Men with relapsed or advanced prostate cancer tend to live much longer than men with other types of cancer. First, PSA testing detects cancer relapse at a much earlier stage compared to other cancers. Second, prostate cancer usually spares critical organs like the brain, the liver or lungs. And third is the availability of so many effective types of treatment: Standard hormonal treatment with Lupron and Casodex, for example, can induce ten-year remissions on average. And amazingly, the FDA has recently approved five new treatments—Provenge, Xtandi, Zytiga, Xofigo, Xgeva and Jevtana.
A prostate cancer relapse is signaled by a PSA rise after treatment. Men with relapsed disease have a number of treatment choices: Observation, radiation, hormone therapy, and cryotherapy. Treatment selection is guided by the cancer location, usually determined by scans, and the PSA doubling time.
The rate that the PSA doubles typically dictates which treatment will be used. For example, if PSA is doubling in less than six months, combination treatment with hormones plus radiation or cryosurgery may be best. If the doubling rate is between six and twelve months, a less aggressive treatment approach with radiation alone, cryosurgery alone or hormones alone may be reasonable. When more than a year is required for the PSA to double, observation without immediate treatment may be considered.
Injectable medications such as Xgeva or Zometa are routinely recommended when bone metastases are present. These medications have three potential benefits: They inhibit cancer growth in the bones; they reduce bone pain; and they help counteract osteoporosis.
Even if the cancer develops resistance to all the medications listed above there are additional treatment options and investigational medications to be considered. Investigational trials represent an opportunity for patients to get medications prior to FDA approval. A patient’s enthusiasm for embarking on a study using an investigational medication, however, needs to be tempered by what is actually known about the effectiveness of the specific medication. Some medications are so new that even the investigators performing the trial don’t know if they are going to work or not.
Since so many effective treatments are available, one should not wast time using a therapy that’s not working. Therefore, close monitoring is essential with monthly blood tests and biannual scans. Ineffective treatment should be stopped as soon as disease progression occurs so that a more effective therapy can be started in a timely fashion.