If you have an advanced stage of prostate cancer (stage III and IV), it means the disease has spread outside your prostate gland. Doctors can treat this type of cancer, but they can’t cure it. Still, there are good options that can ease your symptoms and help you live a long, active life.
Talk with your doctor about the treatment that’s best for you. Ask them about the kinds of side effects you might have. You’ll want to choose a path that gives you the best results with the fewest risks.
Your main options for treating advanced prostate cancer are:
- Hormone therapy
- Watchful waiting or active surveillance
Radiation therapy uses high-energy X-rays to kill cancer cells. It can help shrink tumors and ease bone pain and other symptoms.
Doctors might give you this therapy in a few of different ways:
External beam radiation therapy (EBRT) focuses X-rays on your prostate from a machine outside your body. The doctor will direct the radiation right to the gland and adjust the dose to target the cancer without damaging other parts of your body. The treatment takes just a few minutes, and it doesn’t hurt. You’ll probably go to a clinic and get it 5 days per week for about 7 to 9 weeks.
Brachytherapy uses small pellets, about the size of rice grains, which slowly give off radiation inside your prostate. Doctors will give you medicine to put you to sleep or make your body numb, then put the pellets in through thin needles.
Radiopharmaceuticals use radioactive isotopes to target cancer cells that have spread elsewhere. It is generally taken intravenously. They include radium 223 (Xofigo), strontium-89 chloride (Metastron), or samarium-153 lexidronam (Quadramet) which target cancer that has spread to the bones. It uses a type of radiation that sticks to bone minerals. Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) targets a molecule on the surface of prostate cancer cells called PSMA.
Your doctor will do everything they can to keep from damaging other parts of your body, but some men have side effects from radiation, such as:
- Diarrhea, blood in their stool, and other bowel problems
- Trouble controlling urination, or a leaky bladder
- Erection problems
- Feeling tired
Male hormones like testosterone fuel the growth of prostate cancer cells. The goal of hormone therapy is to keep your body from making these substances and keep your tumor’s cells from using them. Your doctor might call it “androgen deprivation therapy.”
Depending on the stage of your disease, you may get hormone therapy before or after radiation.
There are a few different types of drugs you might take, including:
GnRH agents. They work in different ways to keep your body from making luteinizing hormone (LH), which it needs to make testosterone. Drugs include:
- Buserelin (Suprefact)
- Degarelix (Firmagon)
- Goserelin (Zoladex)
- Leuprolide (Eligard, Lupron Depot)
- Triptorelin (Trelstar)
GnRH receptor antagonist. Currently, there is just one, relugolix (Orgovyx), which is taken orally. It works by blocking the pituitary gland from making hormones, so it reduces the amount of testosterone the testicles are able to make.
Anti-androgens. They stop prostate cancer cells from using any male hormones, called androgens. You might take them along with a GnRH agent.
Newer types of hormone therapy include:
- Abiraterone acetate (Zytiga), which stops prostate cancer cells (and other cells) from making androgens. Your doctor might suggest it if you’ve already tried other hormone therapies.
- Enzalutamide (Xtandi), which blocks cells from using androgens. You might get it if you’ve tried other hormone therapies and the chemotherapy drug docetaxel.
Hormone therapy can cause side effects, such as:
- Low sex drive
- Erection problems
- Breast growth and tenderness
- Hot flashes
- Bone thinning
Depending on how far your cancer has spread, your doctor might be able to remove it with one of two operations.
Radical prostatectomy. If your tumor hasn't spread much beyond the prostate gland, your doctor might remove the whole organ, plus some of the tissue around it. The most common way to do this is through a cut on your lower belly. You might also get radiation after surgery to kill any cancer cells left behind.
You’ll be in the hospital for a few days, but you can usually go back to normal activities in 3 to 5 weeks. Afterward, you might have problems controlling your urine, trouble getting or keeping an erection, and a hard time getting a woman pregnant.
Transurethral resection of the prostate (TURP).This surgery does not cure the cancer, but it can ease symptoms, like problems controlling urine. Your doctor will put a tool called a resectoscope into your prostate. It delivers electricity or heat that removes a part of the gland. You’ll get medicine to put you to sleep or to make your body numb during the surgery.
You’ll recover in the hospital for 1 or 2 days, and you can usually go back to your normal activities after a couple of weeks. You may see some blood in your urine afterward, and you could be at risk for an infection.
Watchful Waiting or Active Surveillance
Prostate cancer treatments can have side effects. If you're worried about these risks, you can decide to hold off on these treatments and see if your tumor grows. Waiting is also an option if you’re older, your cancer is growing slowly, or you don't have symptoms that bother you.
Waiting does not mean that you do nothing about your cancer. Your doctor will keep a close eye on the tumor and watch for any signs that it’s getting worse.
Watchful waiting means you and your doctor will look out for symptoms. The doctor may do tests from time to time to make sure the cancer hasn't grown.
Active surveillance means your doctor will do tests, including PSA blood tests and rectal exams, usually about every 3-6 months to check on it. You may also have a biopsy, when a doctor takes a small piece of tissue from your prostate and checks it for cancer.
If radiation, hormone therapy, or surgery isn't right for you, your doctor might suggest a few other treatments:
Chemotherapy. Drugs kill cancer cells throughout your body. You might get chemo if the disease has spread outside your prostate and hormone therapy isn't working. It might also ease symptoms.
Vaccine therapy. Most vaccines help your body prevent disease, but some also treat conditions like cancer. Sipuleucel-T (Provenge) removes cells from your blood and exposes them to a protein from prostate cancer cells in a lab. Then your doctor injects the cells back in your body to attack the cancer. This treatment is for men with advanced disease when hormone therapy has stopped working.
Bisphosphonates. These drugs relieve the pain of prostate cancer that has spread to bones.
Clinical trial. Scientists are always looking for new ways to treat prostate cancer in clinical trials. These trials test new drugs to see if they're safe and if they work. They often are a way for people to try new medicine that isn't available to anyone. Your doctor can tell you if one of these trials might be a good fit for you.