Treating Advanced and Metastatic Prostate Cancer

Sometimes prostate cancer is found to have spread beyond the prostate — most often to lymph nodes or bone — either at first diagnosis or later. This is more serious, but it is very treatable, and many men live well for a long time with it. While it usually cannot be cured, it can very often be controlled for a long time, and the aim of treatment shifts from removing the cancer to controlling it effectively across the whole body.

Prostate cancer growth is usually driven by the male hormone testosterone. The foundation of treatment is therefore to lower testosterone or block its effect — known as hormone therapy, or androgen deprivation therapy. This can shrink the cancer and control it, often for a considerable time, and can be given as injections or, in some situations, through an operation to remove the testosterone-producing part of the testicles.

It is now standard to strengthen this initial hormone treatment by adding a second medicine from the outset, rather than using hormone therapy on its own. Adding a further agent early has been shown to help men live longer and keep the cancer under control for longer. Your team will discuss which combination is most appropriate for you, taking into account the extent of the cancer and your general health.

In selected men presenting with metastatic prostate cancer, treating the prostate itself — in addition to systemic therapy — can improve outcomes, though the benefit depends heavily on how much the cancer has spread. The strongest evidence is for radiotherapy to the prostate. In the STAMPEDE trial, adding prostate radiotherapy to standard systemic treatment improved overall survival in men with a low metastatic burden (broadly, a limited number of bone metastases, with or without distant nodes), while offering no survival benefit in those with high-burden disease. On this basis, prostate radiotherapy is now a standard option for newly diagnosed, low-burden metastatic prostate cancer, and is generally well tolerated.

The role of surgery (cytoreductive radical prostatectomy) in this setting is more investigational. Removing the primary tumour is being tested in randomised trials — including SIMCAP, TRoMbone, g-RAMPP, PRESIDENT, and SWOG-1802 — but robust survival evidence comparable to the radiotherapy data is not yet available. At present, cytoreductive prostatectomy is best regarded as a treatment offered within a clinical trial, or after careful individualised discussion, rather than as a routine standard. In all cases, radical local treatment is given in addition to systemic therapy — not instead of it — and the decision is made by a multidisciplinary team based on the extent of disease, the response to initial treatment, and your general health.

Alongside cancer treatment, supportive care matters a great deal: protecting bone health, staying active, managing the effects of hormone therapy, and looking after emotional wellbeing. Many men continue their normal activities for years. Your team can arrange support for any part of this, and it is always reasonable to ask what to expect.

Whatever your situation, a few things consistently help. Bring someone with you to key appointments, as two people remember more than one. Write your questions down beforehand. Ask for information in writing, and ask how each option would affect the things that matter most to you. Staying active, eating well and, if relevant, stopping smoking all support your general health and your ability to tolerate treatment.