Stage 4 Prostate Cancer – Diagnosis and Treatment
Diagnosis
PSA Blood Testing to Detect Cancer Spread
Doctors use a blood test to measure prostate-specific antigen (PSA) levels as a key part of diagnosing advanced prostate cancer. Prostate cells make PSA, a protein found in the blood.
Higher-than-normal PSA levels can signal prostate cancer or its return after treatment. Doctors often track PSA numbers over time.
A rising PSA can be the first clue that prostate cancer has spread or come back. Doctors then order more scans and tests to look for cancer in other parts of the body.
Quick Facts
| Test | What It Measures | Why It’s Used |
|---|---|---|
| PSA test | PSA levels in blood | Signs of prostate cancer |
Scans and Imaging for Detecting Spread
Doctors use different imaging tests to check if prostate cancer has moved to other areas. These scans show where cancer cells are in the body and help guide treatment choices.
Types of Imaging Used:
| Imaging Test | What It Detects | Key Use |
|---|---|---|
| Bone scan | Cancer in the bones | Finding bone spread |
| CT scan | Tumors in soft tissues and lymph nodes | Checking lymph node/organ spread |
| MRI | Tumors in prostate, lymph nodes, or organs | Local and distant spread |
| PET scan | Metastatic cancer anywhere in the body | Detecting cancer activity |
| PSMA PET scan | Small deposits of prostate cancer in the body | More sensitive detection |
| Choline C-11 PET scan | Areas with aggressive cancer cell activity | When other scans aren’t clear |
Bone Scan: This test uses a special tracer to highlight areas in the bones where cancer cells may be growing.
CT Scan: A CT scan uses X-rays to make cross-section pictures of the body and helps doctors see if cancer has grown into lymph nodes or organs.
MRI: An MRI uses strong magnets and radio waves for clear pictures of the prostate, nearby tissues, and sometimes organs further away.
PET Scan: A PET scan uses a small amount of radioactive tracer to find cancer cells. The tracer collects in spots where the cancer has spread.
PSMA PET Scan: This newer scan uses a tracer that attaches to prostate-specific membrane antigen, a protein found on most prostate cancer cells, and helps spot even small areas of cancer growth.
Choline C-11 PET Scan: When other scans aren’t clear, this scan looks for tracer uptake in cancer cells that take in more of the labeled choline.
Imaging tests can show:
- If cancer has entered the bones.
- Spread to lymph nodes nearby or far away.
- Growth in organs like the liver or lungs.
Getting a Tissue Sample from Secondary Sites
Doctors may take a small tissue sample from where the cancer has spread, not just from the prostate. They often use a needle through the skin to collect cells from the suspicious area.
Lab experts look for prostate cancer cells under a microscope. Additional lab tests, called biomarker tests, help predict which treatments could work best.
These tests can also show if the cancer has changed, such as becoming castration-resistant prostate cancer, which does not respond to traditional hormone therapy.
Genetic and Molecular Testing for Personalized Care
Doctors use genetic testing to look for changes or mutations in a person’s DNA. They do this with a blood or spit sample.
In advanced prostate cancer, genetic tests check for inherited gene mutations and changes found only in the cancer. Knowing specific DNA changes helps guide treatment, as some medicines work better for people with certain gene faults.
Genetic test results can also be important for family members, since some gene changes raise cancer risk for relatives.
Doctors also use genetic testing to spot aggressive forms of prostate cancer and see if advanced options like targeted therapies or immunotherapy might help.
What Affects Long-Term Survival
Many factors affect the outlook for someone with advanced prostate cancer. Metastatic prostate cancer can often be controlled for long periods, but is usually not curable.
Key things that affect prognosis include:
- Age and general health. Younger, healthier people may do better with treatment.
- First diagnosis or recurrence. Cancer that returns may be harder to treat.
- PSA levels. Rising PSA often means the cancer is more active.
- Symptoms. Bone pain or other symptoms from spread can signal more advanced disease.
- Number and location of metastatic sites. More places with cancer or cancer in vital organs can mean a shorter survival time.
- Gleason score. This grading system describes how abnormal cancer cells look under the microscope. High scores usually mean a more aggressive cancer.
- Response to hormone therapy. Cancers that still respond to hormone-lowering treatment tend to have a better prognosis.
- Genetic changes in the cancer. Some gene mutations can make the cancer harder to treat or may open up new treatment options.
Treatment
Hormone-Based Therapies for Advanced Prostate Cancer
Doctors often start with hormone-based treatments for prostate cancer that has spread. These treatments aim to remove or block testosterone, a hormone that helps prostate cancer cells grow.
There are several ways to do this:
Medications that Stop Testosterone Production: Drugs like luteinizing hormone-releasing hormone (LHRH) agonists and antagonists stop the body from making testosterone.
Medications that Block Testosterone’s Action: Antiandrogens stop testosterone from attaching to cancer cells. Doctors sometimes use these medicines with other hormone therapies.
New Antiandrogens: Newer drugs, called androgen receptor pathway inhibitors, further block testosterone from feeding cancer.
Blockers for Non-Testicular Hormones: Some medicines target other hormone sources in the body, cutting off cancer cell growth.
Surgical Removal of Testicles: Orchiectomy is an operation that quickly drops testosterone levels.
Doctors may combine more than one type of hormone treatment. These therapies can cause side effects such as hot flashes, reduced libido, tiredness, muscle loss, weight gain, and a higher chance of diabetes or heart disease.
Cancer-Killing Drugs for Advanced Cases
When hormone therapy does not control metastatic prostate cancer, doctors often add powerful cancer-killing drugs. These medicines attack rapidly dividing cancer cells throughout the body.
Doctors usually give chemotherapy for advanced prostate cancer through a vein (IV). Treatments are often given in cycles, such as once every three weeks. Chemotherapy helps when hormone treatments stop working or the cancer has spread widely.
Side effects may include tiredness, infections, numbness in fingers or toes, and bruising. The care team chooses medicines based on the cancer’s situation and how well the patient can handle possible side effects.
Common Chemotherapy Side Effects:
- Tiredness
- Weakened immune system (more infections)
- Numbness or tingling in extremities (peripheral neuropathy)
- Loss of hair
- Nausea
Precision Treatments Focused on Cancer Cell Changes
Some people with advanced prostate cancer may benefit from medicines that target specific changes in their cancer cells. These targeted treatments focus on molecules or pathways that help cancer survive.
Doctors often use targeted therapy when the cancer stops responding to hormones. These medicines come as pills or capsules. Doctors test patients for special DNA changes in their cancer before using targeted medicines.
If these changes are present, patients have a better chance of responding to the treatment. Side effects often include tiredness, lower appetite, nausea, diarrhea, and sometimes more infections.
Boosting the Immune System Against Prostate Cancer
Immunotherapy helps the body’s own defense system fight cancer cells. For metastatic prostate cancer, doctors usually use checkpoint inhibitors.
These medicines help immune cells recognize and attack cancer that tries to hide. Immunotherapy for advanced prostate cancer works for a small number of people with certain DNA changes in their cancer cells.
Doctors use tests to see if patients are likely to benefit.
Possible Side Effects:
- Fatigue
- Rash or itchy skin
- Diarrhea
- Loss of appetite
Sometimes, immune treatments can cause the immune system to attack healthy organs, leading to serious complications.
Radioactive Medications That Seek Out Cancer
Doctors use radiopharmaceutical treatments to deliver radioactive particles directly to cancer cells. These medicines have two parts: one that sticks to cancer cells and one that delivers radiation.
Some radiopharmaceuticals target a protein called PSMA (prostate-specific membrane antigen) found on prostate cancer cells. Medicines like lutetium Lu-177 vipivotide tetraxetan attach to PSMA and deliver radiation to the cancer wherever it is in the body.
| Radiopharmaceutical | Target | Delivery |
|---|---|---|
| Lutetium Lu-177 | PSMA-positive cells | Intravenous (IV) |
These treatments can help people whose cancer has spread widely or stopped responding to other treatments. Side effects can include low blood counts, dry mouth, or nausea.
Doctors use special imaging before treatment to check if the cancer fits the criteria for PSMA therapy.
External Radiation for Spreading Prostate Cancer
Doctors use radiation therapy to damage or kill cancer cells. For metastatic prostate cancer, they often use it to control pain or treat tumors that have spread to bones or organs.
Types of Radiation Therapy:
- External Beam Radiation: Doctors aim beams of radiation at specific sites, such as painful areas in the bone.
- Targeted Radiation: Advanced methods like proton therapy deliver focused doses to cancer cells and spare healthy tissue.
- Internal Radiation (Brachytherapy): While often used for earlier stages, doctors may consider this in some cases for advanced cancer.
Radiation can help shrink tumors or reduce symptoms like bone pain. Common side effects include tiredness, skin irritation, and sometimes urinary or bowel problems.
Comfort Care and Symptom Relief in Advanced Cancer
Palliative care helps people stay comfortable and improve quality of life at any stage of cancer. It does not mean end-of-life care; doctors can use it alongside other treatments for metastatic prostate cancer.
The palliative team manages symptoms like pain, tiredness, loss of appetite, or emotional stress. They also address problems from cancer treatments, such as hot flashes or nerve pain from chemotherapy.
Palliative services may include:
- Pain medications and procedures for bone pain.
- Counseling and support for patients and families.
They offer techniques to manage fatigue or shortness of breath. The team gives advice about nutrition and activity. Doctors may use treatments like radiation or bone-strengthening drugs mainly to control symptoms, not to cure the cancer.
Alternative medicine
Some people try complementary and alternative therapies to manage cancer symptoms like pain. These methods do not cure advanced prostate cancer, but they might help with relief.
Common options include:
- Acupuncture
- Acupressure
- Hypnosis
- Massage
- Relaxation techniques
If pain is still hard to manage, talk with a healthcare professional about other choices.
Managing Emotions and Finding Support
Gain Knowledge About Your Diagnosis
Learning about cancer, treatments, and side effects helps people make care decisions. Talking with healthcare providers gives clear answers to important questions.
With this knowledge, people can consider options like active surveillance, watchful waiting, or supportive care.
Reach Out to Someone Who Listens
Talking to someone trustworthy, such as a family member, friend, counselor, or clergy member, can help. Support can also come from group meetings, online or in person.
These groups offer a place to share feelings and learn from others with similar challenges. Support groups can provide tips for dealing with treatment side effects and improving quality of life.
Connect to Something Bigger
Many people find comfort by connecting with their beliefs or a greater purpose. This might include joining religious communities, meditating, or spending time in nature.
Exploring spiritual practices can help people manage stress and feel less alone with advanced cancer.
Getting Ready for Your Visit
Steps to Take Before Your Appointment
Before seeing a doctor or specialist, check if you need to do anything special, like fasting for a test. Bring a trusted friend or family member to help you remember what the doctor says.
If you are seeing a urologist, radiation oncologist, or another cancer specialist, find out if you are scheduled for a radical prostatectomy or other procedure. Call the clinic to confirm any instructions before your visit.
Information to Gather for Your Visit
Write down important details to share at your appointment:
- Symptoms and History: List all symptoms, when they started, and if they relate to past prostate cancer or new issues.
- Medicines and Supplements: Write down everything you take, including prescriptions, over-the-counter pills, vitamins, and herbal products, with the amounts.
-
Questions for the Care Team: Prepare questions for your doctor or specialists. Examples include:
- What might be causing my symptoms?
- Could anything else cause these issues?
- What tests should I expect?
- What treatments are likely next, such as radical prostatectomy?
- How can my other health problems be managed at the same time?
- Do I need to follow any special restrictions?
- Is a second opinion from another urologist or radiation oncologist a good idea?
A simple table can help keep your notes organized:
| Item | Details |
|---|---|
| Symptoms | List here |
| Medications | Name, dose, frequency |
| Questions | List main concerns |
What Your Doctor Might Ask
During the visit, your doctor might ask questions like:
- Are your symptoms steady, or do they come and go?
- Do your symptoms change your daily activities?
Your doctor may also ask:
- What helps relieve your symptoms?
- What seems to make them worse?
Prepare this information before your appointment. This will help your healthcare team understand your situation and suggest the next steps.
