Outlook for men with advanced prostate cancer improved

Dr Ahmed El-Modir

Ahmed El-Modir, consultant oncologist
Birmingham Prostate Clinic

 

The outlook for men with advanced prostate cancer has been transformed in recent years. A decade ago, once prostate cancer had spread beyond the prostate capsule, options were very limited. The most common scenario was hormone therapy for 18 to 24 months, followed by chemotherapy for approximately a year, once the disease became castrate refractory.

Now, men are commonly living with advanced prostate cancer for five or six years and we are able to continually improve their quality of life.

The advancements that have contributed to this transformation can be broken down into the following categories:

  • Improvements in the treatments to control the spread of cancer
  • Improvements in the treatments to treat the symptoms of metastatic disease
  • Improvements in scanning technology which have opened new options for men with very early metastatic disease (known as oligometastatic prostate cancer)

In this section, we consider some of the main changes and advancements in options for men with advanced prostate cancer.

Hormone treatment first, then chemotherapy? Not necessarily

The long established approach has been to start with hormone treatment and only commence chemotherapy once hormone treatment ceases to be effective (castrate refractory prostate cancer). Recently, a landmark study has called this into question, achieving unprecedented improvements in survival, particularly in men with a high number of metastases. In other words, if the prostate cancer is very aggressive and advanced, we should ‘hit hard’ to achieve maximum survival, rather than taking a stepped treatment approach.

Using a broader arsenal of treatment options

There is now a far broader range of treatment options than ever before. At BPC, we provide Docetaxel, Cabazitaxel, Mitoxantrone, Enzalutamide, Abiraterone, Radium-223 (Xofigo). What this means in practice is that if a patient is not responding to one type of treatment, we have options and equally, if a treatment has been effective but is becoming less so, we can switch to other options. This can also be very helpful if a patient has trouble tolerating one treatment but may find another option much more manageable.

Wider range of treatment for symptoms of advanced disease

This is also an area which has improved very significantly in recent years. We have a wide range of options to address individual needs and symptoms including: palliative radiotherapy, Strontium-89, Samarium-153, Zolidronic acid and Denosumab.

New options for men at early stages of metastatic disease

Advances in scanning technology have opened up new treatment options for men at the early stage of advanced prostate cancer, known as oligometastatic prostate cancer. Oligometastatic prostate cancer is defined as disease with less than three metastases. Up until very recently, it was very hard to identify metastases at a very early stage, as they were not visible on standard scans. This meant men with rising PSA after primary treatment would be treated ‘blind’ with radiotherapy to the prostate bed (as the most likely possible site of metastases). Now, some BPC patents have travelled to Germany for PSMA scans and there is growing evidence that the much more detailed images they provide mean we can target metastases precisely and accurately. This treatment may be surgery or Cyberknife radiotherapy and we consider approaches for men with oligometastatic prostate cancer in more detail in this section. It is early days, but there is also consideration of whether the highly precise cyberknife treatment can be used as an alternative to hormone therapy, for men who would prefer not to start hormone treatment if there is a different option.