How is metastatic and advanced prostate cancer treated?

Updated: Dec 29, 2020
  • Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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Discerning whether the patient has widely advanced disease versus locally advanced disease (clinical stage T3) assists in determining what treatment options are available.

Historically, systemic therapy for metastatic and advanced prostate cancer has involved androgen suppression. In metastatic disease, this palliative therapy has yielded a median progression-free survival of 18-20 months and an overall survival of 24-36 months. However, virtually all patients develop hormone-refractory disease.

Although hormone therapy is associated with significant responses, its curative potential is limited because of the inherent heterogeneity of prostate cancer and the inability of hormones to eradicate all prostate cancer clones, both the androgen-dependent and androgen-independent components.

Despite the steady decline in the incidence of newly diagnosed metastatic prostate cancer and microscopic lymph node metastasis, from 20% in the 1970s to 5% in 2013, the risk of extraprostatic disease in patients with clinically localized disease remains high, at 30-60%. Depending on the prostate-specific antigen (PSA) value, pathologic stage, and histologic grade of the tumor, approximately 50% of clinically localized prostate cancers are estimated to progress despite initial treatment with intent to cure. In some cases of hormone-refractory prostate cancer, the prostate cancer may continue to exhibit hormone dependence. Currently, it is not possible to predict whether these patients may benefit from androgen withdrawal versus continued hormone therapy.

Supportive inpatient care may be required for pain management in terminally ill patients with progressive prostate cancer in whom all measures have failed to elicit response.

Patients diagnosed with impending paralysis due to spinal cord compression or patients with pathologic fractures should be immediately immobilized until appropriate consultations are obtained.

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