Second-Line Treatment Options For Prostate Cancer
- Androgen deprivation therapy (ADT), also known as hormonal therapy, is the foundation of treatment for men with metastatic prostate cancer. It works by lowering the body’s levels of male hormones which help fuel cancer growth or blocking the effect of testosterone on cancer cells.
- Over time though, cancer will progress even with low hormone levels for many men. When this happens, the cancer is said to have become castration-resistant prostate cancer (CRPC). While this will require a new approach to treatment, there are still many options available.
- Treatment might include next-generation androgen receptor-targeted therapies, chemotherapy, radiopharmaceuticals, immunotherapy, or other approaches.
- While these treatments are not curative, they can significantly prolong life and help maintain a good quality of life.
Since prostate cancer cells often rely on these hormones to grow, ADT can be highly effective at slowing disease progression, relieving symptoms, and extending life. For many men, this therapy can keep the disease under control for years.
Read MoreHow Is Cancer Progression Detected?
Your healthcare team will monitor you closely while you are receiving ADT. Even if you are feeling well, your doctor will regularly check your prostate-specific antigen (PSA) levels through blood tests. A rising PSA level — particularly if it increases steadily over time — can be an early sign that your cancer is no longer responding to hormone therapy.
Imaging studies, such as bone scans, CT scans, or PET scans, may also be performed periodically to look for new or growing tumors.
Resistance is diagnosed when there is evidence of cancer growth or spread despite testosterone levels being in the castrate range (usually below 50 ng/dL).
Some men will notice new symptoms as well, such as:
- Bone pain
- Fatigue
- Weight loss
- Urinary changes
Resistance can also develop quietly, though, without obvious symptoms, which is why routine monitoring is so important.
Treatment Options
When prostate cancer becomes resistant to ADT, additional treatments are available to help regain control of the disease.
These may include:
Next-Generation Androgen Receptor-Targeted Therapies
Drugs such as abiraterone, enzalutamide, apalutamide, and darolutamide work in different ways to block the androgen receptor or further reduce hormone production. Even when testosterone levels are very low, these medications can prevent the cancer from using any remaining hormones for growth. They may be used as part of your initial treatment plan as well.
Chemotherapy
Docetaxel and cabazitaxel are the main chemotherapy drugs used for metastatic prostate cancer. They work by interfering with the cancer cells’ ability to divide and spread. Chemotherapy is often recommended for men whose disease is progressing quickly or who have symptoms that need rapid relief.
Radiopharmaceuticals
Certain radioactive drugs, such as radium-223 or lutetium-177, can target prostate cancer cells. These treatments deliver radiation directly to the tumors while minimizing damage to surrounding healthy tissue.
Radium-223, which is given by itself, targets cancer cells that have spread to the bone, while lutetium-177 is bound to an antibody and goes after cells expressing prostate-specific membrane antigen (PSMA).
Immunotherapy
Some patients may be candidates for immunotherapy approaches, such as sipuleucel-T, which is a personalized treatment designed to stimulate the immune system to attack prostate cancer cells.
Targeted therapies
If genetic testing reveals specific mutations — such as BRCA1 or BRCA2 — PARP inhibitors like olaparib or rucaparib may be used. These drugs work by exploiting weaknesses in cancer cells’ ability to repair DNA damage, leading to cancer cell death.
Clinical trials
Ongoing research is constantly bringing new therapies forward. Clinical trials may offer access to innovative treatments that are not yet widely available.
Second-Line Treatment Goals
The effectiveness of second-line therapies can vary from person to person. Some men experience a significant drop in PSA levels, improvement in symptoms, and months or even years of disease control. Others may have only a partial response.
Next-generation hormone therapies, for example, have been shown to extend survival by many months, and in some cases by years, compared to ADT alone. Chemotherapy can be effective at reducing tumor burden and improving quality of life in symptomatic patients. Radiopharmaceuticals often provide excellent relief from bone pain and can also help extend survival in selected patients.
While these treatments are not curative, they can significantly prolong life and help maintain a good quality of life. The best approach is usually individualized, taking into account your overall health, the extent of disease, previous treatments, and personal preferences.
Side Effects Of Prostate Cancer Treatment
Like all cancer treatments, the therapies used after ADT resistance can have side effects.
These vary depending on the drug or approach used.
- Next-generation androgen receptor blockers can cause fatigue, high blood pressure, fluid retention, hot flashes, gynecomastia (enlarged breast tissue), and in some cases, an increased risk of falls or fractures. Abiraterone can also affect liver function and potassium levels, requiring regular monitoring.
- Chemotherapy may cause hair loss, lowered blood counts, fatigue, nausea, and a higher risk of infections. Some men experience numbness or tingling in the hands and feet (peripheral neuropathy) as a result of nerve irritation.
- Radiopharmaceuticals are generally well-tolerated but can lead to low blood counts and, rarely, mild gastrointestinal symptoms.
- Immunotherapy side effects can include fever, chills, headache, and fatigue shortly after infusion.
- Targeted therapies such as PARP inhibitors may cause anemia, nausea, fatigue, and, in rare cases, more serious side effects affecting the bone marrow.
Your doctor will discuss the potential benefits and risks of each treatment before starting, and many side effects can be managed with supportive care, dose adjustments, or temporary treatment breaks.
Living With Metastatic Prostate Cancer
It’s important to remember that cancer becoming castration-resistant does not mean treatment options are exhausted. In the past decade, the number of available therapies has grown rapidly, giving men more opportunities for long-term disease control.
Good communication with your healthcare team is essential. Make sure you understand the goals of each treatment, what to expect in terms of benefits and side effects, and how the therapy will be monitored. It can be helpful to bring a family member or friend to appointments to help take notes and ask questions.
Lifestyle measures — such as staying active, eating a balanced diet, managing stress, and addressing symptoms early — can also improve quality of life during treatment.
“Food is medicine in many cases if you eat the right kind of food,” Dr. Jones explains. “… Exercise [is also] very important for any kind of cancer therapy — to exercise, to oxygenate the tissues, to improve the flow, the blood flow, to get circulation to the areas that need it.”
While ADT resistance is a turning point in the journey with metastatic prostate cancer, it is not the end of the road. With the right combination of medical treatment, monitoring, and support, many men are able to live fulfilling lives for years after resistance develops.
Questions To Ask Your Doctor
- What is the next step after my cancer is ruled castration-resistant?
- What are the risks vs. benefits of your recommended treatment approach?
- What can I do at home to help with side effects?
- How will I be monitored during treatment?
Content independently created by SurvivorNet with support from Novartis Pharmaceuticals Corp.
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