Advanced Prostate Cancer

OK , but what if my cancer is advanced? Don’t panic! Advanced prostate cancer has limited treatment options and surgery is not available. Advanced prostate cancer is not curable and the standard first line treatment are monthly or three monthly injections of a drug to slow the cancer and prolong your life. However, there are some new, exciting treatments now becoming available for treating advanced prostate cancer. See us for information & support.

Treatments for Advanced Prostate Cancer Hormone Treatment: Most men where the cancer has spread outside the prostate gland into the bones will be given Hormone treatment. This treatment reduces the supply of the male hormone testosterone on which the cancer feed. This is given either as one monthly or three monthly injections. This usually dramatically reduces the PSA level and can keep the level low from 1 year to even 6 years. Sometimes, in conjunction with this treatment Palliative radiotherapy is given to reduce pain. Bone health is important, see our leaflet enquire about drugs to help with this. Hormone therapy definitely will cause loss of libido, the inability to have an erection and fatigue. However, it is the only treatment which will control (not cure) the cancer and your overall quality of life should be very good.

Degarelix (Firmagon): Hormone treatment will produce a Testosterone Flair and a drug called bicalutamide will be given for the first couple of week so control this. This flair really matters in patients with spinal metastasise because it will cause the cancer to become temporally very active. Degarelix (Firmagon) does not produce a flair, and should now be given instead of other hormone treatments, if the patient has  spinal metastasise.

Intermittent Therapy Treatment
:  When you’re PSA level has reduced to a very low level and is stable, your hospital doctor might try intermittent therapy. This means taking you off hormone treatment completely until your PSA level rises again. This can be anything from 6 months to a year. When PSA rises again, hormone treatment will be started again and the process will be repeated as often as possible. This is to extend the time before the patient becomes immune to hormone treatment and improve the quality of life. About three month after hormone treatments has been stopped, all of the side affects are very much reduced or disappear altogether.

Palliative Radiotherapy:  
Dependent on the opinion of the oncologist, palliative radiotherapy may be given to control pain, where this is regarded as the appropriate form of treatment. Improvements are continually being made.

Chemotherapy
: When Hormone therapy fails, it is then up to the oncologist, what the next course of treatment will be. Chemotherapy (Docetaxal) treatment used to be the first option, but other treatments are becoming available. At this point it might be worth the patient enquiring about the availability of clinical trials. Click on the link below to find out more: http://www.cancerresearchuk.org/cancer-help/trials/ In most patients, Chemotherapy is well tolerated, with the most common side affects being loss of hair, fatigue and the higher possibility of infection. Temperature should be taken every day and if it rises to 38º your oncology department should be contacted without delay.

STAMPEDE Trial: The STAMPEDE Trial is the largest trial ever undertaken into the treatment of advanced prostate cancer. It has many arms and is on going. It has recently reported on one of it’s initial findings. It has been found that if Docetaxel chemotherapy is given within the first 3 months of diagnosis, then it shows an average 2 year increase in survival. This is a massive and important finding that has now been adopted as standard treatment within the NHS.

Abiraterone (Zytiga) 
This drug, invented in the 1990’s and has been available, post chemotherapy from the NHS for sometime, it should now be given before Chemotherapy. It is four tablets per day, taken with two 5mg tablets of Prednisalone.  It works by destroying the patient’s ability to manufacture the testosterone on which the cancer needs to feed. It is perhaps the biggest advance in advanced prostate cancer treatment in the last 25 years. For those patients for whom it works and this is around 43%, it’s effect is quite remarkable. Toxicity can be a problem with Abiraterone, particularly affecting the liver. As with all of the advanced prostate cancer drugs, monthly blood tests will be given to check on progress. Abiraterone is now available for both Pre-Chemotherapy and Post-Chemotherapy

Enzalutamide (Xtandi) is the most recent hormone therapy to be licensed in the UK. It blocks a number of steps in the process by which male hormones, including testosterone, cause prostate cancer cells to grow. It is taken as a once daily dose of four tablets and does not require prednisalone. It can be taken before or after food, at any time of the day. Patients have reported that, if taken in the evening, the problems of  fatigue associated with Enzalutamide are much reduced. Enzalutamide is now available for both Pre-Chemotherapy and Post-Chemotherapy.

In July 2014, NICE made their final decision on the use on the end of life drug, Enzalutamide. The recommendation from NICE is that Enzalutamide is passed for use in advanced cancer patients whose have had chemotherapy. The recommendation specifically does not cover the use of Enzalutamide after Abiraterone, which was refused under the Cancer Drugs Fund. This meant that this decision was left to local CCG’s, making a postcode lottery. NHS England have now stepped in and softened this stance. Enzalutamide can now be given after Abiraterone, if Abiraterone has been stopped within three months due to toxicity problems. Not disease progression. They have also turned it round so that Abiraterone cannot be given after Enzalutamide.

Radium-223 dichloride (Xofigo) is now available under the Cancer Drugs Fund. Radium is very similar to calcium, as like calcium, active bone cells take it up. This makes it a good way of targeting bone cancer cells. Cancer cells are more active than bone cells and so more likely to pick up the Radium 223. Radium 223 treatment uses a type of radiation called alpha particles to kill cancer cells. Radium 223 is injected into your blood and it circulates to your bones. The cancer cells in the bone take it up. The radiation only travels a short distance, between 2 and 10 cells deep. This is much less than a millimetre. So it means that the cancer cells receive a high dose of radiation, but healthy cells receive only a low dose or no radiation. So this treatment causes fewer side effects and is more successful than some other types of radiotherapy. Radium 223 is now available for all patients, whether or not they have received Docetaxel, providing there is no known visceral metastases (soft tissue).

Cabazitaxel is a new and novel form of chemotherapy. It is available for patients for whom all else has failed. It is very well tolerated, and can keep the cancer from progressing for some considerable time (sometimes years) The patient will be given 10 cycles at 3 week intervals. It is very important to guard against infections whist on treatment.  Temperature must me taken at least 3 times per day and if it raises to 38º you should ring the emergency number you will have been given.

Below is a Table showing the latest treatments for advanced prostate cancer and the involvement of ‘Tackle Prostate Cancer’ in achieving this.

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