There is no cure for advanced prostate cancer. However, there are various treatments that can help you reduce symptoms, relieve pain, and control the spread of your cancer for many years.
Being diagnosed with cancer—advanced, localized, or metastatic—can be difficult to deal with.
There are many types of advanced prostate cancer:
- Cancer that has spread beyond the prostate—”advanced cancer”
- Cancer that has spread beyond the lymph nodes to other parts of the body (most commonly the bones)—”metastatic cancer”
- Cancer that comes back after the initial treatment (surgery, radiation therapy, or hormone therapy)—”recurrent cancer”
- Cancer that has been treated with hormone therapy, but has become hormone‑resistant—”hormone-resistant cancer”
In most cases, the most effective treatment for advanced prostate cancer is still hormone therapy. However, recent studies have shown that chemotherapy can be effective for castrate‑resistant prostate cancer or CRPC cases. This type of cancer, also called “hormone‑refractory prostate cancer”, is defined by the continuing growth of the cancer despite hormone therapy.
Diagnosing advanced prostate cancer
The following factors are taken into consideration while screening for advanced prostate cancer:
- racial origin
- family history
- state of health
- medical background and existing comorbidities
- PSA level
- biopsy results
- Gleason score
Your Gleason grade and score
To determine the grade of your prostate cancer, a tissue sample of prostatic tumour cells is obtained by biopsy and is then examined under a microscope. By examining the similarities or differences between cancer cells and normal prostate cells, your doctor can determine if you have high‑ or low‑grade cancer.
Cells are graded from one to five on a scale of aggressiveness:
- Grade 1–2: low grade
- Grade 3: medium grade
- Grade 4–5: high grade
Grades are given to the most common pattern and second-most common pattern of cancer growth. The two grades are added together to give the Gleason score. The higher the Gleason score the more aggressive your cancer.
Your biopsy results
If the biopsy confirms the presence of cancer, it may be necessary to undergo further testing in order to determine how far the cancer has spread.
These additional tests are especially important for men with particularly severe symptoms such as an induration or bump extending into the prostate, a high PSA level, or a prostate biopsy that reveals an aggressive cancer.
- A more comprehensive PSA test
- A lymphadenectomy to determine whether ganglion metastases are present (a surgical procedure performed under general anesthesia)
- A pelvic tomodensitometry (CT scan) to examine abdominal and pelvic anatomy in order to determine whether or not the patient is intermediate-high-risk or high-risk for metastases.
- A bone scan to see if the cancer has spread into the bone (bone metastases) for high-risk patients
- A pelvic magnetic resonance imaging (MRI) to examine abdominal and pelvic anatomy in order to establish if metastases are present.
The clinical stage of your prostate cancer
Your urologist will analyze the results of the tests you have done and will attribute a stage for your cancer depending on the size and spread of the tumour. The various stages of the TNM system are as follows:
Primary tumor (T)
- T1: The tumour is confined within the prostate and is not detectable (found during a PSA test).
- T2: The tumour is localized, but can be felt during a digital rectal exam.
- T3: The tumour has spread beyond the prostate.
- T4: The tumour has reached nearby structures (neck of the bladder, rectum, etc.)
Regional lymph nodes (N)
- N0: There is no cancer in nearby lymph nodes.
- N1, N2, and N3: One or more lymph nodes are affected.
Distant metastasis (M)
- M0: No metastasis beyond the lymph nodes
- M1: Metastases have formed in the bones or other distant organs.
See Biopsy and Diagnosis
Advanced prostate cancer, or metastatic prostate cancer, is cancer that has spread to other areas of the body far from the prostate. Prostatic metastases usually form in the bones and lymph nodes. Bone pain, fatigue, and urinary disorders are among the symptoms associated with advanced cancer. For more information, see our Living with cancer section.
Advanced prostate cancer is more difficult to treat than early cancer that is still confined within the prostate:
- Metastatic prostate cancer (cancer that has spread to the lymph nodes and to other parts of the body) and, in most cases, advanced cancer and localized (cancer that has spread beyond the prostate to neighbouring tissues but no further) prostate cancer are incurable.
- Treatment can help prolong your life, slow the growth of cancer, relieve symptoms, and improve your quality of life.
- The good news is that treatment (medication, radiation therapy, and surgery) is still possible. The chosen treatment depends on a number of factors:
- Treatments already received
- Location of your recurrence
- Existing conditions such as heart disease or diabetes
- Personal preferences
In most cases, the most effective treatment for advanced prostate cancer is still hormone therapy. Other treatment options include radiation therapy, chemotherapy, and surgery.
Cancer that comes back after a radical prostatectomy or radiation therapy—whether or not these treatments were used in conjunction with hormone —is considered to be advanced cancer. Whether or not the recurrence is local or metastatic, it is still considered to be advanced
Local recurrence: your cancer can reappear in the same place it was before your first treatment. Local recurrence means that some cancerous cells survived treatment and remained in the prostate region
With metastases: your cancer may show up in another part of your body. This is called a metastatic recurrence.
Recurrences can occur at any time. After treatment, the risk of recurrence decreases as the years pass. Although you often hear that the “magic number” of years is five, but there is no absolute guarantee, which is why long-term follow-up is still required. See Dealing with Recurrence.
The doctor usually detects a recurrence when you PSA level begins to climb again. The speed at which your PSA level increases (doubling time) with the grade and stage of your removed tumour will help the doctor determine whether it is a local or metastatic recurrence. The higher these factors, the more likely it will be a metastatic recurrence.
Hormone therapy is the main treatment for recurrent prostate cancer. When prescribed immediately, hormone therapy can significantly impede the progression of your cancer. Palliative care may also be added to reduce your symptoms of bone pain.
Recurrence after radical prostatectomy
In most cases, PSA levels provide an early warning, several months or years before a recurrence is widespread enough to cause problems or be detected by radiology or during a physical exam
Radiation therapy with or without hormone therapy – In some cases of localized recurrence, it is even possible to completely cure the disease through radiation therapy alone or in combination with hormone therapy.
- If your recurrence appears to be localized, slow‑growing and not particularly worrisome in any other respect, the doctor may recommend that you forgo treatment altogether. For example, in a case where PSA levels begin to rise five years after an operation, there will likely be no metastasis for another 10 or 15 years.
- If you are already quite old or you have a short life expectancy, it might be a better idea to avoid or delay treatment instead of introducing hormone therapy that will impair your quality of life.
- If you are younger and have a longer life expectancy, the doctor will probably take a more aggressive approach and prescribe radiation therapy, either alone or in combination with hormone therapy.
Once the decision has been made to forgo radiation therapy, you can choose to wait for a significant increase in PSA levels before beginning hormone therapy, to postpone the side effects described above.
If the progression of the disease becomes worrisome at any time, treatment can begin immediately. Every case is unique. You need to weigh the pros and cons of each option carefully in close consultation with your doctor.
Recurrence after external radiation therapy or brachytherapy
Hormone therapy – Hormone therapy is often considered the standard treatment for cancer recurrence after radiation therapy. It is usually prescribed for life on an ongoing basis. In the absence of metastasis, intermittent hormone therapy is a valid option. Again, if the recurrence is slow‑growing, the patient can choose to delay treatment.
Surgery – In rare cases, the doctor will recommend a radical prostatectomy to remove your prostate. This only happens if the doctor is convinced that the recurrence is limited to the prostate. The few candidates who undergo this procedure should expect more severe side effects than those experienced with radical prostatectomy as the first treatment.
Focal therapy – Other options are currently being studied: cryotherapy and HIFU. These approaches are used only when the doctor believes the recurrence is still limited to the prostate. At the moment, neither of these techniques can be considered a viable alternative to standard treatment options for prostate cancer.
Other types of treatments are currently being tested for recurrence cases following radiation therapy. This will make more choices available for future patients
Advanced non‑metastatic cancer
There are some cases in which the locally advanced non‑metastatic cancer spreads beyond the prostate and become too advanced to benefit from radical prostatectomy or radiation therapy alone.
For example, stage T3 cancers (the cancer has spread beyond the prostate capsule) and T4 (the tumour has reached neighbouring tissue such as the bladder, external sphincter, or rectum) are not constrained to the prostate, even if there are no detectable metastases according to the bone scan and other diagnostic exams.
Hormone therapy – In these cases, hormone therapy is frequently recommended as a complement to radical prostatectomy or radiation therapy.
Please note: Radiation therapy is usually prescribed for stages T3+ and T4, since the cancer is too advanced to be treated surgically.
- Hormone therapy is generally prescribed for two or three years in combination with radiation. However, if the tumour is deemed worrisome enough, the doctor can immediately prescribe hormone therapy for life.
- Medical follow-up and regular PSA measurements allow the doctor to judge whether or not the cancer has stabilized. If your PSA levels begin to climb again, hormone therapy is resumed, generally for life; if they stay where they are for five years or more, the cancer is possibly cured.
Hormone therapy – When prostate cancer reaches the lymph nodes—confirmed with a lymphadenectomy (the surgical removal of lymph nodes which are then analyzed under a microscope) or strongly suspected based on the usual factors—the standard treatment is lifelong hormone therapy.
In some cases, the doctor may prefer to wait and monitor your PSA levels. In approximately 10 to 15 percent of nodal metastases, PSA levels remain stable for a number of years.
- With regular follow-up every three to six months, intervention is possible as soon as PSA levels begin to rise, months or even years before the cancer has metastasized anywhere else.
- The decision to wait is generally made when you want to maintain your sexual capacity for as long as possible.
Hormone therapy – Cancer that has spread to the lymph nodes may eventually attack the bones, particularly the pelvis and spine. When metastases are pronounced, your bones become very fragile and are easily fractured.
Hormone therapy is prescribed as soon as the doctor observes the presence of bone metastasis, whether or not there is also pain. The treatment is almost always continuous and for life.
Hormone therapy eases the pain and significantly prolongs your life. Additional palliative care can help relieve your symptoms or bone pain.
In 2014, after 10 years of research, it was found that patients live much longer and metastasis-related symptoms are delayed if hormone therapy is combined with docetaxel (chemotherapy) early on, rather than waiting for the cancer to become resistant to hormone therapy.
- Hormone therapy was given in the standard fashion but docetaxel chemotherapy was added for six treatments every three weeks.
- This regimen was much easier for patients to tolerate, and they also responded far better to the standard hormone therapy.
- In addition, older patients (over 70) benefited as much as younger ones.
- Chances of seeing the PSA levels drop to zero doubled and patients remained stable for much longer.
Hormone therapy can help keep your cancer under control for a number of years. However, over time, cancer can become hormone‑resistant and begin to grow and spread again, in other words, hormone therapy is no longer effective. Treatments for hormone‑resistant cancer do exist, but differ depending on whether or not metastases are present.
At every checkup, the doctor will do a blood test to monitor your PSA level.
- If the PSA level starts to rise, the doctor will monitor how long it takes to double. The shorter this period is, the higher the risk of recurrence and the more aggressive the recurrence will be. Your prostate cancer has developed into a castration‑resistant prostate cancer (formerly known as hormone‑refractory prostate cancer)
Hormone‑resistant cancer without metastases
With this type of cancer, metastases are not yet perceptible through diagnostic examinations, although it has already taken place on a microscopic level and will eventually cause pain.
The new generation of hormone therapy – Hormone‑resistant cancer without detectable metastases is currently the most studied area in prostate cancer research. Chemotherapy also offers hope as a potential treatment for this stage of cancer, thanks to positive results in patients suffering from castration‑resistant prostate cancer with detectable metastases.
- If the tumour becomes resistant to the initial hormone therapy treatment, another hormonal agent will be recommended. Among the new generation of hormone therapy agents, the two most commonly recommended agents are: abiraterone acetate (Zytiga) and enzalutamide (Xtandi). In this situation, your doctor will explain the treatment and side effects that may occur.
- You may also consider participating in a research protocol that will give you access to these new forms of therapy.
Hormone‑resistant cancer with metastases
Chemotherapy – If your hormone treatments do not have any effect or have little effect, or if your cancer‑related symptoms are significant and bothersome, chemotherapy is preferred.
Chemotherapy can also improve the patient’s general state after the disease has taken a tight hold. Dietary supplements (such as Ensure) and blood transfusions in cases of anemia are also useful.
You may also consider the possibility of participating in a research protocol that will give you access to these new forms of therapy
Additional palliative treatments may be added to reduce your symptoms or bone pain. To relieve pain, bone and other pain, analgesics, treatments to strengthen the bone, and even palliative radiation therapy are prescribed.
Palliative radiation therapy
Radiation therapy destroys metastatic cells in the bone that cause pain (in the spine, hips and back, for example). This does not change the course of the disease, but it can provide quick comfort and strengthen the bone, thereby reducing the risk of fractures.
External radiation therapy
- In most cases, palliative radiation therapy is used when pain-relieving drugs are insufficient or the bone has a high risk of breaking. However, because any area of the body can generally be irradiated only once, radiation therapy is usually a last resort.
- If the pain returns to the irradiated area, only painkillers and bone-targeted therapy can help. These medications can also be used in combination with radiation therapy.
- It is not administered in the 4 to 6 weeks following a transurethral resection of the prostate (TURP), in order to reduce scar tissue formation in the urethra (urethral stricture).
Systemic radiation therapy
Radium dichloride 223(Xofigo) is a drug administered in systemic radiation therapy that is injected into a vein. The radioactive substance travels through the bloodstream to where the cancer is growing. The agent then emits radiation that destroys cancerous cells. Radium dichloride 223 may be recommended if your cancer has become hormone‑resistant and has spread to the bones
Transurethral resection of the prostate – A transurethral resection of the prostate (TURP) can be an option for hormone‑resistant or androgen‑independent prostate cancer. This type of surgery helps relieve urinary tract obstruction symptoms caused by the prostate tumour.
Biological therapy may be an option for recurrent prostate cancer. The biological drug administered to men with recurrent prostate cancer is denosumab (Xgeva).
- Denosumab can help prevent fractures in men whose cancer has spread to the bones.
- It can also help prevent the spread of cancer to the bone in men with increased PSA levels but who show no signs that the cancer has spread to the bone.
If your prostate cancer has spread to the bones, bisphosphonates may be used to alleviate bone pain or prevent fractures in men with advanced hormone‑resistant prostate cancer. The bisphosphonate administered is Zoledronic acid (Zometa).
About palliative care
Pain is not present in all cases of recurrent prostate cancer. However, metastases to bones are common and these are often painful. The palliative care team specializes in pain control in cases where the situation is not straightforward. In this case, the palliative care physician may use a combination of medications (such as opioid analgesics, nonsteroidal anti-inflammatory agents, steroids, bisphosphonates), as well as asking for a radiation therapy assessment. Occasionally the physician will enlist the help of an anesthetist who can perform nerve blocks to reduce pain. Pains due to specific nerve involvement may require the use of medication for so-called “neuropathic” pain, such as gabapentin, tricyclic antidepressants or methadone.
Bladder, stomach and bowel symptoms may arise, requiring specific combinations of medications for their control. Laxatives are almost universally required to combat the side-effects of pain killers or the “lazy bowel” that is a frequent complication of prostate cancer. Lymphedema (manifest in prostate cancer as swelling of one or both legs) may also require attention and the prescription of a massage technique known as manual lymph drainage, special bandages or compression stockings. Fatigue is a common symptom. If this is due to anemia, blood transfusions may be recommended. If mobility is reduced, the occupational or physical therapist will prescribe regimes to help maintain functioning and independence.
If there are psychological or family concerns, the palliative care team is available as much to the family members as to the patient. They can help deal with social and financial worries. This is a time for honesty and openness amongst all concerned, and the palliative care team can help with any communication difficulties. Family meetings are often organized to deal with issues around death and dying. The team is available on a long-term basis to the family members if there are bereavement issues and individuals require grief counselling.
The palliative care team
The palliative care team may be consulted to help control symptoms. The team can help with pain or other symptoms at any stage of the illness. In the later stages, this team may help with advice on how to maximize functioning. Or the team may be called in to help with distressing psychological symptoms.
These teams operate in the home setting, in outpatient hospital clinics and on inpatient units. The palliative care network includes hospital services or hospices that can offer institutional inpatient care if there are particularly difficult symptom issues, or if the family cannot manage to give the care required at home. For more information on available services you can consult the Quebec Association of Palliative Care.
The inpatient hospital or hospice teams include:
- Physical or occupational therapist
- Social worker
- Pastoral worker (spiritual counsellor)
- Art or music therapist
- Bereavement counsellor
These individuals will work very closely with the patient and family members in an individualized program to help ensure the best quality of life possible. Usually, there are facilities for family members to stay overnight in the patient’s room. Sometimes, after a palliative care admission, the patient and family members feel able to resume home care.
Advanced illness may make people feel hopeless, that all is finished. However, with the re-organization of priorities there is much to hope for, achieve and even take joy in. One remembers that family, children and friends and whatever legacies one can organize are all important. It is paradoxical that the palliative phase can be a time of hope – not for life prolongation but for high quality and meaningful interactions. The palliative care team may be called upon to help you achieve this.
Other biological therapies
Biological therapies use natural or manufactured substances that imitate or block natural cellular reactions to kill, control, or change the behaviour of cancer cells. It is also called biotherapy or biological response modifiers (BRMs).
While biological therapies have been used for a number of years to treat other diseases, using BRMs as a cancer treatment is still relatively new.
Sipuleucel-T is a therapeutic vaccine used to treat cancer rather than prevent it.
This vaccine is made using white blood cells* taken from the patient’s blood and exposed to proteins* from cancerous prostate cells called prostatic acid phosphatase (PAP).
After this process, the cells are injected back into the same patient. The modified cells then incite the body’s other immune cells to attack the cancer.
Vaccines can be used to treat patients with metastatic prostate cancer, particularly when hormone therapy does not or no longer works.
Sipuleucel-T is administered by infusion 3 times every 2 weeks and costs US$93,000.
Gene therapy is a relatively new approach to cancer treatment. It is the intention with this therapy to alter the tumour or the patient so that the cancer can be eliminated more easily.
The Toronto General Hospital has used a virus to transport a gene (IL2) into the prostate before radical surgery in patients who have a likelihood of failing surgery. With the approach one injection is given directly to the prostate 4 weeks before surgery.
The early results have suggested that this type of treatment may encourage the body to kill small amounts of cancer cells that may have escaped from the prostate.
The hope with this and other treatments such as this is that one day an experimental approach to treating prostate cancer may prove to become a successful treatment.
Undergoing biological therapies
Every cancer is different and as such, each requires a different treatment plan. Your healthcare team will assess the frequency and duration of your biological therapy sessions.
Side effects of biological therapies
Biological therapy drugs circulate throughout the body, which is why side effects can affect the entire body.
- The severity of side effects depends on the type of biological therapy, the dosage of medication administered, the method of administration, and the administration schedule.
- Most biological therapy side effects can be treated with other medications. Side effects will fade once treatment is complete.
Traditionally, men with localized prostate cancer are offered either active surveillance or treatment with surgery and/or radiation.
Although surgery and radiation have comparable long‑term survival rates, they can be associated with significant morbidity, including incontinence and erectile problems.
On the other hand, active surveillance is not always acceptable to men with prostate cancer and their doctors.
Focal therapy aims to offer a compromise between these two options, because it is less invasive.
Types of focal therapy
Two focal therapeutic techniques, cryotherapy (or cryoablation) and high intensity focused ultrasound (HIFU) are currently being used extensively.
At present, however, neither can be considered a viable alternative to the standard treatment options for localized prostate cancer.
Traditionally, cryosurgery has been used to treat external tumours such as with skin cancer. Recently, some physicians have begun using it as a treatment for tumours that occur inside the body.
Cryotherapy uses extreme cold to destroy cancerous prostate cells. This new alternative to surgery and radiation is used in some Canadian healthcare centres.
- This procedure is done through the perineum (between the testicles and anus), like brachytherapy. Catheters are placed within the prostate gland and the temperature is lowered to extremely cold temperatures that cause cell death. This procedure should not be considered for patients with a large-volume prostate.
- The results to date are encouraging patients with persistent local disease that radiation therapy has failed to control. Recently, cryotherapy has become a viable alternative for some patients. This treatment is sometimes recommended when cancer recurs despite the use of other treatments.
- Although it is still too early to assess the long‑term efficacy of this treatment, short‑term results appear comparable to those of external beam radiation therapy in select patients.
- The future will show if this type of treatment will become another option for patients with localized prostate cancer.
- Possible risks and complications of cryoablation include erectile dysfunction, incontinence, and rectal injury.
High Intensity Focused Ultrasound (HIFU)
High-intensity focused ultrasound (HIFU) is a procedure in which a probe inserted into the rectum emits a focused sound wave at the prostate, raising the temperature and destroying cells. The treatment usually takes one to three hours, depending on the size of the prostate.
- HIFU has been used for several years in Europe and is now available in Canada. HIFU is not available in the United States because the FDA (Food and Drug Administration) has made no decision as to its safety or efficacy in the treatment of prostate cancer.
- This type of treatment targets the tumour and not the whole gland. It is recommended for patients with localized prostate cancer in one lobe.
- Interest in this treatment is growing and research is underway to assess the efficiency of this treatment as well as which patients will most likely benefit from this type of treatment.
- Possible side effects include urinary incontinence and erectile dysfunction.
Participating in a clinical trial
One way to access new treatments before they become widely available is to participate in clinical trials.
A clinical trial is a research study that uses volunteers, called participants, to test new ways of preventing, detecting, treating, or managing prostate cancer or other illnesses. Some clinical trials help determine whether or not a new drug or device is effective and safe.
Participating in a clinical trial is a valuable contribution to research as clinical trials answer important questions that can lead to better health outcomes. Participation can be a good way for participants to access free treatments.
To learn more about clinical trials speak with your healthcare team.
To get more information about clinical trials, please visit:
Questions for your healthcare team
To get answers to your questions, you need to be prepared. Before seeing your doctor or nurse, prepare a list of questions about your advanced cancer treatments. Making a list of questions before your doctor’s appointment and putting down on paper what concerns you can help calm you down.
- Keep a running list of your questions as they come to mind.
- Take a relative or friend with you.
- Remember that this is not your only chance to ask questions.
- Try to accept that uncertainty exists. The doctor does not have a definitive answer to every question.
Making a list of questions before your doctor’s appointment and putting down on paper what concerns you can help keep you calm.
- Will the cancer treatment I receive cause fatigue? If so, how intense will it be?
- Are there treatments to help control or relieve my fatigue?
- What options do I have if the treatment is not successful?
- What are the most likely side effects of the treatments you are recommending?
- Can other members of the healthcare team help me manage my fatigue?
- (If you are experiencing fatigue) is my fatigue caused by anemia? If so, how will it be treated?
- What are the most common side effects? How serious are they
- How soon will these side effects start and how long will they last?
- What can I do to manage the side effects?
- Are there symptoms that I should call you about right away?
- Who do I call? Who do I call after hours?
- Under what circumstances would my chemotherapy be delayed or reduced?
- Why may my chemotherapy be delayed or reduced?
- What can be done to make sure that my treatment is not delayed or reduced?
- Are there any current clinical trials relevant to my condition or treatment?
- If there are, would I be an eligible candidate for these trials?
- Is there any particular information I should know about these trials?
- Is there anything I should do before starting chemotherapy?
- I take medication regularly for other health reasons. Should I keep taking it?
- Can I take medicine if I get a cold?
- Can I take vitamins or herbal supplements?
- Should I eat before my treatment session? After?
- Are there special foods I should eat or avoid?
- Can I drink alcohol (beer, wine, spirits) during my treatment?
- Can I keep working?
- Are there activities I should avoid while receiving chemotherapy?
- Who can I contact if I feel emotionally troubled?
- Are there symptoms that I should call you about right away?
- Who should I call? After hours?
- What support services are available in my area?
- Are there any ongoing clinical trials that I may want to participate in?
- Should I be having this side effect?
- How long will side effects last?
- What can I do about these side effects?
- Are there symptoms that I should call you about right away?
- Who can I contact if I feel emotionally troubled?
- What support services are available in my area?
- Will I need further treatment?
- Which doctor will be responsible for my follow‑up care?
- How often do I have to see my doctor once my chemotherapy treatment is finished?
- Will I need follow‑up tests?
- What tests will I need and how often?
- What do I need to watch for?
- What do I need to report to my doctor?
- Who do I contact after hours?
- Will my family doctor be involved in my follow‑up care? How?
- Can I provide support to patients about to receive chemotherapy?