If you have prostate cancer, you’ll feel relief when your treatment has finished. But sometimes, you can get unwelcomed news: Your prostate cancer has returned or spread.
When this happens, your medical team usually recommends changing your treatment protocol. The good news is there are many therapies for prostate cancer. If your first treatment didn’t work, there’s a good chance that the next one (or the one after that) will be successful.
Why Did My Prostate Cancer Treatment Stop Working?
There are many excellent prostate cancer treatments available today. But almost all of them have one thing in common: Eventually, your prostate cancer cells may become resistant (not respond anymore) to them.
Sometimes, clever cancer cells can figure out how to adapt to the drug you take. They may develop changes that allow them to avoid treatment. Other times, a small group of cancer cells that never responded to a certain drug multiply to the point where they can cause cancer to come back. Sometimes, this can happen within weeks. Other times, it takes months or years.
If your prostate cancer has spread, it’s a sign that your treatment no longer works. The best thing to do is to change your treatment protocol.
What to Expect When Your Treatment Protocol for Prostate Cancer Changes
To shake things up, prostate cancer specialists often recommend that you start androgen deprivation therapy (ADT), also called hormone therapy.
Prostate cancer cells rely on testosterone to grow. ADT shuts off testosterone, which causes prostate cancer cells to “starve” and then die.
It’s usually given as a drug. The two main options are:
GnRH agonists. Drugs such as goserelin (Zoladex), leuprolide (Lupron, Eligard), and triptorelin (Trelstar) turn off your testicles' production of testosterone. As a result, your prostate – and cancer cells – will shrink. They’re given as shots every one to six months. GnRH agonists actually boost androgen, or male hormone production, at first and can cause your prostate cancer to get worse. Your doctor may recommend that you take "antiandrogen" drugs like bicalutamide (Casodex), flutamide (Eulexin), or nilutamide (Nilandron) at first to prevent this.
GnRH antagonists like degarelix (Firmagon) or relugolix (Orgovyx). These are similar to GnRH agonists but work faster. These may be used if doctors worry your cancer is spreading very quickly.
They can cause side effects like low sex drive, erection problems, hot flashes, and breast enlargement. They can also weaken your bones. Your health care team can work with you to prevent and treat many of these.
Your medical care team may also have you layer a second treatment on top of the ADT. They may suggest:
- Abiraterone (Zytiga) to block androgen production by the adrenal glands and the prostate cancer itself, along with androgen production in your testicles (taken with the steroid prednisone to prevent side effects)
- Apalutamide (Erleada), darolutamide (Nubeqa), and enzalutamide (Xtandi), which also block androgens and prevent them from feeding prostate cancer cells
- Chemotherapy
If your cancer has spread a lot or spreads quickly, your doctor may suggest a triple combination that includes ADT, chemotherapy, and either abiraterone or darolutamide.
The Importance of Biomarkers for Prostate Cancer Treatment
Your health care team may also rely on biomarker testing to help guide treatment once your prostate cancer has spread. A biomarker is a substance in your blood or prostate cancer tissue. It reveals molecular changes that may show how your cancer has spread and/or how your cancer may respond to certain drugs. It may be helpful for your doctor to know about certain biomarkers when they draft a new treatment plan.
One biomarker that you probably already know about is prostate-specific antigen or PSA. It’s a protein released by your prostate gland. It can be measured with a blood test. Doctors often use it to measure a man’s risk of prostate cancer.
PSA is also often measured in men who already have prostate cancer. It’s monitored as a way to see if you have had a recurrence.
Another common biomarker is prostate-specific membrane antigen, or PSMA. It’s found on the surface of prostate cancer cells. If you already have had prostate cancer treatment but your PSA levels are high, your doctor may suggest an imaging test called a PSMA PET scan. It uses a radioactive substance to hunt for PSMA throughout your entire body. It shows where your cancer has spread. It can also guide your treatment.
If your PSMA levels are high, your medical team may recommend a certain treatment, lutetium Lu 177 vipivotide tetraxetan (Pluvicto). It’s a radiopharmaceutical, which means it’s a radioactive drug. It’s most effective in people who have a lot of PSMA in their bodies.
Your doctor may also recommend somatic or genetic testing of your prostate tumor if you didn’t have that done already. Advances in genetic testing have allowed doctors to learn about DNA mutations that might affect how you respond to specific treatments. This can either be genetic mutations that you inherit (like a BRCA mutation) or mutations that develop in the prostate cancer cells.
Certain therapies specifically target certain genetic mutations. Even if there’s currently no treatment available for your specific mutation, there may be one in the pipeline you could try later.
Second-Line and Third-Line Treatments for Advanced Prostate Cancer
Most men with advanced prostate cancer respond well to hormone therapy, either alone or with other treatments too. But still, their prostate cancer can come back and spread. When this happens, you’ll need to change your treatment protocol once again.
Your doctor may refer to your prostate cancer at this point as “castration-resistant prostate cancer.” This may sound alarming, but it just means that it’s no longer responding to hormone therapy. The good news is more treatments are available now than in the past. Some options include:
Immunotherapy. This type of therapy uses your body’s immune system to stop cancer cell growth. Your immune system uses “checkpoint” proteins to prevent your immune cells from attacking other cells in your body. Cancer cells sometimes hijack these checkpoint proteins, to prevent your immune system from destroying them.
The two drugs used are dostarlimab (Jemperli) and pembrolizumab (Keytruda). You may be a fit for one of them if your prostate cancer has one of these three gene changes:
- Microsatellite instability (MSI-H)
- A defect in a mismatch repair gene (dMMR)
- A high tumor mutational burden (TMB-H)
Most men with advanced prostate cancer don’t have these changes.
Sipuleucel-T (Provenge). This is a cancer vaccine that boosts your immune system to fight cancer cells. To make it, white blood cells are removed from your blood. They’re then mixed with a protein from your cancer cells before they are reinjected into your body. It can’t stop prostate cancer cells from growing, but studies show it'll help you live longer.
Targeted therapies. About a quarter of men with advanced prostate cancer have a gene mutation such as BRCA1, BRCA2, or ATM. Certain drugs known as PARP (poly ADP ribose polymerase) inhibitors can kill off cancer cells in people with these mutations. They include:
- Olaparib (Lynparza)
- Niraparib (Zejula)
- Rucaparib (Rubraca)
- Talazoparib (Talzenna)
If your prostate cancer cells were found to have the PSMA protein, your doctor may suggest lutetium Lu 177 vipivotide tetraxetan (Pluvicto).
When Cancer Spreads to Your Bone
Advanced prostate cancer often spreads to your bones and causes pain. To treat this, your doctor may recommend several different treatments:
Radiation therapy. This is a good option if you have pain in just one or two bones. You’ll only need a few treatments. Your pain may worsen for a day or two and then get better.
Bone-strengthening drugs like denosumab (Prolia, Xgeva) or zoledronic acid (Zometa). These help to prevent fractures and may even allow you to avoid radiation therapy.
Radium-223. This is another radiopharmaceutical drug. It’s best for people whose prostate cancer is mainly in the bone. It can relieve bone pain, prevent fractures, and extend your life.
Men who live with advanced prostate cancer may find that they eventually cycle through most of the available drugs. In these cases, you may want to talk to your prostate cancer care team about clinical trials. This is a way for doctors to study new drugs or a new combination of existing drugs. Check out advanced prostate cancer clinical trials at the National Cancer Institute or at ClinicalTrials.gov.
How to Communicate With Your Prostate Cancer Team
Men with advanced prostate cancer often find that their treatment protocol frequently changes. It may not be very clear. You may wonder why your team wants to switch therapies, what the side effects are, and how effective new medications will be.
You must communicate well with your care team to ensure the best care possible. Research shows that people who do this have a better quality of life than those who don’t.
Some questions to ask your team include:
- What does the term advanced prostate cancer mean for me?
- How long can I live now that my prostate cancer has spread?
- Are there tests I should have now that could influence treatment recommendations?
- What treatment do you recommend now and why? What’s the end goal?
- Will this new treatment slow the growth of my cancer and/or help with side effects?
- What are the possible side effects of this treatment?
- How can I manage the symptoms of my advanced prostate cancer as well as the side effects of my treatment?
- Are there other treatments that you would recommend?
- Would a clinical trial be right for me?
- What will happen if I decide to stop active treatment?
Where to Find Support
Changes in treatment protocol may leave you with feelings of anxiety, depression, or confusion. It’s a good idea to connect with support groups to help you through this time. Support groups have been shown to improve the quality of your life and possibly even help you live longer.
You may find it helpful to talk to others who have advanced prostate cancer. You can learn about why they made the treatment decisions they did and what it was like for them to take certain medications or try certain therapies. You may be reassured to talk to those whose initial, second-, or third-line treatments failed. They most likely had many of the same emotions you face now.
You can find a support group through prostate cancer advocacy organizations such as:
- Zero Prostate Cancer
- Prostate Cancer Research Foundation
- American Cancer Society
The hospital or cancer center where you get care may offer support groups as well.
Recap
Your doctor may recommend that you change your treatment protocol for prostate cancer if your prostate cancer has returned or if it has spread. While the first-line therapy is usually hormone therapy, there are other new treatments available as second- or third-line options. You may also be able to join a clinical trial. Remember, even though your prostate cancer has spread, you can still live comfortably for years. Changes in treatment protocols play an important role in helping you get to that point.
Show Sources
Photo Credit: The Image Bank/Getty Images
SOURCES:
American Cancer Society: “Immunotherapy for Prostate Cancer,” “Hormone Therapy for Prostate Cancer,” “Targeted Drug Therapy for Prostate Cancer,” “Treatments for Prostate Cancer Spread to Bones.”
Association of American Medical Colleges: “Not All Cancer Needs to be Cured: Five Ways that Prostate Cancer Treatments Have Improved.”
JAMA Oncology: “PSMA Pet Scan.”
National Cancer Institute: “Biomarker,” “Questions to Ask Your Doctor About Advanced Cancer,” “Why Do Cancer Treatments Stop Working?”
UCSF Health: “Guide to Coping with Prostate Cancer.”
UptoDate: “Patient Education: Treatment for Advanced Prostate Cancer (Beyond the Basics).”
