What Does It Mean to Have Metastatic (Stage 4) Prostate Cancer?

What is metastatic (stage 4) prostate cancer?

Prostate cancer is usually a slow-growing type of cancer. But over time, the cancer cells can grow and spread beyond the prostate. 

Metastatic prostate cancer happens when cancer cells spread to other parts of your body, like the lymph nodes, lungs, and bones. This is also known as stage 4 prostate cancer.

Being diagnosed with metastatic prostate cancer isn’t easy. But there’s reason for hope. Many treatment options can slow metastatic prostate cancer and relieve symptoms.

What are the symptoms of metastatic prostate cancer?

Some symptoms of advanced prostate cancer are:

• Fatigue

• Bone pain

• Trouble starting or keeping a steady stream of urine

• Blood in your urine

• Trouble controlling your bladder (incontinence)

• Difficulty getting or keeping an erection, or pain during ejaculation

• Tingling or weakness in your legs and feet

But many people don’t have any symptoms, even when the cancer has spread. That’s why it’s important to have regular follow-ups and tests after treatment, to make sure the cancer isn’t coming back and the treatments are working.

What causes metastatic prostate cancer?

Metastatic prostate cancer happens when cancer cells travel to other parts of your body through the bloodstream and lymphatic system. 

People find out they have metastatic prostate cancer either at the time of their initial diagnosis or if they have a prostate cancer recurrence. Recurrence means that the prostate cancer came back after treatment such as surgery or radiation. 

Learning that you have metastatic prostate cancer is difficult, whether it’s the first time or if it has recurred. But these two situations can have different treatment approaches. That’s why it’s important to know the difference.

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How is metastatic prostate cancer diagnosed?

An increasing prostate-specific antigen (PSA) level can be one of the first signs that prostate cancer has come back or spread, even before symptoms develop. In these cases, you would need imaging studies to look for cancer in other parts of your body. Your care team might recommend a:

• CT scan or MRI

• PET scan

• Bone scan

For people with a new diagnosis of prostate cancer, metastatic prostate cancer is diagnosed in the same way. The difference is that they may also need a prostate biopsy, or a biopsy of an area where the cancer may have spread.

What treatment options are available for metastatic (stage 4) prostate cancer?

There’s no cure for stage 4 prostate cancer. But there are many treatment options that can help slow the cancer’s growth and help people live longer. Treatment options include hormone therapy, immunotherapy, radiopharmaceuticals, and other specialized treatments. Often, people will get a combination of different treatments over time.

Hormone therapy

Testosterone helps prostate cancer cells grow and divide. Hormone therapy works by blocking testosterone’s ability to do these things. There are four types of hormone therapy that are used to treat metastatic prostate cancer:

1. Standard androgen deprivation therapy (ADT): Standard ADT works by lowering testosterone levels in your body. ADT includes orchiectomy, a surgery that removes the testicles. It also includes luteinizing hormone-releasing hormone (LRH) agonists and antagonists medications. All of these methods are equally effective. ADT is usually combined with another type of hormone therapy. 

2. Older anti-androgens: These medications block testosterone from binding to the androgen receptor within prostate cancer cells. Examples include bicalutamide, flutamide, and nilutamide.

3. Newer anti-androgens: These medications also block testosterone from binding to the androgen receptor within prostate cancer cells. But these medications are stronger than the older ones. When combined with ADT, they help increase survival in people with metastatic hormone-sensitive prostate cancer. Examples include enzalutamide, darolutamide, and apalutamide.

4. Androgen synthesis inhibitors: Abiraterone acetate lowers androgen levels by blocking your body’s ability to make androgens. It improves survival and reduces metastases in people with metastatic hormone-sensitive prostate cancer and very high-risk non-metastatic prostate cancer. It’s usually given along with ADT. 

Hormone therapy is an important treatment option for metastatic prostate cancer. Most people receive combinations of these therapies because they work better when used together. Hormone therapy can also be used with chemotherapy.

Radiation therapy

External beam radiation treatment (EBRT) reduces pain related to cancer in up to 80% of people. It can also help with symptoms like difficult urination or blood in the urine. 

Radiation is offered to people with metastatic prostate cancer, even if they only have small metastasis. This is because radiation helps people live longer. Radiation therapy is often offered along with hormone therapy.

Radiopharmaceuticals

Radiopharmaceuticals are medications that deliver radiation directly to cancer cells. Two examples include:

1. Lu177-PSMA-617 (Pluvicto): This is a radiopharmaceutical that’s FDA-approved to treat metastatic prostate cancer that no longer responds to hormone therapy (also called metastatic castration-resistant prostate cancer). In clinical trials, people who received Pluvicto lived longer than those who received other treatments. This medicine is only approved for people with metastatic castration-resistant prostate cancer and whose tumors make enough PSMA protein. 

2. Radium-223 (Xofigo): This is another FDA-approved radiopharmaceutical that treats bone metastasis. 

Chemotherapy

Chemotherapy works by destroying cancer cells or stopping them from dividing. Unlike other types of cancer, chemotherapy is only used to treat advanced prostate cancers. The two most common chemotherapy medications are docetaxel and cabazitaxel. Chemotherapy is used along with other treatments when treating metastatic prostate cancer.

Polyadenosine diphosphate (ADP-ribose) polymerase (PARP) inhibitors

Polyadenosine diphosphate (ADP-ribose) polymerase (PARP) inhibitors are medications that can stop prostate cancer cells from growing. These medications don’t work for everyone. Your oncology team may order genetic testing to see if this treatment is right for you. PARP inhibitors are only approved for people with metastatic hormone-resistant prostate cancer.

Immunotherapy

Immunotherapy is a type of therapy that uses your immune system to fight cancer. It can help people with metastatic hormone-resistant prostate cancer. Two types include: 

1. Sipuleucel-T 

2. Pembrolizumab (Keytruda)

These therapies are an option if your tumor has certain genetic markers and other treatments aren’t helping.

Clinical trials

People with metastatic prostate cancer may also qualify for clinical trials. The benefit of participating is that you get access to treatments that aren’t available yet. But these treatments are experimental — they might not work and can have side effects. Signing up for a clinical trial is a big commitment. You’ll want to work with your treatment team to decide if it’s right for you. 

How serious is metastatic (stage 4) prostate cancer?

Metastatic prostate cancer is the most serious form of prostate cancer. While there’s no cure, there are treatment options that can help you live longer and improve your quality of life.

It’s important to talk to your treatment team about your care goals. Some people want to live as long as possible and are willing to try any treatment available. Others might want to relieve symptoms so they can have the best quality of life possible. It’s important to define what’s important to you and talk to your team. There are many treatment options, but it’s important to choose the one that best fits your goals.

Treatment for prostate cancer, including metastatic prostate cancer, is always changing and improving. Working with an experienced care team is the best way to make sure you have access to the most up-to-date options.

Treatment options do come with side effects. Your team should help you manage them. Talk to your team about ways to improve your quality of life during treatment. Things like complementary therapies and mental health support can be helpful.

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Written by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

Reviewed by:

Brandon R. Mancini, MD, MBA, FACRO

Brandon R. Mancini, MD, MBA, FACRO, serves as medical director at BAMF Health in Grand Rapids, Michigan in the emerging field of theranostics. His primary clinical focus is on the treatment of people with metastatic prostate and neuroendocrine cancers.

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