Treatment of Stage IV Prostate Cancer

This content has been reviewed and approved by

Daniel P. Petrylak, MD
Associate Professor of Medicine
Director, Genitourinary Oncology Program
Columbia University Medical Center

Stage IV prostate cancer refers to cancer that has spread to distant locations in the body, which usually includes the bones. Stage IV disease may be further classified into two groups depending on the extent of the cancer (tumor). 

  • Stage IV (D1) - The tumor has spread to pelvic lymph nodes or is obstructing the ureters (the tubes from the kidneys to the bladder) or both. 
  • Stage IV (D2)  - Cancer spread (metastasis) to lymph nodes outside the pelvic area, bone involvement, or spread to other distant parts of the body. 

Prostate cancer diagnosed at stage IV is often difficult to cure, although some patients can live for several years with effective treatment. 

Treatment of Localized Stage IV or D1 Prostate Cancer 

If your cancer has invaded adjacent organs, such as the rectum or bladder, or spread to lymph nodes in the pelvis, surgery is not likely to be helpful. Recommended treatment involves a combination of external beam radiation therapy (EBRT) and hormone therapy. Hormone therapy removes the male hormones necessary for prostate cancer to grow. In localized stage IV prostate cancer, hormone therapy and radiation therapy are often given together. 

Clinical studies are ongoing comparing hormonal treatment to radiation treatment alone to determine whether radiation is necessary. Delivery of hormonal therapy or chemotherapy before radiation treatment (neoadjuvant therapy) may also be a more promising way to combine these treatment approaches. 

Treatment of Metastatic Stage IV or D2 Prostate Cancer 

Prostate cancer that has spread to distant organs and bones is treatable, but not curable with current standard therapies. Hormonal therapy has been the standard treatment of metastatic prostate cancer for many years. Metastatic prostate cancer usually can be controlled with hormone therapy for a period of time, often several years. Eventually, however, most prostate cancers are able to grow despite hormone therapy. 

Treatment of Bone Complications 

Patients with stage IV prostate cancer often have cancer spread to the bones (bone metastases). Bone metastases commonly cause pain, increase the risk of fractures, and lead to a life-threatening condition characterized by an increased amount of calcium in the blood (hypercalcemia). Treatments for bone complications may include bisphosphonate drugs or radiation therapy. 

  • Bisphosphonate drugs - can effectively treat bone metastasis by preventing bone loss, thereby, reducing the risk of fractures, and decreasing pain associated with bone metastasis. FDA-approved bisphosphonates for the treatment of cancer-related skeletal complications include Zometa® (zoledronic acid) ) and Aredia® (pamidronate). 
  • Radiation therapy - Pain from bone metastases may also be relieved with radiation therapy directed to the affected bones. The side effects of radiation therapy for relief of bone pain depends on the area of the body being treated. Radioisotopes, such as strontium-89, can be used to treat bone pain. Strontium-89 is given intravenously and accumulates in bones, where it kills prostate cancer cells by delivering small amounts of radiation. Since strontium-89 is given through a vein, it can affect all bones in the body, whereas external radiation therapy is limited to only small areas of the body. The major side effect of strontium-89 is a reduction in blood cell counts. 

Research is in progress to refine existing treatments and develop new ones. For information on some of the techniques currently under investigation, see Strategies to Improve Treatment.

This content was last reviewed August 15, 2010 by Dr. Reshma L. Mahtani.
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