From the Guidelines
Yes, metastatic prostate cancer can occur with a mildly enlarged prostate. The size of the prostate does not reliably indicate whether cancer is present or if it has spread beyond the prostate gland. Prostate cancer often develops in the peripheral zone of the prostate, which means a man can have a relatively normal-sized or only mildly enlarged prostate while harboring cancer cells that have already metastasized to other parts of the body such as bones, lymph nodes, or other organs. This is why prostate cancer screening typically involves both a digital rectal exam (DRE) and a PSA (prostate-specific antigen) blood test, as PSA levels can be elevated in men with prostate cancer even when the prostate feels normal or only slightly enlarged 1.
Key Considerations
- Men with concerning symptoms like bone pain, unexplained weight loss, or urinary problems should be evaluated regardless of prostate size.
- Diagnosis of metastatic disease typically requires imaging studies such as bone scans, CT scans, or MRIs, along with prostate biopsies to confirm the presence of cancer.
- Treatment for metastatic prostate cancer usually involves systemic therapies like hormone therapy (androgen deprivation therapy), chemotherapy, immunotherapy, or targeted therapies rather than just treating the prostate itself.
- According to recent guidelines, clinicians should obtain a bone scan and either pelvic multi-parametric magnetic resonance imaging (mpMRI) or CT scan for patients with high-risk prostate cancer 1.
Imaging and Diagnosis
Imaging studies are intended to define the local extent of disease as well as determine the presence of nodal and distant metastases, and thereby inform management. For patients with high-risk prostate cancer, CT scan or mpMRI scan should be obtained to evaluate the loco-regional extent of disease and presence of distant metastasis 1. The assessment of nodal metastasis is based on size criteria, and these modalities have similar accuracy. To evaluate for the presence of bone metastasis, conventional bone scan should be obtained as the initial staging study.
Treatment and Management
Early identification of patients with bone metastases is critical if the treatment options are to be best used to shift the balance from palliative treatment towards prevention of skeletal-related events (SREs), thus maintaining patients’ quality of life 1. The risk of SREs can be reduced through the use of agents such as the receptor activator of nuclear factor kappa B (RANK) ligand (RANKL) inhibitor denosumab and bisphosphonates, such as zoledronic acid. Tumor-specific androgen pathway inhibitors, such as abiraterone acetate and enzalutamide, also have beneficial effects on bone in patients with prostate cancer. Radium-223 dichloride has been shown to improve overall survival significantly compared with placebo in men with castration-resistant prostate cancer and bone metastases 1.
From the Research
Metastatic Prostate Cancer with Mildly Enlarged Prostate
- Metastatic prostate cancer can occur with a mildly enlarged prostate, as the size of the prostate is not always directly correlated with the presence of metastatic disease 2.
- The primary factor in determining the presence of metastatic prostate cancer is not the size of the prostate, but rather the spread of cancer cells to other parts of the body, such as lymph nodes or distant organs 2, 3.
- Studies have shown that approximately 10% of patients with prostate cancer present with metastatic disease, which can occur regardless of the size of the prostate 2, 4.
- The treatment of metastatic prostate cancer typically involves androgen deprivation therapy, which can be effective in reducing the size of the prostate and slowing the growth of cancer cells, regardless of the initial size of the prostate 5, 6.
- Recent advances in the management of metastatic prostate cancer have led to the development of new treatment options, including combination therapies and novel agents, which can improve survival outcomes for patients with metastatic disease 3, 4.