T4, N0, M0, any prostate-specific antigen (PSA), any Gleason.
Any T, N1, M0, any PSA, any Gleason.
Any T, any N, M1, any PSA, any Gleason.
Extraprostatic extension with microscopic bladder neck invasion (T4) is included with T3a.
Treatment selection depends on the following factors:
Coexisting medical illnesses.
The presence of distant metastases (most often bone) or regional lymph node involvement only.
The most common symptoms originate from the urinary tract or from bone metastases. Palliation of symptoms from the urinary tract with transurethral resection of the prostate (TURP) or radiation therapy and palliation of symptoms from bone metastases with radiation therapy or hormonal therapy are an important part of the management of these patients. Bisphosphonates may also be used for the management of bone metastases.
Standard Treatment Options for Stage IV Prostate Cancer
Standard treatment options for stage IV prostate cancer include the following:
External-beam radiation therapy (EBRT) with or without hormonal therapy.
Palliative radiation therapy.
Palliative surgery with transurethral resection of the prostate (TURP).
Watchful waiting or active surveillance.
Hormonal treatment is the mainstay of therapy for distant metastatic (Jewett stage D2) prostate cancer. Cure is rarely, if ever, possible, but striking subjective or objective responses to treatment occur in most patients.
Hormonal manipulations effectively used as initial therapy for prostate cancer include the following:
Orchiectomy alone or with an androgen blocker as seen in the SWOG-8894 trial.
Luteinizing hormone-releasing hormone (LH-RH) agonists, such as leuprolide in daily or depot preparations. These agents may be associated with tumor flare when used alone; therefore, the initial concomitant use of antiandrogens should be considered in the presence of liver pain, ureteral obstruction, or impending spinal cord compression.[4,5,6,7][Level of evidence: 1iiA]
Leuprolide plus flutamide; however, the addition of an antiandrogen to leuprolide has not been clearly shown in a meta-analysis to improve survival.
In some series, pretreatment levels of PSA are inversely correlated with progression-free duration in patients with metastatic prostate cancer who receive hormonal therapy. After hormonal therapy is initiated, a PSA reduction to beneath a detectable level provides information regarding the duration of progression-free status; however, decreases in PSA of less than 80% may not be very predictive.
Orchiectomy and estrogens yield similar results, and selection of one or the other depends on patient preference and the morbidity of expected side effects. Estrogens are associated with the development or exacerbation of cardiovascular disease, especially in high doses. DES at a dose of 1 mg per day is not associated with cardiovascular complications as frequent as those found at higher doses; however, the use of DES has decreased because of cardiovascular toxic effects. DES is no longer commercially available in the United States.