What is advanced prostate cancer?

Advanced prostate cancer is cancer that has spread from the prostate to other parts of the body. It develops when prostate cancer cells move from the prostate to other parts of the body through the blood stream or lymphatic system. The lymphatic system is part of the body’s immune system.

Watch our animation to find out more about prostate cancer:

Find out more about prostate cancer.

Diagram of where the prostate is

Prostate cancer can spread to any part of the body, but most commonly to the bones. More than four out of five men (80 per cent) with advanced prostate cancer will have cancer that has spread to their bones.

Another common place for prostate cancer to spread to is the lymph nodes (sometimes called lymph glands). Lymph nodes are part of your lymphatic system and are found throughout your body. Some of the lymph nodes are in the pelvic area – near the prostate.

Where Pc Might Spread

You might hear the cancer that has spread described as metastatic or secondary prostate cancer, secondaries, metastases or mets. It is still prostate cancer, wherever it is in the body.

Advanced prostate cancer can cause symptoms, such as fatigue (extreme tiredness), bone pain and problems urinating. The symptoms you have will depend on where the cancer has spread to. Some men only get a few symptoms. If you do get symptoms, speak to your doctor or nurse. There are treatments available to help manage them.

It’s not possible to cure advanced prostate cancer, but treatments can keep it under control, sometimes for several years.

If you’re not sure whether your prostate cancer is advanced, speak to your doctor or nurse. They can explain your test results and the treatments available. Or you could call our Specialist Nurses.

How is advanced prostate cancer diagnosed?

If you’ve been diagnosed with advanced prostate cancer, you will have had some or all of the following tests. These are the main tests used to diagnose prostate cancer, but you might have other tests as well.

Prostate specific antigen (PSA) test

This measures the amount of PSA in your blood. PSA is a protein produced by normal cells in the prostate and also by prostate cancer cells, wherever they are in the body. Read more about the PSA test.

Digital rectal examination (DRE)

The doctor or nurse feels the prostate through the wall of the back passage (rectum). They feel for hard or irregular areas that might be a sign of cancer. Read more about having a DRE.

Prostate biopsy

Thin needles are used to take small samples of tissue from the prostate. The samples are looked at under a microscope to check for cancer. You might not need a biopsy if other tests show you have advanced prostate cancer. But you may need one to take part in some clinical trials (see page X). If you might want to join a clinical trial in the future, talk to your doctor about having a biopsy. They can help you think about the pros and cons. Read more about having a prostate biopsy.

Magnetic resonance imaging (MRI) or computerised tomography (CT) scan

These scans take images of your body to see whether the cancer has spread outside the prostate, for example to the lymph nodes or nearby bones. You might not need an MRI or CT scan if you’ve already had a bone scan (see below). Read more about having a scan.

Bone scan

This can show whether any cancer cells have spread to the bones, which is a common place for prostate cancer to spread to. Read more about having a scan.

Alkaline phosphatase (ALP) test

This measures the amount of a protein called ALP in your blood. The test may help to show how much the cancer is affecting your bones. It can also be used to see how well your treatment is working if your cancer has spread to the bones.

What do my test results mean?

Your doctor will look at all your test results to get an idea of how quickly your cancer might grow and whether it has spread. This will help you to discuss which treatments might be suitable for you.

PSA level

It’s normal to have a small amount of PSA in your blood, and the amount rises as you get older. Other things can also affect your PSA level. You may have had a PSA test that showed your PSA was raised, and then had other tests to diagnose your prostate cancer.

After you’ve been diagnosed, you will have regular PSA tests. If you have treatment, this is a useful way to check how well your treatment has worked. If your PSA level falls this usually suggests your treatment is working.

If you decide not to have treatment straight away, you will have regular PSA tests to check if your cancer might be growing.

Gleason grade and Gleason score

Your doctor may talk about your Gleason grade and Gleason score after your biopsy.

Gleason grade

Prostate cancer cells in your biopsy samples are given a Gleason grade. This tells you how aggressive the cancer is – in other words, how likely it is to grow and spread outside the prostate.

When cancer cells are seen under the microscope, they have different patterns, depending on how quickly they’re likely to grow. The pattern is given a grade from 1 to 5. This is called the Gleason grade. If a grade is given, it will usually be 3 or higher, as grades 1 and 2 are not cancer.

Gleason score

There may be more than one grade of cancer in the biopsy sample. An overall Gleason score is worked out by adding together two Gleason grades.

The first is the most common grade in all the samples. The second is the highest grade of what’s left. When these two grades are added together, the total is called the Gleason score.

Gleason score = the most common grade + the highest other grade in the samples.

For example, if the biopsy samples show that:

  • most of the cancer seen is grade 3 and
  • the highest grade of any other cancer seen is grade 4, then
  • the Gleason score will be 7 (3+4).

A Gleason score of 4+3 shows that the cancer is slightly more aggressive than a score of 3+4, as there is more grade 4 cancer.

If you have prostate cancer, your combined Gleason score will be between 6 (3+3) and 10 (5+5). You might only be told your total Gleason score, and not your Gleason grades.

What does the Gleason score mean?

The higher the Gleason score, the more aggressive the cancer, and the more likely it is to spread.

  • A Gleason score of 6 suggests the cancer is slow-growing.
  • A Gleason score of 7 suggests the cancer may grow at a moderate rate.
  • A Gleason score of 8, 9 or 10 suggests the cancer may grow more quickly

Staging

Staging is a way of recording how far the cancer has spread. The most common method is the TNM (Tumour-Nodes-Metastases) system.

  • T stage - how far the cancer has spread in and around the prostate.
  • N stage - whether the cancer has spread to the lymph nodes.
  • M stage - whether the cancer has spread to other parts of the body.

You might not be told your N stage or your M stage – your doctor may just tell you whether your cancer has spread to the lymph nodes or to other parts of your body.

T stage

The T stage shows how far the cancer has spread in and around the prostate. A digital rectal examination (DRE) is usually used to find out the T stage. You might also have an MRI scan or a CT scan to confirm your T stage. You may not be told your T stage if other tests show your cancer has spread to your bones.

N stage

The N stage shows whether your cancer has spread to the lymph nodes near the prostate. This is a common place for prostate cancer to spread to. An MRI or CT scan is used to find out your N stage.

The possible N stages are:

  • NX - the lymph nodes were not looked at, or the scans were unclear.
  • N0 - no cancer can be seen in the lymph nodes.
  • N1 - the lymph nodes contain cancer.

If your scans suggest that your cancer has spread to the lymph nodes (N1), it may be treated as either locally advanced or advanced prostate cancer. This will depend on several things, such as which lymph nodes are affected and how far the cancer has spread.

You might not be told your N stage if other tests show your cancer has spread to your bones.

M stage

The M stage shows whether the cancer has spread (metastasised) to other parts of the body, such as the bones. A bone scan is usually used to find out your M stage.

The possible M stages are:

  • MX - the spread of the cancer wasn’t looked at, or the scans were unclear.
  • M0 - the cancer hasn’t spread to other parts of the body.
  • M1 - the cancer has spread to other parts of the body.

If your cancer has spread (M1), you will be diagnosed with advanced prostate cancer.

Example of staging

For example, if your cancer is described as T2, N0, M0, it is likely that your cancer:

  • is completely contained inside the prostate
  • has not spread to your lymph nodes
  • has not spread to other parts of your body.

This is localised prostate cancer.

Ask your doctor or nurse to explain your test results if you don’t understand them.Or call our Specialist Nurses.

What treatments are available?

Hormone therapy

Hormone therapy is the standard first treatment for men with advanced prostate cancer. Prostate cancer needs the male hormone testosterone to grow. Hormone therapy works by stopping testosterone from reaching prostate cancer cells. This causes the cancer cells to shrink, wherever they are in the body.

Hormone therapy will be a life-long treatment for many men with advanced prostate cancer. It won’t cure your cancer, but it can keep it under control, sometimes for several years, before you need further treatment. Hormone therapy can also help to control the symptoms of advanced prostate cancer, such as bone pain.

Like all treatments, hormone therapy can cause side effects. These are caused by lowered testosterone levels. There are a lot of possible side effects, but hormone therapy affects men in different ways. Some men get few side effects and others don’t get any at all. The chances of getting each side effect depend on which type of hormone therapy you’re on and how long you’re on it for. There are ways to manage side effects, so speak to your doctor or nurse.

Read more about hormone therapy and its side effects.

Watchful waiting

Watchful waiting is a way of monitoring prostate cancer that isn’t causing any symptoms or problems. The aim is to keep an eye on the cancer and avoid treatment unless you get symptoms. This means you will avoid or delay the side effects of treatment. If you do get symptoms, you’ll be offered hormone therapy to control the cancer and help manage symptoms.

Watchful waiting isn’t usually recommended for men with advanced prostate cancer. But it may be an option if you don’t have symptoms and you want to avoid the side effects of treatment. If you’d prefer not to have treatment, speak to your doctor. They can help you think about the pros and cons of watchful waiting.

Read more about watchful waiting.

What happens if my cancer starts to grow again?

The first hormone therapy you have may keep your cancer under control, sometimes for several years. But over time, the cancer may change and your treatment may stop working so well. This means your cancer may start to grow again. But there are other treatments available that can help to control the cancer and manage any symptoms you might have.

More hormone therapy

You will usually stay on the first type of hormone therapy, but you may be offered another type of hormone therapy as well.

Read more about other types of hormone therapy in our Tool Kit fact sheet, Second-line hormone therapy and further treatment options.

Chemotherapy

Chemotherapy uses anti-cancer drugs to kill the cancer cells. It is an option for men whose prostate cancer is no longer responding to hormone therapy.

Chemotherapy doesn’t get rid of prostate cancer, but aims to shrink it and slow its growth. It may help some men with advanced prostate cancer to live longer. Chemotherapy can also help to improve symptoms.

Read more about chemotherapy.

Abiraterone (Zytiga®)

This is a type of hormone therapy for men with advanced prostate cancer that has stopped responding to other hormone therapy treatments.

Abiraterone is available on the NHS for men whose cancer has stopped responding to hormone therapy and the chemotherapy drug docetaxel.

Abiraterone is also suitable for men whose cancer has stopped responding to hormone therapy, but who haven't yet had chemotherapy. If you live in England, Wales or Scotland, you should be able to have abiraterone before chemotherapy. If you live in Northern Ireland, you may not be able to get abiraterone before chemotherapy.

Getting abiraterone might depend on whether you’ve had a drug called enzalutamide (see below) in the past.

Read more about abiraterone.

Enzalutamide (Xtandi®)

This is a new type of hormone therapy for men with advanced prostate cancer that has stopped responding to other hormone therapy treatments.

Enzalutamide is available on the NHS for men whose cancer has stopped responding to hormone therapy and the chemotherapy drug docetaxel. It is also available on the NHS for men who haven’t yet had chemotherapy.

Getting enzalutamide might depend on whether you’ve had abiraterone in the past. Early research has shown that enzalutamide only has a small effect in men who have previously had abiraterone. But we need more research into this.

Read more about enzalutamide.

Clinical trials

A clinical trial is a type of medical research. Clinical trials aim to find new and improved ways of preventing, diagnosing, treating and controlling illnesses. There are clinical trials looking at new treatments for men with advanced prostate cancer. You can ask your doctor or nurse if there are any clinical trials you could take part in, or call our Specialist Nurses. You can also find details of clinical trials for prostate cancer at www.cancerhelp.org.uk/trials

Read more about clinical trials.

Treatments to help manage symptoms

If you have advanced prostate cancer, you may have symptoms such as bone pain. Hormone therapy and chemotherapy may help to relieve or reduce these. There are also specific treatments to help manage symptoms. Speak to your doctor or nurse if you have symptoms.

Pain-relieving drugs

Treatments to control pain include mild pain-relieving drugs such as paracetamol and non-steroidal anti-inflammatory drugs such as ibuprofen. There are also stronger drugs called opioids, which include codeine and morphine, so speak to your doctor or specialist nurse if you’re having problems with pain.

Read more about ways to control pain in advanced prostate cancer.

Radiotherapy

Radiotherapy can help control symptoms by slowing down the growth of the cancer. This is sometimes called palliative radiotherapy.

There are two types of radiotherapy to reduce symptoms.

  • External beam radiotherapy - this is where radiation is directed at the area of pain from outside the body.
  • Radioisotopes - this involves an injection of a very small amount of a radioactive liquid.

Read more about radiotherapy for advanced prostate cancer.

Bisphosphonates

These are drugs that treat pain caused by cancer that has spread to the bones. Cancer can damage the bones and make them weaker. Bisphosphonates bind to damaged areas of bone, slowing down the breakdown of the bone and relieving pain.

Read more about bisphosphonates.

What is my outlook?

Many men will want to know how successful their treatment is likely to be in controlling their cancer. This is sometimes called your outlook or prognosis. While it isn’t possible to cure advanced prostate cancer, hormone therapy can keep it under control, sometimes for several years. And when hormone therapy stops working, there are other treatments available to keep the cancer under control for longer.

No one can tell you exactly what your outlook will be, as every cancer is different and will affect each man differently. And not everyone wants to know about their outlook. But some men find it helpful to discuss their outlook so they can make plans for the future. Speak to your doctor about your own situation.

Dealing with advanced prostate cancer

Some men say being diagnosed with prostate cancer changes the way they think and feel about life. If you are dealing with prostate cancer you might feel scared, worried, stressed, helpless or even angry.

At times, lots of men with prostate cancer get these kinds of thoughts and feelings. But there’s no ‘right’ way that you’re supposed to feel and everyone reacts in their own way.

Find out what you can do to help yourself and who can help.

Questions to ask your doctor or nurse

You may find it helpful to keep a note of any questions you have to take to your next appointment.

  • What type of hormone therapy are you offering me and why?
  • What are the advantages and disadvantages of my treatment?
  • What treatments and support are available to help manage side effects?
  • How often will I have check-ups and what will this involve?
  • How will we know if my cancer starts to grow again?
  • What other treatments are available if that happens?
  • Can I join any clinical trials?
  • If I have any questions or get any new symptoms, who should I contact?

References

Updated: August 2014 | Due for Review: July 2016

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