Metastatic (advanced) prostate cancer: symptoms, treatment and living with it

Macmillan explains that cancer cells spread from the prostate through the blood or the lymphatic system and start growing when they reach a new area. The most common places are the lymph nodes and the bones, and it can also spread to organs such as the liver or lungs. Even if it spreads, it is still prostate cancer and is treated as such.

It may be advanced at the time of first diagnosis, or it may be found after treatment aimed at cure for early or locally advanced prostate cancer, because cancer cells outside the gland could not be detected at the time.

Macmillan states that prostate cancer often grows slowly and symptoms may not develop for many years, which is why advanced disease can feel very different for different people: some live with it for a long time, and some need more intensive treatment.

The NHS says prostate cancer often has no symptoms at first. When it grows, it can press on the urethra and cause urinary changes such as difficulty starting, a weak flow, stop-start peeing, needing to pee urgently or often and feeling that you still need to pee. Other symptoms include erectile dysfunction, blood in the urine or semen, and lower back pain and weight loss without trying to, which the NHS says may be symptoms of advanced prostate cancer.

Macmillan says symptoms may also be caused by spread. These can include being more tired than usual, pain around the bottom when sitting, feeling generally unwell, less appetite and weight loss for no obvious reason. Secondary cancer in the bone is most commonly felt as an ache in the bone, often in the hips or back, and bones may gradually become weaker and break more easily. If cancer reaches the bone marrow it can cause anaemia, with low energy, breathlessness, dizziness or light-headedness.

• Bone pain, often in the hips or back.

• Unusual tiredness, loss of appetite or weight loss.

• Urinary changes, blood in the urine or semen, or erectile dysfunction.

• Breathlessness, dizziness or low energy from anaemia.

• New back pain, leg weakness or bladder and bowel changes need urgent review (see below).

Macmillan explains that if the cancer in the spine grows and presses on the spinal cord, it is called metastatic spinal cord compression (MSCC). It is not common, but it needs to be treated quickly to stop permanent damage to the nerves, usually with radiotherapy to the spine, sometimes surgery or cancer drugs, and steroids to relieve the compression.

It lists the symptoms: new pain that can feel like a band around the chest or tummy; new pain that spreads down an arm or leg or into the lower back or buttocks; pain that can be severe, worse with movement and disturbing sleep; weakness in the arms or legs; unsteadiness; numbness or pins and needles in the legs; and bladder or bowel problems such as constipation, not passing much urine or poo, or problems controlling the bladder and bowel. It says to get medical advice immediately, even at the weekend or on a holiday, to contact the usual cancer hospital team, and to go to the nearest A&E if you cannot reach anyone.

Macmillan says that if you have just been diagnosed with cancer in the prostate gland you will have further tests to see if it is advanced, including a bone scan and an MRI or CT scan. People who have previously had treatment and have new symptoms or a rapidly rising PSA will usually have a bone scan and may have CT, MRI or a type of PET scan.

The PSA test is a blood test measuring prostate-specific antigen, and with other tests it helps to diagnose prostate cancer. A special type of scan, the PSMA PET-CT, uses a tracer that detects a protein prostate cancer cells have more of and can help detect cancer cells elsewhere earlier. A biopsy of the prostate, or sometimes of the metastasis, may be done to decide whether certain treatments or trials are suitable. Results guide staging, which describes size and spread, and grading, which gives an idea of how quickly the cancer might grow.

The NHS lists surgery, radiotherapy and hormone therapy as the main treatments for prostate cancer and says chemotherapy may be needed if the cancer has spread. For advanced disease, hormone therapy, often androgen deprivation therapy (ADT) to reduce testosterone, is usually recommended for everyone, and may be combined with chemotherapy or radiotherapy. The NHS explains that the hormone testosterone causes prostate cancer to grow, and hormone injections and tablets stop it being produced or block its effects.

Macmillan says chemotherapy with docetaxel can be given with hormone therapy when advanced cancer is first diagnosed, starting within 12 weeks of beginning ADT or an androgen receptor pathway inhibitor, and that cabazitaxel is another chemotherapy drug used later. Radiotherapy can be used in different situations, and radioisotope therapy can treat cancer that has spread to the bones when ADT is no longer helping. A PARP inhibitor such as olaparib may be used when hormone therapy is no longer working, particularly if tests show a BRCA gene change. Surgery can sometimes help symptoms, and supportive treatments, also called palliative care, relieve and control symptoms.

Macmillan says advanced prostate cancer can cause physical symptoms that are difficult to cope with, but there are ways to manage them. Tiredness may be due to cancer or treatment and can be helped, and a blood test for anaemia may be offered. Pain should always be mentioned to the cancer team; if it is ongoing, regular rather than as-needed painkillers may be advised, and a specialist pain team may help. Bone pain can be treated with NSAIDs, a bone-strengthening drug such as zoledronic acid, and one or two sessions of radiotherapy, which can take a few weeks to work. Physiotherapists can plan exercise and help with mobility, and occupational therapists can suggest equipment.

The NHS notes that treatments for prostate cancer can cause side effects, and Macmillan mentions bone thinning as a side effect of long-term hormonal therapy, which bisphosphonates can help prevent or reduce. The NHS says if a person decides not to continue with treatment the care team will respect their decision and refer them to the palliative care team, who can also help loved ones get support.

On the NHS, advanced prostate cancer is managed by a urology or oncology multidisciplinary team, with a clinical nurse specialist, hormone therapy, chemotherapy and radiotherapy, and palliative care. Macmillan emphasises knowing who to contact out of hours.

Treatment decisions, such as whether to start chemotherapy within 12 weeks of hormone therapy or whether a PARP inhibitor is appropriate, depend on test results, and it helps to ask your team which treatments are available and what each is expected to achieve. Anyone seeking a second opinion can ask their cancer team how to arrange one.