Stage 4 Prostate Cancer

Diagnosis

Metastatic prostate cancer diagnosis often involves blood tests and imaging tests. This type of cancer is advanced and has spread to other parts of the body, making it a stage 4 prostate cancer.

PSA testing measures the amount of prostate-specific antigen in the blood. Prostate-specific antigen is a substance made by prostate cells. A small amount circulates in the blood, and a PSA test detects that level. A high PSA level can be a sign of prostate cancer. Many people continue having PSA tests after treatment. A rising PSA level may be the first indication that the cancer has returned. When PSA levels increase, imaging tests may be recommended to check for metastatic prostate cancer.

Imaging tests create detailed pictures of the inside of the body and can show where metastatic prostate cancer has spread.

Imaging tests used to detect metastatic prostate cancer include:

• A bone scan. This nuclear imaging test uses small amounts of radioactive tracers along with a special camera and computer. The tracer may highlight areas of cancer within the bones.
• A computerized tomography scan. Also called a CT scan, this test uses X-ray techniques to create cross-sectional images of bones and soft tissues. It can detect prostate cancer that has spread to the lymph nodes, organs or other locations.
• Magnetic resonance imaging. MRI uses a magnetic field and radio waves to create body images. It can detect cancer in the prostate, lymph nodes and other areas.
• A positron emission tomography scan. A PET scan uses a radioactive tracer injected into a vein. The tracer builds up in certain cells, creating whole-body images that can show sites of metastatic cancer.
• A prostate-specific membrane antigen PET scan. Also called a PSMA PET scan, this imaging test uses a tracer that sticks to prostate cancer cells by attaching to a protein known as prostate-specific membrane antigen. It can detect cancer spread throughout the body.
• A choline C-11 PET scan. This type of PET scan uses a radioactive tracer that prostate cancer cells absorb more than other cells. It may be used when other imaging tests do not detect metastatic cancer.

A biopsy removes a sample of tissue for lab testing. The type of biopsy depends on where the cancer has spread. Often a needle is placed through the skin into the suspicious area to collect cells. In the lab, tests show whether the cells are prostate cancer. Biomarker tests may provide information about which treatments are likely to work.

Genetic testing uses blood or saliva to check for DNA variations. Some treatments work better for people with specific inherited or acquired DNA changes. Genetic testing also may offer information about cancer risk for blood relatives.

Metastatic prostate cancer usually cannot be cured. However, treatments can slow cancer growth and extend life. Some people want to know their prognosis, which refers to how long they may live with advanced cancer. Factors that can affect prognosis include age, overall health, whether this is a first diagnosis or a recurrence, PSA levels, symptoms, the number and location of cancer sites, response to hormone therapy and the cancer’s genetic makeup. Your healthcare team can explain how these factors relate to your personal outlook.

More information
Metastatic stage 4 prostate cancer care at Mayo Clinic
Bone scan
CT scan
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Treatment

Treatment for metastatic prostate cancer typically begins with hormone therapy. This therapy blocks hormones that prostate cancer cells depend on to grow. If the cancer begins growing again, other treatments may be added.

Most metastatic prostate cancers eventually grow without hormones. When this occurs, the cancer is called castration-resistant prostate cancer. Hormone therapy usually continues, but other treatments may be added, such as chemotherapy, targeted therapy, immunotherapy and radiopharmaceutical treatments. These treatments may slow cancer and extend life, but metastatic prostate cancer often cannot be cured.

Hormone therapy lowers testosterone or prevents it from acting on prostate cancer cells. Reducing testosterone can cause cancer cells to die or grow more slowly.

Hormone therapy treatments for metastatic prostate cancer include:

• Medicines that stop the body from making testosterone. These medicines block signals that trigger testosterone production. Examples include degarelix, leuprolide and similar medicines.
• Medicines that stop testosterone from acting on cancer cells. Called antiandrogens, these medicines are often used with LHRH agonists. Examples include bicalutamide and similar medicines.
• Newer antiandrogen medicines. Also known as androgen receptor pathway inhibitors, these medicines block testosterone from reaching cancer cells. Examples include apalutamide, darolutamide and enzalutamide.
• Other medicines that block hormones. Some medicines block additional sources of hormones. One example is abiraterone.
• Surgery to remove the testicles, called orchiectomy. This procedure quickly lowers testosterone levels.

Side effects of hormone therapy may include hot flashes, hair loss, reduced muscle mass, increased body fat, loss of sex drive and difficulty with erections. There is also an increased risk of diabetes and heart disease.

Chemotherapy uses strong medicines to treat cancer and may be given along with hormone therapy. It is also used when hormone therapy is no longer effective. Common chemotherapy medicines include docetaxel, cabazitaxel and others. These medicines are given through a vein, often every three weeks. Side effects include fatigue, easy bruising, infections and nerve damage in the hands and feet, known as peripheral neuropathy.

Targeted therapy uses medicines that attack cancer cells in specific ways. These medicines may be used when hormone therapy is no longer working. Targeted therapy options for metastatic prostate cancer include niraparib, olaparib, rucaparib and talazoparib. These medicines block enzymes that help repair DNA breaks in cancer cells. They work best for people with certain DNA changes. Side effects may include fatigue, nausea, appetite loss, diarrhea, cough, bruising and infections.

Immunotherapy helps the immune system find and kill cancer cells. Immune checkpoint inhibitors are most often used for metastatic prostate cancer. These medicines block signals that tell the immune system not to attack. They only work for cancers with specific DNA changes. Pembrolizumab is one example. Side effects can include fatigue, itchy skin, diarrhea, appetite loss and rash. In some cases, the immune system may attack healthy organs.

Radiopharmaceutical treatments use medicines that contain radioactive substances. These treatments deliver radiation directly to cancer cells.

Radiopharmaceutical options include:

• Treatments that target PSMA. One example is lutetium Lu-177 vipivotide tetraxetan, which attaches to PSMA proteins on prostate cancer cells and delivers targeted radiation. Side effects may include dry mouth, dry eyes, nausea and fatigue.
• Treatments that target the bones. These medicines travel to bones and release radiation, helping with pain and symptoms. One example is radium Ra-223. Side effects may include diarrhea and fatigue.

Radiation therapy uses high-energy beams to treat cancer. It may be used on the prostate if the cancer has spread only to a few areas. It also may help treat bone pain and lower the risk of bone fractures.

Clinical trials study new treatments and offer access to options that may not be widely available. Ask your healthcare team if a clinical trial may be suitable.

Palliative care focuses on improving comfort and quality of life. It helps manage pain, symptoms and emotional needs. A team of trained professionals works with you and your healthcare team to provide support. Palliative care can be given at any time during cancer treatment and may help people feel better and live longer.