If you or your loved one has just been told by the doctor that prostate cancer has returned or that it is not responding to therapy, you probably have a million questions: Why isn’t the treatment working? What does this mean? What options do I or my loved one have? You may be feeling anger, frustration, and even fear, but it is incredibly important that you work closely with the doctor to consider your options.
This section describes what to expect and what treatment options are available to you or your loved one if prostate cancer has come back after receiving therapy or is not responding to hormone therapy. It also describes questions you may want to ask the doctor.
When you or your loved one was first diagnosed with prostate cancer, the doctor would have determined the likelihood that the cancer would come back after treatment based on the PSA level, the Gleason score, and the stage of the cancer. The doctor would have then chosen the most appropriate treatment option, weighing the risks of side effects and the probability of successfully treating the cancer.
Regardless of the therapy you received, your doctor should monitor your PSA level and perform a DRE every 3-6 months. If the PSA begins to rise, different options are available depending on the initial treatment given. For men initially treated with radical prostatectomy, the options include radiation therapy or androgen deprivation therapy. One problem, however, is trying to determine if the recurrence is in the prostate bed or if the cancer has spread elsewhere. Salvage radiation makes no sense if the cancer is somewhere other than the prostate bed. A bone scan, CAT scan and Prostascint scan can be done to determine the location of the cancer. However at PSA values under 2-3 ng/ml, none of the tests are completely reliable. Also, no randomized studies have been done to determine if either therapy improves survival. Both treatments have side effects and until proper studies are done, you and your doctor will need to weigh the risks against the potential benefit to decide what to do.
A rising PSA after either seed implantation or external radiation also presents a challenge. A spike in PSA can occur within 1-2 years, which is not caused by a cancer recurrence. The PSA eventually goes back down. If the PSA does continue to rise, it means the cancer has recurred. The options include a salvage prostatectomy, cryosurgery and ADT. HIFU is not currently available in the U.S. No study has yet proven that any of the options improve survival. The most aggressive treatment is prostate removal. Before considering a prostatectomy or cryosurgery, a repeat prostate biopsy must be done to determine that cancer is in the prostate gland and a bone scan and CAT scan should be considered to demonstrate the cancer has not spread.
For those men treated initially with cryosurgery or HIFU, both treatments can be repeated; but again, their impact on mortality is unknown. ADT is an option for all PSA recurrences unless it was initially used to treat the cancer. It has the advantage of treating cancer cells anywhere in the body but can cause many side effects that affect a man’s quality of life. Your doctor should carefully discuss each of the options so a shared decision can be made.
If you or your loved one has already received hormone therapy, but PSA levels continue to rise or the doctor can detect tumor growth, you have hormone-resistant or androgen-independent prostate cancer. The treatment options available depend on whether the cancer has spread to other parts of the body. Doctors often recommend secondary hormone therapies including anti-androgen such as CASODEX® (bicalutamide), Eulexin® (flutamide), or NILANDRON® (nilutamide), or ketoconazole, or estrogens when the cancer has not spread. Here too, no study has demonstrated a survival benefit from any of these options but they will lower PSA. If cancer is detected in the bones or lymph nodes the options include PROVENGE® (sipuleucel-t), XTANDI® (enzalutamide), and ZYTIGA®, which is combined with prednisone. Doctors are working on determining the best sequence of these therapies. If the PSA again rises while taking these drugs, the next treatment to prolong survival is chemotherapy beginning with docetaxel. A second option is cabazitaxel. Both agents improve survival in men with metastatic disease. Another option is to participate in a clinical trial. The best way to find one is to visit the government website, http://www.cancer.gov/clinicaltrials. Clinical trials offer an opportunity to receive a new drug years before it is available to everyone. Although it is not known whether a particular treatment will be successful, a participant will be cared for and closely monitored by a team of experts during the trial. The doctor can explain more about specific clinical trials that are going on now and the risks and benefits of participating in a clinical trial.
When prostate cancer has spread to other tissues in the body, particularly the bones, it can cause pain. Recently, Radium-223 (Xofigo®) was approved to treat pain in men with painful bone metastases. In addition to improving this symptom, it also prolongs survival. Other options also are available if Xofigo is not helpful. External beam radiation or systemic radiation therapy such as samarian-153 (Quadramet®) and strontium-89 (Metastron®) can reduce bone pain caused by metastases. Bisphosphonate medications, usually pamidronate (Aredia®) and zoledronic acid (Zometa®), can slow the growth of bone metastases and reduce pain.
XGEVA® (denosumab) is indicated for the prevention of skeletal-related events in patients with bone metastases from solid tumors. Xgeva is a fully human monoclonal antibody that binds to RANK Ligand, a protein essential for the formation, function and survival of osteoclasts (the cells that break down bone). Xgeva prevents RANK Ligand from activating its receptor, RANK on the surface of osteoclasts, thereby decreasing bone destruction.
Your pain may also be attributed to a spinal fracture, as prostate cancer cells often metastasize to the spine and make it more vulnerable to fracture. The individual bones in your spinal column, called vertebrae, are less dense and more “spongy,” yet as cancer spreads (metastasizes), it can either abnormally build additional bone or break it down further. It is difficult to feel changes in your bones while they are happening. In fact, many people are unaware that there is anything wrong until a fracture occurs. Learn more about spinal fractures and treatment options here.
The following is a list of questions to ask the doctor if you or your loved one has been diagnosed with hormone-resistant prostate cancer or has experienced a relapse. It may be worthwhile to audio record your conversation with your doctor so that you can review the answers to each question and be able to make informed decisions about treatment options.
Read a list of questions for urologists, radiation oncologists and medical oncologists , as compiled by an experienced prostate cancer patient.
You can also post questions for physicians and join discussions on specific topics about prostate cancer on the Physician-to-Patient (P2P) bulletin board located in the Online Communities: Prostate Pointers section of this Web site.