Stage IV Prostate Cancer
- From: J <ercent@xxxxxxxx>
- Date: Sat, 21 Oct 2006 18:23:24 -0400
http://cancer.swedish.org/TypesOfCancer.aspx?section=typesofcancer&id=901
[excerpts]
By Charles H. Weaver, MD
Date Created: 3/23/2004
Date Modified: 4/18/2006
Overview
A stage IV prostate cancer is said to exist if the final evaluation shows
that the cancer has spread to distant locations in the body, which usually
includes bones. Stage IV disease may be further classified as the
following depending on the extent of the cancer (tumor):
* The tumor has spread to pelvic lymph nodes or is obstructing the
ureters (the tubes from the kidneys to the bladder), or both.
* Cancer spread (metastasis) to lymph nodes outside the pelvic area,
bone involvement, or spread to other distant parts of the body.
Prostate cancer diagnosed in this stage is often difficult to cure,
although patients may live for several years with effective treatment.
A variety of factors ultimately influence a patient's decision to receive
treatment of cancer. The purpose of receiving cancer treatment may be to
improve symptoms through local control of the cancer, increase a patient's
chance of cure, or prolong a patient's survival. The potential benefits of
receiving cancer treatment must be carefully balanced with the potential
risks of receiving cancer treatment.
The following is a general overview of the treatment of stage IV prostate
cancer. Circumstances unique to your situation and prognostic factors of
your cancer may ultimately influence how these general treatment
principles are applied. The information on this Web site is intended to
help educate you about your treatment options and to facilitate a mutual
or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are
studies that evaluate the effectiveness of new drugs or treatment
strategies. The development of more effective cancer treatments requires
that new and innovative therapies be evaluated with cancer patients.
Participation in a clinical trial may offer access to better treatments
and advance the existing knowledge about treatment of this cancer.
Clinical trials are available for most stages of cancer. Patients who are
interested in participating in a clinical trial should discuss the risks
and benefits of clinical trials with their physician. To ensure that you
are receiving the optimal treatment of your cancer, it is important to
stay informed and follow the cancer news in order to learn about new
treatments and the results of clinical trials.
Patients diagnosed with stage IV prostate cancer can be broadly divided
into two groups. Patients with cancer locally confined to the pelvis, but
involving adjacent organs or lymph nodes have localized stage IV or D1
prostate cancer. Patients with disease that has spread to distant organs,
most commonly the spine, ribs, pelvis and other bones have metastatic
stage IV or D2 prostate cancer.
Treatment of Localized Stage IV or D1 Prostate Cancer
Prostate cancer may not be diagnosed until it has invaded adjacent organs,
such as the rectum or bladder, or spread to lymph nodes in the pelvis.
When this occurs, surgery (radical prostatectomy) is seldom an effective
treatment. Current treatment involves a combination of external beam
radiation therapy (EBRT) and hormone therapy. Hormone therapy deprives a
man?s body of male hormones necessary for prostate cancer to grow. In
localized stage IV prostate cancer, hormone therapy and radiation therapy
are often given together; however, new treatment strategies that offer
patients a chance of cure are needed.
Combined Modality Therapy
Patients with prostate cancer documented to involve the pelvic lymph nodes
have an average time to cancer progression of approximately 18 months and
this is reduced to less than 12 months in patients with high-grade cancer.
Historically, standard treatment of these patients has involved hormonal
therapy, surgery or radiation therapy. Treatment with either hormonal
therapy or radiation therapy is associated with an approximate 55% chance
of patients surviving 5 years without evidence of cancer progression,
compared to approximately 20-40% for patients treated with surgery.
It has been demonstrated in several other cancers that multi-modality
treatments that use combinations of chemotherapy, surgery, radiation and
hormonal therapy improve cure or survival rates compared to treatment with
a single therapy. In order to evaluate whether combination therapy could
be beneficial in the treatment of prostate cancer that involves pelvic
lymph nodes, a clinical study compared radiation therapy followed by
immediate hormonal therapy to radiation therapy followed by delayed
hormonal therapy, which was initiated only at the time of cancer
progression.
Patients treated with radiation therapy and immediate hormonal therapy
were more likely to be alive 5 years from initiation of treatment without
evidence of cancer progression or development of distant metastatic
disease than patients treated with radiation and delayed hormonal therapy.
Both treatments, however, produced a similar chance of survival 5 years
following treatment. The results of this clinical study suggest that the
combination of radiation therapy and hormonal therapy reduces the time to
cancer recurrence and development of metastatic disease, and may improve a
patient's quality of life. The combination of radiation and immediate
hormonal therapy increased the survival of some patients.
Treatment of Metastatic Stage IV or D2 Prostate Cancer
Prostate cancer that has spread to distant organs and bones is treatable,
but not curable with current standard therapies. Hormonal therapy has been
the standard treatment of metastatic prostate cancer for many years.
Metastatic prostate cancer usually can be controlled with hormone therapy
for a period of time, often several years. Eventually, however, most
prostate cancers are able to grow despite the hormone therapy. To learn
more, go to Hormonal Treatment of Prostate Cancer.
Some patients with metastatic prostate cancer may not have any symptoms
from their cancer. Previously, many of these patients were "observed" and
only treated when problems did eventually develop. The results from a
clinical study conducted by doctors in England comparing immediate hormone
treatment to hormone treatment at the time of worsening cancer has shown
improved survival for men treated immediately compared to those receiving
treatment at the time of cancer progression. Complications from metastatic
prostate cancer were also less frequent in men receiving immediate
treatment. Patients with metastatic prostate cancer are currently being
treated with hormone therapy using medications or orchiectomy soon after
diagnosis.
Treatment of Bone Complications
Patients with advanced prostate cancer can have cancer cells that have
spread to their bones, called bone metastases. Bone metastases commonly
cause pain, increase the risk of fractures, and lead to a life-threatening
condition characterized by an increased amount of calcium in the blood
called hypercalcemia. Treatments for bone complications may include
bisphosphonate drugs or radiation therapy.
Bisphosphonate drugs: Bisphosphonate drugs can effectively prevent loss
of bone that occurs from metastatic lesions, reduce the risk of fractures,
and decrease pain. Bisphosphonate drugs work by inhibiting bone
resorption, or breakdown. Bone is constantly being ?remodeled? by two
types of cells: osteoclasts, which break down bone; and osteoblasts, which
rebuild bone. Although the exact process by which bisphosphonates work is
not completely understood, it is thought that bisphosphonates inhibit
osteoclasts and induce apoptosis (cell death) in these cells, thereby
reducing bone loss. There is also evidence that these drugs bind to bone,
thereby blocking osteoclasts from breaking down bone.Cancer cells release
various factors that stimulate osteoclastic activity, causing increased
breakdown of bone. By inhibiting osteoclasts, bisphosphonate drugs
effectively reduce the detrimental impact that cancer cells have on bone
density.
Bisphosphonate drugs that are FDA-approved for the treatment of
cancer-related skeletal complications include Zometa® (zoledronic acid)
and Aredia® (pamidronate). Of these two drugs, Zometa® appears to
demonstrate the strongest activity. An added benefit of Zometa® is that it
is administered in a dose ten times lower than Aredia®, which considerably
reduces the administration time from several hours to 15 minutes,
resulting in a more convenient regimen for patients.
Zometa® has been shown to be a safe and effective treatment in prostate
cancer patients with bone metastases. Zometa® significantly reduces the
proportion of patients who experience skeletal complications, extends the
time to first skeletal complication, and reduces the risk of skeletal
complications.1
Zometa® also appears to benefit patients with prostate cancer undergoing
androgen deprivation therapy, or ?hormonal therapy?. Hormonal therapy in
the treatment of prostate cancer has been shown to cause bone loss.2
Researchers from Massachusetts General Hospital and 5 other medical
institutions conducted a clinical trial evaluating Zometa® in patients
with localized prostate cancer being treated with androgen deprivation
therapy. This study included 106 men who were randomly selected to receive
either Zometa® or a placebo for one year. Bone mineral density in the
spine, hips, and legs increased among patients who were treated with
Zometa® and decreased in patients who received placebo.3
Radiation therapy:
Pain from bone metastases may also be relieved with radiation therapy
directed to the affected bones. The side effects of radiation therapy for
relief of bone pain depends on the area of the body being treated.
Another method for treatment of bone pain is the use of radioisotopes,
such as strontium-89. Strontium-89 is given intravenously and accumulates
in the bones where it kills prostate cancer cells by delivering small
amounts of radiation. Clinical studies have shown that bone pain and the
need for pain medications can be reduced in the majority of patients
treated with strontium-89. Since strontium-89 is given by vein, it can
affect all bones in the body, whereas external radiation therapy is
limited to only small areas of the body. The major side effect of
strontium-89 is a reduction in blood cell counts.
.
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