eMedicine Specialties > Urology > Cancer, Prostate

Prostate Cancer - Metastatic and Advanced Disease

Author: Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Coauthor(s): Audrey Rhee, MD, Resident, Department of Urology, Medical College of Georgia; Shaukat M Qureshi, MBBS, FACS, Consulting Staff in Urology, Department of Surgery, Memorial Hospital of Salem County; Clinical Instructor, Department of Urology, Thomas Jefferson University Hospital
Contributor Information and Disclosures

Updated: Jun 4, 2009

Introduction

Background

Prostate cancer is the second leading cause of cancer-related death in the United States among men and is the most commonly diagnosed cancer in American males. Most prostate cancer–related deaths are due to advanced disease. Continuous advances have provided a new understanding of the diagnosis, staging, and treatment of metastatic and advanced prostate cancer. The earlier definition of advanced disease (bone metastasis and soft-tissue involvement) has been improved in recent years. This article provides an overview of the current modalities available in the treatment of advanced prostate cancer, highlighting the following points:

  • Identification of the population at risk of developing advanced prostate cancer
  • Evolution of clinical staging and therapeutic options currently available to these patients
  • Controversies surrounding early versus delayed treatment and combined androgen blockade (CAB)
  • Definition and management of biochemical failure
  • Hormone-refractory prostate cancer

Pathophysiology

Advanced prostate cancer results from any combination of lymphatic, blood, or contiguous local spread.

Frequency

United States

An estimated 1 in 10 men will develop prostate cancer in their lifetime, with the likelihood increasing with age. Since the advent of prostate-specific antigen (PSA) screening, prostate cancer is being detected and treated earlier; however, approximately 10%-20% of newly diagnosed prostate cancer cases involve locally advanced disease. It is comparably less common because more early-stage cancer is currently being discovered. Accumulating evidence is showing that, owing to early diagnosis and treatment, the mortality rate associated with prostate cancer has declined since the 1970s.

Despite the apparent survival advantage of early diagnosis conferred by PSA screening, a recent U.S. Preventive Services Task Force statement recommends against screening for prostate cancer in men aged 75 years or older. The statement also concludes that, currently, the balance of benefits versus drawbacks of prostate cancer screening in men younger than age 75 years cannot be assessed because of insufficient evidence.1

Because of its genetic linkage, prostate cancer is more common in males with a strong family history of prostate cancer. Likewise, people who smoke, African American males, and patients who consume a diet high in animal fat or high in chromium are at an increased risk.

International

The mortality rate associated with prostate cancer continues to increase in countries such as Australia, Europe, Japan, and Russia.

Mortality/Morbidity

Prostate cancer is the second leading cause of cancer death in the United States among men and is the most commonly diagnosed cancer in American males.

Race

Prostate cancer is more common in African American males, in whom it tends to be more aggressive and progressive, leading to advanced disease. Furthermore, Fowler et al also demonstrated clearly that African Americans tend to have higher-grade carcinoma at diagnosis.2

Age

The incidence of prostate cancer increases with age.

Clinical

History

  • Advanced prostate cancer results from any combination of lymphatic, blood, or contiguous local spread.
  • Manifestations of metastatic and advanced prostate cancer may include anemia, bone marrow suppression, weight loss, pathologic fractures, spinal cord compression, pain, hematuria, ureteral and/or bladder outlet obstruction, urinary retention, chronic renal failure, urinary incontinence, and symptoms related to bony or soft-tissue metastases.
  • Treatment-related symptoms, such as rectal bleeding, gross hematuria, and urethrorectal fistula, which are sometimes associated with radiation therapy, should also be kept in mind.

Physical

  • Obliteration of the lateral sulcus or seminal vesical involvement found during rectal examination often indicates locally advanced disease.
  • Physical examination findings of adenopathy, lower-extremity edema, and bony tenderness may indicate metastatic disease.
  • Neurological examination, including determination of external anal sphincter tone, should be performed to help detect possible spinal cord compression.

Causes

  • The most important and established prognosticators for prostate carcinoma include the Gleason grade, the extent of tumor volume, and the presence of capsular penetration or margin positivity at the time of prostatectomy.
    • High-grade prostate cancer, particularly the percent presence of Gleason grades 4 and 5, is associated with adverse pathologic findings and disease progression.
    • Conversely, low-grade prostate tumors can also be biologically aggressive.

More on Prostate Cancer - Metastatic and Advanced Disease

Overview: Prostate Cancer - Metastatic and Advanced Disease
Differential Diagnoses & Workup: Prostate Cancer - Metastatic and Advanced Disease
Treatment & Medication: Prostate Cancer - Metastatic and Advanced Disease
Follow-up: Prostate Cancer - Metastatic and Advanced Disease
References
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Further Reading

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Keywords

advanced prostate cancer, metastatic prostate cancer, prostate-specific antigen, PSA, Gleason score, prostatic cancer, combined androgen blockade, CAB, biochemical failure, hormone-refractory prostate cancer, HRPC, luteinizing hormone-releasing hormone, LHRH, androgenic suppression, antiandrogens, orchiectomy

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Contributor Information and Disclosures

Author

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Coauthor(s)

Audrey Rhee, MD, Resident, Department of Urology, Medical College of Georgia
Disclosure: Nothing to disclose.

Shaukat M Qureshi, MBBS, FACS, Consulting Staff in Urology, Department of Surgery, Memorial Hospital of Salem County; Clinical Instructor, Department of Urology, Thomas Jefferson University Hospital
Shaukat M Qureshi, MBBS, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and Medical Society of New Jersey
Disclosure: Nothing to disclose.

Medical Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine
Martin I Resnick, MD † is a member of the following medical societies: American College of Surgeons, American Federation for Medical Research, American Institute of Ultrasound in Medicine, American Medical Association, American Society for Bone and Mineral Research, American Society for Reproductive Medicine, American Society of Andrology, American Surgical Association, American Urological Association, Association for Academic Surgery, Endocrine Society, National Kidney Foundation, Ohio Urological Society, and Pan American Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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