Additional Director, Urology, Fortis Hospital, Shalimar Bagh, New Delhi
Part 6 of 8 in Prostate Cancer: Diagnosis and Latest Treatment Guidelines
Advanced and Hormone-Resistant Prostate Cancer Management
May 5, 2024
Treatment shifts from curative to suppressive intent once prostate cancer has spread widely, and shifts again when the cancer stops responding to hormone therapy.
Metastatic and hormone-resistant disease
When prostate cancer has spread to the bones, the goal is no longer cure but suppression, achieved through hormonal suppression: either surgical orchidectomy (removing both testes) or regular hormone-depleting injections. If the cancer becomes hormone-resistant, meaning it no longer responds even as testosterone is suppressed, chemotherapy (docetaxel) or oral agents such as abiraterone and enzalutamide are added.
Matching treatment intent to disease spread
Early, organ-confined disease is treated with curative intent (robotic surgery or radiotherapy). Locally advanced disease, spread just outside the prostate but not to lymph nodes or bone, may still use surgery or radiotherapy combined with androgen deprivation therapy. More extensively spread, unresectable disease is treated less aggressively, with radiotherapy plus hormone deprivation, and true metastatic disease shifts to suppressive hormonal treatment as described above.
This article is based on a Jivo Masterclass session conducted by Dr. Anurag Puri, Additional Director, Urology, Fortis Hospital, Shalimar Bagh, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Anurag Puri taught doctors across Africa on May 5, 2024.
FROM THE LIVE Q&A
Moderator
What is the benefit of alfuzosin in the symptomatic management of BPH, and is there a newer drug?
Dr. Anurag Puri
Alfuzosin is a commonly used drug that relieves the urinary symptoms of BPH. Silodosin is a newer, more potent alternative. Alfuzosin is generally preferred in younger, sexually active men, while silodosin is preferred in older patients because of its sexual side-effect profile.
Frequently Asked Questions
Is there really no treatment available for prostate cancer above the age of 80?▼
That is not the case. Between the ages of 80 and 90, up to 80% of men are found to harbour some focus of prostate cancer, but most die of other causes rather than the cancer itself. Because it is often a low-risk, indolent disease in this age group, treatment is sometimes deliberately avoided if the patient is asymptomatic.
Does declining male sexual performance with age relate to atherosclerotic changes in penile vessels? Is there a better urological explanation?▼
Yes - this is generally due to atherosclerosis: as blood vessels narrow with age, blood supply to the penis decreases, and this reduced blood flow is the main driver of declining sexual performance.
What are the principles of prostate cancer management, the survival rates by stage, and can advanced disease be managed locally?▼
Management is decided by the disease's staging and parameters: PSA level, Gleason score, and clinical stage on digital rectal examination. Survival rates vary sharply by stage - low-risk, early disease has close to a 100% cure rate, and even metastatic (stage four) patients now have meaningfully better life expectancy with appropriate treatment than with many other stage-four cancers.
What does a kidney transplant require if the donor's genetic makeup is different, and what can be done to restore a failing transplanted kidney?▼
Kidney transplant is the treatment of choice for renal failure, and results are best with a related, genetically matched donor. Even without a genetic match or matching blood group, plasmapheresis, an advanced technique that lowers the antigenicity of the donor organ, can still allow a transplant to proceed.
Is it true that many patients who undergo prostate surgery end up dying, as some patients believe?▼
This is a misconception. The great majority of prostate operations are for benign BPH and are done endoscopically with little morbidity; patients are very satisfied. Even for cancer, with modern robotic surgery, hospital stay is just about three days, and patients are often fit to fly home within two to three weeks without a catheter.
How is metastatic prostate cancer treated?▼
With hormonal suppression, either surgical orchidectomy or regular hormone-depleting injections, since the goal shifts from cure to suppression.
What happens when prostate cancer becomes hormone-resistant?▼
Chemotherapy (docetaxel) or oral agents such as abiraterone and enzalutamide are added, since the cancer no longer responds to hormone suppression alone.
In This Series: Prostate Cancer: Diagnosis and Latest Treatment Guidelines
- 1.Prostate Cancer
- 2.Prostate Cancer Risk Factors and How It Presents
- 3.Diagnosing Prostate Cancer: PSA, Biopsy and Staging
- 4.Gleason Score and Risk Stratification in Prostate Cancer
- 5.Prostate Cancer Treatment: From Active Surveillance to Robotic Surgery
- 6.Advanced and Hormone-Resistant Prostate Cancer Management
- 7.Managing BPH: Medications and When Size Doesn't Matter
- 8.When to Refer a Prostate Cancer Patient for Treatment Abroad