A metastatic prostate cancer can be diagnosed in several ways. The patient may present with “systemic” symptoms such as fatigue, weight loss, or bone pain.

On the other hand, there may have been a diagnosis of localized prostate cancer at intermediate or high risk. Subsequently, additional tests may demonstrate that the cancer has already spread to other organs (metastases).

In all cases, a diagnosis of metastatic prostate cancer is based on the identification of cancer cells in other organs (bones, lymph nodes, liver, etc.). This is usually done using different imaging modalities, including:

• Bone scintigraphy – Used to detect the presence of cancer cells in your bones, where prostate cancer most commonly spreads.
• Abdominopelvic computed tomography – It allows the evaluation of intra-abdominal anatomy and the identification of suspicious lesions. Since prostate cancer can spread to your pelvic and abdominal
• lymph nodes, your urologist will be particularly interested in these small organs of the immune system and will seek to determine if the cancer has lodged there.

In recent years, several treatments initially used after the failure of injection hormone therapy, such as chemotherapy and/or new generation hormone therapy in tablet form, are now sometimes used when there is a new diagnosis of metastatic prostate cancer (see below). This allows for a strong initial attack on the cancer and thus keeps it in remission for as long as possible.

Lymph node metastases

When prostate cancer has reached the lymph nodes, discovered either on imaging during the assessment of a new prostate cancer diagnosis or following the removal of the pelvic nodes sometimes performed during a radical prostatectomy, the standard treatment is usually lifelong hormone therapy. Significant published studies have shown that starting hormone therapy as soon as there are lymph node metastases, before the appearance of bone metastases (the most common metastases), significantly prolongs survival.

Your doctor may also propose a radical prostatectomy with removal of your pelvic lymph nodes if your lymph node burden is minimal, meaning that very few lymph nodes are affected by cancer.

The doctor may prefer to wait and monitor your PSA level. Indeed, in about 10% to 15% of cases of lymph node metastases, the PSA level remains stable for several years.

• With medical follow-up every three or six months, the doctor monitors your situation and intervenes as soon as he notices that this level starts to rise. He then has time to react since it will take several more months or even years before the cancer metastasizes elsewhere.
• The decision to wait may be taken to avoid the side effects of hormone therapy for as long as possible.

Bone Metastases

Cancer that has spread to the lymph nodes will eventually attack the bones, especially those of the pelvis and spine. If the metastases are large enough, the following symptoms may sometimes occur: lower back or hip pain, numbness or paralysis of the lower limbs (metastases to the spine can compress the spinal cord), constant fatigue, loss of appetite, and paleness (bone metastases can cause anemia). At this stage, your bones have become very fragile and susceptible to fracture.

Hormone therapy is prescribed as soon as the doctor observes the presence of bone metastases, whether or not accompanied by pain. Treatment is almost always applied continuously and for life.

Hormone therapy relieves pain and significantly prolongs your survival. Additional palliative treatments may be added to reduce your symptoms or bone pain.

Advances in Research

It has been observed that patients live much longer and that the onset of symptoms related to metastases is delayed if hormone therapy is early combined with chemotherapy, such as docetaxel (Taxotere), or with new generation hormone therapy, such as abiraterone (Zytiga), enzalutamide (XTANDI), apalutamide (Elreada), rather than waiting for your cancer to no longer respond to standard hormone therapy.

What research says in 2023 – In patients with prostate cancer that has spread significantly throughout the body, treatment options beyond hormone injections, such as triple therapy (standard hormone therapy, chemotherapy, and oral tablets), should be discussed with their doctor. In this regard, here is a video capsule that may interest you with Dr. Vincent Fradet, uro-oncologist at the CHU de Québec-Université Laval, following the scientific conference of ASCO-GU in 2023.

As mentioned earlier, this allows for a strong initial attack on the cancer and thus keeps it in remission for as long as possible.

The addition of chemotherapy or new generation hormone therapy to your standard hormonal treatment will depend on whether you have many or few metastases, the risks of progression of your cancer, your overall health, the pros and cons. Your doctor is best placed to plan your treatment and you should not hesitate to ask your questions.

What You Need to Know

Older forms of hormone therapy are still useful and should continue to be prescribed, but the addition of the new generation of hormonal agents brings significant benefits to patients. This class of drugs is also an option that can be used if you have been diagnosed with castration-resistant metastatic cancer.

If your cancer develops resistance to this class of drugs, you may be treated with chemotherapy, with radium-223 if you have metastases that cause bone pain, or through a research protocol, if there is one available, of course.

One thing is certain – Your treatment aims to prolong your life, slow down the progression of your cancer, relieve your symptoms if you have any, and enhance your quality of life.