistant’ Cancer
Over time, some prostate cancer cells can learn to adapt and grow even when testosterone levels are very low due to ADT. When this happens, the cancer is called hormone-resistant or castration-resistant prostate cancer (CRPC). This doesn’t mean the cancer is completely independent of hormones, but it has found ways to bypass the initial hormone therapy.
This means a different treatment approach is needed.
Your doctor might suspect CRPC if your prostate-specific antigen (PSA) level starts rising again, even though your testosterone levels remain low. They may also look at your PSA doubling time (how quickly your PSA level is increasing) to help guide treatment decisions.
For CRPC, several advanced treatment options are available, often used in combination with continued ADT to keep testosterone low.
These include:
Androgen Receptor Pathway Inhibitors (ARPIs)
Medications like abiraterone, enzalutamide, apalutamide, or darolutamide work by further blocking testosterone signaling inside the cancer cells, even tiny amounts. These are typically oral medications, and while side effects like fatigue can occur, many men tolerate them well.
Radioligand Therapy (RLT)
This is a cutting-edge approach where a radioactive payload is attached to a “ligand” that specifically targets prostate cancer cells expressing a protein called PSMA (prostate-specific membrane antigen). PSMA is found on most prostate cancer cells but not on normal tissues, making it an excellent target. Pluvicto (Lutetium Lu 177) is a prominent example of an RLT that delivers radiation directly to cancer cells.
Radium-223 (Ra-223), another radiopharmaceutical that targets symptomatic bone metastases, deposits high-energy radiation directly at the site of disease while minimizing harm to healthy tissue. It is typically used for patients with symptomatic bone metastases and no visceral disease.
Chemotherapy
Drugs such as docetaxel or cabazitaxel can effectively combat fast-growing tumors and help alleviate symptoms like bone pain. Your medical team will carefully determine the right timing for chemotherapy to maximize benefits and minimize discomfort.
Immunotherapy
For a specific group of patients whose genetic testing reveals a high tumor mutational burden (TMB) or mismatch repair deficiency (dMMR), immunotherapy drugs like pembrolizumab may be an option. These treatments work by boosting your body’s own immune system to recognize and attack cancer cells. For eligible patients, responses can be significant.
PARP Inhibitors
This class of drugs, such as olaparib or rucaparib, targets specific genetic changes (like BRCA1 or BRCA2 mutations) found in some prostate cancer cells. These are typically considered for patients with homologous recombination repair deficiencies.
Your Role In Decision-Making
Navigating prostate cancer treatment is a deeply personal journey, and there is no single “right” path for everyone. While medical guidelines and “standard of care” are vital, your individual circumstances, preferences, and quality of life goals are equally important.
We encourage you to engage in shared decision-making with your healthcare team. This means bringing your questions, concerns, and even your “bucket-list” items to your appointments.
Questions To Ask Your Doctor
- Is my cancer still hormone-sensitive, or is it becoming resistant?
- What is my current PSA doubling time?
- Would a specific scan, like a PSMA PET scan, change my treatment plan?
- Which treatment option offers the greatest benefit against the cancer with the least impact on my daily routine?
- How can we protect my heart, bones, and mind while I’m undergoing therapy?
Content independently created by SurvivorNet with support from Novartis Pharmaceuticals Corp.
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