From the Guidelines
Advanced prostate cancer is considered at the stage of metastatic castration-resistant prostate cancer (mCRPC) when the cancer has spread to distant organs, as indicated by the presence of metastases (M1) in the TNM staging system. This stage is characterized by the cancer's resistance to traditional androgen deprivation therapy (ADT) and its ability to progress despite castrate levels of serum testosterone (<50 ng/dL) 1. The TNM staging system evaluates the size and extent of the primary tumor (T), involvement of lymph nodes (N), and presence of distant metastases (M).
Key Considerations
- The presence of distant metastases (M1) is a key indicator of advanced prostate cancer, as it signifies the spread of cancer to other parts of the body, such as the bones, liver, lungs, or other organs.
- The cancer's progression to mCRPC is marked by its resistance to traditional ADT, despite castrate levels of serum testosterone (<50 ng/dL) 1.
- The staging of prostate cancer is crucial for determining treatment approaches, which may include hormone therapy, chemotherapy, immunotherapy, targeted radiation, or newer treatments like PARP inhibitors.
Treatment Approaches
- For patients with mCRPC, treatment options may include continued ADT, secondary hormone therapies, chemotherapies, immunotherapies, radiopharmaceuticals, and/or targeted therapies, as discussed in the NCCN clinical practice guidelines in oncology 1.
- The choice of treatment approach depends on various factors, including the patient's overall health, age, PSA velocity, and Gleason grade, as well as the presence of distant metastases and other clinical factors 1.
Recent Guidelines
- The NCCN clinical practice guidelines in oncology (2023) recommend that patients with mCRPC receive a laboratory assessment to assure castrate levels of testosterone (<50 ng/dL) and consider imaging tests to monitor for signs of distant metastases 1.
- The AUA/ASTRO/SUO guideline (2021) recommends that clinicians offer ADT with either LHRH agonists or antagonists or surgical castration in patients with metastatic hormone-sensitive prostate cancer (mHSPC) and consider continued ADT in combination with either androgen pathway-directed therapy or chemotherapy 1.
From the Research
Definition of Advanced Prostate Cancer
Advanced prostate cancer is typically characterized by the presence of metastases or locally advanced disease.
- According to 2, advanced prostate cancer was traditionally defined as patients with bony metastases, but the definition has evolved to include patients with locally advanced or metastatic lesions, corresponding to stages T3, N+, or M+.
Tumor (T), Node (N), Metastasis (M) Staging
The T, N, M staging system is used to classify the extent of prostate cancer.
- Stage T3 indicates locally advanced disease, with the tumor extending outside the prostate gland 2.
- Stage N+ indicates the presence of lymph node metastases 2, 3.
- Stage M+ indicates the presence of distant metastases, such as bony metastases 2, 3.
Survival Differences in Clinical T4, Nodal, and Metastatic Disease
There are survival differences between patients with clinical T4 disease, nodal disease, and metastatic disease.
- According to 3, patients with clinical T4 disease have better outcomes than those with N1 or M1 disease, with survival differences most pronounced in younger patients.
- The study found that factors such as higher tumor grade, unknown tumor grade, and absence of a spouse were associated with poor survival 3.
Management of Advanced Prostate Cancer
The management of advanced prostate cancer involves various treatment options, including androgen deprivation therapy, chemotherapy, and radiation therapy.
- According to 4, the Advanced Prostate Cancer Consensus Conference (APCCC) 2022 addressed questions on the management of advanced prostate cancer, including metastatic hormone-sensitive, non-metastatic, and metastatic castration-resistant prostate cancer.
- The study found that adding abiraterone and prednisolone to androgen deprivation therapy significantly improved metastasis-free survival in men with high-risk non-metastatic prostate cancer 5.