If prostate cancer reaches an advanced stage and cancer cells have spread to other parts of the body, treatment is a necessity. Watchful waiting is no longer an option, if that was the informed course of action with your doctor.

Fortunately, men with advanced prostate cancer now have more available treatment options than ever before. These include both hormone therapies and non-hormone treatment options. The exact treatment you’ll receive depends on your stage of prostate cancer and any underlying conditions you have. Remember that your treatment experience can be quite different from someone else’s.

To decide on a treatment, you’ll need to consider the overall goal of the treatment, its side effects, and whether or not you’re a good candidate. Being informed about the available treatments can help you and your doctor decide which treatment, or combination of treatments, is best for you.

Hormone therapies for advanced prostate cancer

Hormone therapy is also known as androgen deprivation therapy (ADT). It’s often described as the mainstay for treatment of metastatic prostate cancer.

How does hormone therapy work?

Hormone therapy works by decreasing the levels of hormones (androgens) in the body. Androgens include testosterone and dihydrotestosterone (DHT). These hormones encourage prostate cancer to multiply. Without androgens, tumor growth is slowed and the cancer may even go into remission.

Approved hormone treatments

There are several approved hormone treatments for prostate cancer. These include:

  • GnRH agonists, such as leuprolide (Eligard, Lupron) and goserelin (Zoladex). These work by lowering the amount of testosterone made by the testicles.
  • Anti-androgens, such as nilutamide (Nilandron) and enzalutamide (Xtandi). These are usually added to GnRH agonists to help prevent testosterone from attaching to tumor cells.
  • Another type of GnRH agonist called degarelix (Firmagon), which blocks signals from the brain to the testes so that production of androgens is stopped.
  • Surgery to remove the testicles (orchiectomy). In effect, this will stop the production of male hormones.
  • Abiraterone (Zytiga), an LHRH antagonist that works by blocking an enzyme called CYP17 to halt the production of androgens by cells in the body.

Goals of treatment

The goal of hormone therapy is remission. Remission means that all of the signs and symptoms of prostate cancer go away. People who’ve achieved remission aren’t “cured,” but they can go many years without showing signs of cancer.

Hormone therapy may also be used to reduce the risk of recurrence after preliminary treatment in men who are at a high risk of recurrence.

How are treatments administered?

GnRH agonists are either injected or placed as small implants under the skin. Anti-androgens are taken as a pill once per day. Degarelix is given as an injection. A chemotherapy drug called docetaxel (Taxotere) is sometimes used in combination with these hormone therapies.

Zytiga is taken by mouth once per day in combination with a steroid called prednisone.

Surgery to remove the testicles can be done as an outpatient procedure. You should be able to go home a few hours after an orchiectomy.

Who is a candidate?

Most men with advanced prostate cancer are candidates for hormone therapy. It’s usually considered when prostate cancer has spread beyond the prostate, and surgery to remove the tumor is no longer possible.

Prior to starting treatment, you’ll need to have a liver function test along with a blood test to make sure your liver can break down the medications properly.

Currently, enzalutamide (Xtandi) is only approved for use in men with prostate cancer that has already spread to other parts of the body, and who no longer respond to medical or surgical treatments to lower testosterone levels.

In some cases, prostate cancer cells can resist hormone treatments and multiply even in the absence of male hormones. This is called hormone-resistant (or castration-resistant) prostate cancer. Men with hormone-resistant prostate cancer aren’t candidates for further hormone therapy.

Common side effects

The most common side effects of hormone therapies include:

  • hot flashes
  • thinning, brittle bones (osteoporosis) because lower testosterone levels cause loss of calcium
  • weight gain
  • loss of muscle mass
  • erectile dysfunction
  • loss of sex drive

Non-hormone therapies for advanced prostate cancer

If hormone treatment isn’t working or your cancer is growing and spreading too quickly, treatment with other non-hormone options may be recommended.

Approved non-hormone treatments

Non-hormone treatments for advanced prostate cancer include:

  • Chemotherapy, such as docetaxel (Taxotere), cabazitaxel (Jevtana), and mitoxantrone (Novantrone). Chemotherapy is sometimes given in combination with a steroid known as prednisone.
  • Radiation therapy, which uses high-energy beams or radioactive seeds to destroy tumors. Radiation is typically used in combination with chemotherapy.
  • Immunotherapy, including sipuleucel-T (Provenge). Immunotherapy works by using the body’s own immune system to kill cancer cells.
  • Radium Ra 223 (Xofigo), which contains a small amount of radiation and is used to destroy prostate cancer cells that have spread to the bone.

Goals of treatment

The goal of chemotherapy, radiation, and other non-hormone treatments is to slow down the growth of the cancer and extend a person’s life. Chemotherapy and other non-hormone agents probably won’t be able to cure the cancer, but they can significantly prolong the lives of men with metastatic prostate cancer.

Who is a candidate?

You may be a candidate for non-hormone treatments such as chemotherapy or radiation if:

  • your PSA levels are rising too quickly for hormone treatments to control it
  • your cancer is spreading rapidly
  • your symptoms are getting worse
  • hormone treatments fail to work
  • the cancer has spread to your bones

How are treatments administered?

Chemotherapy is typically given in cycles. Each cycle typically lasts a few weeks. You might need multiple rounds of treatment, but there’s usually a period of rest in between. If one type of chemotherapy stops working, your doctor may recommend other chemotherapy options.

Sipuleucel-T (Provenge) is given as three infusions into a vein, with about two weeks between each infusion.

Radium Ra 223 is also given as an injection.

Common side effects

Common side effects of chemotherapy include:

  • hair loss
  • nausea and vomiting
  • diarrhea
  • fatigue
  • loss of appetite
  • low white blood cells (neutropenia) and higher risk of infection
  • changes in memory
  • numbness or tingling in the hands and feet
  • easy bruising
  • mouth sores

Radiation treatments can reduce your red blood cell count and cause anemia. Anemia causes fatigue, dizziness, headache, and other symptoms. Radiation treatment can also lead to loss of bladder control (incontinence) and erectile dysfunction.

The bottom line

Hormone therapies and surgeries are typically recommended first to treat advanced prostate cancer. They may be used in conjunction with chemotherapy. But after a period of time, many prostate cancers may become resistant to hormone therapy. Non-hormone options become the best choice for men with metastatic prostate cancer that no longer responds to hormone treatments or chemotherapy.

Even with treatment, not all cases of advanced prostate cancer can be cured, but treatments can slow the growth of the cancer, reduce symptoms, and improve survival. Many men live for years with advanced prostate cancer.

Making decisions about treatments can be confusing and challenging because there’s a lot to consider. Remember that you don’t need to make the decision alone. With guidance from your oncologist and healthcare team, you can make an informed decision on the best treatment plan for you.