Where is the Prostate Cancer?

What Do You Do if It Spreads?

As technology advances, our depth of insight improves. In the past, saying “Cancer” would say it all. It meant that someone is dying. Thankfully this is changing and we define a specific individual’s prognosis based on where he falls within a broad spectrum.  Many factors define prognosis including the size, location and grade of the tumor. In this short article, I’ll introduce some basic concepts about the cancer’s location and how it relates to prognosis and treatment selection.

Prior to the development of 3-Tesla multi-parametric MRI, extra-capsular prostate cancer was only detected when the doctor felt an abnormality outside the gland with a digital rectal examination. Now, modern imaging and biopsy technology enables us to detect much smaller degrees of cancer spread through the capsule. Cancer spreading just outside the capsule of the gland or into the seminal vesicles, when CT and bone scan that are otherwise clear, is termed “locally advanced.” Despite having cancer spread past the capsule of the gland, modern radiation with IMRT, often with a brachytherapy boost, can be very effective at controlling the primary tumor.

Cancer can still be cured when it is locally advanced as long as the tumor remains confined to the general region immediately surrounding the prostate. Experience shows that locally advanced prostate cancer will often be associated with microscopic metastases in the pelvic lymph nodes.

Prophylactic pelvic radiation along with testosterone inactivation pharmaceuticals (TIP) should be strongly considered as a preventative measure.

After initial staging with a CT or bone scan, sometimes  one or two metastases are detected.  A metastatic situation with 5 or fewer metastases is called “oligometastases” (oligo in Greek means “few”).

Traditional oncology lore dictates that any detectable metastases are only “the tip of the iceberg,” that even a single metastasis invariably indicates that additional microscopic metastases are located in other areas of the body. This belief originated in a past era when scans were crude and only large metastasis could be detected.

Now, the possibility of curing men with oligometastases with targeted radiation should not be overlooked. Forgoing potentially curative treatment almost always leads to further metastases down the line. It's sad when straightforward treatment such as radiation to an isolated lymph node or bone metastasis is withheld simply out of a pessimistic fear that it “won’t work.” When oligometastases are treated with radiation, additional systemic treatment with TIP, and possibly with Taxotere should strongly be considered.

When bone scans or CT scans show a more extensive number of metastases, standard radiation is no longer feasible because radiation to multiple areas of the bone will damage the bone marrow.

TIP is the standard initial treatment for men with multiple bone metastases. There is now also strong evidence that adding Taxotere chemotherapy to TIP significantly prolongs survival and improves cancer control rates. In addition, supportive agent such as Xgeva or Zometa should also be administered. A FDA-approved form of injectable radiation called Xofigo has also been shown to prolong survival and also effectively controls bone pain.

Uncommonly, usually at very advanced stages prostate cancer may spread to the lung or the liver. Men with lung metastases often respond well to a variety of treatments. Liver metastases are more dangerous and less likely to respond to hormonal treatment. When liver metastases are present, immediate chemotherapy is indicated. I have also seen meaningful remissions from liver metastases with a treatment that is FDA-approved for colon cancer called “SIR-Spheres,” a form of radiation therapy that is infused into the blood supply of the liver.

Prostate cancer presents in a broad variety of ways. Optimal management requires accurate staging and a tailored treatment plan.  For best results, patients should undergo aggressive multimodality therapy whenever the staging scans shows cancer spread outside the prostate. 

Continue Reading