Overview

Stage 4 prostate cancer is cancer that begins in the prostate and spreads to nearby lymph nodes or to other areas of the body.

Stage 4 prostate cancer is an uncommon diagnosis. Most often, prostate cancer is diagnosed at an earlier stage, when the cancer is confined to the prostate.

Treatments may slow or shrink an advanced prostate cancer, but for most men, stage 4 prostate cancer isn't curable. Still, treatments can extend your life and reduce the signs and symptoms of cancer.

Symptoms

Signs and symptoms of stage 4 prostate cancer may include:

• Painful urination
• Decreased force in the stream of urine
• Blood in the semen
• Bone pain
• Swelling in the legs
• Fatigue

When to see a doctor

Make an appointment with your doctor if you have any persistent signs or symptoms that worry you.

Causes

Doctors aren't certain what causes stage 4 prostate cancer.

Stage 4 prostate cancer occurs when prostate cancer cells break away from the prostate and spread to the lymph nodes or to other areas of the body.

Prostate cancer cells that spread beyond the prostate most often travel to the:

• Lymph nodes
• Bones
• Liver

Risk factors

Factors that may increase your risk of stage 4 prostate cancer include:

• A family history of prostate cancer. Men with certain inherited gene mutations that increase the risk of prostate cancer have an increased risk of more-aggressive prostate cancers.
• African-American race. Black men have an increased risk of aggressive prostate cancer.

Diagnosis

If your doctor suspects you may have prostate cancer, tests and procedures may include:

• Imaging tests. Imaging tests may help your doctor understand the size and extent of your prostate cancer. Tests may include ultrasound, MRI, CT, positron emission tomography (PET) and bone scans.

  Which tests you undergo depends on your situation, such as whether you're experiencing signs and symptoms.

• Biopsy. To confirm the diagnosis of prostate cancer, your doctor may recommend a biopsy procedure to remove a sample of suspicious cells for laboratory testing. In a lab, doctors can examine the cells and determine if they're cancerous.

Treatment

Treatments for stage 4 prostate cancer may slow the cancer and extend your life. But stage 4 prostate cancer often can't be cured.

Hormone therapy

Hormone therapy is treatment to stop your body from producing the male hormone testosterone or to block the effects of testosterone on the cancer. Prostate cancer cells rely on testosterone to help them grow. Cutting off the supply of hormones may cause the cancer to shrink or to slow its growth.

In men with stage 4 prostate cancer, hormone therapy is most often used alone, but it can be combined with chemotherapy and it may be used after radiation therapy or, rarely, surgery. Hormone therapy may be continued for as long as the treatment continues to work.

Hormone therapy options include:

• Medications that stop your body from producing testosterone. Medications known as luteinizing hormone-releasing hormone (LH-RH) agonists and antagonists prevent the testicles from receiving messages to make testosterone. Drugs typically used in this type of hormone therapy include leuprolide (Eligard, Lupron Depot, others), goserelin (Zoladex), triptorelin (Trelstar), histrelin (Vantas) and degarelix (Firmagon).
• Surgery to remove the testicles (orchiectomy). Removing your testicles reduces testosterone levels in your body. The effectiveness of orchiectomy in lowering testosterone levels is similar to that of hormone therapy medications, but orchiectomy may lower testosterone levels more quickly.

• Medications that block testosterone from reaching cancer cells. Medications known as anti-androgens prevent testosterone from reaching your cancer cells. Examples include bicalutamide (Casodex), flutamide and nilutamide (Nilandron). These drugs may be given along with an LH-RH agonist or given before taking an LH-RH agonist.

  Apalutamide (Erleada) and enzalutamide (Xtandi) work differently from other anti-androgen drugs and may be an option if other hormone therapy treatments are no longer effective.

• Other medications. Other medications that work differently from other hormone therapies to control testosterone in the body may be options. Examples include abiraterone (Yonsa, Zytiga), the antifungal medication ketoconazole, the female hormone estrogen, and steroid drugs.

Side effects of hormone therapy may include erectile dysfunction, hot flashes, loss of bone mass, reduced sex drive, breast enlargement and weight gain.

Most advanced prostate cancers will eventually adapt to hormone therapy and begin growing despite treatment (castration-resistant prostate cancer). When that occurs, your doctor may recommend switching to a different combination of hormone therapy drugs to see if your cancer responds.

Radiation therapy

Radiation therapy uses high-powered beams of energy, such as X-rays and protons, to kill cancer cells. Radiation therapy for stage 4 prostate cancer uses a large machine that moves around your body, directing energy beams to the area around the cancer (external beam radiation therapy).

In men with very large prostate tumors or cancer that has spread to nearby lymph nodes (locally advanced prostate cancer), radiation therapy may be combined with hormone therapy. Or it may be used after surgery to kill any cancer cells that might remain.

In men with cancer that has spread to other areas of the body, radiation therapy is used to relieve pain or other symptoms.

Surgery

Surgery isn't often used to treat stage 4 prostate cancer, but it might be recommended in certain situations. In men with stage 4 prostate cancer, surgery is generally limited to men who are experiencing signs and symptoms that would be relieved by surgery, such as difficulty passing urine.

Surgery may include:

• Radical prostatectomy. Your doctor may recommend surgery to remove your prostate and any cancer that has grown locally beyond the prostate. Surgery may be an option if your prostate cancer is locally advanced and hasn't spread to other areas of the body.
• Lymph node removal. Your doctor may recommend removal of several lymph nodes near your prostate (pelvic lymph node dissection) to test for cancer cells.

Surgery can cause infection, bleeding, incontinence, erectile dysfunction and damage to the rectum.

Treatments for cancer that spreads to other areas of the body

If your cancer has spread beyond your prostate to other areas of your body, your doctor may recommend:

• Chemotherapy. Chemotherapy can slow the growth of cancer cells, relieve signs and symptoms of cancer, and prolong the lives of men with advanced prostate cancer.
• Training your immune system to recognize cancer cells. Immunotherapy uses your immune system to kill cancer cells. Sipuleucel-T (Provenge), a form of immunotherapy, has been developed to genetically engineer your immune cells to fight prostate cancer.
• Bone-building medications. Medications used to treat thinning bones (osteoporosis) may be helpful in preventing broken bones in men with prostate cancer that has spread to the bones.
• Infusions of a radioactive drug. Men with prostate cancer that has spread to the bones may consider treatment that infuses a radioactive substance into a vein. Strontium-89 (Metastron), samarium-153 (Quadramet) and radium-223 (Xofigo) are medications that target fast-growing cancer cells in the bones, and may help relieve bone pain.
• Radiation therapy. External beam radiation therapy may help control bone pain in men with prostate cancer that has spread to the bones.
• Targeted drug therapy. Targeted drugs attack specific weaknesses in the cancer cells. Your doctor might have samples of your cancer tested in a lab to see if targeted therapy might be helpful for you.
• Pain medications and treatments. Medications and treatments are available if you experience cancer pain. Which pain treatments are right for you will depend on your particular situation and your preferences.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery, chemotherapy or radiation therapy.

When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.

Alternative medicine

No alternative medicine treatments have been proved to cure stage 4 prostate cancer. But complementary and alternative medicine may help you cope with symptoms of your cancer.

Prostate cancer often spreads to the bones, which can cause bone pain. Your doctor can offer treatments and medications to control the pain. But you may also find that complementary therapies can help relieve your pain when used in addition to treatments recommended by your doctor.

Complementary and alternative medicine treatments that may reduce cancer pain include:

• Acupuncture
• Acupressure
• Hypnosis
• Massage
• Relaxation techniques

If your pain isn't adequately controlled, talk with your doctor about your options.

Coping and support

Learning you have stage 4 prostate cancer can be shocking and devastating. With time, each man figures out his own way to cope with the emotions he experiences, and you will find what works for you, too. Until then, you may find it helpful to:

• Learn enough about cancer to make decisions about your care. Ask your doctor about your prostate cancer, including your treatment options and, if you like, your prognosis. As you learn more about advanced prostate cancer, you may become more confident in making treatment decisions.
• Keep friends and family close. Keeping your close relationships strong will help you deal with your stage 4 prostate cancer. Friends and family can provide the practical support you'll need, such as helping take care of your home or your pets if you're in the hospital. And they can serve as emotional support when you feel overwhelmed by cancer.

• Find someone to talk with. Find a good listener who is willing to listen to you talk about your hopes and fears. This may be a friend or family member. The concern and understanding of a counselor, medical social worker, clergy member or cancer support group also may be helpful.

  Ask your doctor about support groups in your area. Or check your phone book, library or a cancer organization, such as the National Cancer Institute or the American Cancer Society.

• Look for a connection to something beyond yourself. Having a strong faith or a sense of something greater than oneself helps many people cope with cancer.

Preparing for an appointment

Make an appointment with your primary care doctor or family doctor if you have any persistent signs and symptoms that worry you. If your doctor determines that you have advanced prostate cancer, you'll likely be referred to a doctor who specializes in treating cancer (oncologist).

Because appointments can be brief and because there's often a lot of ground to cover, it's a good idea to be well-prepared. Here's some information to help you get ready, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Make a list of all medications, vitamins or supplements that you're taking.
• Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For prostate cancer, some basic questions to ask your doctor include:

• What is likely causing my symptoms or condition?
• What are other possible causes for my symptoms or condition?
• What kinds of tests do I need?
• What is the best course of action?
• What are the alternatives to the primary approach that you're suggesting?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a specialist? What will that cost, and will my insurance cover it?
• Are there brochures or other printed material that I can take with me? What websites do you recommend?
• What will determine whether I should plan for a follow-up visit?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions that occur to you.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may allow time later to cover other points you want to address. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?