Royal is defined as the presence of metastases located outside the pelvic lymph nodes or the development of resistance to one of the Lupron-like drugs. Royal is potentially the most life threatening of all the Stages and requires aggressive treatment. The goal is to use maximal treatment to achieve a complete cancer remission and reduce the PSA level to less than 0.1. 

There are two pathways to Royal. One begins with PSA screening leading to the initial diagnosis of localized disease followed by local treatment. After a period, a relapse occurs, the Stage of Blue becomes Indigo and hormonal therapy with Lupron is started. Normally, after about 10 years, resistance to Lupron develops and the Stage becomes RoyalRoyal can also occur by a different pathway in men who forgo PSA screening. These individuals come to medical attention when they seek an explanation for bone pain. Evaluation with diagnostic scans reveals that the cancer has already metastasized to the bone.

Three subtypes of Royal can be defined: Low, Basic and High. In Low-Royal, Lupron-resistance exists, but the scans are clear of metastatic disease. Basic-Royal occurs when there are five or fewer metastases are detected by a scan, with at least one of the metastasis located outside or beyond the pelvic lymph nodes. High-Royal means that there are over five metastatic sites with at least one of them located outside the pelvic lymph nodes.

When men are receiving ongoing treatment for Royal, continual monitoring is needed to assess the effectiveness of the therapy. In addition to blood testing and querying patients about any changes in pain symptoms, scans of the body and bones should be performed at least every 6 months. The optimal method for interpreting the results of new scan is to compare it with the results of previous scans. This improves the doctor’s ability to determine if the cancer is progressing or regressing. 



Mark Scholz, MD is the Executive Director of the Prostate Cancer Research Institute. He is also the Medical Director of Prostate Oncology Specialists Inc. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is co-author of Invasion of the Prostate Snatchers.  He has authored over 20 scientific publications related to the treatment of prostate cancer.