Clinical Overview: Treatment Options for Prostate Cancer

The prostate, a walnut-sized gland located below the bladder, is responsible for both creating seminal fluid and maintaining the health of the sperm. As a person grows older, the prostate can enlarge, which may lead to conditions such as benign prostate hypertrophy (BPH), whereby the urethra becomes blocked. Prostate cancer occurs when the cells in the prostate grow out of control and cause a tumor.¹

According to the National Institutes of Health (NIH), there were approximately 250,000 new cases of prostate cancer identified in the United States in 2021, which is considered approximately 13% of all cancer cases. There were approximately 35,000 deaths due to prostate cancer in 2021, which represents 5% of overall cancer deaths. However, with new medication options available, the 5-year survival rate for these patients is as high as 97.5%.²

Prostate cancer is different than other cancers, in that it can grow very slowly and show no symptoms for an extended duration. Unlike other cancers that spread to other organs rapidly, prostate cancer may spread slowly and even if it spreads to other organs, it can be managed effectively. The main approach to prostate cancer includes monitoring the development of the cancer to keep tabs on the speed of the growth.¹

Based on the histology of the disease, prostate cancer has various types, including adenocarcinoma, the less common neuroendocrine prostate cancer, as well as small cell prostate cancer. These variants can be less common but more aggressive, producing fewer prostate-specific antigens (PSA) and spreading outside of the prostate gland to other organs.¹ PSA is a protein created by the cells in the gland, mostly found in semen, as well as in blood.³

PSA levels, especially in the blood, are measured in nanograms per milliliter and there is no set cutoff when connecting its levels to prostate cancer. Most physicians and specialists use PSA cutoff point of 4 ng/ml or higher when deciding whether the person needs further testing to confirm cancer or not.

Some specialists would prefer lower levels, such as 2.5 or 3 ng/ml, to start taking action. PSA levels between 4 and 10 have an approximately 1 in 4 chance of being prostate cancer. If the PSA level grows more than 10 ng/ml, then the chance of developing prostate cancer would be about 50%.³

Symptoms of prostate cancer include fatigue, nausea, and pain. Signs of the disease that can be measured include fever, rash, or elevated pulse. The overall signs and symptoms of prostate cancer that can alert the person to refer to a specialist include frequent urination, weak or interrupted urination, mostly seen urge to urinate much more frequently than usual at night, having blood in the urine, experiencing erectile dysfunction, pain and burning during urination, and discomfort because of the enlarged prostate gland. Other uncommon symptoms may include change in the bowel movement habits, unexpected weight loss, and extreme fatigue.¹

The tests that can help diagnose prostate cancer include a PSA test, digital rectal exam, and biomarker tests. A specialist may order 1 more combination of these tests for further follow up and to help with diagnosing and differentiating cancer from other aspects of the disease.

A biopsy of the gland could be another way of discovering whether prostate cancer has developed. MRI fusion biopsy, PET scans, and transrectal ultrasound are other techniques that may help specialists determine whether the gland is cancerous or not.¹

Treatment of prostate cancer may include active surveillance. Treatment options could be different depending on the patient, the type of prostate cancer, and the speed in which it is growing based on active surveillance and diagnostic tests. Treatment options include surgery, radiation therapy, focal therapies, and systemic therapies.¹

The types of medications used in systemic therapy for prostate cancer include hormonal therapy, targeted therapy, chemotherapy, immunotherapy, and radiopharmaceuticals. Hormonal therapies may include drugs such as luteinizing hormone-releasing hormonal drugs, such as degarelix (Firmagon) and relugolist (Orgovyx). There are also sndrogen receptor inhibitors, which include bicalutamide (Casodex), flutamide, nilutamide (Nilandron), apalutamide (Erleada), darolutamide (Nubeqa), and enzalutamide (Xtandi).¹

Targeted therapies for prostate cancer include olaparib (Lynparza) and rucaparib (Rubraca). Standard chemotherapy may start with docetaxel (Taxotere) combined with prednisone or other medications, such as cabazitaxel (Jevtana), which is considered a microtubule inhibitor. For some patients with castration-resistant metastatic prostate cancer who have no or very few symptoms and who have not had chemotherapy, vaccine therapy with sipuleucel-T (Provenge) may be an option.¹

With so many diagnostic and treatment options available for patients with prostate cancer, the prognosis for these patients is bright. If patients report unusual symptoms to their provider and specialist as soon as possible, the disease can be detected early on and be treated as aggressively as needed for better control and recovery.

About the Author

Saro Arakelians, PharmD, is vice president of pharmacy operations at a pharmacy in Los Angeles, California.

References

1. Screening Tests for Prostate Cancer. American Cancer Society. Website. Accessed September 27, 2022. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/tests.html
2. Cancer Stat Facts: Prostate Cancer. National Institutes of Health. Website. Accessed September 27, 2022. https://seer.cancer.gov/statfacts/html/prost.html
3. Prostate Cancer: Introduction. Cancer.Net. Website. Accessed September 27, 2022. https://www.cancer.net/cancer-types/prostate-cancer/introduction