Shifting goals: Managing advanced prostate cancer

Navigating the transition from early to advanced prostate cancer reveals a shift in treatment goals from cure to management. In his latest online article, Dr Mark Tuthill examines the factors driving prostate cancer progression, risk considerations, metastatic routes, and evolving prognosis dynamics. He explores the journey of prostate cancer, highlighting the challenges and strategies in its progression and management.

What are the key differences between early stage and advanced stage prostate cancer?

Early prostate cancer, confined to the prostate or lymph nodes, is a potentially curable. Treatment options vary: active surveillance for less aggressive cases, while more urgent cases may require surgery, radiotherapy, or hormonal therapy combined with radiotherapy, all aiming for cure. Advanced prostate cancer involves spread beyond the prostate or lymph nodes, requiring treatments to control rather than cure it. Despite this, many patients now experience long-term control, with over half of patients still on their initial hormonal therapy five years post-diagnosis, signifying significant progress in rates of longer-term control over the last few years.

What causes prostate cancer to advance to a more advanced stage?

The reasons why some patients present with more advanced prostate cancer than others remain unclear. However, certain factors contribute to this variation, such as the type of prostate cancer detected. For instance, higher grade or high Gleason prostate cancer is more prone to spreading to an advanced stage.

Another factor is the timing of diagnosis. Men experiencing symptoms like changes in urination habits or blood in the urine are more likely to be diagnosed early. Conversely, many men may not exhibit noticeable symptoms and are often diagnosed at an advanced stage. The reasons for this complexity vary from patient to patient and can't be generalised. However, factors like tumour characteristics and access to a PSA test leading to timely diagnosis and referral likely play significant roles.

What are the risk factors for developing advanced prostate cancer?

There are few identifiable risk factors for developing advanced prostate cancer in individuals without a history of the prostate cancer. The most common risk factor observed is a history of prior treatment for localised prostate cancer, such as radiotherapy. Clinical characteristics, including the size of the prostate cancer within the prostate, Gleason score, number of affected lymph nodes, family history, and other tumour characteristics, also contribute to the risk profile.

How does advanced prostate cancer spread throughout the body?

The precise mechanisms of prostate cancer metastasis remain unclear. However, when prostate cancer spreads to the bone, it is believed to occur through either the bloodstream, or the lymphatic system. Similarly, prostate cancer metastasis to lymph nodes typically involves those in the pelvic region. In rare instances where prostate cancer is found in other organs like the lung or liver, where the spreading process is not well understood. Nevertheless, treatments have shown effectiveness in targeting metastatic cells in these locations.

How does the prognosis change as prostate cancer progresses to an advanced stage?

Unfortunately, once prostate cancer has spread, it cannot be cured, but it can be effectively managed. The outlook for recurrent prostate cancer depends on various factors, including whether progression occurs despite testosterone suppression, indicating castrate resistance—a more severe form of the disease. Predicting prognosis accurately can be challenging. Therefore, for individuals with advanced, previously treated prostate cancer, consulting oncologists about available treatment options and prognosis, such as lutetium treatment, theragnostic, chemotherapy, or participation in clinical trials, is advisable.

Dr Mark Tuthill is an esteemed medical oncologist. You can schedule an appointment with Dr Tuthill on his Top Doctors profile.