Navigating the Path Forward: A Guide for Veterans Facing Metastatic Prostate Cancer
Resources, expertise, and survivor support to help you after a diagnosis

To help along the way during your fight against advanced prostate cancer, SurvivorNet has developed a series called Navigating the Path Forward: A Guide for Veterans Facing Metastatic Prostate Cancer.

This series is designed to help you and your family navigate some of the challenges that may pop up during treatment and beyond.

General Information

General information to help along the way

First and foremost, we want to express our deepest gratitude for your service to our country. Your commitment, bravery, and sacrifice have not gone unnoticed.

We understand that receiving a prostate cancer diagnosis is an overwhelming and challenging moment in your life. In the spirit of the military ethos — adapt and overcome — we are here to provide guidance on how to navigate this difficult journey.

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There are a few basic things you can do to help manage the process when you first learn of your cancer diagnosis.  Dr. Heather Yeo, a surgeon at Weill Cornell and an advisor to SurvivorNet, has these tips for patients:

  • Have someone come with you to the doctor — It is important to bring a close friend or family member not only to support you, but also to help you understand and digest all the information.
  • Take notes — Writing down what you hear can help you focus and create a record of the information so you can refer to it later on.
  • Don’t be afraid to get a second opinion — Your doctor won’t be offended if you get a second opinion. It is extremely important to go through the process with a doctor you trust — and make sure you’re getting the best care possible with a doctor you feel comfortable with.

When to consider a second opinion

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“What would you do if someone in your family got cancer?” We put that question to some of the most renowned cancer doctors in the country. National Cancer Institute Chief of Surgery Dr. Steven Rosenberg recommends seeking out multiple professional opinions to confirm a diagnosis and figure out the options.

Patients should not feel guilty about doing this — as many doctors will recommend and even encourage it.

As we highlight in several areas of SurvivorNet, highly respected doctors sometimes disagree on the right course of treatment, and advances in genetics and immunotherapy are creating new options.

Also, in some instances the specific course of treatment is not clear cut. That’s even more reason why understanding the potential approaches to your disease is crucial.

Learning to live with uncertainties

Lean on Your Support Network

Just as you relied on your comrades during your military service, now is the time to lean on your support network.

Share your diagnosis with trusted family members, friends, and fellow veterans.

They can provide emotional support, accompany you to medical appointments, and offer a listening ear when needed. You are not alone in this battle, and your support network is a crucial asset.

Dr. William Breitbart, the chair of the Department of Psychology and Behavioral Sciences at Memorial Sloan Kettering Cancer Center, explained that learning to embrace that uncertainty is a part of living not just for those fighting cancer, but for everyone.

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“What the task becomes is having the courage to live in the face of uncertainty, realizing that you cannot necessarily control the uncertainty in life … the suffering that occurs, challenges both good and bad,” Dr. Breitbart said.

“You may not be able to control those but you have control over how you choose to respond.”

Those struggling with feelings of loss of control that cancer can bring can seek help in many different ways — from traditional therapy to support groups for people living with cancer to making lifestyle adjustments to help cope with stress.

It's OK to take time to adjust

Assembling Your Team

Assembling your treatment team

The process of finding the right doctor and deciding where to get treatment can be stressful in itself.

Just as in the military, communication is key.

Establish open and honest communication with your healthcare team. Discuss your concerns, ask questions, and actively participate in decisions about your treatment plan.

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Your input is invaluable, and a collaborative approach ensures that your unique needs are addressed.

When faced with something as life-changing as a cancer diagnosis, it can be easy to overlook some options. For prostate cancer, multidisciplinary centers are a great option because they offer patients the opportunity to work with multiple specialists all in one place.

Regardless of where you begin your treatment process, there may be several specialists involved in your care — your treatment team, if you will.

Why assembling a team you can trust matters

To get the top-notch care for your prostate cancer, it’s essential to have a medical team that collaborates. This means doctors and experts from different areas team up to figure out the best ways to make your life longer and better.

Considering your bravery in serving our country, it’s crucial to ensure that your healthcare providers are really working together for your health.

This includes collaborating and keeping in regular contact so everyone is up-to-date on your condition, and they can continue providing the best care possible.

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Your medical team may consist of:

  • A Urologist — A surgeon who focuses on treating issues with the urinary tract and the male reproductive system. If you have prostate cancer, the urologist may help with the diagnosis and offer surgery as a potential treatment option. A urologist is often involved in caring for men with prostate cancer through multiple steps in the journey.
  • A radiation oncologist — Someone who uses radiation to tackle cancer. Radiation is one of the most used treatments for prostate cancer. Radiation can cure early stage disease and help men live longer who have metastatic disease. A radiation oncologist along with a urologist are most involved in treating prostate cancer in the United States.
  • A medical oncologist — A doctor who specializes in using systemic agents like chemotherapy or immunotherapy to treat cancer. They’re trained to diagnose it, figure out how bad it is, and treat it using things like chemotherapy, endocrine therapy, and other medications.
  • A physical therapist — A pro at helping people get their strength, mobility, and function back. If you’re dealing with prostate cancer, physical therapy can counter some of the side effects of treatment, like bone weakening from hormone therapy. It can also make you feel more in control of your body and help with stress and anxiety.
  • A nutritionist or dietitian — An expert in what your body needs to stay healthy. They can suggest what to eat to keep you strong and combat some of the side effects of treatment.
  • A social worker — Can offer counseling and support in many different ways. They’re there when families dealing with prostate cancer face tough challenges.
  • Mental health professional — Professionals such as a therapist, counselor, psychologist, or psychiatrist might be helpful to you if you are struggling mentally or emotionally after a diagnosis. Those looking for spiritual guidance may find helpful support from clergy, including hospital chaplains.
  • Genetic counselor — A healthcare professional who collects your personal and family health history and uses this information to help determine the likelihood of having a genetic condition or mutation. The genetic counselor can help you decide whether or not genetic testing might be right for you or your family members, and can help explain genetic testing results.

Your Diagnosis

Understanding your diagnosis

During the workup for prostate cancer, a tissue biopsy will be obtained along with various lab tests and imaging to determine if you have localized prostate cancer, which is confined to the prostate and surrounding tissues, or metastatic disease, which has spread to distant sites.

How the disease behaves can vary significantly based on several factors, including the initial stage of disease at presentation, an individual’s health, available treatment options, and behavior and genetics of the cancer.

Some patients present with metastatic disease on initial diagnosis, and sometimes patients previously treated for localized disease can develop metastatic disease in the years after their initial treatment.

“Metastatic prostate cancer means cancer that’s escaped from the prostate and traveled through typically the bloodstream to another organ.” – Dr. Matthew Rettig, medical oncologist at the VA Medical Center in Greater Los Angeles and professor of medicine at UCLA School of Medicine, explains to SurvivorNet.

“The most common organ that’s affected when prostate cancer does metastasize is the bones. The bones provide a very hospitable environment, a hospitable milieu for the cancer to grow. And second most common would be lymph nodes.” – adds him.

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Prostate cancer can spread anywhere but most commonly spreads to the:

  • Bones
  • Lymph nodes
  • Liver
  • Lungs

Genetic testing and profiling of the tumor is most often indicated when a patient has prostate cancer that has developed into metastatic disease.

The results of this testing have several implications for future treatment. Understanding the testing options and when to get treatment is important when making informed decisions regarding your future cancer care.


What are the treatment options?

If prostate cancer has metastasized (spread to other parts of your body), there are several different treatment approaches your doctor may suggest.

These include:

  • Hormone therapy
  • Chemotherapy
  • Radiation
  • Targeted therapy
  • Immunotherapy

Your doctor may also suggest a combination of these therapies.

Anti-androgen therapy or hormone therapy is the backbone of treatment for metastatic prostate cancer.

Prostate cancer uses testosterone to grow, and these therapies turn your body’s testosterone off, slowing cancer growth.

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In addition to hormone therapy, your doctor may recommend chemotherapy. This treatment uses strong drugs to kill cancer cells throughout the body.

Fortunately for men with metastatic disease, there are many new drugs available that have the potential to keep the cancer under control for many years. These include androgen deprivation therapy, chemotherapy, radiation therapy, targeted agents, immunotherapy, and Radium-223 treatments. Sometimes, if one treatment stops working your doctor may switch to another that works better at keeping your cancer under control.

Your doctor may also discuss the use of radiation therapy. Radiation therapy in advanced disease can be used to eliminate any pain or issues your cancer is causing. In some cases, your doctor may consider giving radiation to the prostate, as well as to cancer cells that have spread throughout your body.

The goal of treatment for men with metastatic prostate cancer is to prevent symptoms and control the cancer for as long as possible. Given the many new advances in treating prostate cancer, men with metastatic disease can live for many years after their diagnosis with good quality of life.

For advanced prostate cancer, treatment is improving

The aim of treating advanced prostate cancer is to reduce or manage tumor growth and control symptoms. Deciding which treatment, or combination of treatments, to use and when to begin will depend on your individual disease and discussions with your doctor.

It’s important to have a talk with your doctor about managing side effects before deciding on a plan.

When is chemotherapy used?

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Chemotherapy for Advanced Prostate Cancer

According to Dr. David Wise, medical oncologist and the director of Urologic Medical Oncology at Perlmutter Cancer Center, there are two standard chemotherapy options. One is called docetaxel (brand name Taxotere) and the other one is called cabazitaxel (brand name Jevtana).

“These options have been around for a fair bit of time. They’re both approved for hormone resistant metastatic prostate cancer. But we’ve now understood how to better incorporate these chemotherapies into the context of different treatment paradigms,” Dr Wise said.

“For example, we now have an approval for docetaxel in the context of hormone sensitive prostate cancer. When a man is initially diagnosed having never been exposed or treated to hormonal therapy with metastatic prostate cancer.”

He also explains that nowadays, physicians know better how to handle these drugs.

“We’re understanding that we don’t need to use the high dose that was originally the approved dose for cabazitaxel. We get comparable outcomes with far less toxicity.”

Metastatic Hormone Sensitive Prostate Cancer (mHSPC)

Metastatic hormone-sensitive prostate cancer (mHSPC) is when cancer has spread beyond the prostate, but can often be treated with therapies that target the hormones.

This treatment involves blocking or stopping male sex hormones, such as testosterone, to slow down the growth of cancer.

“Androgen is the medical term for male hormones. So suppressing male hormones or androgen deprivation therapy is the backbone of the medical treatment for prostate cancer.” – Dr. Matthew Rettig, medical oncologist at the VA Medical Center in Greater Los Angeles and professor of medicine at UCLA School of Medicine, told SurvivorNet.

So by using hormone therapy, also known as Androgen Deprivation Therapy (ADT), we can put a brake on this process and help control the cancer.

How does androgen deprivation therapy (ADT) work?

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For men with advanced prostate cancer, ADT is often the first treatment suggested. It can be paired with another drug depending on factors like how fast the cancer might progress and where it has spread.

“If we take away testosterone, we can shrink down the tumor and hold it in check for often years and years and years,” Dr. Stephen Freedland, a urologist at Cedars-Sinai Medical Center, explains.

According to Dr. Freedland, it is traditionally given as a shot once a month or less frequently, depending on the particular case.

ADT can be done by taking medications that interfere with male hormones or by having surgery to remove the testicles (called an “orchiectomy” or castration).

In many places, including the United States, using medications is usually preferred over surgery. These medicines work like surgery, essentially acting as a “chemical castration” to halt the production of male hormones, even without removing the testicles.

What are the side effects of ADT?

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GnRH agonists are medications that temporarily “turn off” the production of male hormones (androgens) in the testicles. This helps starve the cancer cells, making the prostate shrink. You typically get these as shots every one to six months or as a depot (a slow release injection) that lasts for 12 months. Examples include leuprolide (brand name: Lupron) and goserelin (brand name: Zoladex).

When you start this treatment, there might be a temporary increase in the body’s androgen levels before they start decreasing (called a “flare”). This can lead to a brief growth of the tumor, causing some men to experience worsened symptoms like bone pain. To prevent this, doctors may add a second medication, known as an “antiandrogen,” to the GnRH agonist, at least in the beginning. This helps manage symptoms and improve your overall experience with the treatment.

Degarelix, known as Firmagon, is a type of medication that, unlike a GnRH agonist, swiftly stops the testicles from producing male hormones (androgens). This can be especially helpful when there’s a significant worry about the disease progressing before the treatment takes full effect.

Another option is Relugolix, also called Orgovyx, which is a GnRH antagonist available in pill form. This might be more convenient compared to getting shots of either a GnRH agonist or antagonist.

Metastatic Castration-Resistant Prostate Cancer (mCRPC)

“Another term that you may come across is castration resistant. What that means is that your cancer has been treated with castration, typically in the form of a medicine to suppress the male hormone levels.” – Dr. Matthew Rettig, medical oncologist at the VA Medical Center in Greater Los Angeles and professor of medicine at UCLA School of Medicine, explains to SurvivorNet.

“Over time, the cancer has learned to grow despite the blood levels of male hormones being suppressed by the castration based therapy. In that context, we call it castration resistant, and it’s manifested typically by the PSA test coming up while you’re on castration, but it may also include your scans showing more cancer or you’re developing symptoms related to your cancer.” – adds Dr Rettig.

“That’s important to recognize because there are specific treatments for castration resistant prostate cancer that we don’t necessarily use for other states of the disease.”

In summary, metastatic castration-resistant prostate cancer can be defined as mHSPC that has spread and progressed further and is no longer controlled by hormone blocking medications.

Notably, this type of cancer doesn’t fully respond to treatments that lower testosterone. It keeps growing, as seen with an increasing PSA (prostate-specific antigen), even when testosterone levels are low.

Unfortunately, this is a more advanced form of disease and yields a poorer prognosis. This type of prostate cancer often requires aggressive treatments including chemotherapy.

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Both Castration-Resistant Prostate Cancer (CRPC) and Metastatic Castration-Resistant Prostate Cancer (mCRPC) are advanced forms of prostate cancer.

They no longer completely respond to treatments that lower testosterone (ADT) and they show signs of growth, like a rising PSA even with low levels of testosterone.

Treatment for metastatic castration-resistant prostate cancer may include chemotherapy and radiation.


Drugs like docetaxel and cabazitaxel may help extend how long men can live with CRPC and mCRPC.

Cabazitaxel is given with the steroid prednisone (brand name Jevtana), and is an option when docetaxel doesn’t help, for mCRPC patients.

Radioactive treatments

Some treatments like Xofigo (radium-223 dichloride) can be used  to attack cancer cells in bones.

It is an injection used to treat prostate cancer that no longer responds to hormonal or surgical treatment that lowers testosterone.

It is for men whose prostate cancer has spread to the bone with symptoms but not to other parts of the body.

In CRPC the disease is confined to the prostate and surrounding tissues. And in mCRPC, the cancer has spread to distant sites, such as:

  • Bones
  • Lymph nodes
  • Liver
  • Lungs

The main goal for treating CRPC and mCRPC is to control symptoms and slow progress. Even though androgen deprivation therapy or hormone therapy may no longer work completely to stop prostate cancer from growing, most men remain on ADT because some prostate cancer cells will continue to respond to it.

Other cells need additional treatment to keep the cells from forming.


Prostate-specific membrane antigen (PSMA) Treatment

Prostate-specific membrane antigen (PSMA) positron emission tomography-computed tomography (PET-CT) scans is especially helpful for veterans with prostate cancer at high risk of spreading outside the prostate gland or those who have recurrent cancers.

What is a PET-CT scan?

A PSMA PET-CT scan is an imaging technique that detects clusters of prostate cancer cells anywhere in the body. In principle, it is just like a regular PET-CT scan, but also highlights cancerous areas within the body.

Dr. Asit Paul, hematologist-oncologist at the Massey Cancer Center, explains the regular PET-CT like this: “PET-CT is a hybrid imaging system that combines two different modalities to image cancers. In a PET scan, radioactive material is injected into the body, which travels through the bloodstream and preferentially accumulates in the cancer cells more than normal cells.”

Why is the PSMA PET scan so important for men with advanced prostate cancer?

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He continues, “Once the radioactive compound is taken up by the cells, it provides imaging signals that are captured by highly sophisticated cameras. But PET scan does not provide a structural outline of the organ being imaged. A CT scan uses regular X-rays to outline the structure which is being imaged. As a result, we get composite images of cancer cells along with their structural outline.”

A regular PET-CT scan uses a molecule called 18F-fluorodeoxyglucose (FDG). This is essentially a glucose molecule tethered to a radiotracer (any material that can be detected based on its radioactivity). FDG is preferentially taken up by cancer cells in the body, as they tend to burn more glucose to fuel their growth than most of the other cells within the body.

This action by cancer cells is seen as bright areas on the PET portion of the scan. Then, PET imaging is combined with a high-resolution CT scan (obtained at the same time as the PET) to generate a combined image that precisely pinpoints the location of the cancer cells.

How is the PSMA-PET scan different? What are the benefits?

The FDG PET-CT scan, however, cannot easily pick up prostate cancer because FDG does not routinely bind to prostate cancer cells. To overcome this shortcoming, researchers designed different radiotracer drugs like 68Ga-PSMA-11 or 18F-DCFPyL, that seek out PSMA, a protein that is reliably present in high amounts on prostate cancer cells.

Once this drug binds to PSMA, it emits signals that identify the body’s PSMA-rich regions. Much like the FDG PET-CT scan, this information is combined with a CT scan to precisely highlight prostate cancer cells’ location(s) within the body.

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These scans are revolutionary and have vastly changed the way modern medicine treats prostate cancer.

Summarizing the need for a PSMA PET-CT scan, Dr. Paul says: “The most used PET-CT is FDG PET-CT. FDG targets the property of increased glucose metabolism of cancer or other cells. Prostate cancers, unlike many other cancers, especially in early stages are slow growing and not very metabolically active.  Therefore FDG PET-CT may not provide the whole picture of cancer spread. PSMA PET-CT is different because it images different properties of cancer cells. PSMA is found in [more than] 80% of prostate cancer cells. As a result, it better depicts the distribution of cancer spread.”

He continues, “Multiple research studies have shown PSMA PET-CT has better accuracy and detection capability of prostate cancer than conventional CT scans and bone scans. As a result, a treatment plan can be changed based on PSMA PET-CT results. For example, PSMA PET-CT may detect cancer spread outside the prostate earlier than a conventional scan. Those patients may not benefit from prostate-directed radiation or prostate surgery. PSMA PET-CT can also help cancer doctors in treatment decisions when PSA is detectable but still too low to be detected by conventional scans.

Pluvicto provides hope for vets with metastatic prostate cancer

A specific treatment option based on PSMA

Pluvicto is what we call a radiopharmaceutical and it’s really part of this new era of a class of treatments called theranostics,” Dr. David Wise, medical oncologist and the director of Urologic Medical Oncology at Perlmutter Cancer Center, tells SurvivorNet.

“Theranostics are treatments that rely on a very precise visualization of a feature of the cancer on a PET scan (a protein that prostate cancer cells produce called PSMA),” he adds.

Dr. Wise explained that if this protein is present, a treatment that directly targets cancer cells can be used. That is what is known as targeted therapy.

“Identifying that the prostate cancer produces PSMA then directly translates into a real benefit from using Pluvicto . Which essentially directly hones in on that prostate cancer protein and delivers a very effective radiation dose to that tissue and thereby sparing a lot of the healthy tissue.”

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When discussing how Pluvicto is given, Dr. Wise explained: “It’s an intravenous treatment, it’s delivered quite quickly, it’s delivered once every six weeks and it’s usually administered by either a nuclear medicine physician or a radiation oncologist.”

“Patients tolerate it really well and that’s why it’s so sought after. It really can work in the majority of patients and in a subset of patients we see a large and significant reduction in the burden of the cancer and the symptoms from the cancer,” he said.

Unfortunately, however, it’s important to remember that Pluvicto is not a cure.

“I think it’s important that patients understand … Pluvicto is really meant to be used to dramatically reduce the burden of the cancer and give more time and give better quality of life, but also open up more opportunities for follow-up treatments potentially on clinical trials that are designed to give us even a bigger upside,” Dr. Wise added.

What about side effects?

According to Dr Wise, there are three main side effects from the treatment, including:

  • Dry mouth
  • Marrow side effects (low red blood cells or platelets)
  • Stomach upset and fatigue

“Although the dry mouth with Pluvicto is really not very significant. It comes on very slowly so the dose can be reduced or the number of treatments can be minimized in order to prevent that toxicity from becoming significant.”

“Pluvicto can lower the red cells, the white cells or the platelets. And so it’s important that those are monitored very carefully before and after each cycle to be sure that the next cycle should be continued at the same dose.”

“And finally, some people report some stomach upset and fatigue. Pluvicto has only been studied in men who’ve already been treated with prior chemotherapy and a novel hormonal agent. So these are men with metastatic disease who’ve been through a lot. The cancer has led to symptoms, the treatment has led to symptoms. So any fatigue or nausea is not to be minimized,” Dr. Wise added.

“But generally we’re talking about a week where there’s some fatigue, some stomach upset, usually not requiring medications, and then really those symptoms tend to dissipate and men tend to do really well.”

Cutting-Edge Diagnosis and Treatment of Prostate Cancer with Theranostics

Genetic Testing

How Molecular Testing Can Impact Your Treatment Plan

Next-generation sequencing (NGS), a type of molecular testing, can help you and your doctor decide on the best course for prostate cancer treatment. This sort of testing may be recommended for men with advanced prostate cancer. Genetic or germline testing is also considered very important in both early and advanced stages of prostate cancer.

Here, Dr. Michael Carducci, a medical oncologist at Johns Hopkins Kimmel Cancer Center, explains how these tests help doctors determine the best course of care for men with prostate cancer.

Molecular testing for prostate cancer

What are prostate cancer mutations?

DNA damage is an ongoing occurrence that is repaired naturally when cells are healthy.

In healthy cells, DNA may sometimes act strangely. When that happens, DNA is repaired via several mechanisms including the homologous recombination repair (HRR) pathway. In the presence of HRR gene mutations (HRRm), cells are unable to effectively repair broken DNA — and that could lead to cancer.

The most famous of these homologous recombination repair genes are called BRCA1 and BRCA2.

HRR gene mutations occur in approximately 25% of patients with advanced prostate cancer.

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Mutations in HRR genes can be hereditary (germline) or sporadic or nonhereditary (somatic).

Around 5% to 15% of prostate cancers develop due to a risk inherited from family (hereditary cancer). When men have certain special gene changes they inherited, the prostate cancer can be tougher than in those without these gene changes.

If a person’s dad, brother, or son had prostate cancer, his chances of inheriting it become two to three times higher. This chance gets even more likely if more family members had prostate, breast, or ovarian cancers. The age when a close family member got cancer matters, too.

Up to 15% of men with cancer that has spread (metastatic cancer), and 10% of men with cancer that hasn’t spread, have changes in certain genes related to fixing DNA, like BRCA2, BRCA1, ATM, CHEK2, PALB2, and other DNA repair genes (MLH1, MSH2, PMS2, MSH6).

How is molecular testing performed?

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Molecular testing “gives us more tools to personalize that treatment,” Dr. Hannah McManus, a genitourinary oncologist, at Duke Cancer Center Genitourinary Clinic, told SurvivorNet.

“It gives us more information to understand how a cancer may respond to a treatment. And it gives us more information to make other new treatment options, things like clinical trials or potential options for you, as well.

“And I think that’s just going to increase as we do more and more studies and understand how these genetic changes drive prostate cancer. It helps us personalize that treatment and our discussion together even more. So I think it’s really exciting.”

National Comprehensive Cancer Network (NCCN) guidelines recommend germline and tumor testing for HRRm in all patients with metastatic prostate cancer and consideration of testing for patients with regional disease.

“I think really any patient with prostate cancer can ask their doctor if they should get germline genetic testing or genetic testing, looking to see if they have an inherited mutation that may have made them more at risk for prostate cancer. That can impact your treatment and it can impact your family and potential screening for cancers for them in the future,” Dr. McManus added.

For advanced prostate cancer, molecular testing matters


Immunotherapy for late stage prostate cancer

For the many veterans currently living with late-stage prostate cancer, a treatment option called immunotherapy has emerged as a beacon of hope.

What is immunotherapy?

The immune system uses its white blood cells to attack cells in the body that are abnormal or foreign. Cancerous cells have the ability to prevent the immune system from doing its job. The cancer produces certain proteins to protect the tumor from white blood cells. As a result, the body does not recognize the tumor as abnormal.

Immunotherapy drugs stop this from happening and ensure the white blood cells recognize the cancer cell properly and attack it. The cancer cells themselves are not necessarily difficult to fight. However, they continue to divide rapidly. So, immunotherapy drugs help a patient’s immune system control their cancer on its own before it can spread.

What is immunotherapy? An explainer in Star Trek terms

PARP inhibitors

Taken as a pill, PARP inhibitors are a form of targeted therapy that works on the genetic level, by preventing cancer cells from repairing their damaged DNA.

“It’s really important that we have molecular testing available for cancer because these new treatments are based on having molecular testing showing that there is [something known as a BRCA mutation], that would make your cancer potentially susceptible and most responsive to this type of treatment,” Dr. McManus explained.

Some examples of PARP inhibitors that could potentially be helpful include:

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Lynparza and Rubraca are approved for men with metastatic castrate-resistant prostate cancer (mCRPC) either before or after chemotherapy, as monotherapy drugs. Monotherapy refers to when doctors use one specific drug to fight your cancer instead of a combination of drugs.

These medications are only for patients who have certain mutations, such as BRCA 1 or 2 mutations.

More recently, the FDA approved a fixed dose combination of two drugs (niraparib and abiraterone) with prednisone. This new medication is a once-daily dual-action tablet (brand name Akeega). It includes a PARP inhibitor (niraparib) and an androgen biosynthesis inhibitor (abiraterone acetate).

Akeega is indicated with prednisone to treat adults with mCRPC and BRCA-positive mutations.

Other good news for metastatic castration-resistant prostate cancer has been the recent approval by the FDA, of the combination of enzalutamide (brand name Xtandi) and talazoparib (brand name Talzenna).

Talzenna is also a PARP inhibitor and this new combination (Xtandi + Talzenna) is approved for the treatment of adult patients with homologous recombination repair (HRR) gene-mutated metastatic castration-resistant prostate cancer (mCRPC).

It’s important to note that this medication is an option for adult patients with homologous recombination repair (HRR) gene-mutated metastatic castration resistant prostate cancer (mCRPC).

HRR gene mutations occur in approximately 25% of patients with advanced prostate cancer.

What is a homologous recombination deficiency?

Homologous recombination deficiency, or HRD, is a genetic factor in which cells have difficulty repairing themselves. These cells can then become cancerous. The reverse is also true: Genetic mutations in cancer can also cause HRD.

“Homologous recombination is when our genes are being transcribed cell is being split into two daughter cells,” explains Dr. David Engle, a gynecologic oncologist at Baptist Medical Group in Memphis, Tennessee. “If there is a replication error that occurs while those two cells are being split, then you have homologous recombination where they go back incorrectly.”

According to Dr. Engle, the human body has a set of genes whose sole purpose is to scan and correct these ‘transcribed’ cells. “They’ll actually remove that abnormal area and place the correct sequence back in there,” he says.

But because this process involves several different genes, if there is a defect in any one of them, it may affect the body’s ability to rewrite damage, or incorrect codes, that are put into our genome. “If we have the wrong codes, that could potentially lead to cancers,” adds Dr. Engle. “Meaning, if our genes are not correctly interpreted from the parent cells, that may increase our risk for developing cancer.”

Immunotherapy Vaccine

You may have heard about Provenge (also known as Sipuleucel-T), which is the only immunotherapy vaccine currently FDA-approved for the treatment of late-stage prostate cancer. Like other immunotherapy drugs, it uses a patient’s own immune system to attack the cancer cells. The vaccine is usually given to men who have early metastasis and are not responding to androgen deprivation therapy.

The treatment involves taking immune cells out of the patient’s body, exposing them to proteins made by the tumor and then putting those cells back to fight the cancer. The vaccine is showing “phenomenal responses” according to Dr. Stephen Freedland, Director of the Center for Integrated Research in Cancer and Lifestyle at Cedars-Sinai Medical Center.

However, this treatment is less commonly used now given the many excellent options available to men with this disease.

What is the immunotherapy vaccine?

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Provenge works differently from other cancer treatments, such as chemotherapy or hormone therapy. Unlike these treatments, this drugs may not lower your PSA level. The goal of treatment with Provenge is not to lower PSA level, it is to extend life and activate your immune system to fight your prostate cancer.

When is the right time for Provenge Immunotherapy?

It may be considered before or after receiving other treatments for advanced prostate cancer. Provenge has no contraindications, and does not preclude other treatments for prostate cancer.

Common side effects

The most common side effects are generally mild to moderate and are well-tolerated.

Most infusion-related side effects are resolved within 1 or 2 days.

However, there are potential risks associated with this drug. Around 71% of men treated with Provenge developed an acute infusion reaction.

The most common adverse events were chills, fever, and fatigue.

Only 1.5% of men discontinued their treatment with due to adverse events

Potential side effects of targeted therapy

The negative effects of targeted therapy can be quite severe, so it’s important to inform your physician as soon as you experience any abnormal symptoms. Those who are taking more than one immunotherapy drug, referred to as combination therapy, are at an increased risk of experiencing side effects.

Fatigue is one of the most common side effect, affecting more than half of people who take these drugs.

Common immunotherapy side effects include:

  • Nausea/vomiting
  • Decreased white blood cell count
  • Anemia: decreased hemoglobin
  • Constipation
  • Decreased appetite

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There were several other potential side effects as well. Before beginning any new treatment, it’s important to discuss potential side effects with your doctor or medical team.

To help manage the side effects, the healthcare provider may:

  • Reduce the dose
  • Delay the dose
  • Stop the medication

Side effects are usually worst at the beginning of treatment, but they should gradually improve the longer you are on the medication. The first month on maintenance therapy can be a little rocky, since doctors are still trying to adjust the dose for the patient.

After the first month or two, you should level out and start to feel more comfortable on the medicine.

Clinical Trials

SurvivorNet's guide to clinical trials: What are they and should you consider enrolling?

Sometimes, joining a clinical trial is a good decision.

Every life-saving or life-extending treatment that’s available today for cancer started its journey in a clinical trial. A clinical trial is a study that helps doctors better understand cancer, and discover safer and more effective ways to treat it. Clinical trials also give patients a chance to try a treatment before it’s approved by the U.S. Food and Drug Administration.

This is SurvivorNet’s guide to clinical trials, where we’ll explain what clinical trials are, why they’re so important and how to go about taking part in one. These trials can give patients access to incredible new therapies, or what some would call “tomorrow’s medicine,” today.

If you’re looking for a clinical trial, check out SurvivorNet’s simple Clinical Trial Finder.

Expert shares why he'd choose a clinical trial for himself

What is a clinical trial?

A clinical trial is a research study involving volunteers that looks into using new drugs or therapies. The goal of these studies is to test if new treatments are safe and effective.

Clinical trials can be an option for people with cancer at many points during the treatment process. Your doctor may have spoken with you about possibly enrolling in a trial if you have advanced disease or if there’s a drug that’s currently considered investigational that may work better than the standard for you.

A lot of patients may feel uncomfortable about the thought of participating in a trial, but the trials can provide amazing opportunities for patients. For one thing, they give patients access to a bevy of new drugs that are currently being developed by pharmaceutical companies.

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Do I have to pay for a clinical trial?

Most of the time, when a person takes part in a clinical trial, the study’s sponsor pays for the treatment and any additional care (like extra doctor visits) that may be required during the trial. Some sponsors even pay for travel to and from appointments or treatment centers. Patients should make sure they ask what exactly will be paid for before signing up to be part of a trial.

The Affordable Care Act also mandates that health insurance companies pay for routine patient care costs while people are enrolled in clinical trials. This means that any care that would normally be covered for a cancer patient is still paid for throughout the trial, according to the American Cancer Society.

Clinical trials: What else to consider

In the U.S., all new drugs have to go through clinical trials before the FDA will approve them. In addition to being potentially live-saving for patients, these trials are also necessary to advance science and cancer treatments.

However, participating in a trial comes with risks as well, and it’s important to talk to your doctor about this before getting involved in one. Some risks to consider are:

  • The chance of harm and/or side effects due to experimental treatments
  • Researchers may be unaware of potential side effects for experimental treatments
  • The treatment may not work for you, even if it has worked for others

Still, joining a clinical trial comes with benefits as well. You will be given access to treatments that could be life-saving, but simply haven’t made it through the approval process yet.

Clinical trials: What is an 'exceptional' responder?

Who Can Sign Up for Clinical Trials?

If you’re interested in taking part in a clinical trial, the first thing to do is to speak to your doctor about the possibility of enrolling.

Blindly searching trials on the internet might not be the best advice available; using either the government’s clinical trials database or SurvivorNet’s resources specifically for cancer patients is more likely to yield results you can actually use.

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However, just because you’re willing to take part in a clinical trial doesn’t necessarily mean you will be able to join. These trials have specific criteria that patients need to meet in order to take part. At the end of the day, even though these trials can have incredible results and provide you with access to cutting-edge therapies, these are controlled experiments.

For each trial, there will be certain inclusion and exclusion criteria.

However, if you are not eligible to participate in a trial, you may still be able to get access to the new drugs due to recent legislation.

Sometimes, patients may be excluded from certain trials if their cancer has spread to their brain. If the metastases aren’t under control, the patient may be unable to participate because researchers are concerned that they won’t be able to complete the whole study.

There are options for people who may not be eligible for the clinical trials they wish to participate in, but still want to try the therapies.

A few years ago, the U.S. passed something called “Right to Try” legislation. This gives terminally ill people access to highly experimental drugs that are in “phase one” of the clinical trial process.

Your doctor may also request access to a single patient IND (investigational new drug) on your behalf, which can also give access to treatments that the FDA has not yet approved.

Why do people get excluded from clinical trials?

‘Informed consent’ for a clinical trial

The informed consent process for a clinical trial will usually involve the research team presenting you with both standard consent forms as well as any other relevant information you may need about the treatments to know whether you wish to begin a clinical trial or stay in one if you’re already enrolled.

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Before you enroll in a trial, you must be given the opportunity to read the consent documents fully and to ask any questions you may have. The documents will likely contain the following:

  • The purpose of the research
  • Any risks and benefits expected from the research
  • Information about procedures that may cause discomfort (like frequent blood tests)
  • Any alternative procedures the patient might consider instead
  • How the patient’s information will be kept private
  • How long the study is expected to take
  • A form confirming you are participating in research voluntarily
  • Whether any compensation or additional medical care is available if some sort of injury occurs
  • The patient’s rights (like the right to stop research in the middle of the trial)
  • Contacts for any patient questions

Living with Cancer

Living with prostate cancer

We understand that a diagnosis of prostate cancer can be overwhelming, and the prospect of treatment might feel like an arduous journey.

However, it’s crucial to recognize that life after prostate cancer can indeed be fulfilling, and there are ways to navigate this path with hope and optimism.

Surround yourself with a support network of fellow veterans, friends, and family who can provide encouragement and understanding.

As you embark on this journey, remember that your military training has equipped you with the resilience needed to overcome adversity.

Prostate cancer & sexual side effects

It may be a taboo topic and it may not be at the forefront of your treatment conversation, but it’s important to know that a healthy sex life is still possible after a prostate cancer diagnosis — though it may be different.

A large percentage of men suffer from problems in the bedroom, or sexual side effects, as a result of radiation or surgery. Some men may have trouble getting or maintaining an erection, while others can no longer have an erection at all. But there are ways men can get back to being sexually active, Dr. James Brooks, Chief of Urologic Oncology at Stanford Medicine, explained.

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There are several different medications on the market that work for prostate cancer survivors. We’ve all heard of Viagra and Cialis, as well as different devices including the Vacuum Erectile Device (VED).  A prosthesis is also an option.

“Prostate cancer can require couples to think more broadly about their intimacy,” Dr. Brooks explained. He suggested men talk about with their urologist and perhaps seek counseling with a sex therapist.

What treatment options are out there?

When to consider a penile prosthesis

Vet Survivor Stories

Inspiring survivor stories

After — or during — the cancer treatment process, it can be really helpful to hear the stories of people who have been through the same struggles and how they coped and learned to live with, and move on from, the disease.

In this section of our Navigating the Path Forward: A Guide for Veterans Facing Advanced Prostate Cancer guide, we’re sharing the stories of incredible (and inspiring) prostate cancer survivors.

A devastating diagnosis & an innovative new drug: A WWII vet's story

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George Crawford, a native New Yorker, has been through a lot in his 81 years. He lived through World War II, he was in the Navy during the Cuban Missile Crisis; he’s done a lot of living and he has a lot of stories to tell. But receiving his prostate cancer diagnosis still came as a big shock.

“When my doctor told me that I had stage four cancer, a very, very aggressive cancer, he didn’t say in so many words I had four months to live … but he gave every signal that he could that this was not a good story at all,” George says. “I told my wife, and I told immediate family, but I asked them not to tell anybody else because I hadn’t even come to terms with it myself.”

Despite his grim prognosis, George happened to get lucky. He was undergoing a summer-long regimen of chemotherapy when his doctor went away to a symposium and was told about a drug called Zytiga — a type of hormonal therapy that blocks the production of androgens, which are the hormones that help prostate cancers to grow. “He came back and he said, there’s a new protocol, you start taking Zytiga as quickly as you can,” George says. “He said I [was] really, basically, the first person in America to do this.”

And the Zytiga worked for George — over time, his prognosis got better and batter. And after all was said and done, George says something good did come out of his cancer journey — it brought his family closer together.

Helping the wave of veteran aviators getting diagnosed

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For as long as he can remember, Mike Crosby wanted to fly.

When he got prostate cancer, his wife explains, “I knew he would land this, just like he landed everything else.”

Crosby is now 63-years-old. He’s a retired Naval Commander whose call sign was “Bing.” He beat prostate cancer three times and has now turned his diagnosis into a new life of service by offering much-needed hope and resources to veterans also dealing with the disease.

“We’re not taking care of these guys, and we need to do a better job,” Crosby, 63, told SurvivorNet from his home in San Diego.

Make sure to read Crosby’s full Story

More Resources

Living with Prostate Cancer

We have made it to the end of the Navigating the Path Forward: A Guide for Veterans Facing Metastatic Prostate Cancer series. We hope that you were able to find some helpful information and some of the support you are looking for as you embark on your journey as a cancer survivor.

Remember that life after prostate cancer can be a new chapter filled with hope, renewed purpose, and meaningful experiences.

Be sure to check out SurvivorNet’s designated Prostate Cancer section for a breakdown of the basics of the disease, treatment options, and what you can expect as a survivor.

Embrace the support available to you, and don’t hesitate to seek guidance from fellow veterans who have navigated similar paths. Your journey may be challenging, but with the strength that defines you as a veteran, there is immense potential for a fulfilling life beyond prostate cancer.

At SurvivorNet, we’re here to help survivors navigate the complex world of living with cancer. Thank you for being part of the family!


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