Stage 4 prostate cancer

Overview

Stage 4 prostate cancer happens when cancer spreads beyond the prostate to other parts of the body.

Most prostate cancers are diagnosed when the cancer is only in the prostate. Sometimes prostate cancer doesn't cause symptoms, and the cancer may not be detected until it has spread. When prostate cancer spreads to other parts of the body, it's called metastatic cancer.

Treatments can slow or shrink a stage 4 prostate cancer. But most stage 4 prostate cancers can't be cured. Still, treatments can lengthen life and reduce symptoms of cancer.

Symptoms

Signs and symptoms of stage 4 prostate cancer may include:

• Pain while urinating.
• Trouble starting to urinate.
• Trouble emptying the bladder all the way.
• Weaker urine stream.
• Urinating more often.
• Blood in the urine or semen.
• Pain in the back, hips or pelvis.
• Tiredness.

When to see a doctor

Make an appointment with a doctor or other health care professional if you have ongoing symptoms that worry you.

Causes

The cause of stage 4 prostate cancer is not known. Stage 4 prostate cancer happens when prostate cancer cells break away from where they formed in the prostate. The cancer cells spread to other parts of the body.

Prostate cancer starts when cells in the prostate develop changes in their DNA. A cell's DNA holds the instructions that tell a cell what to do. In healthy cells, the DNA gives instructions to grow and multiply at a set rate. The instructions tell the cells to die at a set time. In cancer cells, the DNA changes give different instructions. The changes tell the cancer cells to replicate much more quickly. Cancer cells can keep living when healthy cells would die. This causes too many cells.

The cancer cells form a mass called a tumor in the prostate. These tumors can grow to invade and destroy nearby healthy tissue. In time, cancer cells can break away and spread to other parts of the body.

Prostate cancer cells that spread past the prostate most often go to the:

• Lymph nodes.
• Bones.
• Liver.

Risk factors

Factors that can increase the risk of stage 4 prostate cancer include:

• Getting older. The risk of prostate cancer increases with age.
• Having a family history of prostate cancer. Certain DNA changes that are passed from parents to children can increase the risk of prostate cancer. These inherited DNA changes also increase the risk of more-aggressive forms of prostate cancer.
• Being Black. For reasons not yet known, Black people have a greater risk of prostate cancer than do people of other races. Black people also are more likely to have prostate cancer that is aggressive or advanced.

Diagnosis

Tests and procedures to diagnose prostate cancer may include:

• Blood tests. Blood tests can measure the level of prostate-specific antigen in the blood. Also called PSA, this chemical is made in the prostate. Sometimes prostate cancer causes the prostate to make extra PSA. Having a higher than expected level of PSA in the blood may be a sign of prostate cancer.
• Imaging tests. Imaging tests take pictures that show the inside of the body. Tests for prostate cancer may include MRI, CT, bone scans and positron emission tomography scans, also called PET scans.

• Removing a sample of tissue for testing, also called a biopsy. A biopsy is a procedure to remove a small sample of tissue for testing in a lab. A health professional might remove the sample using a needle that is put through the skin and into the cancer. Sometimes surgery is needed to get the tissue sample. The sample is sent to a lab for testing.

  In the lab, the sample is tested to see if it is cancer. Other specialized tests can show what DNA changes are present in the cancer cells. The results help your health care team create your treatment plan.

Treatment

Treatments for stage 4 prostate cancer may slow the cancer and extend your life. But stage 4 prostate cancer often can't be cured.

Hormone therapy

Hormone therapy for prostate cancer is a treatment that stops the hormone testosterone either from being made or from reaching prostate cancer cells. Most prostate cancer cells rely on testosterone to grow. Hormone therapy causes prostate cancer cells to shrink or to grow more slowly.

Hormone therapy options include:

• Medicines. Hormone therapy medicines stop testosterone from causing prostate cancer cells to grow. Many hormone therapy medicines exist. Some work by stopping the signals that tell the body to make testosterone. Others stop testosterone from acting on the cancer cells.
• Surgery to remove the testicles, called orchiectomy. Surgery to remove both testicles lowers testosterone levels in the body quickly. This might bring quick relief for a cancer that's causing pain or other symptoms.

Hormone therapy side effects may include not being able to get and keep an erection, called erectile dysfunction. Other side effects include hot flashes, loss of bone mass, lower sex drive, growth of breast tissue on the chest and weight gain.

Radiation therapy

Radiation therapy uses powerful energy beams to kill cancer cells. The energy can come from X-rays, protons and other sources. During radiation therapy, you lie on a table while a machine directs radiation to precise points on your body.

Some people with stage 4 prostate cancer have radiation to the prostate or other areas. When the cancer has spread to other areas of the body, radiation therapy can relieve pain or other symptoms.

Surgery

Surgery isn't often used to treat stage 4 prostate cancer. It might be recommended if the cancer causes symptoms that might be helped by surgery, such as trouble passing urine.

When surgery is an option, the operation may include:

• Radical prostatectomy. This procedure involves removing the prostate and any cancer that has grown near the prostate.
• Lymph node removal. When prostate cancer spreads, it often goes to the lymph nodes first. The surgeon might remove several lymph nodes and have them tested for cancer cells. This procedure is called pelvic lymph node dissection.

Surgery carries a risk of infection and bleeding. Other risks include not being able to control urinating, erectile dysfunction and damage to the rectum.

Other treatments

Other treatments for stage 4 prostate cancer might include:

• Chemotherapy. Chemotherapy uses strong medicines to kill cancer cells. For stage 4 prostate cancer, it can slow the growth of cancer cells and relieve symptoms of cancer.
• Radioactive medicines that deliver radiation directly to the cancer. Radioactive medicines can carry a small amount of radioactive material directly to the cancer cells. They can target prostate cancer that spreads anywhere in the body. When this type of medicine enters the body, it finds and sticks to the prostate cancer cells. The medicine damages the cancer cells' DNA and causes them to stop growing. One example of this type of medicine is lutetium Lu-177 vipivotide tetraxetan (Pluvicto). This treatment might be an option when chemotherapy and hormone therapy no longer work.
• Targeted drug therapy. Targeted therapy uses medicines that attack specific chemicals in the cancer cells. By blocking these chemicals, targeted treatments can cause cancer cells to die. The cancer cells might be tested in a lab to see if targeted therapy might help.
• Immunotherapy. Immunotherapy is a treatment with medicine that helps the body's immune system kill cancer cells. The immune system fights off diseases by attacking germs and other cells that shouldn't be in the body, such as cancer cells. Cancer cells survive by hiding from the immune system. Immunotherapy helps the immune system cells find and kill the cancer cells. Immunotherapy might be an option when the cancer doesn't respond to hormone therapy or chemotherapy.
• Training your cells to fight cancer. Sipuleucel-T (Provenge) treatment takes some of your own immune system cells and trains them in a lab to fight prostate cancer. The cells are then injected back into your body. It might be an option if hormone therapy is no longer working.
• Radioactive medicines that target the bones. When prostate cancer spreads to the bones, medicines that deliver radiation to the bones might be an option. These medicines use a low level of radioactive material. Once in your body, the medicines travel to the cancer in the bones and deliver the radiation. These medicines may help relieve bone pain.
• Bone-building medicines. Medicines used for people with thinning bones also can help people with cancer that spreads to the bones. These medicines can strengthen the bones and reduce the risk that cancer might cause a broken bone. These medicines can help reduce the pain caused by cancer in the bones.
• Pain medicines and treatments. There are different ways to treat cancer pain. Which pain treatments are right for you depend on your cancer and your needs and preferences.

Clinical trials

Clinical trials are studies of new treatments. These studies provide a chance to try the latest treatments. The risk of side effects might not be known. Ask your health care team if you might be able to be in a clinical trial.

Palliative care

Palliative care is a special type of health care that helps you feel better when you have a serious illness. If you have cancer, palliative care can help relieve pain and other symptoms. A team of health care professionals gives palliative care. This team can include doctors, nurses and other specially trained professionals. Their goal is to improve the quality of life for you and your family.

Palliative care specialists work with you, your family and your health care team to help you feel better. They provide an extra layer of support while you have cancer treatment. You can have palliative care at the same time as strong cancer treatments, such as surgery, chemotherapy or radiation therapy.

When palliative care is used with all of the other appropriate treatments, people with cancer may feel better and live longer.

Alternative medicine

No alternative medicine treatments have been proved to cure stage 4 prostate cancer. But complementary and alternative medicine may help you cope with symptoms of your cancer, such as pain.

Complementary and alternative medicine treatments that may reduce cancer pain include:

• Acupuncture.
• Acupressure.
• Hypnosis.
• Massage.
• Relaxation techniques.

If your pain isn't controlled enough, talk with a member of your health care team about your options.

Coping and support

People who are diagnosed with a serious illness often say they feel stressed. In time, you'll find ways to help you cope with stress and other feelings that come with a stage 4 prostate cancer diagnosis. Until you find what works for you, some of the following suggestions might help:

• Learn about your cancer. Learn enough about your cancer to help you make decisions about your care. Ask a member of your health care team about the details of your cancer and your treatment options. Ask about trusted sources of more information.
• Put together a support system. Ask your friends and family to form a support network for you. They might not know what to do after your diagnosis. Helping you with simple tasks might give them comfort and relieve you of those tasks. Think of things you want help with, such as making meals or getting to appointments.

• Find someone to talk with. Although friends and family can be your best support, they might find it hard to cope with your diagnosis. You might prefer talking with a counselor, a medical social worker, or a pastoral or religious counselor. Ask a member of your health care team for a referral.

  Also ask about support groups in your area. Or check with cancer organizations. In the United States, you might start with the National Cancer Institute and the American Cancer Society.

• Look for a connection to something beyond yourself. Having a strong faith or a sense of something greater than oneself helps many people cope with cancer.

Preparing for an appointment

Make an appointment with a doctor or other health care professional if you have ongoing symptoms that worry you. Your health professional might refer you to a doctor who specializes in treating cancer, called an oncologist.

Here's some information to help you get ready for your appointment.

What you can do

When you call to make the appointment, ask if there's anything you need to do before you go to the appointment, such as restrict your diet. Ask a family member or friend to go with you to help you remember the information you get.

Make a list of:

• Your symptoms and when they began. Include symptoms that don't seem related to why you made the appointment.
• All medicines, vitamins and supplements you take, including doses.
• Questions to ask your health care team.

For prostate cancer, questions might include:

• What is likely causing my symptoms?
• What are other possible causes for my symptoms?
• What tests do I need?
• What is the best course of action?
• I have other health conditions. How can I best manage them together?
• Are there restrictions that I need to follow?
• Should I see a specialist?
• Are there brochures or other printed material that I can have? What websites do you recommend?

Be sure to ask all the questions you have about your condition.

What to expect from your doctor

Be prepared to answer questions about your symptoms and your health, such as:

• Have your symptoms been ongoing, or do they come and go?
• Do your symptoms get in the way of your everyday activities?
• What, if anything, seems to make your symptoms better?
• What, if anything seems to make your symptoms worse?