Can prostate cancer spread to other parts of the body?

Prostate Cancer Metastasis

Yes, prostate cancer can spread (metastasize) to other parts of the body, with bone being the most common site of metastasis, followed by regional lymph nodes, lungs, and liver. 1 The likelihood and pattern of spread depends on the cancer's risk stratification, which is determined by clinical stage, Gleason score/Grade Group, and PSA level.

Risk Stratification and Metastatic Potential

Prostate cancer is categorized into risk groups that help predict the likelihood of spread:

• Low Risk: PSA ≤10 ng/mL, Gleason score ≤6 (Grade Group 1), and clinical stage T1c or T2a

  • Very low metastatic potential when confined to the prostate

• Intermediate Risk: PSA 10-20 ng/mL or Gleason score 7 (Grade Group 2-3) or clinical stage T2b

  • Moderate risk of local spread and potential for distant metastasis

• High Risk: PSA >20 ng/mL or Gleason score 8-10 (Grade Group 4-5) or clinical stage T2c or higher

  • Significantly increased risk of both local extension and distant metastasis 1

Patterns of Spread

Prostate cancer typically spreads in a predictable pattern:

1. Local Extension: First extends beyond the prostate capsule to nearby tissues (seminal vesicles, bladder neck)

2. Lymphatic Spread: Regional lymph node involvement, particularly pelvic lymph nodes

3. Distant Metastasis: Most commonly to:

   • Bone (especially axial skeleton - spine, pelvis, ribs)
   • Distant lymph nodes (retroperitoneal, mediastinal, thoracic)
   • Visceral organs (lung, liver, adrenal glands)
   • CNS (brain, spinal cord) - less common 1, 2

Clinical Subtypes Based on Spread Pattern

The Prostate Cancer Clinical Trials Working Group defines five clinical subtypes based on spread pattern:

1. Locally recurrent/persistent disease without metastases
2. Non-metastatic castration-resistant prostate cancer (nmCRPC)
3. Nodal spread without bone or visceral disease
4. Bone disease with or without nodal involvement
5. Visceral disease with or without spread to other sites 1

Epidemiology of Metastatic Disease

At diagnosis, approximately:

• 75% of patients have cancer localized to the prostate (5-year survival ~100%)
• 14% have regional lymph node involvement
• 10% have distant metastases (5-year survival rate of 37%) 2

Despite definitive therapy, 2-56% of men with initially localized disease will eventually develop distant metastases, depending on risk factors 2.

Factors Affecting Metastatic Potential

Several factors influence the likelihood of metastasis:

• Gleason Score/Grade Group: Higher scores (particularly 8-10) significantly increase metastatic risk
• PSA Level: Higher levels (>20 ng/mL) correlate with increased risk of spread
• Clinical Stage: More advanced T-stage indicates higher risk
• Tumor Volume: Larger tumors and greater percentage of positive biopsy cores increase risk
• Molecular Markers: Certain genetic mutations (especially in DNA repair genes like BRCA2) are associated with more aggressive disease and increased metastatic potential 1, 3

Clinical Implications

Understanding the metastatic potential of prostate cancer is crucial for:

1. Treatment Selection: Patients with high-risk features may require multimodal therapy
2. Surveillance Strategy: Higher risk patients need more intensive monitoring
3. Imaging Decisions: Appropriate staging based on risk (bone scans, CT, MRI, PET)

Key Takeaways

• Prostate cancer can and does spread beyond the prostate in a significant percentage of cases
• The risk of spread correlates strongly with established risk classification systems
• Bone is the most common site of distant metastasis
• Early detection and appropriate risk stratification are essential for optimal management
• Treatment decisions should consider both the current extent of disease and the risk of future spread

For patients with metastatic disease, treatment typically involves androgen deprivation therapy (ADT), often combined with newer androgen receptor pathway inhibitors, which has been shown to improve survival compared to ADT alone 2.