How is prostate cancer diagnosed?
A. Prostate cancer is usually diagnosed by one of
How is prostate cancer initially treated?
of prostate-specific antigen (PSA)- a protein produced by the
prostate gland. Its level goes up in the blood of some men who
have prostate cancer and other conditions.
- Digital rectal
examination (DRE)-a procedure in which a doctor inserts a gloved
finger in the rectum to examine the rectum and prostate gland.
(Since neither the DRE or PSA test can confirm diagnosis of prostate
cancer, a needle biopsy of the prostate gland is also required)
- Surgery for
an enlarged prostate (benign prostatic hypertrophy/BPH). This
surgery can reveal prostate cancer. Occasionally men may be diagnosed
with advanced prostate cancer that has already spread to bones
The treatment of early prostate cancer continues to be controversial
because its behavior may be difficult to predict. Patients may undergo
watchful waiting if they are asymptomatic (having no symptoms) and
have a low-grade tumor that is quite small. Treatments for other patients
Spread of Prostate Cancer
of the prostate gland-a common treatment that can be accomplished
through an incision in the abdomen or between the scrotum and
therapy-may be delivered by a machine (external radiation) or
by implants placed in the prostate gland (brachytherapy or seed
- Hormone therapy-not
curative and may be used if the tumor has a significant risk of
being outside the prostate gland. The goal of hormone therapy
is to reduce the main male hormone testosterone to very low levels.
In the past this was done by removal of the testes or by administration
of estrogen, which blocks production of testosterone by the testes.
More recently, drugs have been developed that reduce testosterone
levels by diminishing the production of a pituitary gland hormone
that controls testosterone release by the testes. These drugs,
such as Zoladex® (goserelin acetate) and Lupron® (leuprolide acetate)
are administered in the doctor's office by injection every 1 to
3 months. In addition to reducing testosterone production, some
patients are given an antiandrogen, such as Casodex® (bicalutamide),
Eulexin® (flutamide), or Nilandron® (nilutamide), that blocks
the effect of remaining amounts of testosterone and other male
hormones on prostate cells. When both types of drugs are given,
this is total androgen blockade. (Please see chart under question
- In some patients,
a combination of surgery, radiation therapy, and combined hormone
therapy is utilized.
4. Q. How often does the initially treated prostate cancer
A. If the tumor is localized to the prostate gland at
the initial time of treatment by surgery or radiation therapy, there
is an excellent chance that the patient will be cured. However, if
the tumor is large or aggressive (growing quickly and ready to spread),
tumor recurrence is common and the overall survival rate is about
50 percent lower than what would be expected 15 years after initial
treatment. If the tumor has spread outside the prostate gland since
the time of original diagnosis, survival rates are lower.
Where in the body does prostate cancer spread?
A. When cancer spreads from the organ of origin, the
distant tumor is termed a metastasis. Prostate cancer frequently spreads
into nearby organs, the lymph nodes and distant organs. The lymph
nodes in the pelvis are the first to be affected, but lymph nodes
in the abdomen, chest, and those above the clavicles may be affected.
The most common site of distant spread is to the bone (80 percent
of late-stage patients). Prostate cancer may also spread to the liver,
lung, and pleura (lining of the lung).
6. Q. What happens when prostate cancer spreads to bone?
A. When prostate cancer grows in bone, it may stimulate
an increase in the number of osteoblasts (cells that produce bone)
and osteoclasts (cells that break down bone). Usually this results
in an excess of abnormally dense bone, although some areas of bone
loss may also be seen.
The presence of prostate cancer in bone causes a variety of symptoms.
Although some patients are pain-free, the majority have moderate to
severe pain. The spine is the most common site of pain, followed by
the pelvis, skull, and ribs. As the disease progresses, fractures
are common complications.
Tumors growing from vertebrae may produce spinal cord compression
and nerve damage if untreated.
In patients with widespread disease, anemia may occur from testosterone
deficiency and possibly the overall toxic effect of the cancer.
Blood calcium levels can be affected by prostate cancer in bone. In
some patients there may be hypocalcemia (a slight lowering of blood
calcium levels) due to the stimulation of new bone by the tumor, which
requires a large amount of calcium. Rarely patients with widespread
disease may develop hypercalcemia (a high blood calcium concentration)
due to a high level of bone breakdown. Nausea, vomiting, impaired
mental function, and weakness are some symptoms of high calcium levels.
7. Q. How is the spread of prostate cancer to bone
of Prostate Cancer That Has Spread to Bone
Bone scan-the most sensitive means of detecting bone metastases
and other abnormal processes in bone. A safe amount of a radioactive
substance is injected and circulates through the bloodstream.
This substance then localizes in areas where there is new bone
formation associated with prostate cancer metastases. A bone scan
may reveal bone metastases before they are visible in an x-ray.
a bone scan does not specifically diagnose bone metastases, x-rays
are often used to help confirm the diagnosis of a bone metastasis.
CT scans or MRI examinations are also sometimes helpful.
- Bone biopsy-in
a small percentage of patients it may be necessary to remove a
small piece of bone for microscopic evaluation if the bone scan
and x-ray results are inconclusive.
What can be done to preserve bone health in men with prostate cancer?
A. It is likely that more than one health
care professional will care for the patient with bone metastases.
Urologists, radiation oncologists, and medical oncologists may provide
care depending on the individual condition of the patient.
If there is risk of a fracture, or if a fracture has occurred, an
orthopedic surgeon will provide appropriate surgical care, possibly
with the assistance of a neurosurgeon if a tumor in the spine is causing
pressure on the spinal cord or nerves. Physical medicine physicians
may assist in prescribing physical therapy.
Oncology nurses, orthopedic nurses, and physical therapists will often
be called upon to assist with the use of medications and rehabilitation
needed to return patients to their usual daily activities.
Because of the emotional and social impact of prostate cancer in bone,
patients may want to consult mental health professionals (e.g., psychologists,
social workers, or psychiatrists). Psychotherapy, antidepressant medication,
and/or support groups may be helpful for some individuals.
Once the prostate cancer has spread to bone, what treatments are given?
A. The treatment of patients with prostate
cancer metastases in bone depends in part on prior treatment of the
cancer. Prostate cancer cells are initially dependent on male hormones
(testosterone mainly) for growth. If surgery or radiation was the
initial treatment, measures can be taken to reduce testosterone production.
This could be accomplished with medication or surgical removal of
the testes. Some patients also receive antiandrogen medications.
If bone metastases develop despite these types of therapies, or if
these therapies fail to relieve bone pain, there are several other
choices of treatment. Second-line hormone therapy such as Cytadren®
(aminoglutethimide), Stilphostrol® or Stilbestrol® (diethylstilbesterol),
Nizoral® (ketocozanole), and Megace® (megastrol), utilizes drugs that
can further suppress production of androgens, or block their actions
at the cancer cell itself. The benefits of second-line hormone therapy
are modest at best.
If hormone therapy fails, chemotherapy (treatment with anticancer
drugs such as Emcyt® [Estramustine]) may be offered. Though still
an active area of research, chemotherapy may benefit one third to
one half of patients with progressive prostate cancer, including reduction
of bone pain or shrinkage of tumors.
Radiation therapy, which can be delivered externally, may relieve
pain in 70-90 percent of patients. However, if there are multiple
painful bone metastases, it is more feasible to treat with intravenous
radioactive drugs such as Metastron® (strontium-89) or Quadramet®
(samarium-153). These agents may relieve pain in 65-80 percent of
patients, though the duration of the effect is limited. (Please see
A class of drugs called bisphosphonates helps to prevent breakdown
of bone. One of these, Aredia® (pamidronate), has been approved for
treatment of bone metastases from breast cancer and for bone disease
in patients with multiple myeloma. The bisphosphonates are being studied
in clinical trials to determine their effectiveness in treating patients
with prostate cancer.
In patients whose pain is not helped by the above types of treatment,
nonspecific pain medications are an important means of relieving pain.
The most severe pain may require narcotic therapy and referral to
pain management specialists. Often pain medications are combined with
the above therapies to achieve adequate pain relief.
Approved by U.S. Food and Drug Administration (FDA) for the
Treatment of Prostate Cancer
Chemotherapy See Question #9
Hormone Therapy See Question #3
Zoladex® (goserelin acetate)
Lupron® (leuprolide acetate)
Radioactive Drugs See Question #9
Second-Line Hormone Therapy See Question #9
Stilphostrol®, Stilbestrol® (diethylstilbesterol)
Antiandrogens See Question #3
Q. What can be done if the tumor has weakened the bone
so that a fracture is likely or has already occurred?
A. In patients with prostate cancer metastases
in bone there is an increased risk of fractures in the long bones,
spine, and pelvis. Fractures are usually preceded by an increase
in pain aggravated by standing or walking. An x-ray may suggest
a risk of fracture or indicate that a fracture has occurred. If
there is a risk of fracture, external radiation may decrease pain
and possibly reduce fracture risk.
Improved surgical techniques for impending or established fractures
have produced excellent results in the great majority of patients.
Pain relief and restoration of the ability to walk can be achieved
in a high percentage of individuals.
Can anything be done to prevent the spread of prostate cancer to
The most effective means of preventing bone metastases is surgery
or radiation therapy prior to the spread of the tumor from the prostate.
This gives the best chance of cure.
Bone Health in Men with Prostate Cancer
Q. What can be done to preserve bone health in men with
nutrition including adequate vitamin intake, and maintenance of
normal weight are helpful in preserving bone. Cigarette use and
a high level of alcohol intake should be avoided, as both can cause
studies of men whose testosterone production is reduced by removal
of the testes or by drug therapy suggest that reduction of testosterone
production may lead to bone loss and greater risk of fractures.
Early studies indicate that if such patients are treated with a
bisphosphonate, bone loss can be prevented or even partially restored.
Q. Is exercise useful and safe in men with prostate cancer?
Exercise is beneficial for all men, but men with prostate cancer
should consult with their physicians to create an appropriate exercise
plan. Exercise may be particularly important for prostate cancer
patients who have reduced testosterone, which can lead to loss of
muscle mass. Muscle weakness may cause falls and fractures. It has
been shown that increased exercise can partially overcome muscle
loss caused by testosterone deficiency and thereby contribute to
fracture prevention. However if patients already have bone metastases,
exercise may cause fracture.
Having too few red blood cells. Symptoms include tiredness, weakness,
and shortness of breath.
Opening at the lower end of the rectum through which solid waste
leaves the body.
prostatic hypertrophy (BPH) Enlargement of the prostate, blocking
urine flow. BPH is not cancer, but can cause some of the symptoms.
Also called benign prostatic hyperplasia.
Removal of a sample of tissue, examined under a microscope to
check for cancer cells.
Drug used to prevent breakdown of bone.
Internal radiation achieved by implanting radioactive material
into the tumor or close to it. Also called internal radiation
therapy, interstital radiation therapy, or seed implant therapy.
Major mineral component of bone, important for normal function
of nerves and other organs.
trial Research study involving volunteers, designed to answer
medical questions and find better ways to prevent or treat disease.
scan (computerized tomography or CAT scan) Series of
detailed pictures of areas inside the body, created by a computer
linked to an x-ray machine.
rectal examination (DRE) Procedure in which the doctor inserts
a gloved finger into the rectum to examine the rectum and prostate.
radiation Use of a machine to aim high-energy rays at cancer.
Body chemicals secreted by glands. Male hormones include androgen
and testosterone (produced primarily by the testes, plays important
role in a man's sexuality and fuels the growth of prostate cancer).
Estrogen is a female sex hormone. These hormones circulate in
the blood- stream, and control the actions of certain cells or
Hormone therapy Use of medications
or surgical removal of the testes to prevent male hormones from
stimulating further growth of prostate cancer.
Into a vein.
Of little degree.
nodes Small, bean-shaped organs that are part of the body's
immune system. They are located throughout the body along the
channels of the lymphatic system. Also called lymph glands.
oncologist Doctor trained in the diagnosis and treatment of
(pl., metastases; v. metastasize) Spread of cancer cells throughout
the body. Cells that have metastasized are the same as those in
the original tumor.
- MRI (magnetic
resonance imaging) Imaging technique that produces detailed
pictures of areas inside the body by linking a computer with a
myeloma Disease of the bone marrow in which certain cells
grow out of control and break down bone.
Branch of medicine dealing with cancer.
gland Master gland in the brain that makes hormones that control
hormone production in other glands such as the testes.
Male sex gland that produces fluid that forms part of semen.
antigen (PSA) Protein produced by the prostate gland. PSA
circulates in the blood and can be measured with a blood test.
PSA levels go up in some men who have prostate enlargement, inflammation,
infection, or prostate cancer.
oncologist Doctor who specializes in using radiation to treat
therapy Treatment with high-energy rays to kill cancer cells.
External skin pouch containing the testes.
Pair of egg-shaped glands contained in the scrotum that produce
sperm and male hormones. Also called testicles.
androgen blockade Complete blockage of androgen production.
Also called combination hormone therapy.
Abnormal growth of tissue. A tumor can be malignant (cancerous)
or benign (noncancerous).
Doctor who specializes in disorders of the urinary system and
male reproductive system.
waiting Following the patient closely. Postponing
aggressive theraphy unless signs of disease progress.
publication was written by:
With the editorial
R. Singer, MD
John Wayne Cancer Institute
Santa Monica, CA
- Gerald Andriole,
Washington University School of Medicine
St. Louis, MO
- William J.
Washington University School of Medicine
St. Louis, MO
Sunnybrook & Women's College Health Sciences Centre
University of Toronto
Toronto, Ontario, Canada
- Allan Lipton,
Milton S. Hershey Medical Center
The Pennsylvania State University College of Medicine
- Maureen Major,
RN, MS, OCN
Memorial Sloan Kettering Cancer Center
New York, NY
- William Oh,
Dana Farber Cancer Institute
Harvard Medical School
Resources for Patients and Family Members
1599 Clifton Rd., NE Atlanta, GA 30329
Cancer Institute (NCI)
31 Center Dr., MSC 2580 Bethesda, MD 20892-2580
Foundation for Urologic Disease
1128 N. Charles St. Baltimore, MD 21201
800-242-2383 410-468-1800 Fax: 410-468-1808
681 5th Ave. New York, NY 10022
800-99-CANCER 212-688-7515 Fax: 212-832-9376
- CaP CURE-Association
for the Cure of Cancer of the Prostate
1250 4th St., Ste. 360 Santa Monica, CA 90401
800-757-CURE 310-458-2873 Fax: 310-458-8074
This booklet was
developed in partnership with the National Institutes of Health Osteoporosis
and Related Bone Diseases~National Resource Center (NIH ORBD~NRC).
The NIH ORBD~ NRC provides patients, health professionals, and the
public with resources on metabolic bone diseases through publications,
online services, professional and patient meetings, and general media
outreach. Operated by the National Osteoporosis Foundation and its
subcontractors, The Paget Foundation and Osteogenesis Imperfecta Foundation,
the Center is supported by the National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS), with contributions from
the National Institute of Child Health and Human Development (NICHHD),
National Institute of Dental and Craniofacial Research (NIDCR), National
Institute of Environmental Health Sciences (NIEHS), NIH Office of
Research on Women's Health (ORWH), Office of Women's Health (OWH),
Public Health Service (PHS), and the National Institute on Aging (NIA).
- Us Too
930 N. York Rd., Ste. 50 Hinsdale, IL 60521
800-80-US TOO 630-323-1002 Fax: 630-323-1003
- Man to
Man (Can be contacted through American Cancer Society)
NIH Osteoporosis and Related Bone Diseases~ National Resource Center
1232 22nd St., NW Washington, DC 20037-1292
800-624-BONE/202-223-0344 Fax: 202-293-2356 TTY: 202-466-4315