Understanding Your Diagnosis
- When someone is diagnosed with prostate cancer, understanding the stage is important because it helps doctors decide on the best treatment approach.
- Prostate cancer stages range from 1 to 4. Stages 1 and 2 are considered localized (confined to the prostate), stage 3 is locally advanced, and stage 4 is metastatic, meaning it has spread to distant parts of the body.
- The treatment approach also depends on castration status — whether cancer is castration-sensitive or castration-resistant. Castration-sensitive prostate cancer responds to androgen deprivation therapy (ADT), also called hormone therapy.
- When cancer becomes castration-resistant, and no longer responds to ADT, it’s key to realize there are still treatment options available — these might include additional hormone therapies, chemotherapy, radioligand therapy, and more.
“The first thing is determine the stage. Prostate cancer is staged in four stages [1 through 4]. Stages 1, 2 and 3 usually describe some form of prostate cancer that’s still localized to the prostate,” Dr. Edward Yen, a medical oncologist at Baylor College of Medicine in Houston, tells SurvivorNet.
Read More- Stage 1: The cancer is small and confined to the prostate. It is often found incidentally or by elevated PSA. It’s usually slow-growing.
- Stage 2: The cancer is still confined to the prostate, but either larger or found in more than one area. PSA or Gleason score may be higher.
- Stage 3: The cancer has grown beyond the capsule of the prostate and may involve nearby tissues such as the seminal vesicles.
- Stage 4: The cancer has spread to nearby lymph nodes or distant areas like the bones or other organs.
Castration-Resistant Prostate Cancer
To understand these terms, it helps to think of testosterone, the main male hormone, as a vital “fuel” for most prostate cancer cells. Most prostate cancer cells need testosterone to grow and survive. When doctors treat prostate cancer, especially if it’s more aggressive or has spread, a primary strategy is to reduce or block this fuel. This approach is called Androgen Deprivation Therapy (ADT), also known as hormone therapy.
Initially, most prostate cancers are responsive to ADT. This means that when you lower the body’s testosterone levels, the cancer cells, which depend on this hormone for growth, are affected. This stage is called hormone-sensitive or castration-sensitive prostate cancer (CSPC).
Over time, some prostate cancer cells can adapt and find ways to grow even when testosterone levels in the body are very low due to ADT. When this happens, the cancer is described as hormone-resistant or castration-resistant prostate cancer (CRPC). This doesn’t mean the cancer is entirely independent of hormones, but rather that it has developed mechanisms to bypass the initial hormone therapy.
“Castration-resistant prostate cancer can come in in a lot of different ways,” Dr. Yen explains. “Sometimes it’s very subtle, and the only manifestation may be that your PSA is rising. Other times, it’s a lot more obvious. Say, for example, your cancer has metastasized to a different site because it’s no longer controlled by the treatment, and unfortunately, that patient will develop a complication.”
Your doctor might suspect CRPC if:
- Your prostate-specific antigen (PSA) level starts rising again, despite your testosterone levels remaining low (typically below 50 ng/dL)
- Imaging tests show that the cancer is growing or new areas of cancer are appearing
A key indicator your doctor might monitor is your PSA doubling time (how quickly your PSA level is increasing). If your PSA doubles in less than six months while on treatment, it often suggests the cancer is becoming resistant.
Treatment Options For CRPC
For castration-resistant prostate cancer, there are an array of options for choose from and no standard order to receive those options in, Dr. Yen says.
“There is no standard of care in terms of the right sequence or a standard sequence of medications — and some may look at that as sort of a really good problem to have nowadays, because we have so many different options and potentially so many different sequences,” he explains.
For CRPC, several advanced treatment options are available, often used in combination with continued ADT to keep testosterone low. We break those options down below.
Androgen Receptor Pathway Inhibitors (ARPIs)
Medications like abiraterone or enzalutamide shut off testosterone signaling deeper inside the cell. These are pills taken at home. Many men feel perfectly normal except for a bit more fatigue on long days.
“A lot of our hormonal therapies, especially the newer ones (ARPIs or androgen receptor pathway inhibitors) are now standard of care for castration sensitive prostate cancer patients,” Dr. Yen explains.
“If you’ve developed resistance while on one of those combinations, including an ARPI medication, we would generally not try to go back to one of those medications (even though ARPIs are also approved for use in castration resistant prostate cancer) … a lot of times in those situations, we would try to use utilize chemotherapy if the patient is agreeable to that, and if they’re fit enough for chemotherapy, great,” he adds.
Targeted Radioligand Therapy
Radioligand therapy is a targeted radiation approach that is showing real promise for some men with advanced prostate cancer.
Pluvicto (Lutetium Lu 177) is the name you’ll likely hear the most. It’s part of a newer class of targeted cancer therapies called radioligand therapies (RLTs). It delivers a small but powerful dose of radiation directly to prostate cancer cells that express a protein known as PSMA (prostate-specific membrane antigen). This protein is found on most prostate cancer cells but not on normal tissues, making it a valuable target for treatment.
“Pluvicto was first looked at in a phase three trial called. On that study, patients were evaluated with Pluvicto with ARPIs versus ARPIs alone. And ultimately, that trial did show not only a benefit in progression free survival, but also overall survival. And that led to the FDA approval of that medication,” Dr. Yen explains.
Chemotherapy
Docetaxel or cabazitaxel knock back fast-growing tumors and can relieve bone pain. The key is timing: using chemo when it brings the most benefit and causes the least harm.
Immunotherapy
If genetic testing shows a high mutation burden, a checkpoint inhibitor like pembrolizumab may spark the immune system. It’s a niche group, but the responses can be dramatic.
Questions To Ask Your Doctor
- Is my cancer still hormone-sensitive, or is it shifting toward resistant?
- What’s my current PSA doubling time?
- Would a PSMA PET scan change the plan?
- Which treatment hits the cancer hardest with the least impact on my daily routine?
- How do we protect my heart, bones, and mind during treatment?
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