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Metastatic Prostate Cancer CONNECT BOOKLET SERIES BOOKLET CONNECT ® TREATMENT UPDATE Metastatic Prostate Cancer CONNECT BOOKLET SERIES BOOKLET CONNECT ® CARE CANCER WWW.CANCERCARE.ORG The CancerCare Connect Booklet Series offers up-to-date, easy-to-read information on the latest treatments, managing side effects and coping with cancer. To order free copies of this booklet, please use the online order form on our website, www.cancercare.org. Founded in 1944, CancerCare® is the leading national organization providing free, professional support services and information to help people manage the emotional, practical and financial challenges of cancer. Our comprehensive services include counseling and support groups over the phone, online and in person, educational workshops, publications and financial and co-payment assistance. All CancerCare services are provided by oncology social workers and world-leading cancer experts. CancerCare relies on the generosity of supporters to provide our services completely free of charge to anyone facing a cancer diagnosis. If you have found this resource helpful and wish to donate, please do so online at www.cancercare.org/donate. You may also mail a check, payable to CancerCare, to CancerCare, Attn: Donations, 275 Seventh Avenue, New York, NY 10001. Thank you. CancerCare® Toll-free 800-813-HOPE (4673) National Office Phone 212-712-8400 Fax 212-712-8495 275 Seventh Avenue Email [email protected] New York, NY 10001 Web www.cancercare.org The content of this booklet is independent, non-promotional and free of commercial influence and bias. TREATMENT UPDATE Metastatic Prostate Cancer Table of Contents Introduction 2 Treatment Options 2 The Importance of Clinical Trials 9 Managing Treatment Side Effects 10 The Importance Of Treatment Summaries 17 Communicating with Your Health Care Team 18 CancerCare’s Free Support Services and Programs 21 Frequently Asked Questions 22 Resources 25 Editor Susan F. Slovin, MD, PhD Attending Physician, Genitourinary Oncology Service, Sidney Kimmel Center for Prostate and Urologic Diseases, Memorial Sloan Kettering Cancer Center, Associate Professor of Medicine, Weill College of Cornell University © 2016 CancerCare®. All rights reserved. 6/16 All people depicted in the photographs in this booklet are models, used for illustrative purposes only. CANCERCARE CONNECT | TreatMENT UPDate: MetaStatIC ProState cancer 1 Men living with metastatic prostate cancer now have more options available than ever before. Each year, over 180,000 American men are diagnosed with cancer of the prostate gland. Other than skin cancer, it is the most common cancer affecting men, occurring primarily in men aged 65 or older. When prostate cancer is diagnosed and treated, most often the tumor is still confined to the gland. But prostate cancer can spread to other parts of the body (metastasize). In cases of metastatic prostate cancer, there are treatments available that can stop cancer growth, control pain and other symptoms, and extend survival. Treatment Options Hormonal Treatments Hormonal therapy, also called androgen deprivation therapy, remains the mainstay for treating metastatic prostate cancer. This type of treatment is aimed at reducing the levels of male hormones (androgens) in the body, or stopping them from affecting prostate cancer cells. The main androgens are testosterone and DHT; they act like a fuel, encouraging prostate cancer to grow. (Most androgens are made by the testes, but a small amount is made by the adrenal glands, which sit above the kidneys and produce a number of important hormones.) Without androgens, prostate cancer 2 WWW.CANCERCARE.ORG goes into remission, often for many years. Remission is when all signs and symptoms of cancer disappear. There are several approaches to hormonal therapy: • Medications called GnRH agonists. These drugs lower the amount of testosterone made by the testicles. They are either injected or placed as small implants under the skin. GnRH agonists available in the United States are triptorelin (Trelstar), leuprolide (Eligard, Lupron, and others), goserelin (Zoladex), and histrelin (Vantas). • Combining GnRH agonists with antiandrogens. When the signals between the brain and the testes have been blocked by GnRH agonists, men with metastatic prostate cancer may experience a surge of testosterone. This can stimulate the growth of the cancer or cause symptoms, so doctors sometimes add antiandrogens to GnRH agonists. The antiandrogens prevent testosterone in the bloodstream from attaching to tumor cells and making them grow. Types of antiandrogens include flutamide (Eulexin and others), bicalutamide (Casodex and others), nilutamide (Nilandron), and enzalutamide (Xtandi). These medications are taken daily as pills. • Degarelix, a GnRH antagonist. Degarelix (Firmagon) blocks signals from the brain to the testes. With these medications, the testes no longer receive “instructions” from the brain to make androgens, and production of the hormones is shut down. This drug lowers testosterone more quickly than do GnRH agonists, and doesn’t cause the surge of testosterone that can be seen with the use of agonists. Degarelix is given as an injection. • Combining hormonal therapy with chemotherapy. Depending on the man’s individual circumstances, the chemotherapy drug docetaxel (Taxotere) might be given CANCERCARE CONNECT | TreatMENT UPDate: MetaStatIC ProState cancer 3 in conjunction with hormone therapy as a first line approach. Studies have shown that it may be possible to slow the growth of cancer cells by combining docetaxel with hormonal therapy (rather than prescribing it sequentially). If a specific androgen deprivation drug does not have the desired result, your doctor may suggest a different drug, or a different form of hormonal therapy. Because one of the liver’s important jobs is to break down toxins and medications in the body, your liver function must be checked with periodic blood tests, especially if you are taking antiandrogens. Tell your doctor immediately if you experience nausea, vomiting, stomach pain, extreme tiredness, loss of appetite, flu-like symptoms, dark yellow or brown urine, and/or yellowing of the skin or eyes. It’s crucial to remember that herbal remedies, megadoses of vitamins, and excessive amounts of alcohol should be avoided, as they can prevent the liver from breaking down antiandrogens. 4 WWW.CANCERCARE.ORG Metastatic prostate cancer usually responds to hormonal therapy and goes into remission, but cancer cells can sometimes resist treatments. Prostate cancer cells can “learn” how to grow, even without male hormones. Doctors call this condition hormone-resistant prostate cancer. In some cases of hormone-resistant prostate cancer, simply stopping antiandrogen treatment causes a man’s PSA level to go down and his prostate cancer to shrink or disappear. (PSA— prostate-specific antigen—is a substance produced by the prostate gland which may indicate the presence of cancer.) In other cases, doctors may prescribe different antiandrogen drugs to try to slow cancer growth. Surgery as a Form of Hormone Therapy Another way to stop the testicles from producing male hormones is an orchiectomy, a surgical procedure in which the testicles are removed. (This surgery is, in effect, a form of hormone therapy.) The removal of the testicles causes most prostate cancers to stop growing or to shrink. In an orchiectomy, the scrotum (the pouch of skin that holds the testicles) and penis are left intact. An orchiectomy is done as an outpatient procedure. While it is probably the simplest form of hormone therapy, some men have trouble accepting the change to their anatomy. However, the insertion of artificial testicles (made of silicone) into the scrotum is an option to discuss with the surgeon who is performing the procedure. CANCERCARE CONNECT | TreatMENT UPDate: MetaStatIC ProState cancer 5 Chemotherapy and Other Treatments Doctors sometimes recommend chemotherapy as a treatment for hormone-resistant prostate cancer, usually for men who fall into one of three groups: • Those with fast-rising PSA levels. When the PSA level begins doubling or tripling so quickly that hormone treatments can’t control it, chemotherapy may be an option. • Those who are developing symptoms. Chemotherapy should be considered if a man with metastatic prostate cancer is losing weight, looking pale, or experiencing physical distress. • Those who have metastatic cancer that is growing quickly. These men are sometimes treated with radiation aimed at multiple tumor sites. However, radiation treatments to the bone can reduce the number of red blood cells in the bone marrow and lead to anemia. (In anemia, a lowered level of red blood cells may result in fatigue and other symptoms such as dizziness or headache.) Using chemotherapy may reduce the need for radiation. In the treatment of metastatic prostate cancer, one chemotherapy drug is usually given, rather than multiple drugs being given in combination. Some of the drugs used are docetaxel (Taxotere), cabazitaxel (Jevtana), mitoxantrone (Novantrone) and estramustine (Emyct). In most cases, the first chemotherapy drug given is docetaxel, combined with the steroid drug prednisone. If this drug does not work (or stops working), other chemotherapy options may be tried. Doctors give chemotherapy in cycles; each cycle 6 WWW.CANCERCARE.ORG typically lasts a few weeks. A period of treatment is followed by a period of rest, which allows the body time to recover. Chemotherapy is very unlikely to cure prostate cancer, but it may slow the cancer’s growth and reduce symptoms. A number of
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