Advanced Prostate Cancer Guide 2009

Advanced
prostate
cancer
Prepared by the Australian Cancer Network and

Australian Prostate Cancer Collaboration based
on the Guidelines for Locally Advanced and
Metastatic Prostate Cancer.
Copies available from Andrology Australia
c/o Monash Institute of Medical Research
Monash Medical Centre
246 Clayton Road, Clayton VIC 3168
PO Box 5418, Clayton VIC 3168
Phone: 1300 303 878
www.andrologyaustralia.org
a guide for men

and their families
Copyright Cancer Council Australia (2009)

ISBN: 978-0-9807421-0-7
Acknowledgements
brochure working group, who generously
We would like to thank Andrology Australia and
shared their ideas and experience.
the Prostate Cancer Foundation of Australia
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may
who, as major sponsors of the Clinical Practice
be reproduced by any process without prior written permission from the Australian Cancer Network.
Guidelines, generously provided funding for
Requests and enquiries concerning reproduction and rights should be addressed to the Copyright
their development. We are also grateful to the
Officer, Cancer Council Australia, GPO Box 4708, Sydney NSW 2001, Australia.
National Seniors Foundation working with
Website: www.cancer.org.au. Email: info@cancer.org.au.
the GM & JA Whitehouse Foundation who
Disclaimer
The information in this guide is not intended to take the place of medical advice. Information on
prostate disease is constantly being updated. A patients general practitioner or specialist may
provide them with new or different information which is more appropriate to their needs.
Where to obtain copies
This guide can be downloaded from the Australian Cancer Network website
www.cancer.org.au/clinicalguidelines, from the Lions Australian Prostate Cancer website
www.prostatehealth.org.au, the Andrology Australia website www.andrologyaustralia.org, the
Prostate Cancer Foundation of Australia website www.prostate.org.au or the beyondblue website
www.beyondblue.org.au.
funded the printing of this Guide. beyondblue

generously provided review, advice, content and
Professor Dianne OConnell and the guidelines

team of Suzanne Hughes, Hayley Griffin, Dr
Annette Moxey and Dr Louisa Jones for their
untiring and excellent work on the production
of the clinical practice guidelines as well as the
Guide. We are grateful to Elizabeth Keam AM
RN, MNSc who drafted chapter 12.
funding towards the production of the Guide. We
We are grateful to Cancer Council NSW for
are particularly grateful to members of support
permission to use material from their booklet:
groups affiliated with the PCFA who gave us
Understanding Clinical Trials.
invaluable feedback on the Guide content.
Lastly we would like to thank the reviewers
The chapter for carers and family members was
and the hardworking members of the steering
developed with the help of Sheila Duke, Trish
committee (listed in Appendix 10) who so
Bartlett and Elizabeth Allen of the Prostate
generously volunteered their time and saw this
Cancer Foundation of Australias carers
project through to completion.
Copies of this guide can be ordered through:

Andrology Australia: 1300 303 878 or email info@andrologyaustralia.org
Prostate Cancer Foundation of Australia: 1800 22 00 99
Cancer Councils in each state: 13 11 20
Related Documents
The NHMRC Clinical Practice Guidelines for the Management of Locally Advanced and Metastatic
Prostate Cancer can be obtained from the Australian Cancer Network, website
www.cancer.org.au/clinicalguidelines.
02
Preface
Preface
How we produced this book
This book was requested by men with prostate cancer as a sequel to
Localised prostate cancer: a guide for men and their families. It aims to
explain the advanced stages of prostate cancer, its treatments and how
men can manage their health and care while dealing with this condition.
Like its predecessor, it draws from the National Health and Medical
Research Councils (NHMRC) clinical practice guidelines. The draft
guidelines for Locally Advanced and Metastatic Prostate Cancer are
produced by the Australian Cancer Network (ACN). A working group
with strong consumer representation was convened by the ACN and
the Australian Prostate Cancer Collaboration (APCC) to produce a
consumer version of the Guidelines with comments and suggestions
from the Urological Society of Australia and New Zealand and the
Support and Advocacy Committee of the Prostate Cancer Foundation
of Australia (PCFA).
The draft was reviewed by members of the national network of prostate
cancer support groups that are affiliated with the PCFA and feedback
was provided to the steering committee through the consumer
representatives on the committee. Reviews of the whole text or
particular sections were undertaken by individuals listed in Appendix 10.
How to use the book
This book is very detailed in parts, and may contain more
information than you need. If this is the case, we suggest you read
the key points at the beginning of each chapter to gain an overview
of that topic. If you want more information, you may want to read
the appendix which has more details on a number of topics. The
glossary at the back can be used to look up any terms that are new
03
to you. We provide resources for further information at the end of

each chapter and questions which may be useful to take to your
doctor in Appendix 9.
A message from the consumer members on the steering committee
When you are told that you have advanced Prostate Cancer, many
thoughts flash through your mind. One is that I need to find out more
about what is happening to my body and what can I do about it. There
are 100s of books available that offer a wide variety of views, some
soundly based, some offering cures without any evidence to support their
theories. If you search the internet there are millions of references.
For the first time consumers now have a reliable source of information,
written and reviewed by some of the nations leading practitioners
in all the modalities of treatment. Being part of the team that has
produced this book has been a privilege and a learning experience.
We strongly recommend this book as being the very best source of
information on Advanced Prostate Cancer.
Consumer Representatives
Don Baumber
Gold Coast Prostate Cancer Support and Information Network
Bill McHugh
Brisbane Prostate Cancer Support Network
Max Shub
Prostate Heidelberg Support Group
04
Foreword
Foreword
Many men find that the topic of their health is not high on their
priority list something to attend to when all other problems are
solved. In particular, with prostate cancer, there is so much uncertainty
and so many conflicting views about this disease, that it may seem
there is nothing that can be done and that ignoring it is the easiest
way to deal with the problem.
However this book is a timely reminder that you can do a great deal for
yourself by engaging with the issues it raises. Even after a diagnosis of
cancer and of advanced cancer, understanding the disease and the help
available to you can help improve the situation, enable good treatment
choices and importantly, help you and your partner maximise your
quality of life. It can help those around you, whom you both support
and whose support you need in turn to address the disease together.
A message from beyondblue

There is a lot of information to take in when you are ill, but we know
that the better you understand what is happening to you, the more you
will be in control of things and the better you will feel.
This booklet provides information about advanced prostate cancer and
importantly, discusses some of the emotional reactions people have
when they are ill or undergoing treatment. It contains advice on looking
after your well-being, strategies for good mental health and information
on depression and anxiety.
Prof David Clarke
beyondblue Research Adviser and Professor at the School of Psychology,
Psychiatry and Psychological Medicine, Monash University
This book is drawn from the findings of a group of experts in the field,
with input from men with the disease and their partners. It is written
in a language which makes it accessible to most and it has plenty of
resources to follow up if further information is needed.
I believe this publication will help men and their partners control
their journey through this condition and avoid some of the common
pitfalls. I congratulate those who have put so much time and skill into
producing it and particularly those who seek to help others with
prostate cancer.
Lieutenant General Ken Gillespie, Vice Chief of the Defence Force and
recently diagnosed with prostate cancer
05
06
Table of Contents
Table of Contents
Chapter 1: Introduction to Advanced Prostate Cancer
11
1.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.2 After a diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.3 What is the prostate?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4 What is prostate cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.5 How common is prostate cancer? . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.6 Is prostate cancer a risk to my family? . . . . . . . . . . . . . . . . . . . . . 16
1.7 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Chapter 2: Following the Progress of Prostate Cancer
18
2.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.2 Staging: the TNM system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3 Grading: the Gleason score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.4 Digital rectal examination (DRE) . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.5 PSA test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.6 Bone scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.7 CT scan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.8 MRI scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.9 Treatment decision points for advanced prostate cancer . . . . . . 24
2.10 Risk and prognosis: what course is the cancer likely to take? . 25
2.11 Advanced prostate cancer: goals of treatment . . . . . . . . . . . . . 26
2.12 Making decisions about prostate cancer treatments . . . . . . . . 28
2.13 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Chapter 3: Members of the Care Team and Their Roles
32
3.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.2 Clinicians who provide care for advanced prostate cancer. . . . . 32
3.3 Coordinating your care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.4 Multi-disciplinary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.5 Obtaining a second opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
07
3.6 Changing doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

3.7 Medicare safety net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.8 Keeping a treatment record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.9 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Chapter 4: Locally Advanced Prostate Cancer
39
4.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.2 What it is, what it means. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.3 Signs and symptoms: how we know the
cancer is locally advanced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.4 Cancer control treatments for locally advanced
prostate cancer and side effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.5 Treatments for cancer-related symptoms. . . . . . . . . . . . . . . . . . . 47
4.6 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Chapter 5: PSA Rising After Treatment
for Localised Prostate Cancer
49
5.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.2 What it is, what it means. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.3 Signs and symptoms of a rising PSA . . . . . . . . . . . . . . . . . . . . . . . 50
5.4 Cancer control treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.5 Symptom control: treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.6 Preventive and supportive care . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.7 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Chapter 6: Complementary Care and Lifestyle
57
6.1 Key messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.2 Physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.3 A diet high in vegetables and fruits and low in animal fats . . . . 60
6.4 Maintaining a healthy bodyweight . . . . . . . . . . . . . . . . . . . . . . . . 61
6.5 Dietary supplements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
6.6 Supportive care for men with prostate cancer: activities and
therapies that can reduce the impact of illness . . . . . . . . . . . . . . . . . 67
6.7 Can I do myself any harm?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
08
Table of Contents
6.8 Confused about terms? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

6.9 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Chapter 7: Metastatic Prostate Cancer
72
7.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
7.2 What is metastatic prostate cancer? . . . . . . . . . . . . . . . . . . . . . . 73
7.3 Treatment to control cancer: androgen deprivation
(hormonal) therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
7.4 Dealing with side effects of androgen deprivation therapy . . . . 89
7.5 Life with metastatic prostate cancer . . . . . . . . . . . . . . . . . . . . . . 101
7.6 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Unresponsive to Hormone Therapy
103
8.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
8.2 What causes androgen deprivation therapy to fail? . . . . . . . . . . 104
8.3 Symptoms and indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
8.4 Treatments for prostate cancer which is no longer
responding to androgen deprivation therapy . . . . . . . . . . . . . . . . . . . 108
8.5 Bone metastases and their treatments . . . . . . . . . . . . . . . . . . . . . 114
8.6 Looking after yourself. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
8.7 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Chapter 9: Clinical Trials and Emerging Treatments
119
9.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
9.2 Clinical trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
9.3 Emerging treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
9.4 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
9.5 Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Chapter 10: Maintaining Your Wellbeing
138
10.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
10.2 Worries and how to deal with them . . . . . . . . . . . . . . . . . . . . . . 138
10.3 Maintaining intimacy and satisfying relationships . . . . . . . . . . 142
10.4 When things seem beyond repair: depression and anxiety . . . . 149
09
10.5 Resources and further help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Chapter 11: Partners, Families and Carers: Your Concerns
153
11.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
11.2 Talking and communicating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
11.3 Emotional and psychological stresses . . . . . . . . . . . . . . . . . . . . . 157
11.4 Resources and further help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Chapter 12: Palliative and End-of-Life Care
167
12.1 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
12.2 Palliative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
12.3 Things you can do for the future. . . . . . . . . . . . . . . . . . . . . . . . . 191
12.4 Advance care planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
12.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
12.6 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Appendix 1: Staging and the TNM System
195
Appendix 2: The Gleason Grading System
197
Appendix 3: PSA rising What Does It Mean?
199
Appendix 4: Resistance Exercises
201
Appendix 5: Body Mass Index (BMI) Calculator
206
Appendix 6: Models of Resistance to Androgen Deprivation Therapy 207

Appendix 7: Do I Have Depression?
210
Appendix 8: Planning Ahead
212
Appendix 9: What Questions Could I Ask?
220
Appendix 10: Steering Committee and Reviewers
222
Abbreviations
225
Glossary
226
References
245
Index
253
010
Chapter 1: Introduction to Advanced

Prostate Cancer
accompany you throughout the cancer journey. This guide aims to

explain what is available, who can help and how you can best support
yourself to lead an active and fulfilling life throughout these years.
1.1 Key points

1.3 What is the prostate?
The prostate is a small gland at the base of the bladder. It

contributes to secretions in the semen.
Prostate cancer arises in the tiny glands within the prostate.
Prostate cancer is the second most common cancer in men after

skin cancer.
About 15% of prostate cancers are diagnosed at the advanced stage.
When you are first diagnosed, or hear that your cancer has
recurred, it may be a shock. Give yourself time to absorb the
news and understand the issues before making any decisions
about treatment.
If you are diagnosed with prostate cancer at an early age

(particularly if under 60 years), male family members of your
immediate family (brothers and sons) may also be at higher risk
of the disease.
The prostate is a small gland about the size of a walnut found only in men.
It sits just below the bladder and surrounds the urethra (the tube which
takes urine from the bladder through the penis). The prostate produces
part of the fluid that makes up semen. The fluid is formed by many tiny
cell-lined glands linked to ducts that lead ultimately into the urethra. The
growth and development of the prostate depends on testosterone (the
male sex hormone). Testosterone is made mainly by the testicles, which
in turn are controlled by the pituitary gland (part of the brain). While the
prostate itself plays an important role in reproduction, it is not essential to
life and many men lead long and productive lives after its removal.
Figure 1.1: Prostate and surrounding anatomy
1.2 After a diagnosis

When you are first told you have prostate cancer, you may not hear
much else. Hearing the word cancer may be a great shock. Some men
may find it hard to think of anything else for quite some time. Just as the
first news of cancer may be a shock, the report that it is advanced or has
returned after treatment can hit hard and revive long-buried fears.
Dont expect too much of yourself during this period. You need time to
take in the information, think about it and discuss it with your family
and friends. The important thing to remember is that even if you have
advanced cancer, there are many treatments available that can help
extend your life for years. A lot of people are available to help you and
011
012
1.4 What is prostate cancer?

Cancer is the name for abnormal cells that divide and multiply
uncontrollably, forming a mass of abnormal tissue called a tumour.
Tumours can have local effects and may disrupt the function of organs
lying close by, such as the bladder. They can also affect the whole system,
causing a person to feel generally unwell, tired and lacking in appetite.
The prostate is made up of tiny branching glands. These are separated
from each other by connective tissue and muscle called stromal tissue.
With age, many men develop an enlarged prostate caused by an
overgrowth in the glandular and stromal tissue. It is not cancerous. This
is called benign prostatic hyperplasia (BPH).
Prostate cancer is different. It results from a cancerous overgrowth in
the tiny glands in the prostate. These glands are lined with cells that
secrete proteins such as prostate specific antigen (PSA). The overgrowth
occurs in these secretory cells. Cancer originating in glandular tissue is
sometimes called adenocarcinoma.
Cancer arises after a series of changes in the genetic material of the cell.
The first noticeable pre-cancerous changes are called PIN or prostatic
intraepithelial neoplasia. These cells are dividing more rapidly than
normal cells but are not yet cancerous. Many men with these early precancerous changes do not go on to develop prostate cancer.
However, some men do develop prostate cancer. Further genetic changes
cause more cells to multiply and these eventually disrupt the internal
structure of the prostate by breaking out of the little glands and invading
the stromal tissue.
When the cancer progresses to an advanced stage, it breaks out of the
prostate capsule and invades tissues surrounding the prostate, namely
the seminal vesicles, the bladder and possibly the bowel.
013
The cancer spreads to lymph nodes, bone and other organs when groups of
cancer cells detach from the tumour and are carried by the lymph and blood
circulation to other tissues, where they start to grow and form metastases.
Each of these stages is accompanied by successive genetic alterations.
A single protein is essential at every stage of disease development.
Called the androgen receptor, it is located on the nucleus in the healthy
prostate cell. The androgen receptor is responsible for binding the male
hormone, testosterone, to the prostate. Prostate cancer cells also need
an active androgen receptor. When the testosterone is bound to the
receptor, it controls the working of the genes in the cells nucleus that
are necessary for cell growth and reproduction. This is essential for the
survival of prostate cancer cells.
By depriving the androgen receptor of testosterone, we can stop it
controlling the cancer cell genes for a while. This is achieved by blocking
testosterone production in the testes.
Unfortunately this treatment often stops working after a period and the
cancer progresses to its most dangerous stage, often termed androgen
independent or castrate-resistant disease. At this late stage, the androgen
receptor continues to function and support the survival of the cancer cells
in the prostate, even in the absence of circulating testosterone.
Considerable energy is now being directed into understanding how this
receptor continues to function, and into designing new ways to target it
during late-stage disease.
1.5 How common is prostate cancer?

Prostate cancer is the second-most common cancer in Australian men
after skin cancer. About one in three men over the age of 50 and nearly
all men aged 80 or more have some cancer cells within their prostate1 but
are not aware of it. As most of these cancers grow extremely slowly they
are not likely to cause any problems, ever, particularly in elderly men.
014
Each year, however, more than 18,000 Australian men are diagnosed with
prostate cancer. Prostate cancer generally affects men over the age of
50, and is rarely found in younger men. Approximately half of all new
prostate cancers and over 85% of prostate cancer deaths occur in men
aged 70 years or more.2 Approximately 2900 men die every year from
prostate cancer.2
In more than 85% of Australian men diagnosed with prostate cancer, the
tumour appears to be contained within the prostate (localised disease).
The remaining 15% are diagnosed with prostate cancer that extends
outside the prostate (advanced disease). This may remain in the pelvic
area (69% of all prostate cancers) or may have spread to distant organs
(46% of all prostate cancers).3
Some men who are initially diagnosed with localised disease will
experience progression of the disease. In approximately 2030% of
patients treated for localised prostate cancer the disease will recur.
Recurrence after treatment for localised prostate cancer is usually first
detected by a rising PSA level. However, while many patients experience
rising PSA levels (sometimes called biochemical recurrence), this is often
controlled with further treatment and only some of these patients go on
to die from their disease.
This guide is for men with locally advanced disease, recurrent disease
(disease which recurs after treatment for localised cancer), and
metastatic prostate cancer (where the cancer has spread beyond the
prostate area to other regions of the body).
More than 18,000 Australian men are diagnosed with prostate

cancer each year (that equates to approximately 1 in every 170
men aged 50 years or over).
Of these 18,000 men, about 8100 (one in every two) are aged 70
years or more.
In more than 15,700 of these 18,000 men (17 in every 20),

the disease appears to be localised at the time of diagnosis
(contained within the prostate).
In less than 3000 of these 18,000 new cases (3 in every 20),

the prostate cancer extends outside the prostate at diagnosis
(advanced disease).
1.6 Is prostate cancer a risk to my family?

Male first-degree relatives (a brother or son) of a man diagnosed with
prostate cancer have a higher risk of prostate cancer. A recent review
found that this risk is from 2.2 to 2.8 times higher than in men without
such a family history.4 If a man were diagnosed before 60 years of
age, the risk for his relatives is at the higher end of the range. If a man
has two relatives diagnosed with prostate cancer, his risk is 3.5 times
higher than normal. Most studies suggest that the risk in brothers is
higher than in fatherson relationships.4 Men with a family history of
prostate cancer are at high risk of prostate cancer at an earlier age. Some
recommendations suggest that if they wish to be regularly tested for
prostate cancer, they should begin earlier, namely at age 40 or 45 years
(www.urosoc.org.au).
The higher risk in families may be due to both environmental and
lifestyle factors and genetic risks shared by the family members. Purely
hereditary cancers are thought to be quite rare and account for roughly
9% of prostate cancers. Many studies have looked for prostate cancer
susceptibility genes, but with little success. This could be because the
015
016
onset of cancer, its progression and outcome, are controlled by many

different sets of genes. A link has been found between prostate cancer
and BRCA2 a gene linked to early-onset breast and ovarian cancer. A
man who is a carrier for a mutation in this gene has an increased risk of
developing prostate cancer (although not necessarily at an early age).
The sons and brothers of a man diagnosed with prostate cancer

are two to three times more likely to develop prostate cancer
than men with no family history.
An individual mans risk will vary by his age and by what age
and how many of his relatives have been diagnosed with
prostate cancer.
Example: of 100 fifty-five year old men with a family history of

prostate cancer, between 17 and 52 of them can expect to be
diagnosed with prostate cancer before they reach the age of 75.
1.7 Resources
Cancer Council Helpline: 13 11 20
Cancer Council Helpline to find your local familial cancer service: 13 11 20
Lions Australian Prostate Cancer Website: www.prostatehealth.org.au
Prostate Cancer Foundation of Australia affiliated peer support groups:
www.pcfa.org.au or phone 1800 22 00 99
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Chapter 2: Following the Progress of

Prostate Cancer
2.1 Key points
Doctors use a number of measures to follow the progress of

cancer. It can be helpful to know about them so you can discuss
your progress with the doctor. They include:
cancer stage (how far it has spread) measured by the
TNM system
cancer grade (how aggressive the cancer is likely to be)
measured using the Gleason score
PSA level, a blood test that measures a protein produced by
prostate and prostate cancer cells
Different scans bone scan, CT scan, MRI are used to

investigate whether cancer has spread to other regions of the
body
Cancer treatments may have different goals. The three main

goals are to:
control the cancer
control symptoms caused by the cancer
improve quality of life
Making decisions about treatments involves weighing up the

pros and cons, but uncertainties can make this difficult. This
guide includes strategies to help your understanding and to help
you make treatment decisions.
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2.2 Staging: the TNM system
T local extent of the tumour
Stage is a measure of spread or extent of the cancer. The stage is summarised

using a system called the TumourNodeMetastasis or TNM staging system.
Localised disease
T stage tells us about the local extent of the tumour
T1
N stage tells us if it is in the lymph nodes
The tumour is so small that it cannot be detected at the rectal

examination or on ultrasound. Tumours of this size are usually
detected by a rise in PSA.
M stage tells us if the cancer has metastasised and spread to distant

parts of the body
T2
The tumour can be felt at the rectal examination but it is still

confined to the prostate.
Note that in the following figure (2.1) and brief description of the
TNM staging system, the T-stages described and illustrated have been
simplified. Within each stage are sub-groupings ac, which indicate the
extent of spread within that stage (see Appendix 1).
Locally advanced disease

T3
Tumour extends beyond the prostate and may have spread into fat
or seminal vesicles immediately next to it, but no further.
T4
Tumour invades pelvic organs such as such as bladder, rectum,

pelvic wall, which are further away than seminal vesicles.
Figure 2.1: The stages of prostate cancer

Stage
How far the cancer has spread
T1
The tumour cannot be felt by the doctor or

detected by ultrasound.
N indicates whether the cancer is present in lymph nodes in

the pelvic region (near the prostate)
t
tumour
Advanced or metastatic disease

T2
T3
T4
The doctor can feel the cancer but it does not

appear to have spread beyond the prostate.
N0
Tumour has not been found in lymph nodes.
N1
Tumour is found in lymph nodes Nx. It is not known whether

tumour is in lymph nodes.
The cancer feels as though it has spread

outside the prostate into surrounding tissues.
M indicates the presence of cancer in distant parts of the

body such as bone or lung (referred to as metastases).
The cancer has grown into surrounding

organs such as the bladder or rectum.
M0
No metastases have been found.
M1
Distant metastases have been found.
Mx
It is not known whether tumour is in distant parts of the body.
The status of tumour spread prostate (T), nodes (N) and metastases
021
022
(M) may be quoted simultaneously. For example, T3 N0 M0 means

that the cancer has spread outside the prostate but only adjacent to the
prostate, no cancer cells have been found in lymph nodes and no distant
metastases have been found.
Tests that give information about the progress of the cancer are the digital
rectal examination (DRE), PSA test, serum prostatic acid phosphatise (PAP)
test, bone scan, CT scan and MRI scan. The Gleason scoring system or
grade gives an indication of how fast the cancer is likely to grow.
2.3 Grading: the Gleason score

Grading systems indicate how abnormal the cancer tissue looks. A higher
score means the tissues look more abnormal. Normal tissue has an
ordered structure but in cancer tissue the cells grow in a more chaotic
fashion, so that the original tissue arrangement is not maintained. The
more abnormal the tissue looks, the faster the cancer is likely to grow, so
cancer grade is also a measure of cancer aggressiveness.
The most commonly used grading method is the Gleason score. The
method assigns a score to the tissue, which ranges from 2 to 10. Ten is
the most abnormal or most aggressive score. To estimate the Gleason
score, the pathologist identifies the two most common tissue patterns in
the tumour and gives them a score from 1 to 5. The score may be quoted
as either the total out of 10, for example 7, or as its component scores,
for example, 4+3 or 3+4. The reason for quoting the component scores is
that a Gleason of 4+3 is likely to represent a greater risk than a 3+4.
Cancers with a Gleason score of 6 are the least aggressive (it is rare to
have a Gleason score less than 6). Those with a score of 6 are called low
grade, 7 are intermediate, and tumours with scores of 8, 9 and 10 are
high grade. High-grade tumours are the fastest growing and pose the
greatest risk (see Appendix 2).
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2.4 Digital rectal examination (DRE)

The DRE is used to check the prostate through the rectum (or back
passage). The prostate is located just in front of the rectum, so your
doctor can insert a gloved finger into your rectum and feel the size of
your prostate through the rectal wall. Cancers feel harder than normal
tissue. This test may feel uncomfortable, but should not be painful. A
DRE can give an idea of how big the prostate cancer is and whether
there is any obvious growth into surrounding tissues. The DRE findings
also assist in determining the clinical stage or the local extent of the
cancer. However, it is not always possible to tell how big the cancer is
in this way. When the gland is removed by surgery, the actual tumour
size does not always correlate well with the estimate made at the
rectal examination.
2.5 PSA test

PSA or prostate-specific antigen is a protein produced by cells in the
normal prostate. It is present in the ejaculate and has a role in nurturing
the sperm. Normally only a little PSA leaks from the prostate into the
blood stream, but when cancer is present there are many more prostate
cells, therefore the PSA level usually increases. Before diagnosis, a
high PSA level can be due to other conditions of the prostate, such as
infection. After the prostate has been removed or largely destroyed
by treatment, PSA is a good measure of how many prostate cancer
cells remain in the body. The PSA test can then be used to measure the
effectiveness of treatments. There is a catch, however. Not all prostate
tumours release PSA. Some particularly aggressive tumours do not
produce PSA and therefore do not cause a rise in PSA.
It follows that the PSA level can give a rough idea of cancer stage. A cancer
with PSA greater than 20ng/ml is more likely to have grown outside the
prostate. The PSA can be in the hundreds before symptoms appear. PSA
levels in the thousands can occur in men with metastatic prostate cancer.
024
The rate at which PSA rises can indicate how much of a risk the cancer
poses. PSA doubling time is the time taken for the level to double. If
doubling time is longer than one year, the risk of death from the cancer is
low.5 If the doubling time is less than three months, then the risk is higher.
2.6 Bone scan

A bone scan is done to see if the prostate cancer has spread to the
bones. A small amount of a radioactive material (called technetium) is
injected into a vein in the arm and a scan done one to two hours later.
The radioactive material is slowly absorbed into the bones in areas of
new bone growth or healing activity. If the prostate cancer has spread
to the bones there will often be many sites of increased activity seen
on the bone scan.
lymph nodes. The test uses magnetic energy to make the images. It
is completely painless, may be noisy, and takes about 45 minutes to
complete. During some MRI scans of the prostate gland, the doctors
may need to place a small inflatable tube into the patients rectum (back
passage) to get the most detailed information about the prostate. The
MRI may be useful for planning radiotherapy as well as detecting cancer
recurrence after removal of the prostate.
2.9 Treatment decision points for advanced prostate cancer

If prostate cancer progresses, there are four or five points at which the
treatment may change or a treatment decision may need to be made (see
Figure 2.2). They are at the finding of:
locally advanced prostate cancer
A bone scan will only find fairly large numbers of cancer cells in the
bones (that is, where numbers are high enough to cause bone damage).
It will not find small numbers of prostate cancer cells and is rarely
positive when the PSA level is less than 10. Arthritis can also appear as
a positive bone scan.
PSA recurrence following surgery or radiation treatment for localised

prostate cancer
metastatic prostate cancer
metastatic prostate cancer which has failed androgen deprivation

treatment
2.7 CT scan
end-of-life care
A CT (computerised tomography) scan is a technique for making detailed

x-ray images. It may be done to detect any spread of prostate cancer
outside the prostate. A CT scan takes about one hour. A dye is injected
into a vein in the arm, then the patient drinks a fluid. The scan gives
images of the pelvic organs including the prostate. Unfortunately, like
bone scans, CT scans do not detect small amounts of cancer. However
they can be useful in planning radiotherapy.
In the following chapters we will describe each of these points, what is

happening with the cancer, signs, symptoms and available treatments. It
should be remembered that even though these points or stages loosely
form a sequence, it is by no means certain that a person reaching one
point will inevitably progress to the next. Treatment for locally advanced
cancer, as for localised cancer, can be curative.
2.8 MRI scan

An MRI (magnetic resonance imaging) scan can tell the extent to which
cancer has spread into the tissues surrounding the prostate and local
025
026
Figure 2.2: Treatment decision points in the progress of prostate cancer
and what their prognosis might be6. The answers to these questions form
the prognosis, or the course of the disease that might be expected for a
particular patient.
While it is not possible to estimate prognosis with any degree of
certainty, we do know that for most men the time taken to reach the
next stage of the disease is measured in years, not months, and can be
very long indeed (Appendix 3). One study showed that the median time
between the first sign of recurrence (raise in PSA) and metastases was
eight years6. Another found the median time between PSA recurrence
and death from prostate cancer was 16 years7, and many patients did
not progress to die of prostate cancer (median means that half of the
patients took a longer time, half a shorter time).
ADT = androgen deprivation therapy
My doctor told me that my cancer was incurable but did not tell
me that it was treatable and that I could expect some years of
reasonable quality of life. I am still functioning well 13 years later.
2.10 Risk and prognosis: what course is the cancer likely to take?
Because individual cancers vary so much, one of the most important
questions doctors are concerned about is How is this particular cancer
going to behave? Even if the cancer has reached a stage where it
cannot be cured, it is still possible that the cancer is slow growing
and not a threat to life. Alternatively it may be many years before
it becomes such a threat. The risk or threat posed by the cancer is
balanced against any likely treatment side effects when choosing if or
when to start a treatment.
These are important questions from the points of view of both patient
and doctor. After curative treatment such as surgery or radiotherapy,
at the first sign of the PSA rising again patients want to know what it
means: whether the cancer has returned, whether it is a threat to life
027
Doctors use risk factors to try to estimate how long it will take a patient
to reach the next stage of disease. These risk factors usually come from
test results. For example, PSA doubling time the time taken for the PSA
level to double is a useful measure of how soon a cancer is likely to
reach the next stage. In the study mentioned above, the doctors found
that if the time taken for the PSA to double was greater than ten months,
men usually did not develop metastases for ten years. They also found
that if it took longer than two years for the PSA to rise after surgery, the
chances were that metastases would not appear for ten years or more. A
Gleason score below 8 also predicts a longer time to the next stage.
Risk factors for progression to the next stage can be different at
different stages of the disease. However, doubling time seems to be
useful across all stages. We will refer to useful risk factors in this guide
as we cover each stage.
2.11 Advanced prostate cancer: goals of treatment

When discussing different treatments, doctors will often talk about the
treatment goal or what they expect the treatment to achieve.
028
There are three broad types of treatment goals:
cancer control (treatments which aim to cure or achieve remission

from the cancer)
symptom control (treatments aimed at removing symptoms caused

by the cancer or other treatments)
quality-of-life improvement (treatments aimed at improving general

wellbeing)
2.11.1 Cancer control: cure or remission

The first purpose is to control the cancer; to reduce its rate of growth, so
that it does not affect daily living. A range of treatments is available for
this purpose and they are discussed in Chapters 4, 5, 7 and 8.
2.11.2 Symptom control

Treatments can cause symptoms such as fatigue and hot flushes. The
cancer itself may also cause symptoms such as pain. Treatments to deal
with these symptoms are aimed at improving day-to-day living. Where
symptom control is complex, palliative care specialists may be consulted
(note that palliative care should not be confused with end-of-life care).
Palliative care is discussed more fully in Chapter 12. Treatments to
control symptoms can involve medications, radiation or surgery.
2.11.3 Quality of life

Treatment to improve quality of life may not involve treating the disease.
Complementary care can include approaches such as meditation to
improve a sense of wellbeing, assistance with daily living needs delivered
by an occupational therapist, and general support. A psychologist
can help develop strategies to deal with anxiety, decision making and
problem solving.
Sometimes different types of doctors provide care in each of these areas.
While you are seeing one specialist, you may also see other types of
029
doctors. The different types of care and the clinical staff that provide
them are discussed in Chapter 3.
It is important to understand the goals of a treatment in making
decisions about it with your doctor.
2.12 Making decisions about prostate cancer treatments

It can be difficult to make decisions about treatment for advanced
prostate cancer for several reasons.
First, your doctor may suggest several different approaches to your
treatment, one of which might even be to watch carefully and monitor
your PSA for the moment. The idea of not actively treating the cancer
as soon as possible goes against the messages we usually hear about
cancer. Having to choose between difficult treatment options can seem
overwhelming. Adding to this, the information about prostate cancer
treatments often includes complex medical terms and statistics that can
be hard to understand. When you are trying to consider a lot of complex
information it becomes difficult to identify the bits that most matter for
you. In other words, you cant see the wood for the trees! As well, the
side effects of treatments can include things like sexual problems. For
most men, these side effects are distressing to think about, making it
difficult to come to a decision about them.
Second, feeling anxious is a normal reaction to finding out about advanced
cancer. When people are anxious it can affect their ability to think through
difficult problems. If you imagine your mind as your thinking work bench
or desk where all your thoughts are laid out, being anxious can make it
harder to organise the thoughts on your work bench and the resulting
clutter makes it more difficult to reach a decision.
As well, most people dont like making decisions when there is
uncertainty about the consequences. In the case of cancer treatments,
where there is uncertainty about many things including the chances
030
of side effects or how well the treatment might work, it can be hard to
make a decision.
Taking time to think it through. Usually there is no urgency to

decide which treatment approach to take. Check with your doctor
whether this applies to your situation.
Writing a list of the pros and cons of each possible treatment

option. This helps to get your thoughts in order (because at times
it can feel as though you are going round in circles). Highlight the
points on your list that matter to you most, then see which option
seems the most favourable. Try talking the options through with
someone close to you, like your wife or partner or a close friend, and
talk to your GP or specialist doctor.
Writing down your questions before you visit your doctor (in case
in the rush of the consultation you forget). Also write down your
doctors answers. This will help you get the best use out of your time
with your doctor. As well, some doctors will tape the consultation for
you to listen to later.
Talking to other men who have advanced prostate cancer can give
you an idea of what treatment might be like. There are prostate
cancer support groups throughout Australia where you can meet
other men who have had prostate cancer. As well, there are men
available to talk one-to-one by telephone (see Resources below).
Involving wives and partners in the treatment decision can

be a good idea as they frequently prefer to be involved, and men
themselves often find this support helpful. Probably the most
important discussion is about how you would like to manage
treatment decisions and how involved you each wish to be. Then
tell your doctor about your decision. Communicating in an open
way about how you will make treatment decisions can prevent
misunderstandings and help both you and your partner feel less
alone. In brief, work together as a team.
There are strategies that can help. You may have tried some; others may
be new to you. They include:
Taking a close friend, family member or partner with you when

you visit the doctor. Two sets of ears are better than one, and having
someone with you can help you feel better supported. Your support
person can also remind you later of things the doctor said that you
may have forgotten or misunderstood.
Seeking credible information. There is a large amount of

information about prostate cancer on the Internet, in popular books,
magazines and from different health organisations across the world.
Some of this will be inaccurate or not relevant in Australia, or not
relevant to you. Check with your doctor and call the Cancer Council
Helpline (13 11 20) for credible and locally relevant information. If
your doctor provides you with medical information such as booklets,
ask which parts are most important for you.
031
Breaking the decision into smaller steps. For example, the first
thing to consider may be whether you and your doctor think that
your cancer needs active treatment now. Once you have an idea of
the answer to this question, then think about the treatment options.
Remember that the decision you make will be the best decision for you.
Be as involved as you would like to be in the process. Look for help and
guidance when you need it. People you can approach for assistance
include all those involved in your care: your GP, urology nurses, urologist,
radiation oncologist or other specialist. You may need to get a referral to
see a specialist talk to your GP about this.
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2.13 Resources
National phone helplines
Multicultural Cancer Information Services: 13 11 20
Contacts for support groups
www.pcfa.org.au Includes a map to locate nearest support group
Helpful books
Cancer Council New South Wales.
Living with advanced cancer: a guide for people with advanced
cancer, their families and friends. 2007, Sydney. Available from
www.cancercouncil.com.au or phone 02 9334 1900.
UsToo International Prostate Cancer Education and Support Network.
What now? Hope and options when experiencing a rising PSA,
a recurrence of prostate cancer or when prostate cancer is not
responding to treatment.
www.ustoo.org/pdfs/160295_PSA_Brochure.pdf.
033
3.1 Key points
Different clinical staff may care for you at different stages in

the progression of prostate cancer. These include your general
practitioner, urologist, radiation oncologist, medical oncologist,
palliative care specialist and urology and palliative care nurses.
Make sure you know who is coordinating your care at any one
time. Talk to your GP if you are uncertain.
If you would like a second opinion on a particular treatment

choice you can talk to your GP or arrange it with your specialist.
You may need to take a summary of your medical record with you.
If you have reached the Medicare threshold in gap payments, you

may be eligible for 100% reimbursement of gap costs. Further
information is available at www.medicareaustralia.gov.au.
Keeping a record of your symptoms, treatments, test results

and medications can be very helpful, both for yourself and
your care team.
Several kinds of clinicians specialising in different types of care are

involved in the treatment of prostate cancer. They are involved at different
points in care, so you may find yourself seeing more than one specialist at
a time. Alternatively, you may be referred from one specialist to the next. It
is important to understand each doctors field of expertise and how each
works with your other doctors to coordinate your care overall.
3.2 Clinicians who provide care for advanced prostate cancer

The urologist is probably the first specialist you will be referred to
if your blood test or rectal examination is abnormal. Urologists are
usually surgeons who treat kidney, bladder, prostate and urinary
036
Chapter 3: Members of the Care Team

and Their Roles
problems. They diagnose the prostate cancer through a biopsy, assess

suitability for treatment and provide surgical or hormonal therapy as
appropriate. Urologists may be involved with your care throughout
the course of your cancer.
Radiation oncologists are specialists in the use of radiotherapy to treat
cancer. For prostate cancer, the specialist may use radiation delivered
externally with beams or internally with implants such as seeds and rods
to treat localised or locally advanced cancer. Radiotherapy can also be
used at a later stage to treat bone or other metastases.
Medical oncologists use chemotherapy to treat cancer. They have a
great understanding of the problems experienced by the person with
advanced cancer. Your urologist may refer you to a medical oncologist to
take advantage of new types of chemotherapy that have recently become
available for the treatment of advanced prostate cancer.
The pathologist is one of the medical specialists you may never meet.
Pathologists examine body tissues and fluids to assess the stage and
aggressiveness of your cancer.
Urology or prostate care nurses can help you throughout your prostate
cancer journey. They can answer your questions about treatment and its
side effects and help you to manage incontinence, sexual dysfunction
and related problems. They can be helpful to both you and your partner.
Palliative care specialists are expert in pain and symptom control,
particularly for people with advanced cancer. They work closely with your
other doctors. You may be referred to a palliative care specialist or team
if you have symptoms that affect your quality of life, particularly if they
are complex and involve several organ systems in the body. The palliative
care team can help you and your family with physical symptoms,
psychological and spiritual needs.
037
Psychologists can help you develop the decision making, problem

solving and other skills to cope with emotional, social and spiritual
challenges. They also help people experiencing anxiety and depression.
A psycho-oncologist is a psychologist who specialises in helping people
deal with cancer.
Social workers help people manage their personal and social problems.
They help people to access useful support services and sometimes
provide counsel through a crisis.
Occupational therapists and physiotherapists can help you with the physical
side of your daily life that is affected by treatments, and provide rehabilitation
exercises to overcome treatment complications such as incontinence.
Your general practitioner (GP) is your family doctor who knows you
and your circumstances personally and who will continue to provide you
with routine medical care and monitor your health and wellbeing. This
doctor can play a key role throughout the course of your prostate cancer,
explaining treatment options to you and your partner, providing referrals,
and following your care when multiple specialists are involved. Your GP
can also deliver hormone therapy and monitor your progress with blood
testing in collaboration with your specialists. It is important to ask your
specialist doctors to keep your GP informed of your care.
Your pharmacist is easy to access and can help you understand and
manage your medications. If you have more than one health problem
for which you are taking medicines, your pharmacist can review your
medicines for any harmful drug interactions and contact your doctor if
necessary. This can be particularly useful if you are receiving care from
more than one doctor. If you are taking a number of medications at
different times, your pharmacist can pre-package them to make it easier
for you to remember which to take, how many and when.
038
If you need to see a different doctor or are travelling, your pharmacist can
print out a list of the medicines you have been taking for your records.
keep your GP up-to-date with your progress, and you can ask any
specialist to do so.
Your pharmacist can help you with the Pharmaceutical Benefit Scheme
(PBS) Safety Net. Once the cost of you or your familys medications
reaches a certain threshold (usually over $1000) you qualify to receive
them at a lower rate. Your pharmacist will issue you with a card when
this happens and can answer your questions about the scheme.
Your specialist will normally coordinate the care for your prostate
cancer. However your GP is still responsible for your overall care and is
the person to return to if you are not sure who is responsible for your
care, or if you develop medical problems other than prostate cancer.
Your GP may be more accessible than your specialist if you develop
acute symptoms or need immediate care. In this case, your GP would
normally contact your specialist, so it is important that he or she has
up-to-date details of the specialists you are seeing. In rural areas, the GP
is sometimes the lead doctor coordinating patient care. You can ask your
specialist doctors to keep your GP informed as your care changes.
Figure 3.1: Specialist clinicians who may provide care at different stages
of advanced prostate cancer
3.4 Multi-disciplinary care

Multi-disciplinary care (MDC) is a new approach to care that provides
many benefits for patients. MDC involves a team of clinicians from
different specialties that meets regularly to plan treatment for a group
of patients. The team includes many of the specialists listed above,
thus ensuring that the patient has access to the full range of therapies.
Sometimes a patients own general practitioner is included. Patients are
told about the teams discussion of their case and its recommendations.
MDC is primarily hospital-based and depends on a specialist leading the
team. Its availability and funding varies between states. Currently it is
available through only a limited number of treatment centres.
3.3 Coordinating your care

Normally when your GP refers you to a specialist, the specialist will
write back to your GP reporting your progress. If your specialist (say
urologist) refers you to another specialist (say medical oncologist)
he or she will report back to the referring doctor (in this case the
urologist) but not necessarily to your GP. It is very important to
039
You and your partner have a primary role with your doctors in making
decisions about your care. You can do this better if you understand the
types of treatments available, how health care is organised and what
resources (human and otherwise) are available to you. That is the aim of
this guide. At the end of the chapter we list other resources you may find
helpful in managing your care.
040
3.5 Obtaining a second opinion
3.8 Keeping a treatment record
It is important that you feel your specialist can give you the help and
answers you need. Obtaining an opinion from another doctor about your
cancer and treatment can help you be confident that you are doing the
right thing. If you would like another specialist to assess your case you
can seek a second opinion. This is your right. Most doctors are used to
patients seeking a second opinion. There are two ways to do this. You
can ask the specialist or your general practitioner to organise a referral.
The second doctor will need to access your medical record or be provided
with relevant information by the referring doctor. Being confident in
your specialist is an important part of your treatment.
You may find it useful to record key information about your diagnosis and
treatment. This can help a doctor track your progress if all your medical
records are not available and it may also help you keep track of changes
in your care. In its simplest form, your treatment record is just a diary
comprising a date, what happened, symptoms, test results and reminders to
yourself about what you need to do.
3.6 Changing doctors
If you enter the date of a future doctors visit use the treatment record
to list your questions before you go.
It is always good to keep a medication list. This records the medication
name (brand name, generic drug name), dose and how often you take it.
Ideally you would also have the start and stop date.
Sometimes a different doctor will take over your care. This can happen
for many reasons including retirement, unavailability, or a change in
treatment approach that requires a specialist in a different discipline. In
addition, you may want a change. Some people find this a difficult time,
particularly if they have been in the care of the first doctor for several
years. Remember that prostate cancer involves a team of people who can
offer you different types of care that is appropriate at different stages.
Your specialist may refer you to the new specialist or your GP can help if
you are not sure who is looking after you or coordinating your care.
The Prostate Cancer Foundation of Australia has produced a Prostate Cancer

Personal Organiser for keeping a record of treatments, investigations, medical
appointments and medications. It will be available from the PCFA in 2010.
3.7 Medicare safety net
Locating a specialist: Lions Australian Prostate Cancer Website

www.prostatehealth.org.au/treatment.html
Frequent visits to the doctor or out-of-hospital treatments can cost a great

deal in gap payments (the difference between the scheduled fee and the
amount Medicare refunds). Once you have paid over a certain threshold in
gap payments, Medicare will increase the amount it reimburses to 100% of
the scheduled fee. Information on this and other safety net features can be
found at www.medicareaustralia.gov.au or call 13 20 11.
One approach developed by US physician Dr Steven Strum is called the

prostate cancer digest. The link is included under Resources.
3.9 Resources
Medicare Safety Net: www.medicareaustralia.gov.au

Prostate Cancer Personal Organiser: Prostate Cancer Foundation of
Australia: www.prostate.org.au or phone 1800 22 00 99
Keeping a record of your treatment: The prostate cancer digest and
other records. www.hrpca.org/bookletch6.htm
041
042
Chapter 4: Locally Advanced Prostate

Cancer
4.1 Key points
Locally advanced cancer has spread beyond the prostate, but is

still within the prostate region.
It is suspected if any of the following has occurred:
to nearby tissue or organs. Locally advanced cancer can still be cured.

Cancer which has spread to more distant parts of the body (such as the
bones) cannot be cured, but can be treated to slow the growth of the
cancer, often for many years. In some men who have surgery to remove
their prostate, prostate cancer cells are found in lymph nodes close by.
Because lymph nodes are the policemen for escaping prostate cancer
cells, this finding suggests that cancer cells may have spread beyond the
prostate and possibly to distant parts of the body.
- cancer can be felt outside the prostate on DRE

- cancer can be seen outside the prostate on scans
- there are cancer cells remaining in the fat outside the
prostate, or in the seminal vesicles after the prostate has been
removed at operation
- the PSA blood test does not go to less than 0.1ng/ml
after surgery
- the PSA went to less than 0.1ng/ml after surgery, but starts
to rise again
It carries a high risk of recurrence around the region of the

prostate, so more than one type of treatment is often used.
The most common treatments are radiotherapy, androgen

deprivation therapy or a combination of these. A combination is
the most effective treatment.
Usually there are no symptoms. However if the cancer is causing

urinary symptoms, these can be relieved with a TURP (trans-urethral
resection of the prostate), radiotherapy, hormone therapy and
occasionally insertion of a stent.
Prostate cancer that has extended beyond the prostate into the
surrounding tissue, into other organs or into distant parts of the body,
is called advanced prostate cancer. Locally advanced refers to prostate
cancer that extends outside the prostate gland itself but is still confined
043
4.2 What it is, what it means

Locally advanced prostate cancer has spread outside (beyond the
capsule of) the gland itself, but is still confined within the prostate
region. It may be in the fat immediately adjacent to the prostate or
may have spread into the seminal vesicles (tumour stage T3, see
Appendix 1) or other surrounding organs such as the bladder or rectum
(tumour stage T4, see Appendix 1).
Locally advanced prostate cancer carries a high risk of recurrence after
treatment by surgery or radiotherapy. This means that more than one
type of treatment may be needed to control that risk, and there is a
higher chance of complications.
4.3 Signs and symptoms: how we know the cancer is locally

advanced
There are unlikely to be symptoms at this stage of disease. However, the
following signs and symptoms can be relevant:
As the tumour grows it sometimes squeezes the urethra, causing

problems with urination. These urinary symptoms can be similar to
those caused by benign enlargement of the prostate. They include
frequent urination (frequency), poor stream, difficulty starting
(hesitancy), and waking frequently at night to urinate (nocturia).
044
The cancer can at times cause bleeding in the urine (haematuria),

which may or may not be visible to the naked eye.
4.4 Cancer control treatments for locally advanced prostate

cancer and side effects
Locally advanced prostate cancer can cause pelvic pain or bowel

symptoms such as constipation and narrow bowel motions.
4.4.1 External beam radiotherapy with a period of androgen

deprivation therapy
A rectal examination (DRE, see Chapter 2) that indicates some

extension beyond the prostate may be the first sign that the cancer
is locally advanced.
A PSA over 20ng/ml means there is a high likelihood that the tumour
extends beyond the prostate.
This is the most proven treatment for locally advanced prostate cancer. External
beam radiotherapy (EBRT) is like having a 15-minute x-ray, five days a week, for
up to eight weeks. It is a fairly simple, non-invasive process. Patients are never
radioactiveyou can still hug your partner and grandchildren.
A positive surgical margin after surgery indicates locally advanced

prostate cancer. Often locally advanced prostate cancer is diagnosed
after a radical prostatectomy when the tumour is found to extend to
the cut edge of the removed tissue (a positive surgical margin). This
means that some cancer tissue remains in the body.
Positive pelvic lymph nodes indicate advanced prostate cancer. These

may be identified by a CT scan or during a radical prostatectomy.
The surgeon may remove lymph nodes to check whether the cancer
has reached them. A pathologist will report the nodes are positive if
cancer cells have been found.
Also after a prostatectomy, the pathologist will report whether the

tumour extends to the seminal vesicles (seminal vesicle invasion)
or into the fat around the prostate (extracapsular extension). This is
called T3 disease and indicates the cancer is locally advanced.
If the PSA has not fallen below 0.1ng/ml and stayed there after radical
prostatectomy, it is considered locally advanced.
If after radiotherapy the PSA stays steady, or continues to rise after

reaching a low point (nadir), it is considered advanced.
045
EBRT has advanced considerably in the past few years, resulting in cure
rates even higher than previously, and having fewer side effects. New
advances such as intensity-modulated radiotherapy (IMRT) and imageguided radiotherapy (IGRT) are being used increasingly. They increase
the accuracy of radiotherapy and decrease the dose of radiotherapy to
normal tissues. These types of radiotherapy accurately target and kill
prostate cancer cells both within the prostate and in the fat and glands
around the prostate. EBRT is able to destroy locally advanced cancer
without patients requiring surgery.
By the time it has been diagnosed, locally advanced prostate cancer
has often already sent tiny cancer cells to other parts of the body, such
as the bones. These micro-metastases are usually not picked up by
scans or tests. To give the best chance of curing the cancer so that it
never returns, successful treatment usually requires a combination of
both EBRT and androgen deprivation therapy (ADT). ADT (see Chapter
7) removes male hormones which are necessary for prostate tissue to
grow and seems to be more effective when combined with radiotherapy.
ADT may be administered before radiotherapy (neo-adjuvant), at the
same time as radiotherapy (concomitant) and/or immediately after
radiotherapy (adjuvant). This therapy may last as long as two to three
years in total. ADT and EBRT combine to cause the death of cancer cells
both within and outside the prostate. Combined therapy using EBRT and
046
hormone therapy gives the highest chance of curing locally advanced

prostate cancer.
4.4.2 External beam radiotherapy plus brachytherapy
Most patients treated with EBRT and hormone therapy are happy
with their results. Mild side effects are common, but usually do not
significantly affect the patients quality of life. Almost all patients are
able to continue normal activities such as working, driving and exercising
during and after radiotherapy. Side effects during EBRT can include
tiredness, the need to pass urine or bowel motions more frequently, and
the feeling of when youve got to go, youve got to go. These symptoms
usually appear towards the end of EBRT and are generally mild and easily
treated. They usually resolve within a month or so of completing EBRT.
Longer-term effects can occur, but again are generally mild. They include
erectile dysfunction, and changes in bowel or bladder function. These
can usually be treated, so it is important to report them to your doctor.
Leakage of urine is another but very uncommon side effect.
Low dose rate: small radioactive seeds are implanted directly into
the prostate. This involves a single procedure as the seeds remain
permanently in the prostate. Low-dose brachytherapy can be done as a
boost to the dose of radiation given to the prostate after EBRT. However
it is usually not recommended for locally advanced prostate cancer.
High dose rate: A highly radioactive source is guided into different

positions in the prostate with multiple catheters. This is repeated
a number of times over a period of days, so that the prostate
receives a high dose. This type of brachytherapy is usually used in
combination with five to six weeks of EBRT as well as two to three
years of ADT for high-risk cancers. High dose rate brachytherapy
appears to give the same results as EBRT, although there is less
evidence to support its use in prostate cancer.
Long-term ADT may have continuing side effects (see Chapter 7).
It is important that your general practitioner (GP) monitor you for
possible side effects.. These can include erectile dysfunction, a drop in
sex drive, shrinking of sex organs (testes and penis), enlarged breasts
(gynaecomastia), tiredness, hot flushes, thinning of the bones which can
lead to fractures, weight gain, diabetes, high blood pressure and cholesterol,
and a reduction in muscle mass and strength. Some men experience mood
swings and notice changes in mental function. Over the short periods when
ADT is used in combination with EBRT for locally advanced disease, the
effects are not as noticeable as when ADT and EBRT are used continuously
as for metastatic prostate cancer. However some effects may be noticed in
the short term. Dietary changes, vitamin D and calcium supplements can
reduce the risk of bone fractures. A regular exercise program, particularly
strength exercises, can reduce muscle loss and tiredness and may help with
mood effects as well. We cover these and other measures you and your GP
can take to reduce these side effects in Chapter 6.
Brachytherapy has similar side effects to EBRT, with urinary symptoms

more common.
047
There are two main types of brachytherapy:
4.4.3 External beam radiotherapy immediately after surgery

(adjuvant radiotherapy)
There are several important things that a pathologist will look for in
tissue removed at surgery for prostate cancer. These important high-risk
features indicate whether the cancer may come back in the area around
the surgical bed where the prostate used to be. The pathologist will
answer questions including:
Has all of the cancer been taken out?

If the cancer goes up to the cut edges of the tissue removed by
the surgeon, there are cancer cells left in the body and the cancer
can return.
048
Has the cancer gone out of the prostate into the fat?
If it extends into the fat (known as extracapsular spread) it can
come back, even if it looks as though the surgeon removed all of
the cancer.
Has the cancer gone into the seminal vesicles?

The seminal vesicles are glands that sit on top of the prostate. Again,
if the cancer is in the seminal vesicles then it can come back in the
surgical bed, even if it looks as though the surgeon removed all of
the cancer.
If the cancer goes right up to the cut edge of the tissue (first question), is
into the fat (second question) or has gone into the seminal vesicles (third
question), then adjuvant radiotherapy is recommended within four months
of surgery. Radiotherapy should be given in any of these situations even if
the PSA is undetectable after surgery (i.e. the PSA is less than 0.1).
Adjuvant radiotherapy is also given immediately after surgery if the PSA does
not fall to less than 0.1, and even if there are no other high-risk features.
Radiotherapy immediately after surgery (adjuvant radiotherapy) has
been shown to improve the cure rate, stop the prostate cancer spreading
to other parts of the body (such as bones), and give the best chance of
long-term survival.
Radiotherapy can also be used many years after surgery if the PSA starts
to rise again. This is called salvage radiotherapy (see Chapter 5).
Side effects of radiotherapy after surgery are similar to those
described for EBRT.
4.4.4 Androgen deprivation (hormone) therapy alone

Androgen deprivation therapy (ADT) aims to reduce levels of testosterone
in the body, thus preventing prostate cells from growing and multiplying
as well as killing cancer cells. ADT is recommended when cancer cells
049
are likely to have spread beyond the prostate region. Specialists agree
that two to three years of ADT should be used when combined with
radiotherapy in locally advanced prostate cancer (neo-adjuvant or
adjuvant therapy). However, not all specialists agree on the best time to
start long-term ADT for patients with locally advanced prostate cancer
who are not being treated for cure, or for patients with metastatic
prostate cancer.
It is not known whether there is a benefit in starting ADT before there is
evidence of metastases, that is, if the cancer has not spread beyond the
prostate region to other parts of the body. At least one study suggests that
ADT in men with positive pelvic lymph nodes improves cancer control and
survival after surgery in men with locally advanced disease.8 However ADT
alone is not as effective in prolonging survival as ADT combined with EBRT.
As we explain above, long-term ADT has considerable side effects that
may affect your quality of life. These are an important consideration in
deciding if or when to go on ADT.
4.4.5 Surgery with or without androgen deprivation therapy

The standard approach when trying to cure patients with locally
advanced prostate cancer is a combination of EBRT and hormone
therapy. There is not a lot of research supporting the use of surgery
when attempting to cure locally advanced prostate cancer. Surgery
is usually used only to help with symptoms of cancer, particularly if
radiotherapy is not possible.
Sometimes surgery (a radical prostatectomy or trans-urethral resection
of the prostate) is done if the patient is experiencing symptoms of
urinary obstruction, or if this is likely to be a problem. The surgery
improves local control in the area of the prostate, so that the
cancer does not cause problems by obstructing the flow of urine and
spreading to the bladder and other organs. However, the purpose of
050
the surgery is to treat or prevent symptoms, not to cure the cancer or

improve overall cancer survival.
4.6 Resources
Side effects of these types of surgery include high rates of erectile

dysfunction (over 50%) and a risk of urine leakage or blockage of urine
due to scar tissue (strictures).
4.5 Treatments for cancer-related symptoms

Locally advanced prostate cancer that has not metastasised may not
cause symptoms. However, if the tumour obstructs the outflow of urine
it may cause urinary symptoms. If the blockage is in the tube carrying
urine from the bladder (urethra), symptoms can include frequent
urination, poor stream, hesitancy, waking at night to urinate and blood in
the urine. More rarely, the tube from the kidney to the bladder (ureters)
can be blocked, and may cause loin pain.

UpToDate for Patients: Patient Information: Advanced Prostate Cancer
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Treatments may include:
Surgery. A trans-urethral resection of the prostate (TURP) in which

a cutting instrument is inserted into the urethra and any tissue
blocking the flow of urine is cut away.
Insertion of a stent. Occasionally a small tube is inserted into the

ureter to support the walls of the urethra and maintain urine flow
from the kidney to the bladder.
External beam radiotherapy. EBRT directed at the prostate destroys

the cancer cells, which may be blocking the urine outflow tubes.
Androgen deprivation therapy (ADT) may also help relieve symptoms.
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052
Chapter 5: PSA Rising After Treatment for Localised Prostate Cancer
Chapter 5: PSA Rising After Treatment

for Localised Prostate Cancer
5.1 Key points
A continuous rise in PSA after surgery, radiotherapy or other

potentially curative treatment for prostate cancer usually means
that cancer remains in the body.
A temporary rise in PSA after radiotherapy may be due to PSA

bounce rather than recurrence.
The first step is to find out whether the recurrence is local

(near the prostate, in the pelvic region) or distant (occurring as
metastases in other parts of the body).
If the cancer is local, salvage treatment (usually radiotherapy)

may destroy the cancer.
If the cancer is metastatic, the usual options are hormone

therapy, chemotherapy, or sometimes just observation.
5.2 What it is, what it means

After surgery or radiotherapy for localised prostate cancer, or when a
patient is on a program of active surveillance, regular testing of PSA levels
is the main way of monitoring the cancer. This can be over months, or
often over many years. If the PSA levels start to rise again, it can be a very
anxious time. It raises many questions: What does it mean? Is the cancer
back? What is the best treatment? When should the treatment be given?
5.3 Signs and symptoms of a rising PSA

Normally there are no symptoms when the PSA is rising because the
cancer can still be at an early stage. Doctors base a decision on whether
the cancer has returned on a precise definition of PSA behaviour. This
definition is different after surgery and radiotherapy.
After surgery, the decline is rapid and the PSA should become
undetectable (less than 0.1ng/ml) within two to three months. If the
PSA does not fall below 0.1ng/ml, or if it rises on two consecutive
occasions above 0.03ng/ml, this is an indication that prostate cancer
cells remain in the body.
After external beam radiotherapy and brachytherapy, the cancer cells
die more slowly and consequently the PSA decline is slower. Counterintuitively, the slower the decline the more promising the result. It can
take up to four years following treatment for the PSA level to reach its
lowest point (the nadir) as some of the normal prostate cell population
recovers. These slow-growing tumours have a good prognosis.
Ideally the lowest point should be less than 0.5ng/ml.9 The PSA decline may
slow, stop, then start to rise again. If the PSA rises by 2ng/ml above the
nadir, there is a high chance that prostate cancer cells remain in the body.
Many PSA rises after radiotherapy are not due to cancer. Sometimes the
rise occurs after stopping hormone therapy as the bodys testosterone
recovers. Very rarely, a second cause of a rise in PSA is a small, slow rise
due to some residual benign prostate tissue that remains after treatment.
A third cause is a temporary rise in PSA called PSA bounce.
After primary treatment, a doctor will first work out whether the rise is
likely to be due to cancer remaining in the body after treatment and if
so, whether it is still in the local prostate region. This will help decide the
best treatment and the timing of the treatment.
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054
5.3.1 PSA bounce

Even in the case of successful radiotherapy, the fall in the level of
PSA is not always smooth. It may rise again for a period of a few
months before falling towards its final minimum value.10 This bounce
in PSA has been studied mainly in men following treatment with
brachytherapy or EBRT.11,12
The reason for PSA bounce is not well understood, but may be due to
its release from dying prostate tissue. Between one third and half of
patients experience bounce, which can occur anywhere between four
months to four years after treatment. The magnitude of the bounce lies
in the range of about 0.53ng/ml. It may last from a few months to a
year or more. Sometimes a second bounce may occur. The other common
cause of a bounce is recovery of testosterone after ceasing ADT used in
combination with radiotherapy.
The amount of PSA variation after treatment is different from patient
to patient. It is important not to jump too rapidly to the conclusion that
treatment has failed because of small increases in PSA values. A doctor
may monitor the PSA at three to six monthly intervals to establish that
the PSA is rising in a sustained and significant way before deciding that
the cancer has recurred.
a CT or MRI scan to look for spread to the lymph nodes or other

organs such as the liver
After radical prostatectomy, indications that the recurrence may be local

(in the prostate region only) are as follows:
the pathology report showed cancer extending to the cut edge of

the tissue removed (positive surgical margin), or cancer extending
into the fat surrounding the prostate (extra prostatic extension) or
invading the seminal vesicles
the PSA rise happens a relatively long time after the surgery (12
years or more13)
bone scans, CT and MRI are all negative
having low-risk disease (Gleason score 7 or less, PSA less than 1.5ng/
ml at recurrence and a long PSA doubling time), which is also thought
to increase the chance that if a recurrence happens it is local only13
After radiotherapy, indications that cancer is in the local region include a

positive DRE and a PSA less than 2ng/ml.
It is important to point out that these indicators are not 100% accurate,
and that recurrence may be local even in other circumstances.
5.3.3 Prognosis
5.3.2 Investigations to find the site of the recurrence
If the PSA rise seems to be due to remaining cancer cells, the next step
is to investigate whether these are located in the prostate region or
elsewhere in the body. Investigations can include:
a biopsy or digital rectal examination to detect cancer in the

prostate region
a bone scan to look for cancer deposits (metastases) in the bone

(however a bone scan will not detect very small deposits [micrometastases] and is usually normal at the time of a PSA rise)
055
Recurrence or treatment failure defined by a rise in PSA does not

necessarily mean that a patient is destined to die of prostate cancer.
A local recurrence of the cancer after surgery can sometimes be
successfully cured with radiotherapy. A distant recurrence can be treated
to slow the progression. The threat posed by the tumour is based on a
number of risk factors:
the PSA before treatment
the Gleason score of the biopsy or pathology specimen (for

surgery patients)
056
the rate of increase of PSA after treatment (often measured as

doubling time) indicates risk (one study reported that a doubling
time of less than nine months following prostatectomy predicted a
higher long-term risk of dying from prostate cancer14
1.01.5ng/ml. However many doctors will offer salvage radiotherapy

when the PSA is lower (eg even when the PSA is less than 0.1). If the
PSA is consistently rising even at very low levels, it may indicate that
cancer cells are growing.
the length of time after treatment before the PSA starts to rise again
(time to PSA failure) also indicates the threat posed by the recurring
tumour a longer time (years) means a better prognosis
Salvage radiation therapy is potentially curative. According to one study,

56% of patients were relapse-free after eight years.17 PSA doubling time
(rate of increase) is a good predictor of response to salvage radiotherapy.
In one study, patients with a doubling time of five months or more all
responded to therapy.18
Sometimes risk factors are combined into tables or nomograms

(mathematical expressions). These give an estimate of the likely course of
the disease, based on the past experience of other patients with similar
clinical measures. One study of patients after surgery gives the likelihood
of surviving for 10 and 15 years after the recurrence. They make these
predictions based on Gleason score, PSA doubling time and the time it
took for the PSA to recur after treatment.15
Your doctor may discuss these factors with you, when talking about
prognosis. One US hospital (Memorial Sloane-Kettering Institute) has
published these prediction tools online for interested patients (see
Resources). You may need to see your doctor to obtain the details of your
cancer if you want to use these tools.
5.4 Cancer control treatment

5.4.1 Local recurrence
After surgery
If the PSA rise is thought to be due to a local recurrence after
prostatectomy, meaning the remaining cancer is still in the prostate
region, salvage radiotherapy may be the best option. This treatment
can sometimes be curative. The chances of successful treatment are
higher if the PSA is low, ideally less than 1ng/ml when the treatment is
started.16 A European expert body has suggested secondary treatment
after local failure of surgery should begin before PSA levels reach
057
Salvage radiation therapy can increase the likelihood of urinary

incontinence and erectile dysfunction.19 These problems can occur some
years after treatment. A small proportion of patients will also experience
rectal problems. However it appears that radiotherapy after surgery
improves long-term quality of life, presumably due to the benefit of
decreasing the recurrence and spread of cancer.
After radiotherapy
If the PSA rises because there is local recurrence after radiotherapy,
surgery is still possible but is less frequently offered as a salvage
treatment. This is because radiotherapy causes scarring in the pelvic
region, which makes surgery more difficult. Complications after surgery,
such as urinary symptoms, incontinence and erectile dysfunction, are
more common. However both surgical and radiotherapy techniques have
improved in more recent times, and these side effects are not nearly as
common as they were. Salvage radical prostatectomy can be suggested
as an option in patients with few other illnesses, low-risk prostate cancer
and a longer life expectancy, according to recent guidelines.20
Salvage treatment after radiotherapy can include ADT alone, or local
treatments such as high intensity focused ultrasound (HIFU) or
cryotherapy (freezing of the tissue). Cryotherapy is most successful in
058
patients with a PSA less than 10ng/ml. It can have side effects such as
impotence, urinary incontinence and perineal pain.20
5.4.2 Distant recurrence

In many men, rising PSA indicates that they have distant recurrence.
Even so, this recurrence may not lead to the development of symptoms
of metastatic disease in all patients. For example, in men with a Gleason
score of 57, the probability of remaining free of metastases for seven
years is 62%.6 Consequently one option for treatment is observation only.
Androgen deprivation therapy (ADT) is the main treatment for men
who have developed metastases. Also called hormone therapy, it involves
removing male hormones from the body, or blocking their action. We
cover this treatment and its side effects in Chapter 7.
ADT given before metastases are proven or highly likely (eg PSA is over
1020ng/ml) is called early hormonal therapy. The therapy is controversial
and ADT has considerable side effects. A number of clinical trials are
underway to see whether early hormone therapy improves survival21
Chemotherapy with agents known to be effective at later stages might
be considered by some doctors (Chapter 8). As is the case for ADT, we
do not know whether chemotherapy given at this early stage is effective
and it does have side effects.
5.5 Symptom control: treatments

As for locally advanced prostate cancer, patients with a PSA rising after a
first primary treatment such as surgery or radiotherapy may still be at an
early phase of their disease. The disease itself is therefore unlikely to be
causing any symptoms.
The symptoms that are experienced may be due to the treatments
offered such as surgery, radiotherapy and androgen deprivation therapy
(see Chapter 7).
5.6 Preventive and supportive care

This period, when there is a signal that the cancer is present but it is still
at an early stage, is an important time for building your bodys natural
resources and resistance. In Chapter 6 we describe diet, exercise and
complementary therapy approaches that can be helpful in a number of
different ways.
5.7 Resources
Memorial Sloan Kettering Prostate cancer nomograms:
www.mskcc.org/mskcc/html/10088.cfm
Observation only. The idea of not taking action if the PSA starts to rise
can be stressful. However, this may be the best course if:
Prostate Cancer Support Groups: www.pcfa.org.au or phone 1800 22 00 99
there are no symptoms such as bone pain
UpToDate for Patients: Patient Information: Advanced Prostate Cancer:

www.uptodate.com/patients/index.html
metastases cannot be shown on scans
the risk of metastases being present is not very high
You can discuss this approach with your doctor.
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060
Chapter 6: Complementary Care and

Lifestyle
impact of the illness. In this chapter we discuss complementary care and

lifestyle changes which may improve aspects of life with prostate cancer.
6.1 Key messages
6.2 Physical activity
There are things you can do which could (we are not sure) slow the
progress of the cancer and will reduce the impact of the cancer and
its treatments. These include:
taking up exercise particularly resistance exercise
maintaining a healthy bodyweight
choosing a healthy diet high in vegetables, fruit and whole

grain cereals and low in saturated fat. Legumes, soy products,
tomatoes and fish all contain nutrients that may be beneficial
for men with prostate cancer
ensuring your diet includes sufficient vitamin D and calcium,

which are important for healthy bones, particularly if on
androgen deprivation therapy (vitamin D comes from sun
exposure as well as diet and can be low in older persons)
note: vitamin supplements have not been shown to be

helpful. Excess amounts of some nutrients, including vitamin
D, can be harmful
considering complementary therapies such as meditation,

massage and touch therapies which can help to relieve stress,
tension and pain
note: always check with your doctor before starting a new

therapy. It is possible to do harm, even with supportive therapies
While you are receiving medical care there are additional ways in which
you can improve your bodys resistance to cancer and its treatments.
We are not certain whether these can change the course of the disease,
but they can strengthen the body in a number of ways and reduce the
061
Any activity that uses muscle to move burns energy (kilojoules/calories)

and is called physical activity or exercise. This includes domestic activities
such as gardening as well as housework, walking, and swimming. Recent
research has found that certain types of physical activity can reduce
the impact of some side effects caused by prostate cancer treatments.
Exercise can also help prevent other common chronic diseases such as
cardiovascular disease. Physical activity does not have to be strenuous to
have a benefit.
6.2.1 Resistance exercise for muscle mass and strength

Moderate to strenuous physical activity in the form of resistance
exercise, with expert supervision, can improve your muscular fitness and
quality of life. Such exercise can reverse some of the effects of androgen
withdrawal (see Chapter 7). It strengthens your bones, increases your
muscle mass and although it sounds odd, resistance exercise can actually
reduce fatigue and its effect on your daily life. Over time it can also give
you a sense of wellbeing, positively affecting your mood.
Resistance exercises can help maintain musculoskeletal fitness and
an active lifestyle by working the muscles of the arms, legs and torso
against a resistance. The resistance can be provided by gravity, devices
such as exercise elastic bands, or a machine at the gym. These exercises
can be done with little or no expensive equipment and do not require
a large amount of space. (See Appendix 4 for more details on this very
helpful approach).
062
Figure 6.1: Reduction in fitness during aging, when on androgen

withdrawal therapy and in resistance-trained men
around the body and reducing the normal heart rate.23 In addition to the
benefits for heart health, exercise can improve erectile function.24 Men
with healthy blood vessels are more likely to have good erectile function
and maintain it after treatment for prostate cancer.
It goes without saying that smoking or too much alcohol is likely to have
the opposite effect.
Note that if you have unstable bone lesions (areas of bone weakness)
or other medical problems such as cardiovascular disease, you may
not be able to do every kind of exercise. Ask your doctor for guidance
in choosing the right type and amount of exercise for you.
6.3 A diet high in vegetables and fruits and low in animal fats
Adapted by permission from Macmillan Publishers Ltd: Prostate Cancer and

Prostatic Diseases, copyright22
Muscle mass and fitness normally decline with aging. Treatments such as
androgen withdrawal (hormone therapy) can speed up this loss, leading
to frailty at an earlier age. Figure 6.1 shows how resistance exercises can
improve the normal decline in musculoskeletal fitness with age, and the
even greater decline with androgen withdrawal therapy.
An example of a resistance exercise program is given in Appendix 4.
6.2.2 Aerobic exercise for cardio-vascular fitness

Maintaining cardio-vascular (aerobic) fitness is also helpful. Aerobic
exercise makes you huff and puff and increases your heart rate. It
can help to increase bone strength, reduce body fat, and increase
endurance all helpful effects for men on androgen withdrawal therapy.
It improves heart health by increasing the amount of blood pumped
063
A healthy diet helps in many different ways. During cancer treatment, it

can help you cope better with any side effects and aid the healing of any
wounds or damaged tissues. A healthy diet also improves the immune
system, which helps to fight off infections, and can promote a healthy
heart and blood vessels. It also helps men who are overweight an
unfavourable factor in prostate cancer.
The NHMRC Australian Dietary Guidelines (2003) recommend that we eat
a variety of fruit, vegetables, wholegrain cereals and reduce the amount
of saturated fat, sugar and salt .
The Mediterranean style of diet is also a good guide for healthy
eating. Followed in countries bordering the Mediterranean, it is rich
in fruits, vegetables, legumes (such as peas, beans and lentils) and
cereals. It is high in fish, includes a little red meat, and olive oil is the
main source of fat.
These types of diets not only increase your intake of anti-oxidants, fibre,
phyto-oestrogens and omega-3 fatty acids, they also reduce intake of
saturated fatty acids. These changes may be directly beneficial for prostate
064
cancer. Fruits and vegetables in particular contain plenty of anti-oxidants

and phyto-oestrogens. Aiming to eat five serves of vegetables and two
serves of fruit every day is good advice and promoted in the Go for 2&5
healthy diet program. The diagram below explains how to estimate a serve.
appears lower due to a dilution effect.28 However, a measure of obesity

called the Body Mass Index (BMI) predicted prostate cancer death
irrespective of clinical stage in one study, suggesting that later diagnosis
is not the whole story.27
Figure 6.2: Serving sizes
You can calculate your BMI by taking your weight in kilograms and
dividing by your height in metres squared. For example, if your weight
was 70kg and height 1.8m, your BMI would be 70 (1.8 x 1.8) = 21.6.
Appendix 5 includes a BMI chart that makes it easy to calculate your
BMI. You have a healthy body weight for your height if your BMI is
between 18.5 and 25.
Waist circumference can also be used to see if you have a healthy
body weight. To work out your waist measurement simply put a tape
measure around your body at the level of your navel. For men, the risk of
disease increases if your waist is 94cm or more. This risk is substantially
increased if your waist becomes 102cm or more.
It is prudent to set a goal to lose weight if your BMI is more than 25 or
waistline greater than 94cm.
Aim for BMI less than 25 and waist less than 94 cm
From: Go for 2&5 campaign: an Australian Government, State and Territory health
initiative www.gofor2and5.com.au
And remember, dont give up too many things you enjoy just get the
balance right!
6.4 Maintaining a healthy bodyweight
6.5 Dietary supplements
Eating a balanced diet and being physically active help in maintaining

a good bodyweight. Recent research suggests an association between
obesity and aggressive prostate cancer.25 Obese men have been reported
to have higher chance of recurrence and death after treatment for
prostate cancer26, 27. It is not clear why this is so, but it is possible that
prostate cancer is diagnosed later in obese men because their PSA
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6.5.1 Vitamin D
Vitamin D is found in food or supplements and can also be produced
in the body after exposure to ultraviolet rays. It is important to have
adequate vitamin D to maintain strong bones and it may also help
maintain a healthy immune system, cell growth and tissue development.
Early findings from a number of studies linked low blood levels of
066
vitamin D to increased risk of prostate cancer, although this has not been
confirmed in recent studies.29
Most vitamin D is made in our skin after exposure to ultraviolet rays
from the sun. However production of vitamin D decreases with age. The
ability of the skin to produce vitamin D in men 75 years and older has
been shown to be about 40% less than in men 60 years and younger.30
The best naturally occurring sources of this vitamin include oily fish,
such as salmon, tuna, mackerel and fish liver oils. Small amounts are also
found in beef liver, cheese and egg yolk. Much of our vitamin D comes
from fortified foods like milk and cereal.
Most of us have enough sun exposure to get all the vitamin D we need.
However it is important to balance the need for a sufficient dose of
sunlight with increasing the risk of skin cancer. It has been estimated that
fair-skinned people can achieve adequate vitamin D levels in summer by
exposing the face, arms and hands or the equivalent area of skin to a few
minutes (59 minutes) of sunlight on either side of the peak UV periods
on most days of the week.31 In winter, in the southern regions of Australia
where UV radiation levels are less intense, maintaining vitamin D levels
may require 3050 minutes of sunlight exposure to the face, arms and
hands or equivalent area of skin over a week.31, 32
At least 200 International Units (IU) (5 g) per day for those less than 50
years, and 600 IU (15 g) per day for those over 70 years are needed for
adequate intake. People who do not have much sun exposure may need
supplementary vitamin D.32
If you do not consume foods rich in vitamin D or fortified foods and do
not have regular sun exposure, you may need to consult your doctor
about a supplement. Older adults particularly may need to boost their
vitamin D intake. Some guidelines recommend that patients on androgen
withdrawal take both a calcium and vitamin D supplement.33
067
While adequate vitamin D intake is necessary, if taken in large

amounts vitamin D can upset calcium metabolism and be toxic.
Symptoms include muscle weakness, nausea, vomiting, headache and
bone pain. It is advisable to talk to your doctor about checking your
vitamin D level before taking a supplement.
6.5.2 Tomatoes and lycopene

Several studies have examined whether tomatoes or tomato-rich foods
can protect against prostate cancer. There is some evidence to support
an anti-cancer effect of lycopene (the anti-oxidant compound that gives
tomatoes their colour). One study found that lycopene combined with
orchidectomy (surgical androgen withdrawal) was more effective in
slowing progression of bone metastases than orchidectomy alone.34 Two
studies suggest that consuming two to five servings of tomato per week
may also be protective against prostate cancer.35
Lycopene belongs to a family of pigments called carotenoids, which are
strong anti-oxidants. While tomatoes are the best source of lycopene,
significant amounts are also present in apricots, guavas, watermelon,
papaya and pink grapefruit. Cooked tomatoes and foods like tomato
sauce and paste are a richer source of lycopenes than fresh tomatoes.
Anti-oxidants can protect body cells against damage from free radicals
(unstable molecules). Vitamin C and vitamin E also act as anti-oxidants.
While there has been concern that anti-oxidant supplements may interfere
with the work being done by chemotherapy or radiation, eating fruits
and vegetables high in anti-oxidants is considered safe during cancer
treatment. If you plan to take lycopene capsules, talk to your doctor first.
6.5.3 Phyto-oestrogens
Foods containing phyto-oestrogens (plant hormones) may also be
beneficial. These are compounds in plants that can block or mimic the
effects of steroidal hormones in the body.
068
Foods that are particularly high in phyto-estrogens include soy products

such as soy milk and yoghurt, tofu and tempeh (a fermented soy product).
In countries where consumption of these compounds is high, such as in
China and Japan, there is traditionally a low level of breast and prostate
cancers. This has raised interest in whether adding these compounds
into the Western diet may reduce the risk of prostate cancer or improve
treatment outcomes.
Phyto-oestrogens may decrease production of the most active form
of testosterone. So far, however, studies have been unable to show a
convincing association between eating soy foods and a lower risk of
prostate cancer. Two randomised controlled trials assessing the effects of a
soy-containing multivitamin supplement found that it slowed the rate of
rise of PSA.21 However the trials did not find an effect on survival, tumour
response, or pain, or report on the potential harms of these treatments.
It is a good idea to eat some soy foods as part of a generally healthy
diet rich in plant foods. Always check with your doctor before taking any
dietary supplements, including soy supplements.
6.5.4 Selenium
Selenium is a trace mineral that is essential for good health. We need only
small amounts. Selenium is incorporated into proteins in the body to make
important anti-oxidant enzymes. The anti-oxidant properties of selenoproteins, as they are called, help prevent cell damage from free radicals.
The selenium content of foods (mainly derived from plant foods such
as bread) depends on the selenium content of the soil where plants are
grown. Some soils in Australia are thought to be deficient in selenium.36
Seafoods such as tuna and some nuts are also a good source.
A study called the Selenium and Vitamin E Cancer Prevention Trial, or
SELECT, investigated whether vitamin E and selenium could prevent
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prostate cancer. This study involved more than 35,000 men in their 50s
and showed that selenium did not lower the risk of prostate cancer.37 It is
thought that selenium may be of benefit, but only in men who start with
low levels of selenium.38 Selenium is toxic in high doses (see below).
A 75-year-old man with prostate cancer read on the Internet that
selenium might be helpful. He ingested 10g of sodium selenite (a
selenium salt) and developed acute selenium poisoning. Despite
intensive care treatment he suffered a cardiac arrest and died six
hours after ingestion.39
6.5.5 Multivitamin supplements

Theoretically, supplements containing anti-oxidants such as multivitamin
preparations should be beneficial if these are the components of
vegetables and fruits which are protective. However, studies to date have
failed to show a benefit.
A major observational study of 295,000 men followed for five years
showed that multivitamin use was not associated with reduced risk of
prostate cancer.40 To the contrary, men reporting excessive multivitamin
use (more than seven times per week) had more advanced or fatal
prostate cancers.
Recent studies of supplements containing vitamins C and E have also
had disappointing results.41
As always, you should talk to your doctor before taking any dietary
supplements.
Having vitamins in food seems to be better than getting them from
supplements. This may be because dietary supplements are unable
to replace all the beneficial properties in food such as fibre and
minerals. In addition, it could be a combination of nutrients in food
that work together against cancer, rather than a single nutrient.
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6.6 Supportive care for men with prostate cancer: activities

and therapies that can reduce the impact of illness
It can be difficult not to focus on your illness; however sometimes dwelling
on your cancer makes it feel overwhelming. At times like this, it can be
helpful to try and shift your thoughts away from what you are going
through. The techniques for doing this may also help change the way in
which you perceive and approach the cancer and its effects. Chapter 10
discusses worries, what causes them and how to deal with them.
Everyone is in a different situation so not everything mentioned here will
be relevant to you.
6.6.1 Meditation
Meditation is an ancient practice that focuses on breathing techniques
and quietening the mind. It can help to relieve stress, tension and pain
and to clarify thoughts and feelings. Typically, it encourages you to
stay in the moment while maintaining a non-judgmental attitude to
whatever thoughts or feelings cross your mind. There are many schools
of meditation.
Yoga, hypnotherapy and guided imagery offer similar benefits. The last is a
type of meditation where a person imagines a series of scenes that promote
healing thoughts in order to achieve peace, pain relief and relaxation.42
Stillness can also come from Tai Chi, which is sometimes called moving
meditation. Tai Chi uses slow, light and gentle movements that incorporate
movement, breathing techniques and meditation to create stability in the body.
6.6.2 Massage and touch therapies

Many scientific studies have been conducted on massage and touch
techniques for people undergoing cancer treatment. Research shows that
they can reduce pain, fatigue, anxiety, depression and nausea.42
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Like food and water, touch is essential. It benefits people at all stages
of life and on every level physical, emotional and mental. It can be
calming, improve sleep and wellbeing, reduce muscular tension and make
you feel better about yourself.
During illness, touch can be a powerful expression of care, acceptance
and emotional nourishment. In the midst of discomfort or anxiety, it can
be reassuring and calming.
Some people find massage helps to reduce their pain and improve their
mood. While the effects may not be long-lasting, a massage has the
potential to interrupt a cycle of distress by inducing relaxation, increasing
blood and lymphatic circulation and manually releasing muscle spasms.
If you are on active treatment or have a high risk of bleeding or fractures,
you should check with your doctor before having a massage. Also, be
sure to visit a qualified massage therapist.
There are several other touch therapies that you can explore, such as
reflexology, which uses pressure points in the hands or feet to positively
affect function in other parts of the body.
6.6.3 Other therapies

Cancer Council NSW has produced a booklet on complementary
therapies that includes a summary of therapies shown to be helpful
(see Resources).
In clinical trials, some therapies have been shown to be beneficial for the
various effects of cancer and its treatment:
counselling, meditation, relaxation, support groups help reduce

stress and improve self esteem
art and music therapy provide focused attention that aids

relaxation, pain reduction, and the expression of feelings
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For guidance, seek professional advice from a qualified complementary

therapist and/or your doctor.
spiritual practices help reduce stress, instil peace and improve ones
ability to manage challenges
massage can help reduce pain, fatigue, insomnia, anxiety, depression

and nausea
aromatherapy improves sleep and aids relaxation
reflexology reduces anxiety
acupuncture reduces nausea, vomiting, fatigue and pain
yoga and physical activity improve sleep, reduce stress, anxiety,

depression, fatigue and muscle wasting
tai chi relieves pain, improves flexibility and strength, and reduces
stress
qi gong improves quality of life, reduces fatigue, pain and side

effects of treatment, and improves mood
Useful questions to ask when considering alternative or new

treatments include:
nutrition helps wounds and damaged tissue to heal better, and

improves the bodys immune system
Is this therapy specifically used for cancer patients?
What will the therapy aim to achieve?
herbal medicine relieves digestive disturbances, improves appetite

and increases resistance to infections
Has it been tested in a clinical trial?
Are there any side effects?
Will it interact with any of my existing treatments?
Who will be involved in delivering the therapy?
6.7 Can I do myself any harm?
Are they qualified and registered with a professional organisation?
You are unlikely to come to any harm in trying different complementary

therapies so long as you discuss your use of them with your health team,
and you use your common sense when finding a therapist, participating
in a class, or taking dietary or herbal supplements.
What are the costs of the therapy and does my health insurance
provider or Medicare cover them?
How long can I use this therapy?
Should I check with my doctor before taking it?
From: Understanding Complementary Therapies: A guide for people with cancer,

their families and friends. Cancer Council NSW October 2008
It is best to do all things in moderation and to talk to your doctor before

starting a new regime. Complementary therapies should be treated in
the same way as conventional therapies: it is important to choose the
most appropriate therapy or the correct remedy and to respect the
recommended dose.
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If you are starting an exercise regime, make sure it wont affect

any of your other conditions and injuries.
Some special diets may be nutritionally inadequate and not

support your body when it is already under stress be careful
not to lose too much weight.
You should be suspicious if a remedy is very costly and claims to

cure your disease no complementary therapies are known to
cure prostate cancer.
6.8 Confused about terms?

Complementary therapies are therapies that can be used in conjunction
with conventional medicine, are fairly safe if used with care, offer
improved wellbeing and reduce side effects for many people.
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Integrative medicine incorporates aspects of complementary medicine

into comprehensive treatment plans alongside orthodox methods of
diagnosis and treatment. Alternative therapies are therapies used instead
of conventional medicine and are often not supported by scientific
evidence. Patients using them may forgo the benefits of conventional
medicine. They may be unsafe.
6.9 Resources
BMI calculator: en.wikipedia.org/wiki/Body_mass_index. Also see
Appendix 5
Food and cancer: a guide to nutrition for people with cancer.
Cancer Council NSW, 2009. www.cancercouncil.com.au
Go for 2&5 campaign: www.gofor2and5.com.au
Massage and cancer: an introduction to the benefits of touch.
Cancer Council NSW. www.cancercouncil.com.au
National Centre for Complementary and Alternative Medicine: nccam.nih.gov
Medicines Line of the National Prescribing Service provides evidencebased information on dietary supplements. 1300 888 763
Promoting Wellness for Prostate Cancer Patients.
Mark Moyad MD, MPH 2006.JW Edwards, Ann Arbor MI.
Understanding complementary therapies: a guide for people with
cancer, their families and friends. Cancer Council NSW 2008.
Available at www.cancercouncil.com.au
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7.1 Key points
Prostate cancer is called metastatic when groups of cancer cells

have left the prostate region and started to grow in other parts
of the body. These deposits are called metastases.
The most common site of metastases is bone.
Bone scans, x-rays, CT and MRI scans are used to look for signs
of metastases.
Bone pain is a common sign of metastases. This can be

effectively treated with radiotherapy.
The best treatment to slow the growth of the cancer outside the
prostate region is called androgen deprivation therapy (ADT) or
hormone therapy.
ADT deprives the cancer cells of the male hormones they need to
grow wherever they are in the body.
ADT can be delivered as drugs (which is reversible) or achieved

by surgical removal of the testes (not reversible). Both forms of
treatment are equally effective.
Both forms of ADT have side effects, which can include hot
flushes, lack of sexual desire, mood changes, bone thinning,
increased risk of cardiovascular disease and muscle wastage.
Exercises particularly the type that build strength medications,

and a type of ADT called intermittent therapy (starts and stops
the medications) can minimise these effects.
This chapter includes other approaches to managing the side

effects of ADT.
Life can be active and rewarding despite a diagnosis of

metastatic prostate cancer
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7.2 What is metastatic prostate cancer?

Prostate cancer is called metastatic when small groups of cells have left
the primary tumour site and started to grow in other parts of the body.
These small deposits of tumour cells are called metastases (secondary
tumours). In prostate cancer, cells are most likely to travel to bone. The
next most common location is the lymph nodes in the same area as the
prostate (pelvic lymph nodes) or the back of the abdominal cavity called
the retro-peritoneum. The cells can also go elsewhere in the body such as
the lungs and liver, but this is far less common.
7.2.1 Signs and Symptoms of metastatic prostate cancer

In its early stages, metastatic or secondary prostate cancer may not
cause symptoms. Doctors rely on investigations such as blood tests and
scans to indicate whether cancer cells have spread to the lymph nodes,
bones or other parts of the body. Back pain and pain in other bones
are symptoms which usually occur at a more advanced stage. Other
symptoms at this stage can be unexplained fatigue and loss of weight.
PSA
A rising PSA indicates disease is growing either in the prostate,
immediately adjacent, or elsewhere in the body. The presence of metastases
is usually suspected if the PSA is above 20ng/ml43, although metastatic
cancer can occur with lower PSA readings. A rapidly rising PSA indicates
a more aggressive cancer and one that has already or is more likely to
metastasise. This is especially true for men with a PSA doubling time (the
time it takes PSA levels to double) of less than three months.44
Bone scan
A bone scan is usually suggested if bone pain is present, the PSA is
above 20ng/ml, or the Gleason Score is 7 or greater.45 A bone scan only
identifies areas of increased bone turnover, so healing fractures and
079
arthritis as well as cancer deposits will show as hot spots. A radioactive

tracer substance is injected into a vein in the arm. The tracer then
travels through the bloodstream and into the bones, where it can be
detected and displayed. The image is recorded by a special camera. A
tracer is an unstable chemical that emits low levels of radiation.
Metastases may still be present even if a bone scan is negative.
Metastases may either be too small to show on bone scans (called micrometastases), or may be in another tissue that the bone scan does not
image (such as lymph nodes).43
X-rays
Sometimes x-rays may be used to examine a painful bone area.
MRI and CT scans
Magnetic resonance imaging (MRI) is useful to look at the soft tissues
of the pelvis and lymph nodes as well as bones. MRI uses a powerful
magnet and radio waves to produce high-quality cross-sectional pictures
in sequence along the body. Each picture represents a virtual slice
through the body. The patient lies on a moving table passing through the
magnetic field. As each picture is taken, you hear a banging noise.
A computerised tomography (CT) scan is also used to produce images
of the soft tissues of the body. A CT scan uses x-ray energy in beams at
different angles to image the area of interest.
CT and MRI scans enable specialists to examine abnormal tissue close to
the prostate such as enlarged pelvic lymph nodes. They can also evaluate
more distant tissue such as liver and show any effects on the kidneys.
For example, if the cancer has grown sufficiently to block the ureters
(the tubes carrying urine from the kidney to the bladder), scans can show
enlargement and distension of the kidney due to back pressure in the
kidneys draining systems.45
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7.2.2 Symptoms of metastatic prostate cancer

The symptoms of metastatic prostate cancer can vary depending on the
extent of spread. If the spread is minimal there may be no symptoms at
all. The most common symptoms result from metastases to the bones.
Metastases in bones can cause a deep pain or stiffness in the lower back,
upper thighs, or hips, or an ache in any bone. The cancer may thin the
bones in the limbs making fractures more likely. Swelling in the legs and
feet from obstruction of the blood vessels of lymphatic system as well as
weight loss and anaemia can also occur, but these are less common as
presenting features of metastases.
Any numbness, pins and needles or weakness in the legs, trunk or arms are
symptoms that need urgent attention as they can be related to instability
in the spine. Unexplained constipation or urine or bowel incontinence
should be investigated, particularly if associated with back pain. If the
cancer spreads in the pelvic region, there can be urinary symptoms.
this treatment are also hormone therapy, androgen ablation or androgen

deprivation therapy (ADT). Throughout this chapter, androgen deprivation
and hormone therapy will be used interchangeably.
All prostate cells and most prostate cancer cells need androgens, in
particular the male hormone testosterone, to survive and grow. Without
it, they die in a process called apoptosis a type of cell suicide (see
Figure 7.1). The sick cell separates from healthy cells and starts to alter
itself. It packages up its internal structures and awaits engulfment by a
clean-up cell known as a macrophage. Apoptosis is used by the body to
remove cells damaged by chemicals, UV radiation or other means. Many
cancer treatments act by triggering apoptosis. Androgen deprivation
causes apoptosis of cells. It also affects the new blood vessels that
tumour masses develop to support their growth.
Figure 7.1: Apoptosis the self-destruct program for getting rid of
damaged cells
Symptoms can usually be controlled with androgen deprivation therapy.

Some bone deposits may require radiotherapy. Sometimes surgery (a
trans-urethral resection of the prostate) is used to remove urinary
obstruction in the pelvic region.
We discuss androgen deprivation to control growth of metastases below.
Radiotherapy to treat painful metastases in bone and drug therapy to
prevent bone loss and fractures are covered in Chapter 8.
7.3 Treatment to control cancer: androgen deprivation

(hormonal) therapy
Once prostate cancer has spread beyond the prostate to distant organs,
a treatment is needed that will attack the cancer wherever it is in the
body. Doctors call this systemic therapy. The most effective systemic
therapy for prostate cancer is called androgen deprivation, or the
removal or blocking of the male hormone. Other terms used to describe
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082
Testosterone is produced mainly by the testicles. Its production is

stimulated by a hormone called leuteinising hormone (LH), which is
produced by the pituitary in the brain. Production of LH is in turn
controlled by another hormone, leuteinising hormone releasing hormone
(LHRH), produced by another part of the brain, the hypothalamus. This
whole sequence of events is called the hypothalamicpituitarygonadal
axis (see Figure 7.2). Each stage of this sequence of events can be
targeted by drugs or treatments to stop production of testosterone.
These treatments decrease testosterone levels in the body and block the
fuel needed by prostate cancer cells to survive. They can prevent the
growth of prostate cancer cells wherever they are in the body.
Testosterone is produced by the testes when they are stimulated by

leuteinising hormone (LH) from the pituitary in the brain. The pituitary
is in turn stimulated by leuteinising hormone releasing hormone (LHRH)
from the hypothalamus, also in the brain. The types of ADT and their
actions are shown in Table 7.1.
Hormonal or androgen deprivation therapy aims either to prevent the

production of testosterone or to block its action in the tissues.
Figure 7.2: Production of testosterone
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Table 7.1 Types of androgen deprivation therapy

Drug or treatment
type
Name
(generic for drugs)
Surgery
Brand names
Where it acts
Action
How administered
Orchidectomy/
orchiectomy
Scrotum
Testes removed from

scrotal sac
Operation under
general anaesthetic
LHRH agonists*
goserelin, leuprorelin
Zoladex
Lucrin
Eligard
Pituitary gland
Suppresses production
of LH and FSH
Injection monthly,
3-, 4- or 6-monthly
Anti-androgens
(non-steroidal)
bicalutamide
flutamide, nilutamide
Cosudex
Eulexin
Anandron
Prostate and prostate

cancer cells
Blocks androgen
receptors on cells
tablet
Anti-androgen
(steroidal)
cyproterone
Androcur
Prostate and prostate

cancer cells
Suppresses adrenal
activity
tablet
*also called gonadotropin releasing hormone (GnRH) agonists
085
086
There are three main categories of ADT: surgery to remove the testicles
(orchidectomy), LHRH agonists (drugs which prevent the production of
testosterone from the testes) and anti-androgens (drugs which prevent the
action of testosterone in the tissues). There are also drugs that suppress
the small amount of androgen production by the adrenal glands.
Another drug, finasteride (Proscar), is used for benign prostate disease
rather than cancer. It blocks conversion of testosterone to its more active
form, 5-alpha-dihydrotestosterone (DHT). Finasteride may help prevent
prostate cancer.46 Combined with an LHRH and anti-androgen, use of
finasteride or a second drug called dutasteride is sometimes referred to
as triple androgen blockade.
7.3.1 Timing of androgen deprivation therapy

Typically, the first indication that cancer may remain in the body after
a radical prostatectomy or radiotherapy for localised disease, is a
rising PSA. One of the uncertain areas is whether to begin androgen
deprivation when the PSA first starts to rise, but before signs and
symptoms of metastases appear. At the time of writing the guidelines,
there is no definitive evidence to show a benefit from starting hormone
therapy early, that is, when PSA first starts to rise. It is probable that
such an early introduction will delay the time to cancer deposits being
seen, but at the cost of longer exposure to hormone therapy and its
side effects. We do not know whether early introduction of androgen
deprivation prolongs life.47
The speed at which PSA is rising can be a guide as to when to start ADT
treatment. Patients who have only a slowly rising PSA may prefer to wait
until metastases are seen on a bone or CT scan. Patients who have severe
osteoporosis, cardiovascular disease or other illnesses that may put them at
risk from ADT may also prefer to wait. ADT can also be delayed for quality
of life reasons. Some guidelines recommend that only men with high-risk
cancer, for example PSA over 50ng/ml and/or rapid rate of PSA increase,
087
would benefit from the early introduction of androgen deprivation.33

However once evidence of metastatic cancer and its symptoms appear,
all men should be offered ADT as it does control such symptoms
effectively. Some doctors recommend the introduction of ADT when the
PSA reaches a certain level, such as between 10 and 20ng/ml.
7.3.2 LHRH agonists and orchidectomy

The most effective forms of systemic therapy are orchidectomy and
LHRH agonists (an agonist is a drug which binds to the same receptors as
the natural hormone).
LHRH agonists are drugs that block production of testosterone. They
do this by initially stimulating release of the pituitary hormone called
leuteinising hormone (LH) that triggers release of testosterone by the
testicles causing flare (see below). Testosterone production then drops.
The drug is delivered by injection into the fat or muscle and can be given
monthly or every three, four or six months. The effect is reversible in
most patients in that if the medication is stopped, testosterone levels
return to normal after some months.
For this reason, many men opt for androgen deprivation using this
method rather than orchidectomy. Examples of LHRH agonists are
goserelin and leuprorelin (Zoladex, Lucrin respectively). These costly
medicines are covered by the Pharmaceutical Benefit Scheme.
Because these drugs may not be fully effective in reducing testosterone
levels in all men, it is normal to check blood testosterone levels some
months after starting the hormone or when they are no longer working.
Unless you choose a form of androgen deprivation called intermittent
androgen ablation (described below), it is normal to continue this form of
androgen deprivation indefinitely.
Orchidectomy (also called orchiectomy) is an operation to remove
the testicles (orchid is the ancient Greek medical term for the testis or
088
testicle). Surgery to remove the testes is performed under anaesthetic.

The procedure requires two small incisions so that the testes can be
removed while leaving the scrotal sac intact. It involves either an
outpatient procedure or a one- or two-day stay in hospital. It can be
considered a convenient option because it is a once-only treatment.
On the other hand, it is irreversible, and does not offer the option of
intermittent androgen deprivation (see below). As with any operation,
there is a risk of infection, although this is very low. Implants can be
used to retain the normal appearance of the scrotal sack if needed.
Orchidectomy can be used to treat those who do not respond to LHRH
agonist drugs, that is, they do not have a lowered testosterone.
of urinary flow or increase in bone pain. Flare can be prevented by

using anti-androgens which block the testosterone from getting to
tumour DNA and stimulating the cell proliferation. This class of drug
(eg bicalutamide, flutamide, nilutamide, also known respectively as
Cosudex, Eulexin and Anandron) is given just before or at the same
time as commencing LHRH therapy.
The patient and the doctor generally discuss which form of ADT is preferred.
Both treatments are equally effective in controlling cancer growth and the
side effects are also similar. Patient preference is an important factor in this
decision. If fertility is an issue, then sperm banking is an option.
7.3.3 Anti-androgens on their own
The benefit of using drugs over surgery is that they can be

discontinued or stopped for a period and started again only when the
PSA starts to rise. This is called intermittent androgen deprivation and
is discussed in detail below.
One temporary effect of using one of the LHRH agonist is called flare.
Specifically, when an LHRH agonist (an agent which causes stimulation)
is first started, it can cause a rise in the pituitary hormone LH during
the first 512 days. The LH rise in turn stimulates the testicles to
make testosterone. After prolonged binding of the LHRH agonist to its
receptor, it turns off production of the LH and testosterone levels then
decrease. The initial surge in testosterone can be seen in a blood test.
Occasionally it briefly stimulates tumour growth (ie in the first month
only, before the testosterone levels decline). If there are metastases
(tumour deposits) close to important structures such as the spinal cord,
this can trigger symptoms such as paralysis, nerve pain, obstruction
089
Oestrogens were used to treat prostate cancer many years ago, as they
also cause a decrease in testosterone production. Use of oral oestrogens,
however, has been largely discontinued as a first-line treatment because
of their tendency to cause blood clotting, heart attacks and strokes.
Anti-androgens (AA) are taken in tablet form and act by blocking the
action of testosterone at the cellular level. Because small amounts of
circulating male sex hormones are produced by the adrenal glands in
addition to the testicles, anti-androgens are often combined with LHRH
agonist therapy or orchidectomy to ensure a complete blockade of
testosterone action (see below).
Anti-androgens (bicalutamide, nilutamide and flutamide, also known
as Cosudex, Eulexin and Anandron, respectively) when given alone
do not have the full spectrum of effects that LHRH agonists and
orchidectomy do and it is possible to retain some sexual function when
taking these alone. On their own they are considered as a form of ADT
(anti-androgen monotherapy). However, they are not as effective in
controlling the cancer, and so are not recommended as a stand-alone
treatment for metastatic prostate cancer.48 They are more likely to cause
breast growth (called gynaecomastia) and breast pain than LHRH, as
well as hot flushes.49 They are not approved as sole agents for androgen
deprivation on the Australian Pharmaceutical Benefits Scheme.
090
7.3.4 Combined androgen blockade

Androgen deprivation removes 95% of circulating male sex hormones.
However it does not remove the small amount produced by the adrenal
glands. Addition of an anti-androgen (non-steroidal) can block the effect
of the remaining testosterone by blocking access to the prostate cancer
cell genes. A combination of LHRH agonists and anti-androgens is called
combined androgen blockade (CAB) or maximal androgen blockade.
Because there is a small benefit of combined treatment compared with
LHRH only (about a 3% increased survival after five years of followup)49 this additional treatment is recommended as a standard by some
guidelines.33, 49 However the survival benefit is small and is at a cost of
increased side effects (see above). Consequently, many doctors do not
start treatment with maximal (combined) androgen blockade.
The time off the drug can be considerable many months to more than
a year in some cases. It is hoped that intermittent androgen deprivation
extends the time before a resistant group of cancer cells starts to appear,
and the androgen deprivation drugs are no longer effective (called
castrate resistance see Chapter 8). We do not know yet whether this
treatment prolongs survival or if it has a big effect on quality of life.
Some results suggest that it is comparable to continuous therapy in
cancer control and has a smaller long-term impact on quality of life.49
Although it is considered only experimental by some47, many doctors use
intermittent androgen withdrawal as a treatment option.
Table 7.2 summarises factors to consider in choosing an ADT.
7.3.5 Intermittent androgen deprivation

Intermittent androgen deprivation is an approach to androgen
deprivation which, it is hoped, will reduce the impact of side effects on
quality of life. There is also speculation that it may extend the useful life
of this treatment, by delaying failure of ADT (see Chapter 8). Definitive
clinical trials addressing these issues have been done, however the
results are not yet known. Typically, the deprivation drug is taken only
until the PSA drops to a low level (less than 4ng/ml) then restarted when
the PSA reaches a threshold of say 1020 ng/ml unless symptoms of
recurrence have occurred at a lower PSA level.
091
092
Table 7.2 Choosing androgen deprivation therapy

Drug or
treatment type
Orchidectomy
Benefits
Effective, inexpensive, convenient once-off
administration
Does not cause flare (temporary worsening of
cancer symptoms)
Disadvantages
and side effects
Person most likely to benefit
Irreversible, cosmetic change,

permanent impact on sexual
function. Intermittent treatment is
not possible
Person with painful metastases,

extensive cancer that could cause
urinary obstruction or spinal cord
compression
Person living in rural or remote area
or who is not able to attend for
monthly or 6-monthly visits to doctor
LHRH agonists
Effective, reversible, albeit after a delay while

testosterone levels return to normal, so can use
intermittently to limit impact on sexual function,
other untoward effects
Requires repeated trips to doctor

for injections
Person with metastases who

prefers a reversible form of
therapy or when used for a time in
conjunction with radiation therapy
for high-risk localised disease
Anti-androgens
(non-steroidal)
Tablet only, fewer side effects including less impact

on potency, libido and bone density when used alone
Not as effective when used on

their own
Most often used with LHRH agonists to prevent

flare or as combined androgen blockade
Can irritate the liver, cause breast

growth, and breast pain, hot flushes
Person with metastases, or who is on

LHRH agonists and needs short-term
protection against flare or prefers
complete androgen blockade
Not as effective when used on their own
Not as effective when used on

their own
Anti-androgens
(steroidal)
Loss of libido, erectile dysfunction, rarely breast

growth, liver problems, and may cause depression
Loss of libido, erectile dysfunction,

rarely breast growth, liver problems,
and may cause depression
Person with metastases, or who is

on LHRH agonists and needs shortterm protection against flare
Combined androgen
blockade
Slightly more effective than LHRH alone

(~3% increased survival in one study)
Combined side effects of both types

of drugs
Person with metastases taking

LHRH agonists who wants
maximum androgen deprivation
after considering the additional
side effects
Intermittent
androgen
deprivation
Gives periods of time without side effects

of LHRH. May extend the effectiveness of
androgen deprivation
Need for close monitoring

(repeated PSA tests).
Person with metastases who wants

to limit side effects of androgen
deprivation and has considered the
uncertainties of intermittent therapy
093
Still considered experimental by some
094
7.4 Dealing with side effects of androgen deprivation therapy
7.4.1 Hot flushes
The side effects of androgen deprivation vary from person to person

and are summarised in Table 7.3. While some men tolerate it quite well,
others can be deeply affected. There are ways of minimising the effects
and we discuss these in this section. We also recommend that you read
Chapter 6 with a view to improving quality of life while on ADT.
One of the most common and sometimes bothersome symptoms is hot

flushes, sudden intense sensations of heat in the face, neck, upper chest
and back. It may be accompanied by sweating or nausea and may be
intense enough to wake you up. Hot flushes may be triggered by heat,
hot liquids, stress, sudden changes of body position50 or just come out of
the blue at any time and last for seconds or up to an hour.
Because testosterone has many functions in the body, removing it has a

number of different side effects. Broadly, these include reduced energy
levels, reduced sexual interest and changed fat metabolism, affecting
quality of life and risk of heart disease. Other effects can include hot
flushes, impotence, mood swings, depression, loss of muscle strength
and osteoporosis. However, because such treatment can control cancer
growth and relieve some of the symptoms, it may be the best treatment
choice. The balance between the benefits of cancer control and symptom
control weighed against the impact it may have on quality of life is an
important consideration and one your doctor will discuss with you.
One approach to reduce the side effects of ADT would be to use only
anti-androgen drugs (anti-androgen monotherapy). Because these drugs
do not reduce circulating levels of testosterone but rather, block its
effects in the prostate tissues, they have less of an impact on diminishing
quality of life. On the other hand they have been shown not to be as
effective in controlling the cancer as treatment with LHRH agonists, and
so it is not recommended to use this class of agents alone.33 Intermittent
androgen deprivation is another approach that has quality of life
benefits (see above) and may be as effective as continuous LHRH therapy,
although it is too early to say definitely.
The other way of managing side effects is to treat each one individually
and these approaches are described below. Your doctor will discuss the
best approach with you.
095
A number of drugs can be used to treat hot flushes, including lowdose Androcur, progestins, some anti-depressants drugs called SSRIs
(selective serotonin reuptake inhibitors), and small doses of oestrogens.
Some alternative treatments reported to be helpful include acupuncture,
soy products (probably for their phyto-oestrogen content) and vitamin E,
or even drinking an ice cold drink when you feel a hot flush coming on.50
Most drugs have their own set of side effects and so the benefit of these
treatments needs to be balanced against any new side effect they may cause.
7.4.2 Reduced sexual function

Because testosterone plays an important role in normal male sexual
function, loss of sexual interest and poor erections are common side
effects of treatment with androgen deprivation. These side effects
can have a significant impact on relationships, which is something to
discuss and plan for with your partner. In Chapter 10 we list some of
the ways of maintaining closeness and intimacy in a relationship while
receiving this treatment.
The effects of androgen deprivation on sexual function are not as
marked with anti-androgens, although the latter drugs are not as
effective in cancer control (see Table 7.2). Intermittent therapy,
described above, also appears to reduce these effects. Some normal
sexual function may return during the off phase of the treatment
cycle, and this may be quite long (many months).
096
There are some treatments for erectile dysfunction that may help some
men. They include medications similar to viagra (also called PDE5 inhibitors), penile injections and vacuum erection devices. As with
treatment for erectile dysfunction after surgery, there can be benefits
to exercising the penis using these means to maintain healthy blood
flow and erectile tissues. This is something you can discuss with your
urologist at the time of starting androgen deprivation. Urologists are
specialists in the area of erectile function.
7.4.3 Bone pain and fractures

Androgen deprivation increases osteoporosis or thinning of the bones.
This can particularly affect the hip, spine and forearm bones. Older men
treated with androgen deprivation have been reported to have 2.5 times
the rate of fractures compared with those not treated.51
This side effect is particularly of concern for patients who may be on
hormonal therapy for a long time before the cancer grows and also
causes bone problems. For example, a person who starts androgen
deprivation after prostate gland removal on a rising PSA and no evidence
of metastases, may be on the treatment for many years. He may be
more troubled by a fracture caused by bone thinning due to androgen
deprivation than by bone metastases due to progressive cancer.
In contrast, a person with cancer seen on a bone scan is more likely
to have pain from progressive and untreated cancer, and the risk of a
fracture from bone thinning due to osteoporosis is far less relevant.
It is important to assess bone health and vitamin D levels before
beginning ADT, particularly if other factors such as age and history of fall
may mean you are at risk of bone-related side effects.
097
A number of lifestyle changes can help prevent bone loss with

androgen deprivation:
taking regular weight-bearing (resistance) exercise
ceasing smoking
moderating coffee and alcohol intake.
These can also benefit other side effects such as metabolic changes,
mood changes and fatigue (see Chapter 6).
Resistance exercises are particularly effective. They work the muscles
of the arms, leg and torso against a resistance and have been shown to
improve quality of life and reduce fatigue on men with ADT.52, 53 We give
examples of these exercises in Appendix 4.
Increasing vitamin D and calcium intake can also be beneficial, particularly
if your intake of these nutrients and your blood levels are low. Your doctor
may recommend these supplements when you start ADT.
A class of drugs called bisphosphonates can increase the bone mineral
density when given with calcium and vitamin D. Work is continuing
to determine when it is best to commence these agents. We discuss
bisphosphonates and their side effects in Chapter 8.
7.4.4 Mood and cognitive changes

Studies have shown that men receiving hormone therapy have higher
levels of anxiety and depression than men receiving other treatments.
However we do not know whether that is related to the stage of cancer
rather than the treatment.54
Experience of anxiety and depression prior to treatment does increase
the risk of psychological problems down the track, however55, so it
can help to be aware of this possibility and be willing to take action
at an early stage. Lifestyle factors such as general engagement in
activities with friends and family, exercise and the willingness to seek
098
help are all important approaches to minimising the impact of these

challenges on mood and wellbeing.
Take action early if low mood persists and discuss it with your doctor.
It may be related to your treatment, which can be changed. Help is
available for this problem.
Every treatment for cancer involves some losses, and grief for them can
go unrecognised. You and your partner will experience some shared
losses and some that are different for each of you. Talking through grief
can be an important part of coming to terms with these issues. We
discuss approaches to maintaining wellbeing for men in Chapter 10, and
their partners and family in Chapter 11.
Men on this therapy may notice small changes in memory function. They
may have a reduced ability to multi-task and also may notice changes
in spatial ability. However according to one investigator56, these are
subtle changes and not across all areas of functioning. Some reports
also suggest that depression may be more common in men receiving this
treatment for prostate cancer57 and that depression, as well as the low
testosterone level, may be contributing to any memory difficulties.
In Chapter 10 we discuss the importance of keeping alert for these signs
and what to do if you feel they are affecting you. It is possible that a
treatment can lead to a sequence of side effects. It may be difficult to
separate the side effects from those of the cancer, its treatment and
other sources of normal health problems. Having someone with whom
to discuss these changes (a family member, GP, nurse or counsellor) can
provide a helpful external reference point if this happens.
7.4.5 Changes in body composition, metabolism and risk of heart

disease
Androgen deprivation tends to decrease the muscle mass in the body and
increase fat mass. The reduction in muscle can reduce capacity for strenuous
activities such as gardening and increase frailty and consequently the risk of
falls. It can also contribute to fatigue. These effects can be minimised with
resistance exercises (see Chapter 6 and Appendix 4).
Androgen deprivation also has effects on the bodys fat and sugar
metabolism58, increasing total cholesterol, particularly the bad fats (low
density lipoprotein cholesterol) and reducing the good ones (high density
lipoprotein cholesterol). It also increases fasting insulin levels, a marker
of insulin resistance. These changes are associated with an increased risk
of diabetes and heart disease. One study of 22,816 men diagnosed with
prostate cancer found that those on ADT had a 20% greater risk of a new
cardiovascular event than those not on the therapy.59
On balance, we know hormonal therapy has definite benefits in terms of
increasing overall survival in some situations (eg hormone therapy can
improve survival when added to radiation therapy in patients with highrisk localised cancer). However, the side effects of hormone therapy mean
that the benefits need to be carefully weighed up against the risks.
Because the risk factors for heart disease can be reduced with diet and
exercise, these lifestyle changes are particularly helpful for men on ADT.
Diet changes that decrease saturated fats and increase plant-derived
oils (from fish, nuts and cooking oils) as well as dietary fibre also help.
Avoiding smoking and taking moderate aerobic and resistance exercise as
discussed in Chapter 6 are recommended. A heart-healthy lifestyle is also
a prostate-healthy lifestyle.60
Improving the diet and taking up exercise can have many benefits for
men on ADT
099
0100
7.4.6 Lethargy and fatigue

Fatigue is a very common problem in man receiving ADT. It may be
enhanced by anaemia, with muscle loss and cognitive changes, and
may contribute to or be caused by depression. Fatigue can limit your
engagement in normal activities. It is an important factor in your quality
of life. Exercise can counter some of these effects by building muscle
mass and fitness, which have been shown to reduce fatigue.61
Table 7.3 Side effects of treatments for metastatic prostate cancer and
their treatment
Drug or
treatment
type
Orchidectomy
or LHRH
agonists
If anaemia is present this can also be treated. We discuss lifestyle

changes, including exercise that may be helpful, in Chapter 6. Keeping
up active interests, including exercise (both aerobic and resistance) for at
least 30 minutes a day, is recommended by experts in this area.60
0101
Side effect
Treatment or side effect
Hot flushes
Drugs such as progestins,

antidepressants
Alternative: phyto-estrogens such
as soy, vitamin E, acupuncture
Loss of libido
Intermittent androgen
deprivation if on LHRH agonists
Erectile dysfunction
Sildenafil and similar drugs,

penile injection, vacuum devices
Increase in body
weight and fat tissue
Aerobic and resistance exercise
Muscle wasting
Resistance exercise
Anaemia
If present is mild and may not

require therapy
Thinning of the
bones
Exercise, calcium and vitamin D,

(bisphosphonates if severe loss
present)
Antiandrogens
non-steroidal
Breast growth, breast

pain, hot flushes
Radiotherapy to affected area

prior to starting anti-androgen,
mammectomy, discontinuing
anti-androgen
Oral
oestrogens
Cardio-vascular effects,
stroke, thrombosis
Anticoagulants, avoid usage in

oral form
0102
7.4.7 Breast growth (gynaecomastia)

Enlargement of the breast is most common in patients receiving nonsteroidal anti-androgens such as bicalutamide (Cosudex), particularly at
high doses. It can also be accompanied by breast pain.
Radiation prior to starting on the medication or tamoxifen (a drug which
opposes the effects of oestrogen) taken at the same time as the antiandrogen can prevent this symptom in most cases.62
This list of side effects is not exhaustive, for example, LHRH agonists
can produce joint and muscle pains among other unwanted effects in
some patients. As with oral oestrogens, steroidal anti-androgens are not
recommended as first-line drugs for prostate cancer.49
Although the list of side effects is extensive, many men tolerate the therapy
well and lead successful and active lives. Table 7.4 will help you and your
doctor prepare when you are starting on androgen deprivation treatment.
0103
0104
Table 7.4: Checklist for starting on androgen deprivation treatment

Tests your doctor can do to
monitor your health
To check for
How you can reduce risk from the condition and maintain your health
Bone mineral density (DEXA scan)
Osteoporosis risk
Healthy diet with calcium, foods rich in vitamin-D, resistance exercise
Blood calcium and vitamin D
Bone health
Calcium, vitamin-D rich foods
Full blood count
Anaemia
Iron-rich food
Cardiac assessment
Risk of heart attack
Healthy diet, aerobic exercise
Body mass index, weight
Overweight
Healthy diet, aerobic exercise
Blood pressure
Risk of cardiovascular disease
Healthy low-salt diet, exercise
Muscle mass, balance
Risk of falls
Healthy diet, resistance exercise
Screen for distress (anxiety and

depression) and psychosocial
problems
Depression and any concerns or

causes of distress
Accept help, support and encouragement from family and friends. Seek
information from health professionals. Keep active interests, exercise
regularly, healthy diet
If low feelings persist, speak to your doctor
Cognitive screen
Memory loss or thinking difficulties
Maintain an active body and active mind
PSA
Cancer control
See Table 7.2
Liver function tests
Liver working well
Healthy diet, low alcohol intake
Blood sugar levels
Diabetes risk
Healthy diet, exercise
0105
0106
A healthy diet for men starting ADT60 means foods low in saturated fat,
a diversity of fruits and vegetables, high dietary fibre, moderate amounts
of soy and plant oestrogen products such as ground flax seed, fish and
other sources of omega-3 fatty acids, dietary vitamin D, vitamin E and
selenium (supplements not recommended).
Goals pull you forward. It is like throwing an anchor out into

the distance then pulling yourself in on a rope. While you are
doing that you are more concerned about the achievement of
getting there than what might or might not be happening and
you experience a much richer and satisfying quality of life.
Exercise in this context means physical activity for at least 30 minutes a

day and resistance exercise several times a week.60, 61 See Chapter 6 and
Appendix 4 for more details.
It may be useful to re-read Chapters 6, 10 and 11 at different stages in

your prostate cancer journey as some of the approaches may be helpful
at different times. The chapters also include lists of useful resources.
Working with your GP on these changes can motivate you as well as

ensuring you exercise and modify your diet safely. A dietitian can help
you create a diet plan to meet your specific needs.
7.5 Life with metastatic prostate cancer

ADT can be effective in controlling the cancer and its symptoms for many
years. There are ways to minimise its effects on your quality of life. In
Chapters 6, 10 and 11 we talk about approaches that may help.
Life can be active and enjoyable despite a diagnosis of advanced prostate
cancer. The activities that men have described while on ADT show that
active life can continue. These included chairing meetings, organising
fund-raising events, public speaking, ball games, practising soccer
skills with grandchildren, walking in hilly country, taking interstate
and international trips, writing an autobiography, composing music,
performing as a singer-songwriter and forming a new relationship. If
you join a prostate cancer support group in your local area you will meet
others who are enjoying life, even with advanced prostate cancer. This can
give you a sense of what is possible and awareness that you are not alone.
Barry Oakley, a long-term prostate cancer survivor, writes about how to
maintain a quality of life in his book: Lifes in the Pink.63 He writes about
the importance of a positive story, of maintaining a sense of control, of
support, and of setting long- and short-term goals:
0107
7.6 Resources
Advanced prostate cancer
UpToDate for Patients: Advanced prostate cancer
www.uptodate.com/patients/content/topic.do?topicKey=cancer/4898>
Cancer Research UK: www.cancerhelp.org.uk/help/default.asp?page=2849
Andrology Australia: Advanced Prostate Cancer
www.andrologyaustralia.org/pageContent.asp?pageCode=ADVANCEDPROS
Information on bisphosphonates
Medline Plus:
www.nlm.nih.gov/medlineplus/druginfo/meds/a605023.html
Peer support
Advanced Cancer Telephone Support Group:
www.cancercouncil.com.au/editorial.asp?pageid=238
Cancer Council in your state: 13 11 20
0108
Chapter 8: Metastatic Prostate Cancer Unresponsive to Hormone Therapy

Unresponsive to Hormone Therapy
8.1 Key points
After several years on androgen deprivation therapy (ADT),

prostate cancer may start to progress, despite low testosterone
levels in the body. The cancer is said to have failed ADT and is
sometimes called castrate-resistant prostate cancer.
Symptoms at this stage can include bone pain, urinary

symptoms, anaemia and fatigue.
Treatment for this stage of prostate cancer may include a form of

ADT that is different from the first-line treatment, chemotherapy
and new types of treatments offered in clinical trials.
Treatments for bone metastases include radiotherapy to the

affected bone, radioisotopes and bone-targeting drugs called
bisphosphonates.
All of these treatments have side effects and it is important

to draw on your support team and look after yourself during
this phase of therapy. Refer to the complementary therapies
in Chapter 6 and some of the hints in Chapter 11 to stay as
healthy as possible.
After several years, prostate cancer may progress despite hormone

therapy. If testosterone levels have remained low, this suggests that
the disease is able to progress without normal circulating levels of
testosterone. In the past this condition has been known as hormone
refractory cancer and androgen independence. More recently, doctors
prefer the term castrate resistance because it emphasises progression
despite very low (castrate) levels of circulating testosterone. Within the
cancer cell, androgen activity may still play a role in cancer progression.
0109
8.2 What causes androgen deprivation therapy to fail?

Most prostate cancer cells need the male hormone testosterone to grow
and multiply. For this reason withdrawing the male hormone through
chemical means (drugs) or surgery (removing the testes) is the best way
to stop it growing once it has spread to different areas of the body. This
treatment is called androgen withdrawal or blockade. Without testosterone,
the vast majority of prostate cells that have spread throughout the body
die through a process called apoptosis (see Figure 7.1).
After a number of years, however, prostate cancer cells that escaped
during this treatment can start to grow again, even when testosterone
levels are very low. It is believed that the cells that regrow had already
developed changes during treatment that allow them to grow without
external testosterone. These cancer cells were called androgen
independent, hormone refractory or, more recently, castrate-resistant.
The doctor knows this process has begun if, when a man is receiving
androgen withdrawal therapy, his PSA levels start to rise. The situation
in some patients is a little more complex as the cancer may actually
be growing due to super-sensitivity to persisting but very low levels of
male hormones in the blood. This is probably why some patients respond
to further hormone manipulations such as blocking adrenal gland
production of these hormones using other types of drugs.
The reasons ADT fails are not fully known. However they are the subject
of intense research and investigation as they hold the key to blocking
progression of the cancer. Understanding these mechanisms would
make it possible to target treatments to prostate cancer cells only, thus
reducing the side effects of treatments. We know that a protein in the
cell called the androgen receptor is responsible for binding the male
hormone and activating genes in the nucleus which control cell growth
and development. These receptors may hold the key to the development
of androgen independence. We discuss some of the models by which this
may happen in Appendix 6.
0110
8.3 Symptoms and indications

The most common indicator of resistance to androgen deprivation
therapy is a rising PSA despite very low levels of circulating testosterone
(2050ng/dl).49 The levels of PSA vary, but they may develop into the
hundreds or even thousands in some cases. The rate of PSA increase is an
indicator of the time taken to develop new cancer deposits on scans, and
their symptoms. For example, a PSA doubling time of greater than six to
ten months has a better prognosis than a shorter PSA doubling time.14
A raised PSA does not in itself cause symptoms. However, while it is
uncommon, some patients cancers do progress with only a small change
in PSA levels. Sometimes cells can be so cancerous that they no longer
resemble or behave like prostate cells. Such cells may no longer produce
PSA, although their Gleason score may be as high as 10.
While symptoms are common at this stage, they do not all necessarily
occur and some men continue to have a good quality of life:
I haveplenty of energy leftI chop woodand I go to choir

practice in the evenings andplay guitarso I have plenty to do.64
previous bone loss, and the new bone formed is different from normal
bone. This disruption of the normal bone physiology and structure can
lead to bone pain, fractures and very rarely, high blood calcium levels.
ADT can also contribute to the loss of bone. If the cancer cells invade the
bone marrow they can disrupt blood cell formation causing anaemia and
consequently fatigue and shortness of breath.
Bone pain may correspond to the location of the metastasis, such as a
new and progressive back pain if the metastasis is in the back. Some men
have more diffuse and migratory pains, however. If metastases occur in the
bones around the spine (vertebra) and the cancer is left unchecked, it can
cause a condition called spinal cord compression. This is when pressure on
the cord causes narrowing or distortion of nerve tissue. Symptoms can be
pain, pins and needles in the hands or feet, limb weakness, and decreased
movement. If you experience these symptoms, report them to your doctor
immediately. Early detection of this condition is important in order to
prevent permanent injury such as paralysis of the lower limbs. When
suspected, spinal cord status may be monitored by MRI.
After a cancer diagnosis it is easy to assume every pain is related to

the cancer and this can cause anxiety. It is a normal part of growing
old to have occasional general discomfort, headaches, pains, and
muscle strains in daily life, and this will continue even after a cancer
diagnosis. Not every pain is related to or caused by cancer! The type
of symptoms that often eventually occur depends on where the
metastases or cancer deposit(s) might be. However one of the most
common symptoms is bone pain.
Bone loss or thinning of the bones can also be caused by long-term ADT.
Controlling bone metastases and preventing bone thinning is an important
part of care at this stage. There are a number of effective treatments. These
include radiotherapy, radionuclides and drugs called bisphosphonates.
Bisphosphonates have two roles: preventing bone thinning caused by
ADT, and controlling bone metastases caused by the cancer. We discuss
these later in this chapter. Use of low-dose radiotherapy (spot-welding),
radioisotopes and bisphosphonates are very effective in controlling bone
pain and limiting the progression of bone metastases.
8.3.1 Bone pain
8.3.2 Urinary symptoms and retention
The most common site of prostate cancer metastases is bone. Prostate

cancer cells interact with osteoblasts, the bone-forming cells, stimulating
rapid multiplication and promoting bone deposition. This follows
Local cancer can recur after prostate removal. If the prostate growth blocks
the outflow of urine from the bladder, you may experience slowing of the
stream, increased frequency and other symptoms. If the flow of urine stops
0111
0112
altogether (called urinary retention), this is considered an emergency and

you should seek medical help. It can be temporarily relieved by insertion
of a catheter (a very thin, flexible tube passed along the urethra to the
bladder). Then investigations can be undertaken to find the cause of the
blockage and the best treatment.
Surgery (trans-urethral resection of the prostate or TURP) can effectively
treat such blockages in the prostate region. If the blockage is closer to
the kidney, other measures are possible. Radiotherapy can also be helpful
in some cases.
8.3.3 Fatigue and other symptoms

In Chapter 7 we talked about fatigue caused by ADT. If cancer is in the
bone marrow, it can reduce the number of blood-forming cells causing
anaemia. This can be another source of tiredness. Your doctor can
monitor this with a blood test. Fatigue may be experienced as physical
fatigue and weakness, tiredness, or a lack of mental energy and initiative.
You dont have the same speed, you dont take as much initiative
now as before, you feelwell, its a bit of a problem and you tend
to just sit rather than doing somethingsomething that you
usually do.3,64
Tiredness may interfere with doing physically demanding activities,
such as taking exercise or gardening. However it is by no means a
universal experience.
Swelling in lower limbs can also occur if cancer is in the pelvic lymph
nodes and causing fluid retention by either blocking lymphatic drainage
or blood vessel flow. Mild exercise of the legs, massage and compression
stockings can help the return circulation from the lower limbs.65
If metastases are in the liver they may cause a loss of appetite and weight
loss or nausea, although nausea is not a common symptom at this stage.
0113
Other symptoms can be due to treatments or medications themselves.

For example, constipation can be caused by some pain medications, while
others, such as steroids, have the potential to affect mood.
Every patient responds differently so these are all things to discuss with
your urologist or medical oncologist. There are good medications that
can deal effectively with symptoms such as nausea and constipation
and also improve mood. Talk to your pharmacist and doctor if you need
information on these drugs.
Remember to talk to your doctor if you are having symptoms such
as nausea, pain, dizziness or limb weakness. These symptoms can be
treated with drugs or by changing your treatment regimen.
8.4 Treatments for prostate cancer which is no longer

responding to androgen deprivation therapy
Treatment for ADT-resistant prostate cancer is tailored to the individual.
It depends on the treatments you have had previously, which ones are
effective for you, your symptoms and how the disease is progressing.
The doctor has a number of treatments to choose from. Some are best
at controlling the cancer, some the symptoms, some both. The first
approach generally taken is further androgen deprivation therapy (also
called secondary hormone manipulation).
8.4.1 Further androgen deprivation therapy

Even when cancer becomes refractory to one form of androgen
withdrawal, the androgen receptor in the cancer cells may remain active.
For this reason androgen deprivation using LHRH analogue drugs is
usually continued. In the initial approach to rising PSA levels, different
types and combinations of ADT, called secondary hormone manipulation,
can provide some benefit, reducing PSA levels in a proportion of patients
for some months. The particular combination used depends on the
previous ADT (see Table 8.1).
0114
In a healthy man, a small amount of testosterone is produced by the

adrenal glands. Use of drugs, which block this production, can have some
benefit. Combining anti-androgens with drugs such as ketoconazole, (an
antifungal drug which also blocks the production of male hormones by the
adrenal glands), can extend the time to progression by several months.49
More specific and potent drugs targeting this hormone production
pathway are undergoing clinical trials to determine their effectiveness.
Oestrogens may be beneficial in preventing bone thinning, a common

problem with long-term ADT. They may also have a role in replacing
LHRH agonist therapy when the latter causes agitation and distress in
some patients.
Patients who have not yet been taking an anti-androgen such as

nilutamide, bicalutamide or flutamide (Anandron, Cosudex, Eulexin
respectively) in conjunction with an orchidectomy or LHRH agonist can
be treated by adding this class of drug. This strategy blocks the remaining
testosterone and testosterone-like hormones from driving cancer cells
which are supersensitive to low levels of hormones.
Another treatment manipulation, which may lead to prostate cancer
regression, is to stop the anti-androgen.
This is because these drugs can change from being an off switch to
an on switch due to changes in the androgen receptor. Stopping this
class of drug results in prostate cancer regression in about 1015% of
patients. A favourable response is more common in patients who have
been receiving the agent for a protracted period. This is called antiandrogen withdrawal phenomenon.
Some prostate cancer cells express oestrogen receptors, and oestrogens
such as diethyl stilbestrol (DES) have been investigated as treatments.
While they achieve a PSA response in patients, they also have side effects
such as deep vein thrombosis and heart attack in a significant number
of patients. Therefore oestrogens in an oral form are not normally used.
An alternative delivery method is through the skin, as skin patches may
avoid some side effects.
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0116
Table 8.1 After ADT fails, initial treatment depends on previous treatments
Previous Treatment
Treatment type
Drug
Where it acts
Action
Orchidectomy
Secondary hormonal
manipulation
Anti-androgens
Androgen receptor in
cancer cells
Competitively inhibits residual testosterone

binding to androgen receptor
LHRH agonists
Secondary hormonal
manipulation
Add or change antiandrogens
cancer cells
Competitively inhibits residual testosterone

binding to androgen receptor
Complete androgen
blockade
Secondary hormonal
manipulation
Anti-androgen
withdrawal:
46 weeks after
discontinuing
bicalutamide or
flutamide49
cancer cells
Androgen receptor complex goes from being an

off switch to an on switch due to changes in
the receptor or the complex of proteins in the
cell which regulate its function
Initial or secondary
hormonal
manipulation
Second-line
treatments Steroids
ketoconazole,
corticosteroids,
prednisolone
dexamethasone
cyproterone
Adrenal glands
Inhibit adrenal synthesis of steroids by

suppressing ACTH secretion from the pituitary
Initial or secondary
hormonal
manipulation
Second- line
treatments Oestrogens
Diethyl-stilbestrol
(DES)
Oestrogen receptor on
cancer cell
0117
Corticosteroids may reduce pain, fatigue
Can cause clotting and heart attack.

Trans-dermal delivery (skin patches) may reduce
some of these effects
0118
8.4.2 Tips for taking medications safely

The following tips could help you get the best out of your medication:
Every prescription drug comes with a consumer information leaflet.

These leaflets provide very useful information on risks, interactions
and side effects. Ask your pharmacist for this leaflet whenever you
are prescribed a new medication.
If you are taking a number of medications at different times, your

pharmacist can help you prepare a medication schedule to make it
easier to remember which to take, how many and when. Alternatively
they can pre-package your medications to make things simpler.
counts. Currently there are no treatments for fatigue or hair loss. Sucking
on ice while receiving treatment can prevent mouth problems.
Compared with other agents, docetaxel is the first chemotherapy agent
that has been shown to increase a patients chance of being alive at 12,
18 and 24 months after starting chemotherapy. In addition, despite its
side effects, docetaxel helps maintain function and a satisfactory quality
of life. One third of patients experience a decrease in pain.49 Other agents
such as mitoxantrone do not have an effect on the overall survival, but
can improve quality of life by reducing pain.66
8.4.4 New treatments

8.4.3 Chemotherapy
Chemotherapy is the use of certain drugs that act throughout the
body to cause rapidly dividing cells to die. Because cancer cells are
nearly always divide more rapidly than normal cells, chemotherapy
kills cancer cells at a higher rate than normal cells. The therapy
affects normal rapidly dividing cells such as those at the base of hair
follicles, in the mouth and throughout the digestive system. Because
of this, chemotherapy has significant side effects. The most effective
chemotherapy drug for prostate cancer is docetaxel, trade named
Taxotere. This drug comes from the needles of the English yew plant,
and is also used to treat other cancers, including breast cancer. It kills
cancer cells by disrupting formation of the internal skeleton that allows
cells to divide and multiply.
Like other agents, docetaxel is administered by injection or infusion.
The infusion may take some time, often about an hour, and is therefore
nearly always administered in hospital or a clinic. Side effects may
include low blood counts, lethargy, hair loss, taste and nail changes,
mouth sores, nausea and diarrhoea. Many of these can be managed
or prevented with use of drugs and simple interventions. There are
medications to prevent nausea and drugs to increase white blood cell
0119
New agents and approaches to treat prostate cancer are constantly

being trialled. New chemotherapy agents to use after docetaxel are
called second-line chemotherapy agents. Drugs that interrupt stages
in the pathway to ADT independence are being developed. A new class
of treatments being investigated, called targeted therapies, is designed
to target pathways that are overactive in cancer cells and hopefully
minimise damage to normal cells.
Your best access to new treatments is through a clinical trial, many of
which are designed for men whose prostate cancer is not responding
to ADT treatment. You can ask your doctor about the availability of
trials that may be appropriate for you. Many have strict criteria for
entry, which your doctor can explain. We discuss clinical trials and new
treatments in Chapter 9.
8.5 Bone metastases and their treatments

8.5.1 Radiotherapy
Radiotherapy that targets metastases in bone is very effective and may
control pain for many months. When used locally it has very few side
effects, although it can cause side effects if it is close to vital organs.
0120
This is why the radiation oncologist undertakes careful planning to line

up the area to be irradiated. Be sure to ask your radiation oncologist
about side effects when he recommends your treatment. Some areas in
the body tolerate more radiation than others and can be treated more
than once, whereas others can be treated only once.
Radiotherapy is also very important for decreasing the size of cancer
deposits in very intricate areas such as the vertebrae. Untreated, these
would grow and compress the spinal cord.
Radiotherapy for this purpose can be delivered as a single dose or
fractionated the dose is smaller and given as fractions of the total
dose over a series of repeat treatments. A single dose appears to be as
effective as highly fractionated doses21 and this may be more convenient,
requiring fewer visits to the treatment centre. However, it may not be
feasible if the area to be treated is near an important radiation-sensitive
organ. It also increases the chance the area will require repeat treatment.
8.5.2 Radioisotopes
Bone-seeking radioisotopes are radioactive particles that emit low-dose
energy radiation. When injected into a vein, they concentrate in the areas
of bone that contain cancer and destroy the cancer cells by emitting
radiation over a very short distance.
The most common types of radioisotopes are strontium-89 and
samarium-153. Both of these agents are particles similar to calcium, and
can provide pain relief in about 70% of patients. The maximum effect is
usually within two to four weeks and it can last for periods exceeding
three months.66
The most common side effect is mild suppression of bone
marrow so that it produces fewer white cells or platelets (called
thrombocytopenia) or fewer red cells (anaemia). Because marrow
suppression can persist so that chemotherapy cannot be given,
0121
radioisotopes are not used as frequently now as they used to be. They
may take one to three weeks to have their maximum effect so they are
not used when a more rapid effect is needed.
8.5.3 Bisphosphonates
Bisphosphonates are drugs that are active in bone metabolism. They
prevent bone loss and have been used for many years to treat patients
with osteoporosis or bone thinning. Recently some forms such as
zoledronic acid (also known as zoledronate, brand name Zometa) have
also been used to minimise complications from bone metastases. They
are thought to reduce cancer cell proliferation.
For men with bone metastases that are not causing significant
symptoms, zoledronate has been found to reduce complications such as
fractures and the development of bone pain caused by the cancer cells.
It is the only bisphosphonate to have been shown to be of benefit in
patients with prostate cancer.21
Zoledronate is more effective when used at in the early stages in the
development of cancer that is unresponsive to ADT. It is approved on
the Pharmaceutical Benefit Scheme for men who have bone metastases,
disease growing and a castrate level of testosterone.
The drug is delivered every four weeks by injection. There appear to be
few side effects of zoledronate treatment. Some fatigue, fevers and
muscle pain may occur with the first few doses and can be prevented
with paracetamol. High doses may affect kidney function. Changes in
heart rhythm may also be a concern in some people. Recently there have
been reports67 of a complication called osteonecrosis of the jaw (ONJ) in
patients undergoing bisphosphonate therapy. This refers to areas of dead
bone, not covered by gum in the jaw.
With prolonged use of zoledronic acid there is a 5% risk of this painful
complication, even without any injury to the jaw. There is no treatment
0122
to heal the problem, once started. Prolonged length of time on the drug
is an important risk factor. Dental visits and good dental hygiene are
recommended to prevent this from happening (see below).
Patients should be dentally fit before starting the medication. Symptoms
may persist even when the drug is withdrawn.
Good dental health while on bisphosphonate therapy
8.6 Looking after yourself

If you feel that the experience of illness is becoming too tiring and
stressful, it may be time to revisit the strategies we discuss in Chapters
6, 10 and 11. Some of them, such as relaxation, guided imagery, taking
things one day at a time, can get you through a low point. Friends,
support organisations and help lines can also be useful if you need extra
support. See Resources sections.
The following are tips for maintaining good dental health while
taking bisphosphonates.
8.7 Resources
Have a dental check-up before beginning treatment.
Clinical trials
Be sure to tell your dentist you are being treated for cancer and
with a bisphosphonate drug.
Australia and New Zealand Clinical Trials Registry: www.actr.org.au
Be sure to tell your doctor what medications, herbs and

supplements you are taking there can be interactions.
Gum disease, poor dental health, poor blood circulation, smoking

and alcohol abuse can increase your risk of osteonecrosis of the jaw.
Once treatment has started, if you experience any pain in your

mouth, teeth or jaw, or any other dental problems, tell both your
dentist and oncologist immediately.
Take care of your teeth by gentle brushing after every meal, flossing
once a day, keeping your mouth moist by rinsing with water often,
and avoiding use of mouthwash that contains alcohol.
Cancer Council New South Wales Cancer Clinical Trials website:

Cancer Research UK: www.cancerhelp.org.uk/help/default.asp?page=2849
UpToDate for Patients: Advanced Prostate cancer:
www.uptodate.com/patients/content/topic.do?topicKey=cancer/4898
Information on bisphosphonates
Advanced Cancer Telephone Support Group:
Cancer Council in your state: 13 11 20
Hormone Refractory Prostate Cancer website: www.hrpca.org
Sources: www.us.zometa.com/info/cancer_bones/dental_health.jsp?site=zometa_us,
www.nlm.nih.gov/medlineplus/druginfo/meds/a605023.html (accessed 20.4.09)
Medline Plus: www.nlm.nih.gov/medlineplus/druginfo/meds/a605023.html

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Chapter 9: Clinical Trials and

Emerging Treatments
9.1 Key points
9.2 Clinical trials

Before they can be widely used, new treatments go through a series of
trials called phase 1, 2 and 3 trials. For new drugs, these trials establish
the best way of administering the treatment: the best dose, its safety,
and its side effects (particularly for new drugs). The effectiveness of the
new treatment is also compared with standard treatment. Only when one
phase has been successfully completed, can the new treatment proceed
to the next. The different phases of trials are as follows:
New treatments must go through a series of trials before they

become widely available. Joining a trial can be your best way of
accessing a new treatment.
There can be advantages and disadvantages to joining a clinical

trial. We provide questions that can help you decide whether to
join a trial.
New treatments for each stage in the progression of advanced

prostate cancer are being investigated.
are the first trials that involve people, rather than animals or
laboratory experiments
look at ways of delivering the treatment, how often and, if it involves

medication, what dose is safe
usually involve only a small number of people
New treatments include new types of radiotherapy, new forms

of androgen deprivation (hormone therapy), new chemotherapy
agents, and a new class of treatment called immunotherapies or
cancer vaccines. These have shown encouraging results.
9.2.1 Phase 1 trials
New approaches to psychosocial support and complementary

therapies such as pomegranate juice and green tea are also the
subjects of trials.
continue to test the safety of the treatment using a defined dose

and group of patients
assess how well the new treatment seems to work
Trials are being conducted on combinations of therapies that

show a better result than either therapy on its own.
involve a larger number of people (approximately 30 to 50)
Advances in prostate cancer treatment are likely to be made in

small steps rather than large breakthroughs, but over time they
can have a big impact on prostate cancer control.
New treatments for prostate cancer are continually being developed.

These include new drugs, drug combinations, new types of radiotherapy,
chemotherapy agents, vaccines and other approaches. There is a
particular focus on new treatments for cancer that is no longer
responding to androgen deprivation therapy.
0125
compare the effectiveness of the new treatment to the best standard

(control) treatment
assign people at random to receive the new treatment or the control

treatment (meaning that neither you nor your doctor can choose
which you receive)
sometimes involve blinded treatment (meaning that neither the

doctor nor you know whether you are receiving the new or the
control treatment)
0126
usually involve a larger number of patients, often hundreds and

occasionally thousands of people
By participating in a clinical trial you can gain access to new treatments

before they are widely introduced. Because of their size, phase 3 trials are
usually offered at many different treatment centres or hospitals around
the country. They are the type of trial most accessible to patients.
9.2.4 How new drugs become available to Australian patients

These clinical trials are needed to prove a new drug is both safe and
effective. Once this is shown, they may be eligible to be listed under the
Pharmaceutical Benefits Scheme (PBS). Through the PBS the Australian
Government subsidises the cost of many prescription medicines, making
them more affordable. Around 80% of prescription medicines dispensed
in Australia are subsidised under the PBS.
For a medicine to be subsidised by the PBS:
the manufacturer must supply evidence of the benefit of the

medicine to support a recommendation that it be listed
the manufacturer must register the medicine with the Therapeutic

Goods Administration (TGA) for the treatment of a specific condition
(the TGA through assessment and testing ensures that medicines are
safe and effective)
the governments independent expert committee the

Pharmaceutical Benefits Advisory Committee (PBAC) must evaluate
the medicine, determine whether its benefits are worth the cost and
if so, recommend it be listed on the PBS
As an example, Taxotere (docetaxel) obtained listing on the PBS in 2007

for the treatment of men with prostate cancer that no longer responds
to ADT. According to the trial data supplied by the manufacturer, the
drug improved the chance a patient would be alive two years after
starting the therapy by about 20% compared with another form
0127
of chemotherapy. Before it was listed on the PBS, Taxotere cost

approximately $18,286 for the average course of treatment per patient.
After listing on the PBS, patients pay no more than about $320 for a full
course of treatment.
Non-prescription medicines such as herbal, vitamin, mineral and other
alternative or complementary medicines and preparations are available
without prescription at chemists, supermarkets and health product
shops. These products can be considered for PBS listing but are subject to
the same evidence-based requirements as other medicines. It is unusual
for these types of clinical trials detailing the risks and benefits of a given
herbal medication to have been conducted.
9.2.5 Finding a clinical trial

Clinical trials often have quite strict entry conditions that can restrict
the acceptance of a willing potential volunteer. These may include the
volunteers age and require that he is generally healthy and available for
visits to the trial centre. The trial may include only patients who are at a
particular stage, have had a certain sequence of treatments, have a PSA
within a certain range, and so on. For this reason, if you are interested in
participating in a clinical trial, the first step is to discuss with your doctor
whether there are any trials available that are suitable for you.
You can search for prostate cancer clinical trials yourself through trial
registry websites. One of the most comprehensive is the Australian
and New Zealand Clinical Trials Registry at www.anzctr.org.au. You can
search for prostate cancer trials (use the advanced search function)
and the listing will show the conditions for entry and whether the trial
is still open (currently recruiting patients). The location of the trial and
sometimes a contact person for public enquiries will be given.
0128
9.2.6 Deciding whether to join a clinical trial
All trials require ethical approval from an ethics committee accredited

by the National Health and Medical Research Council (NHMRC).
Consequently investigators are required to disclose any risks for the
patient and to describe what the patient will be asked to do. Your doctor
should discuss with you:
you will receive closer medical attention and personalised care from
doctors and nurses than is usual, although this is often the result of
having to go through extra tests and answer more questions
you are contributing to the growth of knowledge about new

treatments essential for the development of better treatment.
Cons
the expected course of your cancer and its outcome, with and
without treatment
possible benefits from both the standard treatment and the new one
in the study
the new treatment may not be effective or may be less effective than
standard care
any risks and side effects from the new treatment that might
influence your decision
you may not be in the group that receives the new treatment (in
randomised studies)
where and how the treatment will be done
the new treatment may have side effects, including some in addition
to those listed (which are as yet unknown)
where and how the follow-up will be done
the side effects may be worse than those of standard treatments
time and costs involved
you may be required to attend a hospital or clinic more frequently,

or the trial may involve you in extra tests and additional timeconsuming tasks
You should be given a written information sheet, the opportunity to

ask questions and time to consider your decision before completing the
consent form. During the trial you have a right to withdraw at any time.
The decision about joining a trial depends on balancing the advantages
and disadvantages. You should be confident that you understand these
before going ahead.
In general terms, the pros and cons of participating in a clinical trial are
given below. However, it may be helpful to make your own list for the
specific trial you are considering.
Pros
9.2.7 Questions to ask when considering a clinical trial

The following checklist of questions may help you when discussing a
clinical trial.
Which treatments are being tested and why?
What are the possible benefits to me or to others?
What extra tests apart from my normal treatment will I be involved in?
What are the possible risks or side effects?
How long will the trial last?
Will I need to go to hospital for treatment?
you might have access to a new, effective treatment
What will I do if any problem occurs while I am in the trial?
you will receive the current best standard of care, even if you dont
receive the new treatment
Can the trial affect my options for future treatment?
0129
0130
Can I withdraw from the trial if I change my mind?
9.3.1 High-risk or locally advanced cancer
Can I be on more than one trial at a time?
Radiotherapy is a common treatment recommendation for locally

advanced prostate cancer. New methods of delivering radiotherapy, such
as intensity-modulated radiotherapy (IMRT), are under investigation.
Dose escalation (higher doses of radiation) increases cure rates and IMRT
decreases the side effects of radiation. Further phase 3 trials are under way.
The best thing about the trial was all the attention I was getting.
9.3 Emerging treatments
In this section we discuss treatments that are currently being investigated.
Because these are still experimental, no recommendations can be made as yet.
Research into new prostate cancer control therapies has been occurring
at all the stages of prostate cancer discussed in this guide. The different
types of treatments at each stage are shown in the diagram. Some of the
new agents (drugs) are listed in Figure 9.1
Figure 9.1: Emerging treatments currently in phase 3 trials
Adjuvant therapies are additional treatments offered with or immediately

after the first one. Adjuvant therapies after surgery or radiotherapy are being
investigated particularly for high risk or locally advanced prostate cancer.
One recently launched phase 3 trial (radiotherapy adjuvant versus early
salvage, or RAVES trial) for patients at high risk of recurrence following
surgery (they have positive surgical margins or disease extending beyond
the prostate) will compare whether salvage radiotherapy given at PSA
recurrence is as effective as earlier adjuvant radiotherapy given within
four months of radical prostatectomy.
Adjuvant androgen deprivation (hormone therapy) may be particularly
helpful after radiotherapy or surgery.68, 69 Adjuvant chemotherapy is also
being investigated and combined with hormonal therapy. In some cases it is
being used alone. Other studies combine chemotherapy with radiotherapy to
try to improve cure rates of locally advanced prostate cancer.
This is a promising area of research. Its focus is on treatments used early
in the progression of advanced prostate cancer, when the cancer cells are
possibly less resistant to therapy.
9.3.2 PSA rising after surgery or radiotherapy

Sometimes there is a long period between the time the PSA first rises
and the appearance of metastases. A number of studies are examining
the possible benefits of treatment during this period. Starting hormone
therapy early during this time appears to delay metastases in men with
high-risk cancer, but not in all patients. It is also not known whether
0131
0132
the longer exposure to the harmful as well as beneficial effects of the

hormone therapy means there is no improved overall survival.70 The
timing of androgen deprivation (TOAD) trial investigates whether starting
androgen deprivation treatment immediately is better than starting the
same treatment after two years or if the patient has symptoms or a
rapidly rising PSA.
Salvage radiation therapy is another option for local recurrence after
radical prostatectomy. Recent studies show that radiotherapy after
surgery increases cure rates and survival if the cancer extends beyond
the prostate into the tissue surrounding it (extraprostatic extension) or
into the seminal vesicles, or if there are positive surgical margins (not all
the cancer removed at surgery). A recent study suggests that the results
are best if radiotherapy is started early before PSA reaches 0.5ng/ml.71
A phase 2 trial described at the recent American Urological Society
meeting reported that pomegranate juice taken daily by men with a lowto-moderate Gleason score but a rising PSA slowed the rate of this rise.72
A phase 3 trial is now under way. There are no current recommendations
regarding its use.
In the US, a trial is testing the effects on PSA levels of an intensive
nutritional intervention comprising a low-fat diet high in fibre, fruits
and vegetables, green tea and vitamin E. Another dietary trial for men
with rising PSA tests the effects of lycopene plus vitamin E on the rate of
change of PSA.21
9.3.3 Metastatic, androgen therapy responsive cancer

Androgen deprivation therapy (ADT) (see Chapter 7) is the standard
care for men with metastases. New hormone therapy agents as
well as different combinations and methods of delivery are being
investigated. Continuing studies are evaluating whether ADT can be
given intermittently to improve side effects without compromising
0133
outcomes. Other trials are investigating whether bisphosphonates (drugs

which interfere with the development of bone metastasis73) and the
chemotherapy agent, docetaxel slow down progression if they are given
when ADT is first started. In essence, these studies are asking whether
chemotherapy (docetaxel) or Zometa given when starting ADT is more
effective than chemotherapy given only when the cancer is no longer
responding to ADT.
For men on ADT, a number of trials are testing the effect of resistance training
on body composition, bone density, fatigue and physical performance.21
9.3.4 How new drugs are licensed

Recommendations can be made on experimental drugs once they have
finished their phase 3 trials. New drugs need to be approved by licensing
bodies before being made available to patients outside clinical trials. In
Australia, this body is the Therapeutic Goods Administration.
9.3.5 Metastatic prostate cancer no longer responding to ADT

Chemotherapy is the standard treatment normally offered when the
cancer is no longer responding to hormone therapy. A number of studies
are investigating whether adding another treatment to docetaxel, the
main chemotherapy agent, can prolong its effectiveness (see Table 9.1).
Bisphosphonates are also used for patients with this type of cancer. They
are known to prevent complications of bone metastases from prostate
cancer when given before chemotherapy.77
Abiraterone is a new drug that targets the synthesis of testosterone
wherever it occurs in the body, including within the cancer cells
themselves. In earlier trials74 this drug reduced PSA levels by half in
44% of patients who had prostate cancer that no longer responded
to ADT. More recently, nearly three-quarters of patients were reported
to have PSA reductions of 50% or more after 12 weeks of therapy.75 A
0134
large multicentre phase 3 trial is now underway in patients with disease

growing despite a low circulating level of testosterone both before and
after chemotherapy. Abiraterone is taken orally and is often combined
with prednisone to reduce side effects. It is hoped that better methods of
androgen deprivation will lead to longer hormonal therapy control.
MDV3100 is a new synthetic anti-androgen drug. Unlike other antiandrogens, MDV3100 binds very tightly to the androgen receptor (AR)
and stops its translocation into the nucleus of the cell.
This prevents the AR from binding with DNA and stimulating prostate
cancer growth. Taken orally, the drug has shown very high rates of
PSA reduction (13/14 patients) in early studies. It will proceed to a
phase 3 trial later this year.76
Satraplatin is an example of a chemotherapy drug that was evaluated
recently as a second-line chemotherapeutic agent. It showed promise
by increasing time to progression by 30%, however it did not show
improvement in overall survival and was not able to be approved.
Immunotherapy is a particularly promising treatment approach. Usually
the normal immune system does not find it easy to eliminate cancers
for a number of reasons: tumours are not good presenters of antigens
so that immune cells cannot recognise them as foreign cells and mount
an attack. Antigens expressed by a tumour can vary over time and
between patients, making it difficult to develop a vaccine in the way
we do for infectious diseases. Unlike infectious diseases, the immune
response to cancer cells is not perpetuated by memory of an earlier
exposure. This means that the bodys immune response has to be helped
or enhanced to become effective against the cancer.
Dendritic cells are immune cells that present antigens to other immune
cells (T-cells), which then become armed to seek and destroy cancer
cells. In this type of therapy, blood is taken from the patient and his
0135
immune cells are sensitised to antigens expressed by his prostate cancer

and their numbers amplified. The large population of sensitised immune
cells is then returned to the patient. In trials so far, there have been some
very favourable responses to this approach, and some not so.
Sipuleucel-T immunotherapy (Provenge) is one of the earliest and most
successful of this type of treatment and is well advanced in trials. A
patients blood is taken and the dendritic (immune) cells exposed to PAP
(a protein secreted from the surface of 9095% of prostate cancer cells)
and GM-CSF (granulocyte macrophage colony stimulating factor) to
enhance the response. The immune enhanced blood is then returned to
the patient. This is repeated in several cycles.
The results of a small phase 3 trial showed improvements in survival with
34% in the treatment group alive at three years compared with 11% in the
placebo.78 Results from a second and larger phase 3 trial were released at
the American Urological Associations 2009 meeting. The results are similar.79
Provenge improved three-year survival by 38%, with about 31% of patients
who underwent immunotherapy surviving this long, compared to 23% of the
placebo-treated patients according to investigator, Dr David Penson.
Bone targeting treatments. Tumours produce substances that attract
cells (called osteoclasts) which break down bone. This process releases
chemicals that in turn help the tumour cells grow. A number of
treatments are being developed to block this process. One such drug is
denosumab, which targets osteoclasts.
Endothelins are chemicals in bone which are known to stimulate
metastases. New drugs are being developed which block endothelins
from binding to their receptors. One of these is atrasentan. This
drug showed promise in early trials. A phase 3 trial for men without
metastases did not show an overall improvement in survival in treated
patients but did show a trend towards a delay in the development
of bone metastases.80 Atrasentan has shown some synergy with the
0136
chemotherapy drug docetaxel. Trials are continuing.

Another approach is to target an enzyme called cathepsin-k, which
occurs entirely within osteoclasts. Suppressing this enzyme may prevent
bone resorption and this is another area of promising research.
New chemotherapeutic combinations. There was much excitement when
the first chemotherapeutic agent (docetaxel) was found to extend survival
in men with castrate-resistant prostate cancer in 2004.81 Since then,
combinations with other drugs and treatments have been investigated
and shown some promise. Studies include agents that target bone, tumour
blood supply and the vitamin D receptor, as well as other chemotherapy
agents such as Satraplatin (described above). Combining docetaxel with the
immunotherapy has shown promise.82 Some of these combinations, such
as with immunotherapy, resulted in impressive improvements in survival
and in quality of life. Further trials are being planned.
0137
0138
Table 9.1 Types of emerging therapies with examples

Type
Agent
Potential effect
Trial phase
New forms of androgen

deprivation
Abiraterone
MDV3100
May cause reductions in testosterone and PSA levels
Chemotherapeutic agents
as single agents after
docetaxel
Satraplatin
Epothilones
Pemetrexed
Chemotherapeutics which stop the ability of cancer

cells to replicate by blocking processes such as new DNA
production
23
Immunotherapies
Sipuleucel-T
(Provenge)
Enhance bodys immune system to fight cancers
Selective Endothelin A
Receptor Antagonist (SERA)
Atrasentan
Zibotentan
May block prostate cancer growing in bones
Anti-angiogenic drugs
Sunitinib
Bevacizumab
Block new blood vessel formation (angiogenesis).

Bevacizumab is a monoclonal antibody which targets
vasculo-endothelial growth factor
Up to 3
Complementary therapies
pomegranate juice
May slow a rising PSA after treatment for localised

prostate cancer72
Combination therapies
with docetaxel
Docetaxel plus another anti-cancer agent:
Attack cancer cells in different ways and hopefully more

effective in overcoming cancer cell defences
Up to 3
Radiotherapy
Dose escalation
IMRT
Chemotherapy + radiotherapy
Kills more cancer cells and may increase cure rate

Decreases side effects
Kills more cancer cells and may increase cure rate
3
23
23
0139
Calcitriol, Capecitabine, Thalidomide,

Bevacizumab, Atrasentan
0140
9.3.6 Other agents

Statins
Statins are drugs used to lower cholesterol levels in people at risk of
cardiovascular disease. A number of observational studies have shown
that statin use is correlated with lower risk of advanced prostate cancer.83
It was also associated with lower rate of recurrence after prostate
surgery in one recent study.84 However these agents have not yet been
tested in randomised trials and so it is possible these associations are
due to factors other than statin use. This is a developing research area.
Green tea
A phase 2 clinical trial in 2003 found that green tea lowered PSA levels in
2% of men with prostate cancer that no longer responds to ADT.85 Since
then phase 1 and 2 trials have investigated its role in treating patients
undergoing surgery for prostate cancer and in one continuing trial, its
role in preventing prostate cancer. Green tea as a component of dietary
supplements is also being investigated, including one phase 3 trial to see
whether two dietary supplements can reduce PSA levels in patients with
prostate cancer.86 The trial is continuing.
Auron misheil therapy (AMT)
AMT, a blend of camomile extract, calcium, vitamins, antihistamine
and insulin, is being trialed in patients with cancer that is no longer
responsive to ADT to investigate its effects on symptoms, quality of life
and overall survival.
It should be remembered that although some of these agents show
promise, the full regimen of phase 13 trials must be completed before
recommendations based on effectiveness and safety can be made.
0141
9.3.7 New approaches to psychosocial support

The major funding bodies in Australia (Cancer Australia, beyondblue,
Prostate Cancer Foundation of Australia PCFA) are supporting research
into new ways of providing support to men with prostate cancer and
their families. Continuing studies investigate new ways of reducing
psychological distress, supporting couples, and providing telephone
support. This new focus on reducing the impact of the disease on the
psychological wellbeing of men and their families adds to previous
Queensland and NSW research on the support needs of men with
prostate cancer and the beneficial effects of peer support groups.
Today all men diagnosed with prostate cancer and their families should
have access to some form of support. This includes the peer support
groups affiliated with the PCFA (see below), a specialised advanced
prostate cancer telephone support pilot program run by Cancer Council
Victoria, and the Cancer Council Helpline (see Resources). We cover this
topic in Chapter 10.
9.3.8 Future developments

As with other cancer sites, prostate cancer research progresses in small
steps rather than large breakthroughs. Nevertheless improvements at each
stage can have a big impact on the overall course of the disease. Research
suggests that combining treatments with different mechanisms may
have synergistic effectsthe results are better than with each treatment
alone. Support for fundamental researchstudies into the molecular
processes involved in prostate carcinogenesis, clinical trials at all phases,
patient participation and licensing of promising new treatmentsare all
essential to this process. This support will ensure that these incremental
improvements continue into the future, giving ample reason to be
optimistic about our ultimate capacity to control this disease.
0142
9.4 Resources
Clinical trials
Australia and New Zealand Clinical Trials Registry: www.anzctr.org.au
Cancer Council New South Wales Cancer Clinical Trials website:
National Prescribing Service Medicines Line: 1300 888 763
Australian service providing independent advice on prescription and
over-the-counter medicines
NHMRC Clinical Trials Centre: www.ctc.usyd.edu.au
Pharmaceutical Benefits Scheme (PBS), Pharmaceutical Benefits
Advisory Committee (PBAC) Pharmaceutical Benefits Scheme (PBS) and
Therapeutic Goods Administration (TGA):
www.health.gov.au/internet/main/publishing.nsf/Content/health-pbsgeneral-faq.htm-copy2
Therapeutic Goods Administration (TGA): www.tga.gov.au.
This website has a consumer section
US National Institute of Health Trials Registry: clinicaltrials.gov
WHO international Clinical Trials Search Platform: www.who.int/ictrp/en
Support
Cancer Council Helpline: 13 11 20 in each state
9.5 Acknowledgement
We are grateful to Cancer Council NSW for permission to use material
from their booklet: Understanding Clinical Trials:
ww.cancercouncil.com.au/html/research/cancertrials/downloads/
understanding_clinicaltrials.pdf
0143
10.1 Key points
The return of cancer can be difficult to deal with. It can trigger

many questions; grief, anger, fear and anxiety.
Through peer support programs it can be reassuring to talk to

others who have had this experience (see Resource section).
Maintain open communication with your partner on all the

important issues. Couples who face problems together do better.
Use many different ways to maintain intimacy with your partner.

Recognise and solve barriers to intimacy such as not wanting to
upset or involve your partner.
Men and women approach worry and problems in different

ways. Recognise and accept each others differences.
Grief, anger and despair can be a potent mix. If you are feeling
overwhelmed or you are losing interest in life, seek help
from your doctor or the helplines listed under Resources. No
man need travel this path alone. Your local support group or
telephone helpline has people experienced in dealing with
these issues.
Maintain an active lifestyle that includes physical exercise and the

normal activities you enjoy. Many men with advanced prostate
cancer lead active lives as valued members of the community.
10.2 Worries and how to deal with them

Being told that you have cancer or that it has spread or returned
can be devastating. Many men find it more difficult to deal with the
recurrence of prostate cancer than it was to deal with the initial
diagnosis. They experience a range of different emotions and may feel
0146
Chapter 10: Maintaining Your

Wellbeing
shocked and overwhelmed. Some say they feel numb and unable to
take in all that is being said.
I had been worried because I knew my PSA was rising; but when my
doctor finally told us the news, I was numb. I found myself in a daze
for the first few weeks. I couldnt think straight. I just kept thinking
that it couldnt be back there had to be a mistake. What did I do
wrong for this to happen again?
The news triggers many thoughts and questions. What does this mean?
Can I have any further treatment? Am I going to die? Learning that your
cancer is no longer curable threatens your sense of self, your way of life
and your future. You may wonder: What can I expect? Can I keep doing
the things I usually do? How much time do I have?
You may have a deep sense of loss and sadness. If you were previously
treated, you may have thought you had been cured and now wonder
if everything possible was done then. You may feel guilty or somehow
responsible because your treatment has not worked. Other common
reactions include feeling anxious or afraid about what the future may bring.
Some men are confused or feel it is unfair (Why me?). Others feel angry.
I felt really angry. How could this have happened? I had just
retired when I was first diagnosed and we had to put off plans
for our trip overseas. Joan and I have just begun to feel settled
after my radiation treatment and now this! I feel as if my life has
been taken away from me.
If you have these feelings, it is important to understand that you are not
going crazy and you are not weak. You are having a normal reaction to
a very difficult situation. Understanding your reaction can help you to
manage these feelings better and regain a sense of normality.
0147
Most of us have a particular way of responding to difficult situations,

usually without giving it much thought. We learn and practise this
approach to problems as we deal with the challenges of daily life. Some
people get advice or seek information; some distract themselves by
keeping busy; others talk about the problem. Religious faith or a sense
of spirituality can also be a source of strength and comfort. There is no
single best or right way of coping.
10.2.1 Things that may help

You may find the following helpful:
Write down your worries and concerns and then identify practical
steps you can take to address them.
Talk to others about what is happening, especially your partner or

a trusted friend. If you are uncomfortable talking to those close to
you, a prostate cancer support group may be helpful.
Peer support groups, provide patients, carers and family members

with an opportunity to share experiences with others in a similar
situation. It can be reassuring and helpful to meet with others who
have dealt with these problems. The Prostate Cancer Foundation of
Australia has a national network of affiliated support groups. The
Cancer Council Helpline can also put you in touch with a trained
support volunteer or counsellor (see Resources section for details).
Allow yourself to feel sad or fearful from time to time. Remind

yourself that this is to be expected given all that you are facing.
Find ways to help manage stress. The aim of relaxation and stress
management is not to make stress disappear, but to manage it in a
helpful way. See beyondblue Fact Sheet 6 Reducing stress.
Structured education and support programs can relieve worries,

improve wellbeing, and help maintain a positive outlook. Call the
Cancer Council Helpline for programs in your area.
0148
Resistance exercise (i.e. weight bearing exercises) and moderate

to strenuous physical activity can improve quality of life and
muscular fitness and reduce fatigue. Talk to your GP for a referral
to an exercise specialist. See Appendix 4 and beyondblue Fact Sheet
8 Keeping active.
Draw on your strengths. Remind yourself of things that have

helped you manage difficult times in the past and use these same
strategies now.
Dont expect to have all the answers. It is OK to feel unsure about

the future.
Keeping hope alive by allowing yourself plans and dreams.
Spiritual guidance or counsel, as you adjust to the uncertainty of

living with advanced cancer.
Asking your doctor for help or talk with a mental health

professional if you find that sadness or worry is affecting your
relationships or interfering with your daily life. Also see the section
below When things feel beyond repair: depression/anxiety.
All beyondblue fact sheets are available from the beyondblue info line
1300 22 4636 or www.beyondblue.org.au.
10.2.2 The PSA test can be a worry trap

It was hard for me to accept my doctors advice to monitor my
PSA levels only every six months. I wanted the test done monthly.
Surely the sooner we noticed a change, the sooner we could do
something different? He explained how my cancer could change in
time and what the next steps might be. I still get jittery every time
I go to see him for the latest results! Ron 67 years
Managing your cancer over time usually means regular monitoring
of PSA levels. This can be a source of worry as the time for the test
approaches. It is important to learn how to manage the thoughts that
0149
cause anxiety. Our minds like to run away with thoughts of what might
happen in the future, and usually it is the worst-case scenario! Taking
control of your thinking can be as simple as staying focused on the facts
you have in hand and what you know today.
It can also help to acknowledge you are worried and try to distance
yourself from these thoughts. For example, try thinking about putting
your worries in a box and closing the lid. Remind yourself that it is
normal to be anxious about your results and give yourself permission to
worry when you need to.
If you find worries are taking over your life and preventing you from
enjoying normal activities, the section When things feel beyond repair:
depression/anxiety might prove helpful.
10.3 Maintaining intimacy and satisfying relationships

A loving and supportive partner can be a source of comfort and
strength as you face the challenges of advanced prostate cancer as a
couple. However, this experience can also put increased stress on your
close relationships. Your world may feel as though it has turned upside
down and making time to talk, share and stay connected can easily
become a low priority.
Treatment for advanced prostate cancer often means lowering
testosterone levels in the body. These changes commonly lead to
lowering of sexual desire and arousal. This loss of sexual feeling may
cause some men to see themselves as less masculine, particularly if they
are dealing with other body changes from hormone therapy. The effect
of this on their partner may also be a concern.
Some side effects of hormone therapy, such as lowering of sexual desire,
hot flushes and weight gain, are talked about quite openly among
men with prostate cancer. Other effects, such as breast enlargement
and changes in the penis, may be kept more private. Some men are
0150
frustrated to find that since they started hormone therapy, they are no
longer as sharp mentally. They may be forgetful and feel foggy. Others
talk of being irritable and emotionally sensitive, crying easily and for no
apparent reason. Fatigue and muscle weakness can interfere with usual
routines and undermine a mans sense of usefulness.
a belief that there is no point talking or involving your partner as

they wont understand
a belief that there is no point involving your partner or that talking

to them could make things worse
not wanting to upset yourself by talking about difficult issues
The combined effects of diagnosis, treatment and side effects can

induce a deep sense of loss. Some feel they are no longer the man they
used to be and withdraw from their partner and friends. This can be
an emotionally challenging time. Sex and desire may seem even more
important now that they are gone and men may find their thoughts
turning to the past and the memory of all that has been lost. Feelings of
depression are common during this time of adjustment and some men
feel there is nothing out there that could help.
not wanting to upset others by bringing things up
From a wife-carer point of view of wives and carers, it is very

important to keep communicating.
10.3.2 Things you can do to build closeness and trust
Share what is happening for you with your partner and accept
each others differences. It is common for partners to have different
ways of coping when they are feeling down. One partner may want
to talk while the other needs time alone to work out their feelings.
Accepting these differences can help to prevent misunderstandings.
We so easily assume that our view of the world is the only right one
and that others see things just as we do.
Invest in the relationship. It is especially important to do things

together that build closeness, such as fun activities just for the two
of you, and to find different ways to say I love you. Happy couples
tend to keep showing they care about each other. Some couples may
find it helpful to actually sit down and talk about the small things
they can do for each other to show caring and support during this
time. This may be as simple as a cup of tea in bed in the morning or
a back rub in the shower.
Make time regularly to catch up and talk about how you are both
managing. This can be as informal as having a coffee together or
going out for a walk. Staying open and honest about your concerns
helps you both feel connected.
Research has shown that couples who face problems together adjust
better to the uncertainties of advanced cancer, as do men who have
strong support networks, including family members and friends.
10.3.1 Things that can make it more difficult to stay connected

Keeping your feelings from your partner can make them feel shut out
and they may start to believe that you have stopped trusting or caring
for them. Withdrawing also makes it very difficult for your partner to
know how best to support you.
Some of the things that made it harder to stay connected are:
0151
being too busy with the increased demands on your time, for
example, getting things done at work or around the house, attending
doctors appointments, and so on
not knowing what you think or feel or not knowing how to put it
into words
0152
Focus on the strengths in your relationships. Hormone therapy

causes many changes in your body and your sex life. This may lead
you to think of yourself as less masculine and cause you to question
your self worth. Reflecting on the strengths in your relationship,
on your personal achievements and on what others value in you as
a friend, a father, a brother can help you realise you are loved and
valued for so much more than your physical abilities. Make some
time to reflect on your life. Review the ways you have contributed
through family, friends, work and community activities. This can help
remind you of your achievements and strengths.
Work on intimacy every day. Explore other ways to be physically
close and experience sensual pleasure apart from sexual intercourse.
Intimacy is about more than sexual closeness. Be flexible and open
to different ways of expressing love and sharing pleasure. Physical
touch can send powerful messages of love and care. How often do
you look into your partners eyes when you are talking; hold hands
when you are walking or just hug each other?
Set goals and plan together. Learning to talk together about your
needs can help you find ways to move forward and strengthen your
relationship. Remember to plan for things outside of cancer; and to
balance time together with time for your own individual activities as
well as time spent with family and friends.
Use the supports around you. Sometimes, it is easier to talk
with a trusted friend or your doctor about your concerns. Your
local Prostate Cancer Support Group can be a useful source of
information and support.
10.3.3 Finding support: peer support groups

For men who live alone, are widowers or away from their family, the
experience of a serious illness can be a very isolating. They miss not
having a partner, family or friend to accompany them to appointments,
discuss treatment issues and help them find additional information. If
0153
you are alone, it may help if you build up your support network in other
ways. A number of approaches may be helpful.
For men with a partner, support groups can also help by providing the
partner with additional contacts and opportunities to share information.
They can provide man and partner with a support network, so that if one
of you goes through a difficult period, the other has support.
Peer support groups have meetings with invited speakers who are often
experts on prostate cancer. They have good libraries of resource material
and provide a forum to discuss many issues. These groups are located
around the country (see Resources section).
Cancer Councils also have information programs and peer support
services that allow men to talk with others who have had a similar
experience, and a help line which can provide contact details and answer
questions. The Prostate Cancer Foundation of Australia gives information
about where to find support groups.
A number of reputable chat rooms and bulletin boards are now
available on the Internet and may help connect men and provide
updates (see Resources section).
Prostate cancer is a very common condition. Resources and supports
have multiplied in recent years. These days, there is no reason for anyone
to travel this path alone.
10.3.4 Dealing with grief and anger

Two particularly difficult emotions that may seem very much bound
together are grief and anger. Grief experienced by men with advanced
prostate cancer can be caused by a chain of losses loss of health, loss
of time with loved ones, loss of cherished plans such as being present
at birthdays, anniversaries and other special times. Anger grows out of
feeling powerless or being forced into a corner, of feeling that all of this
0154
may have been preventable, of having a sense that an injustice was done,
or out of being fearful.87
Men tend to respond to grief in different ways to women. They may not
be as verbal, self-caring or help-seeking. In his book Taking care of
yourself and your family, John Ashfield explains this:
Men pay less attention to emotional pain than women, until

those around them appear safe and things appear in order. This
is because men often distance themselves from the emotional
content of difficult or threatening situations in order to remain
vigilant and caring to others.
Ashfield suggests that, on the other hand, men get benefit from
activities, action, and mulling things over. They benefit from the
company of other men (or working alongside other men); not necessarily
from any verbal exchange, but just by another man being present who
cares, but doesnt intrude. Having time alone, writing down thoughts,
spending time with supportive people is also helpful.
Anger is a normal and potentially powerful emotion. If used thoughtfully,
it can energise and motivate us to face things previously ignored, solve
problems constructively, even find a solution to injustice.87 However,
when used destructively, it can cause us to be thoughtless, impulsive,
frequently blame others, accuse or be violent. Frequent or prolonged
anger can affect our health and lead to relationship problems.
There are many approaches to dealing with anger. Active problem solving
involves identifying the problem, understanding it, and working towards
a solution. This can restore a sense of control and meaning.
Removing sources of physical stress, and relieving tension through
exercise, relaxation, getting plenty of sleep and spending time with
reliable friends can support this. However, if anger feels overwhelming,
0155
seek professional help from your GP or nearest community health

service. Ashfield suggests asking for someone with knowledge and
experience appropriate to working with men. Finding the right person is
the key to effective assistance and you may need to travel to do this.
Debate and confusion continue to surround many aspects of prostate
cancer in particular who should be tested and which treatment presents
the best chance of a cure. These critical decisions can change the
complications experienced and perhaps the course of the disease.
Although it is not possible to really know what would have happened if
another course were taken, a sense of feeling uninformed, misled, or not
adequately cared for can justifiably cause anger and regret.
When I originally asked my then GP about the test for prostate

cancer, I was firmly rebuffed with a convoluted explanation
about why a man should not be tested, if he had no symptoms
to this day, I remain convinced that had I had a PSA test when I
asked about it, I would have had a reasonable chance of an early
detection, and a good chance of effecting a cure. This is what
made me particularly angry.
Increasingly, health professionals are aware that men with prostate cancer
need to be involved in the major testing and treatment decisions. The clinical
practice guidelines covering PSA testing88 and treatment89 are clear on this,
and increasingly practical guides and information are becoming available
to help in making decisions.90 These days, doctors have an important role in
informing patients so that they can make these major decisions together.
There is no substitute for first-hand experience. Many men with prostate
cancer have helped others by documenting their experience and in peer
support groups by talking with other men about living with prostate
cancer. Undoubtedly, the actions of these individuals have helped men
who are seeking a good outcome by providing guidance and help. Peer
0156
support of this type can help improve the experience of prostate cancer.
See the Resource section for contact details for peer support groups.
10.4 When things seem beyond repair: depression and anxiety

For men who are going through a difficult period anyway, a prostate
cancer diagnosis or a recurrence can seem like the final straw. It may
seem impossible to understand and come to terms with the condition.
Others deal well with the immediate issues, but see their enjoyment of
life sliding away as time progresses, lacking motivation, an ability to
enjoy life or the energy to take on their normal tasks.
For some men, these feelings are very intense or persist over a long
time. The word depression is often thought to mean sadness or a low
mood. However, depression is more than just a low mood it is an
illness for which effective treatments are available. Having a depressed
mood can extend beyond the issue of cancer and into all areas of a
persons life. Men with depression can find it hard to carry out their
normal daily activities.
Depression is very common.91 About one in eight men will experience the
condition during their lifetime. Men with prostate cancer are nearly twice as
likely to experience depression92 and partners of men with prostate cancer
are also at higher risk of experiencing it.91 The risk of depression is higher if
a man has experienced depression before, or if his health condition makes
it more difficult to remain active and connected with family and friends.
Anxiety (worry and nervousness) and depression can be closely linked.
Men who are on androgen deprivation therapy may also be at increased
risk of mood swings and depression because of changes in their
testosterone levels. These men may also notice weight changes, tiredness,
that they are more forgetful and they have trouble concentrating or
making decisions. These changes are similar to the common signs of
depression and so it can be hard to distinguish the two.
0157
Being alert for depression is important because it can be managed with

effective treatments. These include cognitive-behavioural approaches
(changing ways of thinking), talking or interpersonal therapies, and
medications. Appendix 7 includes a checklist from the beyondblue
depression fact sheet that may be helpful.
More information on anxiety and depression is available from the
beyondblue website and their fact sheets (see Resources). If you are not
sure whether you have a depressive illness, it is important to consult
a health professional. A GP, psychologist, psychiatrist, social worker or
occupational therapist in mental health can help, although they may
have different treatment approaches. There are Medicare rebates for
these services when referred from a GP or other doctor. The beyondblue
website and your state/territory Cancer Council may also be able to
provide information on mental health professionals in your local region,
particularly those who have experience in working with people with
cancer. To find out more, call the Cancer Council Helpline on 13 11 20.
10.4.1 Tips for managing depression and/or anxiety

(taken from beyondblue Fact Sheet 34 91)
Speak to a doctor about your concerns and discuss treatment

options.
Accept help, support and encouragement from family and friends.
Reduce isolation by becoming involved in social activities.
Exercise regularly (see Appendix 4, beyondblue Fact Sheet

8 Keeping active)
Get enough sleep (see beyondblue Fact Sheet 7 Sleeping well)
Allow yourself time to relax and reduce your stress (see beyondblue
Fact Sheet 6 Reducing stress)
Limit alcohol intake (see beyondblue Fact Sheet 9 Reducing alcohol

and other drugs)
0158
Eat healthily and include a wide variety of nutritious foods. (See

beyondblue Fact Sheet 30 Healthy eating for people with
depression, anxiety and related disorders).
Bulletin boards, internet chat

New Prostate Cancer Infolink: prostatecancerinfolink.ning.com
Prostate Pointers: www.prostatepointers.org
10.5 Resources and further help

Helpful books
beyondblue Infoline: 1300 22 4636
Carers Australia: Counselling, advice, assistance 1800 242 636
Local services listed at www.carersaustralia.com.au
Life line: 13 11 14
Mensline Australia: 1300 789 978; www.menslineaus.org.au
National telephone support, information and referral service for men
with family and relationship concerns
Multicultural Cancer Information Services: contact Cancer Council
Helpline at 13 11 20
Prostate Cancer Foundation of Australia: 1800 22 00 99.
Support groups
Ashfield, J. Taking Care of Yourself and Your Family: a resource book

for good mental health. 2008, Adelaide: Peacock Publications. 311.
Available free from beyondblue infoline: 1300 22 4636, or online at
www.beyondblue.org.au
Cancer Council New South Wales. Living with advanced cancer: a guide
for people with advanced cancer, their families and friends. 2007, Sydney.
Available from (02) 9334 1900 or online at www.cancercouncil.com.au
Additional resources
beyondblue website: www.beyondblue.org.au
Includes interactive checklists, fact sheets on anxiety, depression,
information on available treatments, how to help someone with
depression, how to reduce stress, sleeping well and many others.
beyondblue info line: 1300 22 4636
Order beyondblue resources, ask questions about signs, symptoms and
available treatments or where to get help in your area.

Mens Sheds: www.mensheds.com.au
0159
0160
Chapter 11: Partners, Families and

Carers: Your Concerns
11.1 Key points
Partners and carers of men with prostate cancer can find

themselves on a long and difficult course. The following
suggestions can make this easier:
Maintain open communication with your partner, particularly on
important issues. If this is difficult, this chapter includes ways to
help.
Maintain open communication with the specialist caring for your

partner. Strategies that can help include attending consultations,
taking notes, listing questions, asking for a longer consultation.
Develop a communication plan with family and friends. One

family member may offer to communicate with others. Accept
offers of help it can mean you have help, for example with
household tasks, at critical times.
You may take on new roles that can be stressful, both

psychologically and physically. There is help available if needed
through your doctor and respite care. Support groups can help
you feel you are not dealing with this burden alone.
Look after your self physically if you can keep up as many of

your normal activities as possible.
If decisions are difficult or there are disagreements, try setting

up a forum, for example with a trusted doctor or nurse, to
discuss them.
If you feel one of you needs psychological support, this chapter

includes suggestions, and if it is your partner, some ways to
discuss it with him.
0161
As the partner of a man with prostate cancer, or a family member caring

for a loved one, you may increasingly take on a new role that of carer.
This role has its own emotional, psychological and practical stresses.
This chapter provides a brief overview of some of them and includes a
Resources section.
11.2 Talking and communicating

11.2.1 With your partner
He wont talk to me.What do I say to make him feel better?
Many people say that talking about the cancer with their partner is very
difficult. This can be for a number of reasons. Withdrawal is a common
way of coping with a problem that seems overwhelming. It may simply
mean a person is thinking through the implications of the situation and
needs time to do so. Alternatively, he may feel that talking about it may
worry his partner and make things worse. Both the carer and the person
with cancer may try to protect each other by avoiding topics that cause
anxiety or are hard to discuss.
On the other hand, others may pine for life to be normal again and
want to exclude the cancer from daily conversation. Some say it becomes
a shadow that intrudes on every conversation.
It is worth looking for ways to discuss what is happening, even though it
is difficult. Putting thoughts into words can help you to see the situation
in a different perspective and regain a sense of control. In doing this
you can establish a communication process that will be invaluable in the
future as new decisions have to be made.
Even through the worst times, weve been reassured by what we

have together and we hang onto the fact that we have a good
relationship and we are not going to let this beat us.
0162
If communication has not been strong point for you both, try to establish
a forum for discussion. You can use outside expertise to do this. Carers
may not be aware that they have access to social workers, psychologists
and other allied help. Your GP could be a place to start. He or she can
explain a lot of the uncertainty about the disease, as well as answering
questions from both of you.
It is better if two people attend the consultation. If possible,

accompany your family member when he visits the doctor. A support
person can remind him later of things the doctor said that he may
have forgotten or misunderstood.
If you have lots of questions, ask for a longer appointment. It may

help to do some research beforehand, particularly if there are words
or terms you dont understand.
Take an active role in the consultation. You have a crucial role in

respecting and supporting the person you care for, so you need to
feel confident about understanding the illness, the treatment, its
impact and overall, and what to expect.
11.2.2 With the doctor
Sometimes, if you dont go to the consultation with your partner,

you may feel out of the information loop. Trying to understand the
true situation can be frustrating. This is particularly true of sons and
daughters of men with prostate cancer.
Ask your doctor if there are any information resources, such as booklets
or websites, which are trustworthy and relevant to your questions.
Remember that framing and viewing things from a different

perspective can make a big difference. For example, Its cancer, but
it can be treated versus Its cancer, hes going to die; This is a
challenging project to be managed rather than This is a miserable
situation to be endured.
Some couples decide to have cancer-free days where they dont

mention the disease. This helps restore normal life, and it is reassuring
to find that while this problem may be a part of your life now, it need
not dominate.
Not all specialists are good communicators, and even if you do attend,
they may use terms you dont understand or speak too quickly for you
to follow. A good doctor will check that the person with the illness
understands, but there also are some things you can do to minimise this
type of problem.
Before you visit the doctor, write down your questions (in case you
forget them in the rush of the consultation). You can ask the doctor to
write down the key points you need to know.
Ask if you can audiotape the conversation. Some doctors are happy
for consultations to be recorded, particularly if they are discussing
treatment options.
Take notes during the consultation.
0163
11.2.3 With family and friends

You may find that you are fielding many phone calls and visits from
family and friends and that this is becoming stressful and timeconsuming. If someone offers to help, you can ask the person to take on
this role, perhaps emailing a list of people who want to be updated.
Deciding when and how much to tell family members can be difficult,
particularly if they live overseas or interstate. Decisions about when to
come home can be very hard for family members who dont live nearby.
Good communication with the doctor about prognosis can help make
decisions like this.
0164
When people ask if they can help, remember that you may need support
from time to time, including respite for a day, help with driving, meal
preparation and so on (see Chapter 10).
grief and anxiety, and adult children who until now have always deferred
to their parents may need to take on the role of lead decision maker.
11.3.2 Grief and distress at the cancers return

11.3 Emotional and psychological stresses
11.3.1 Changing roles
You may notice that the roles of you and your loved one are changing.
This can affect both partners and children. In particular, you may notice
a change in the way decisions are made. The carer may need to take on a
decision-making role that previously belonged to their partner or father,
especially on family issues. Nevertheless, the person himself may need to
retain the decision-making role in relation to his illness and treatment
to maintain his sense of autonomy and a sense of being in control of
his life.93 The mans need for privacy can also be a big issue and hard for
the carer to negotiate. Some men have asked their partner not to tell the
family. This can have the unintended consequence of cutting off sources
of support for their partner. It is important to discuss the needs of both
patient and carer.
If making decisions is causing stress, talk to your partner about what
decisions need to be made now and which ones can be left until later.
Listing the pros and cons of decisions that need to be made now, and
discussing them from each of your perspectives, can help you make
progress. Sometimes you may need to compromise. If necessary,
decisions can be revisited later.
Carers often say they have no training for their new support roles and
this can be stressful.
Dads supposed to be able to solve everything.

Family members may need to manage the finances, which they have never
done before. Similarly, partners may feel isolated and alone in dealing with
0165
After treatment for prostate cancer, the regular program of PSA testing
can be a source of tension and anxiety.
Weve been clear for years, but every time the test comes up, he goes
a little bit quiet. Its the thing we dread and we just hope for zero.
In Chapter 10, we discuss the emotions men experience after the cancer
returns. These apply equally to their partners or carers. If there is a
recurrence, often years after the original treatment, some say that it is
even more stressful than the original diagnosis.
When you manage to get over it and it looms again, you withdraw.
The challenge of facing it again can be harder than the first time.
The treatments and their side effects, pain, and changes in the
appearance of a loved one can be very hard for partners or family
members to witness. The situation may seem relentless. You may also
feel angry at the demands placed on you and the need to give up things
that are important to you. The demands of caring may be so physically
demanding that you wonder how long you can keep it up. Manual
assistance can include showering, toileting and moving a person.
Its all right to feel miserable if youre not coping.

Things that may help:
Do not hesitate to seek help with caring tasks. Help is available

through your GP, your palliative care team and carers services
(see Resources).
0166
A good strategy is to try to keep as much of your normal life

going as possible. Enlist the help of friends or family who have
offered to help.
Participate in activities that both you and your partner enjoy, for
example, take a day off from caring for both of you have a cancerfree day.
Support yourself physically and emotionally (see Chapter 10).
If the demands are overwhelming, there are people to support and help you,
particularly if you have involved a palliative care team (see Chapter 12). Do
not hesitate to discuss this with them or with your doctor.
11.3.3 Prostate cancer care issues

The treatments for advanced prostate cancer, particularly hormone
therapy, can affect a mans emotional state, his levels of energy, his
body shape and his libido. These can have profound effects on your
lifestyle together.94 Symptom control is discussed elsewhere in this
guide, however every family has a different experience of this illness. It
is important that you and your partner have a member of your medical
team who you feel has some empathy and with whom you can talk
frankly. If you dont have such a person, consider contacting your nearest
palliative care team, the Carers Association of Australia, or the relevant
help lines (see Resources section).
As his illness progresses, his needs will change and you may have to
rearrange the house so it remains comfortable. This could involve getting
a chair for the shower or repositioning the bed so it is easier to lift and
wash him. You may have to learn new skills along the way. Various
programs such as palliative care and community nursing services can
help you with this (see Resources).
Decisions about further treatment are not always straightforward.
Some treatments may come with considerable side effects and there
0167
may be times whether the patient and partner do not agree about the
desirability of a particular treatment. Honouring the patients wishes can
be complicated, especially when other members of the family also have
a view. Poor communication on these very important issues can lead to
misunderstandings and long-term feelings of exclusion and hurt. If you
need to, set up a forum to discuss these matters. You can draw on your
doctors and other health professionals, such as oncology nurses, to assist
you in these discussions.
One way to try to avoid this situation is to have a family talk, at an early
stage of the disease, long before decisions have to be made at short
notice. It is also a good idea for the family member with cancer to have a
living will (see Resources) in which he can express his wishes clearly (see
Chapter 12 and Appendix 8).
11.3.4 If the doctor says There is nothing more I can do.

Sometimes a doctor may signal the end of his/her phase of care by
saying, Theres nothing more I can do.
He simply said: I am afraid that I can do no more for you. That

appeared to be the end of the matter with no word of the
next steps, who would take over my care, such as pain control,
palliative care, counselling, radiotherapy, etc. and around whom
I should base that care.
While this may signal the end of one doctors involvement, it is important
to remember that this does not mean the end of treatment and care. As
we said in Chapter 3, different types of doctors step in at different stages
and take over the main role in care.
For example, you may see a medical oncologist, a urologist, radiation
oncologist and palliative care specialist, each of whom can take over care
which targets cancer control and symptom control at different times. If
0168
you are not sure who is coordinating your care, discuss your treatment
plan with your GP or any of your specialist doctors.
That a doctor could not make some suggestions about where

I could find help, or what action I could consider, absolutely
astounded both of us. It was certainly left to us as to what we
could do about any further action.
A strategy to avoid this situation is to have a treatment plan which you
discuss with the doctor. The three goalscancer control, symptom control
and quality of lifeare part of that plan. You can bring in different services,
specialists and approaches at different times to provide support in meeting
these goals. It can help to discuss things that are working and not working
with the doctor, and treatments such as complementary therapy. We know
that good cancer care is multidisciplinarydifferent types of specialists
together develop a plan for you.
can celebrate the ups with you, and support you through the downs.
Some people seek spiritual advice. Dont forget to pat yourself on the
back. Look for the symptoms of depression and anxiety in yourself and
seek help at the earliest sign.
Its taught me that whenever someone has something wrong with

them, it can be a stressful time. You dont know how long its for. Its
important for carers to have a contactsomeone to talk to.
Find respite. Make a plan early on for this allow yourself time to relax
and participate in enjoyable activities. Plan activities like social outings
and time away. Nourish your spirit by engaging in activities that comfort
you. Find ways to ease the load, for example, arrange help from your
family and friends or take carers leave from work.
Maybe once you know how to care, you can do it again, even if
the illness is different.
11.3.5 As a carer, you need to look after yourself

It goes without saying that looking after your own health is important
for both you and your family member with cancer.
Keep well. Eat healthy foods and treat yourself occasionally. Exercise if
you can. With some forms of exercise, such as yoga and tai chi, you dont
need to leave the house once you have some training. Take breaks and
get good sleep if possible. Meditation, relaxation and guided imagery can
be helpful. Limit your alcohol intake and avoid other drugs.
Develop coping skills. Ask for assistance with tasks and meals from
friends and family who have offered it. Set realistic goals. If something
seems overwhelming, break it down into smaller tasks and take one step
at a time. Dont forget to make time for other loved ones.
Manage your emotions. Find ways to blow off steam physical activity,
writing a journal, talking. Find a counsellor or support group, people who
0169
11.3.6 If you feel that one of you needs psychological support

It is not unusual for the experience of a chronic or terminal illness to
trigger depression in some men and their carers. If, as a carer, you feel
overwhelmed by the problems and see no end to it, it may affect your
continuing mood. Depression can be experienced as a persistent loss of
interest or pleasure in normal activities, or feeling sad, down or miserable
most of the time.87
As we discussed in Chapter 10 and Appendix 7, there are questions
you can ask which can help you work out whether youre experiencing
a normal part of the cancer progression, or whether you may be
experiencing depression or anxiety. Your local doctor, the Cancer Council
Helpline, and the beyondblue information line and website can help you
talk about your concerns, and get help.
0170
If it is your partner who is feeling down, it may be difficult to raise the

issue. The free beyondblue book: Taking care of yourself and your family
offers tips and suggestions:
Talk to the person about how they are feeling.
Listen to what the person is saying sometimes when a person

wants to talk, he/she isnt always seeking advice, but just needs to
talk about his/her concerns.
Use open-ended questions such as So tell me about which require

more than a yes or no answer.
If your conversation becomes difficult because the person you are
talking to gets angry, stay calm, be firm, fair and consistent, admit if
youre wrong. Dont lose control.
Often just spending time with the person lets them know you care
and can help you understand what they are going through.
Encourage the person to seek professional help from the family

doctor or a mental health worker.
Take care of yourself. Supporting someone with depression can be

demanding, so make sure you take time to look after yourself.
Changes in personality, such as becoming excessively withdrawn or

uncharacteristically angry, may also be difficult to cope with and may be
a response to either the condition or its treatment.
This may be a difficult burden for you, particularly if you too have
continuing health problems or other issues. Dont hesitate to talk to your
local doctor or specialist about such changes.
The booklet Reactions to prostate cancer: how to manage them provides a

more detailed account of the psychological stresses experienced by couples
facing prostate cancer and how to manage them (see Resources section).
11.4 Resources and further help

beyondblue Info line: 1300 22 4636
Carers Association Helpline: 1800 242 636
Commonwealth Carelink: 1800 052 222
Life line: 13 11 14
Multicultural Cancer Information Services: 13 11 20
Respite care
Commonwealth Respite and Carelink Centre 1800 052 222
Palliative care: 1800 660 055
To find a palliative care service in your area (or discuss it with your GP or
specialist)
Support groups
The beyondblue Guide for carers provides useful information about

caring for people who are experiencing depression or anxiety and about
caring for yourself (see Resources section).

(Partners are welcome at all PCFA support groups)
0171
0172
Further resources
beyondblue website: www.beyondblue.org.au
Interactive checklists, fact sheets on anxiety, depression, information
on available treatments, how to help someone with depression, how to
reduce stress, sleeping well, and many others.
beyondblue info line: 1300 22 4636
Order beyondblue resources, ask about signs, symptoms and available
treatments or where to get help in your area
Cancer Council New South Wales, Caring for someone with cancer. 2007,
Sydney. 48. Available from www.cancercouncil.com.au,
(02) 9334 1900
Department of Veterans Affairs. Carers Booklet: assistance for the
Veteran Community. 2005. Available from 133 254 anywhere in
Australia
Perlman G and Drescher J. A gay mans guide to prostate cancer. 2005:
Haworth Medical Press, Birmingham NY.
(Both sites have partner/family chat groups)
Reactions to prostate cancer: Information on depression and anxiety for

men living with prostate cancer and their partners. Available
from beyondblue infoline: 1300 22 4636; Prostate Cancer
Foundation of Australia 1800 22 00 99; or downloadable from
their websites.
Books
Acknowledgements
Bulletin boards, internet chat

New Prostate Cancer Infolink: prostatecancerinfolink.ning.com
Prostate Pointers: www.prostatepointers.org
Ashfield J. Taking Care of Yourself and Your Family: a resource book for
good mental health. 2008, Adelaide: Peacock Publications. 311.
Available free from the beyondblue info line: 1300 22 4636 or
website: www.beyondblue.org.au
This chapter was developed with the help of Sheila Duke, Trish Bartlett
and Elizabeth Allen of the Prostate Cancer Foundation of Australias
carers brochure working group.
beyondblue Guide for carers supporting and caring for a person with
depression, anxiety and/or a related disorder. Available free
from the beyondblue info line: 1300 22 4636 or website: www.
beyondblue.org.au
Cancer Council New South Wales, Living with advanced cancer: a guide
for people with advanced cancer, their families and friends.
2007, Sydney: Available from www.cancercouncil.com.au,
(02) 9334 1900
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Chapter 12: Palliative and End-of-Life

Care
In this chapter we discuss the nature of palliative care, approaches to

symptom control and some of the planning you can do and services
which are helpful.
12.1 Key points
Palliative care teams are experts in managing symptoms so

that the patient is comfortable and pain free. They can offer
care at any time in the progression of prostate cancer when
management of complex symptoms is needed.
Palliative care teams can arrange equipment and nursing and

other services for those being cared for at home.
Palliative care can be accessed through your doctor or you can

self-refer. Call 1800 660 055 to find a local service.
Pain control is an important part of care. Pain has many contributors

which all need to be addressed. Do not put up with pain.
Different types of medications are used for different levels of

pain. Make sure you have at least one weeks supply at all times.
Nothing in life is to be feared. It is only to be understood.

Marie Curie
Every cancer takes a different course at this stage and so care can be
very different from one person to another. There may be different types
of health professionals providing your care. A medical oncologist or
urologist may be coordinating your care and you may have occasional
treatments from a radiation oncologist. If problems such as availability
develop with a particular specialist, it is not unusual to go back to your
primary carer (GP) or seek help from another specialist. It is important at
this stage to have someone with whom you feel comfortable and with
whom you can discuss your overall treatment.
You and your partner can help to ensure pain relief is effective
by keeping a record using a pain thermometer. This helps
your doctor respond to breakthrough pain by changing your
medication plan.
We describe ways to deal with other symptoms such as

weakness, lack of appetite, nausea and constipation.
Your care continues to be aimed at controlling metastases where they

occur, preventing complications and treating symptoms. Managing
complications and symptoms can become quite complex. Palliative
care physicians and nurses are experts at this, and can help with the
management of symptoms both in hospital and at home. We are
fortunate that Australia has excellent palliative care services in each
state (see Resources).
Many complementary therapies such as guided imagery,

mediation, progressive relaxation can help you stay comfortable.
12.2 Palliative care
Advance care plans can ensure that your wishes are implemented
if you are unable to make decisions (see Appendix 8).
Do not hesitate to let others family, friends and your care

team take on things that have become a burden.
Your palliative care team will support family members and carers
throughout this time.
0175
If your prostate cancer or its treatments causes you to experience

unpleasant symptoms such as pain, difficulty sleeping, nausea, tiredness,
constipation, the approach used to control and manage these problems
is called palliative care.
Palliative care can be provided to you at any time during your treatment
for advanced prostate cancer and alongside other treatments.
0176
The World Health Organization (WHO) describes palliative care as:
An approach that improves quality of life for patients and families

facing the problems associated with life-limiting illness, through the
prevention of suffering by the early identification and impeccable
assessment and treatment of pain and other symptoms, physical,
psychological and spiritual.
The news that treatments are not working or are too risky can be
disturbing. This is the time that palliative care can be most helpful to you.
It can help you understand what to expect, how to prevent unpleasant
symptoms and how to live a life that provides meaning and value for you.
For some men, stopping anti-cancer treatments can provide a sense of
relief from treatments that are unsuccessful, unpleasant and sap energy.
Because palliative care has the ability to enhance your quality of life
it can also positively affect the course of your illness.
Palliative care:
works with you to provide relief from pain and other symptoms
uses a team approach to address your needs
offers support for your family
offers a support system that encourages you to live as actively as

possible until death
affirms life and regards dying as a normal process
intends neither to hasten nor postpone death

Palliative care is successful when you and your family feel
comfortable and supported.
12.2.1 Coming to terms with what is happening for you

It is important to know that you can request palliative care at any time in
your experience with advanced prostate cancer. It means that suffering
can be prevented or managed so that you can better cope with what is
happening to you. For example, most men are anxious about the effect
of their cancer on those closest to them.
My biggest worry was my wifes reaction when I was told that the
cancer had progressed. The palliative care nurse was able to help
her a lot.
0177
Although you may have gone through grieving since your diagnosis,
this may be a time that deepens your grief and you may become
withdrawn as you process your thoughts. This is a normal response.
Your palliative care team is available to help if you are unable to
progress to a calmer state of mind.
The palliative care team can assist you in making end-of-life decisions
such as how to ensure you are not given treatments you do not want,
and in making directions about the treatments that you would like to
have as part of your medical care (see Appendix 8).
12.2.2 Coming to terms with what is happening for your partner,

family and friends
Family members and carers also need information and support at this
stage. They now have equal access to a care team that:
encourages contact with spouses and family members
discusses how family carers may provide care for you if you are no
longer able to do everything for yourself
provides your partner/family and carers with information and

education about your care and your health progress
0178
coaches them through any problem that may occur for them or you
(refer A Caregivers Guide p.7. See Resources.)
advises your carer/partner and monitors their wellbeing
suggests when and how to get the supports you may need, such as
equipment aids, help with showering etc
Without palliative care I dont think I would have coped caring

for Phil. A carer
12.2.3 When to access palliative care
Whenever there are symptoms such as pain, anxiety, depression, fear,
spiritual distress, difficulties in deciding about treatments that are
offered or family issues related to the illness, it is a good time to be in
touch with palliative care. If things are just not right and you cannot
explain it, the palliative care nurse or doctor can help you work through
your problems and suggest helpful ways to proceed.
When you or your family are not coping with your symptoms and
needs, it is a good time to access palliative care.
12.2.5 Accessing palliative care

Usually your treating doctor or GP will refer you to the local palliative
care service. However, family members and patients can self-refer to the
local palliative care service. To find a service near you call 1800 660 055
or ask your doctor to refer you to your local palliative care service (see
Resources).
It is a good idea to contact a palliative care service early. Once the service
has your details, it can be quicker to initiate care when it is needed. The
palliative care team will work with your usual doctor.
12.2.6 Providers of palliative care

Palliative care is an integral part of the standard clinical care delivered by
health professionals. However, if a more specialised approach is needed
or your needs are not being met by your usual treating team, your
urologist, GP, oncologist, radiation therapist or visiting nurse can refer
you to specialist palliative care.
Palliative care is most successful when a team approach is adopted. Your
palliative care team may include any of the following:
12.2.4 Is there a time limit to palliative care?
specialist palliative care doctors and nurses
Palliative care is often required for short periods of time to help solve
different issues that occur as a result of your cancer. The issues can be
yours or your familys. Once the matter is addressed you will be referred
back to your GP and/or specialist for the appropriate cancer-specific
treatments and ongoing care. Sometimes you will have treatments such
as radiotherapy whilst being cared for as a palliative care client. You can
receive palliative care whenever you need it.
your general practitioner
specialist doctors, such as urologist, radiation oncologist, cardiologist
pharmacists
physiotherapists
psychologists, social workers, grief and bereavement counsellors
occupational therapists
pastoral care workers
The level of care and support you and your family need is generally
available in your own community.
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12.2.7 Where is palliative care practised and delivered?
12.2.10 Role for family and friends
Where possible, palliative care is delivered where the person wants

to be at home (70% of Australians), in hospital (some have special
palliative care units), hospice or aged care facility. Family, relatives and
friends are the main caregivers for the majority of people with cancer
throughout the course of the illness. Evidence shows that involvement of
palliative care services also improves the life and health of caregivers 21.
You may find that drawing on family and friends to help with tasks can
free you from some which are more physically difficult at this stage.
Remember that having something to do can be particularly helpful for
those who care deeply for you. Assigning tasks to friends or family can
make them feel able to play a practical role in helping you. If family are
overseas or remote, communication can be difficult, and one family
member can take on this role. Your partner or close family member
will also need support and someone to talk to. Consider talking to your
medical and palliative care team to ensure that this is in place.
12.2.7 What is a hospice?

A hospice is a place devoted to the care of people with life-limiting
illnesses. Hospices are staffed by specially trained doctors, nurses, social
workers, physiotherapists and volunteers who offer total care for patient
and family. Hospice admission may be needed for a time to manage
symptoms that have proved difficult to control. It can provide respite
for a carer who needs a break, or who has become ill or exhausted. It
is common for people to be discharged to home from hospices if their
healthcare needs can be met at home. If your community does not have
access to a hospice, the local hospital is usually able to provide palliative
care on a short- to medium-term basis.
12.2.8 Aged care facility

Staff in aged care facilities have palliative care training and resources
that allow people to receive excellent end-of-life care without having to
relocate. When necessary, specialist palliative care teams can visit and
consult to ensure the most appropriate and effective care is provided for
you and your family.
12.2.9 Supportive care at home

Your palliative care team can organise the equipment you need and
services that can help you to be cared for at home. This can include
walking and lifting aids, or help with showering, for example.
0181
This is also a time to enjoy the company of children and grandchildren

when you are feeling well. Some men find that taking the time to do
something enjoyable and meaningful with those who are important to
them and maintaining normal activity as much as possible is important
to their quality of life.
A sense of autonomy in decision making and a long history of keeping
medical information private may make it difficult for some men to
involve family members in their illness. If this occurs and becomes
a problem, particularly for a carer, an open discussion about the
extent of information sharing can be helpful, so that each person can
understand and respect the others wishes while recognising their own
needs.93 Partners and carers face their own stresses, responsibilities and
information needs that can go unrecognised.95
12.2.11 Symptom control at home

Pain
Not all men with advanced prostate cancer experience pain, but
in common with other advanced cancers, pain occurs in about
70% of people. We have discussed the role of radiotherapy and
bisphosphonates in controlling pain from bone metastases. Pain may
0182
occur from other sources as well as these and its control is important
in advanced prostate cancer.
The approach to pain control can vary depending on the intensity and
duration of the pain as well as its cause (see Table 12.1). The first step in
pain management is to have your pain professionally assessed.
Questions that your healthcare professional may ask when assessing
your pain concern:
the intensity of the pain (see below)
the site of the pain
the description of the pain eg, an ache, a stabbing pain, a burning

pain, a spasm of pain etc.
how long does the pain last?
what brings it on or makes the pain worse?
does the pain prevent you sleeping, eating, walking? Etc.
what helps relieve the pain?
apart from making you hurt, how does the pain make you feel?
Understanding the level of pain

There are several measures that help the doctor to understand the
level of pain. One of these is the pain thermometer a 10-point
scale shown beginning with 0, no pain at all to 10, the worst possible
pain you can imagine.
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Table 12.1: Types of treatments appropriate for different levels of pain.

Level
Description
Treatment
Names of drugs
No pain at all
None
12
Annoying but bearable like a common headache
Over-the-counter remedy or
even ignore the pain
paracetamol, ibuprofen
34
Too painful to ignore; you will look for a remedy
Prescription medicine
codeine,* oxycodone*
56
Interferes with your ability to focus on normal activities:

stronger relief needed
Larger doses of prescription

medications, if needed; longacting prescription medication
oxycodone*
morphine*
fentanyl*
You require pain control that

is continuous
79
10
Pain is almost unbearable. Dealing with pain has taken over

your life. You cannot do normal activities
May require hospitalisation.

Intravenous medications
ramped up to find effective
dose and use of medications
that work on specific pain
mechanisms in combination
with the pain-specific drugs
such as morphine, etc.
morphine*, oxycodone*, fentanyl*
Worst pain youve ever had; unbearable
Increased and/or multiple

drugs, surgical or invasive
options
Combinations of the above and constant

attention from a trained health care
professional until your pain is relieved
Drugs that may be added at any time in

your pain experience, according to the
cause (eg nerve irritation):
antidepressants
steroids
anticonvulsants
local anaesthetic
(called adjuvant pain control)
* prescription only Table drawn from Institute for Continuing Health Care
Education: Living with advanced prostate cancer96
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Medications that give relief from pain are called analgesics. Two types
of analgesics are called opioids and non-opioids by the WHO. Nonopioids include over-the-counter medications such as paracetamol and
ibuprofen. Opioids are used for moderate to severe pain and include
morphine, fentanyl and oxycodone. Note that all opioids have the
potential to cause constipation laxatives are normally required to be
taken on a regular basis to control constipation.
partner or family member can help with this. Do not be afraid to

contact your care team and ask for assistance if the plan needs to be
updated. For example, you are experiencing breakthrough pain and
need to modify dosages or delivery methods.
Mild pain is easier to control than severe pain, so keep to your

pain medication schedule even if you are not feeling pain. This may
involve setting an alarm to wake for medication at night. However,
long-acting medications are available to such disturbances. It also
means that you should report pain and not tough it out.
Multimodal methods or using several approaches at once can be most

effective. Many of the complementary therapiesprogressive relaxation,
guided imagery, meditation, heat, ice, gentle exercise and hypnosiscan
help to control or modify the pain. Your carer can help you with much of
this. We recommend the chapter on complementary care in A caregivers
guide (see Resources) for details of how to use some of these.
Be prepared. Make sure you have at least one weeks supply of

medications at all times. Make sure you have contact details and
know who to contact on your care team should the situation change.
Continue with your life the activities that give you distraction,
purpose and joy. In their booklet Living with Advanced Prostate
Cancer, the US-based Institute for Continuing Health Care Education
states: Athletes, soldiers, artists and volunteers know that when you
are involved and engaged in pastimes and goals that are important
to you, you tend to be less aware of pain.
Some useful things to remember about pain control:
You may have other symptoms or circumstances that contribute

to pain such as nausea, worry, fear, boredom and loneliness, which
should also be addressed.
Depending on these factors, your doctor may recommend a

particular treatment or medication and way of taking it (tablets,
injections, patches, suppositories are possible).
It helps to keep a record or journal of the medication, any positive

or negative side effects, and the level of pain while you are on it. If
you experience a return of pain before the next dose is due, this is
called breakthrough pain. Keeping a record helps with ensuring your
treatment plan is effective.
Whenever you have pain that is present around the clock, your pain
medication needs to be formulated for continuous relief. All opioids
can be administered in this way either as tablets, infusions or patches.
Taking opioids (such as morphine) for cancer pain does not cause
addiction your pain medication is part of your treatment.
You have an important role in achieving good pain control!
0187
Communicate your pain levels to your care team. Recording your

pain levels and medication is an excellent way of letting the team
know your pain status and the effectiveness of the plan to date. Your
What you can do if your pain is not controlled and the care provider
(doctor or other) is not responding to your distress
If your pain disables you, ask your carer to do the following for you.
Do not give up until there is an acceptable response and you (and
your carer) feel comfortable and supported.
0188
Contact your health care professional again
Describe your pain/distress
Describe the effect of your pain medication or the pain you are
experiencing
Request an urgent reassessment
People receiving palliative care services need to feel comfortable in

contacting their professional care providers at any time because there is
a clear understanding that issues affecting your comfort are paramount
and can occur at anytime.
Your palliative care service provider will make sure you have a 24-hour
number to call and a plan for this type of emergency. Palliative care
service providers plan for the worst whilst hoping for the best!
12.2.12 Other symptoms

Symptoms such as pain and tiredness can be caused by the cancer or
arise out of treatments or complications (new conditions) caused by the
cancer or treatments. Some of these symptoms are shown in Table 12.2.
0189
0190
Table 12.2: How to manage symptoms

Symptom
Description
Ways to manage
Fatigue
Persistent feeling of tiredness or a complete lack of energy

that is unrelieved by rest or sleep
Ask your doctor or nurse to assess your fatigue for any reversible causes
such as depression, anaemia, worry/anxiety, treatment side effects, infection
etc.
Fatigue is a common symptom in advanced cancers and

may not have an identifiable other cause
Plan activity when energy levels are best
Prioritise your activities
Do not do too many activities in a short period of time
Try mild exercise such as walking to help you feel more energised
Establish good sleep habits
Avoid stimulants such as coffee and alcohol before bed
Practice relaxation techniques
There are some medications such as low dose corticosteroids and psycho
stimulants that may help your doctor can discuss and advise you.
Weakness
Loss of strength
Tiredness after activities that were once easy, eg moving
about, moving in bed, dressing, bathing
Managing weakness is similar in many ways to managing fatigue. The

treatment for this symptom is to reverse the reversible and find a balance
between rest and activity that is restorative, calming and healing.
Consultation and assessment with your doctor and nurse are important in
managing this symptom.
Table continues next page
0191
0192
Table 12.2: How to manage symptoms (continued)

Symptom
Description
Ways to manage
Lack of
appetite
(anorexia)
Absence of interest, desire or energy to eat
Medical assessment and treatment of reversible causes
Your doctor and nurse can provide valuable insights and

guidance for dealing with anorexia
Check that dentures still fit correctly
Provide nutritional support, especially orally (refer to A Caregivers

Guide in Resource section)
Ensure any food is taken in the normal social setting if possible, even if
only small amounts are consumed
Dont focus on quantity as much as balance and enjoyment
Dont overwhelm with a large array of special foods it is better to eat

serves of well-liked, nutritious foods
Small serves are less off-putting
Check that the smell of the food is not off-putting prepare food
where cooking smells can be lessened where possible
Lack of appetite can be more upsetting for family and caregivers than for
you, however it is a normal part of the end stage of advanced cancer.
Constipation
When you have a bowel motion a stool is passed.

Constipation means difficulty passing a stool
Common causes of constipation include not drinking sufficient fluids or

eating enough food, lack of fibre in the diet, insufficient physical activity,
slowing of your gut cased by medications such as morphine, codeine,
oxycodone, etc. and certain diseases.
-
Try and correct any of the above that you can
Take laxatives if you are on opioids your doctor or nurse can advise
the best ones for you and your problem
If you have no appetite, weakness and fatigue, do not eat high-fibre foods
unless you can easily drink sufficient water. Call for help if you notice blood
in or around the anal area or in the bowel movement.
0193
0194

Symptom
Description
Ways to manage
Diarrhoea
The passing of loose or watery bowel movements 3 or

more times a day
Treatment is aimed at ensuring the bodys fluid and chemical balance is

maintained and keeping the bowels moving. Diarrhoea may be overflow of
liquid bowel movement around hard bowel movement and is a consequence
of untreated constipation. Take fluids often when diarrhoea is present.
Avoid foods that have a stimulating effect on the bowel such as whole
grains, fried and greasy food, raw fruit/ juices/vegetables, carbonated drinks,
strong spices and herbs, caffeine, alcohol and tobacco products when
diarrhoea is present.
Call your doctor/nurse if you:
Mouth sores,
funny taste
Little cuts or ulcers in the mouth
have six or more loose bowel movements for two days or more
notice blood in or around the anal area or in the bowel movement
at any time if the diarrhoea makes life unmanageable for you or your carer
Possible causes: chemotherapy, radiation therapy, infection, lack of fluids,

poor oral hygiene, oxygen therapy, alcohol and tobacco use and some
medications.
-
Check inside the mouth twice a day for ulcers, white patches (thrush)
Report changes in taste sensations to your doctor or nurse
30 minutes after eating clean teeth and rinse mouth with water or
weak solution of teaspoon salt, 1 teaspoon bicarbonate of soda and
4 cups water. Use a soft toothbrush.
Only use commercial mouthwashes ordered by your doctor

Pins and
needles,
numbness
Occurs when the cancer affects bones in the spine and

pressure is placed upon the nerves in the spine
Back pain is often the first sign of spinal cord compression.

If back pain, pins and needles or numbness occurs medical treatment
is needed urgently to prevent paralysis (usually steroids and radiation
treatment).

0195
0196

Symptom
Description
Ways to manage
Difficulty
sleeping
Inability to go to sleep, waking after a couple of hours or

less, restlessness, disturbing dreams that wake you
Being relaxed as possible at bedtime helps, (warm bath, warm milk,

relaxation techniques) can all help at this time and it can be helpful, and it
is quite OK, to take sleeping pills.
If you have a lot on your mind it is good to speak with someone about
anything that is worrying you this is half way to solving any problem.
Incontinence
Incontinence is the accidental or involuntary loss of

urine from the bladder (urinary incontinence) or bowel
motion, faeces or wind from the bowel (faecal or bowel
incontinence)
(Continence Foundation of Australia definition)
Treat causes where possible.

Continence needs to be controlled to maintain your dignity, provide comfort
and prevent the breakdown of skin. There are many ways this can be
achieved your doctor and nurse will be able to work with you to provide
the best solution. For skin comfort there are many creams that are waterrepellent and soothing.
Leakage that is not sufficiently contained using pads and other products
may require a urinary catheter or a condom with a drain attached.
Nausea or
vomiting
Feeling sick with or without vomiting

Anyone who has been sea-sick knows how overwhelming
this feeling can be
Nausea and vomiting can have many causes, including illness, medication,
irritation of the digestive system, infection, constipation or movement.
Sometimes it may have no connection to advanced prostate cancer and
could be influenza or food poisoning.
In life-limiting illness, nausea and vomiting may be more severe and so if
present need prompt assessment and treatment. Anti-emetics (drugs to
prevent vomiting) such as Maxolon or Stemetil may be prescribed.
-
Keep a record of nausea (present/absent) and the amount and

appearance of vomit in your record.
Notify your doctor or nurse immediately if blood or material that

resembles coffee grounds is in the vomit.
0197
Try and sip fluids or ice chips to maintain hydration while you are awake.
Notify the doctor or nurse if you cannot keep medications down.
0198
Your palliative care team can discuss any symptoms with you and your
partner and the best approach to managing them. Often specialist
nurses, such as a palliative care nurse or continence nurse, can help if
problems arise. Contact details are given in the Resources section.
12.3 Things you can do for the future

A new idea that has been developed recently is to leave thoughts and
messages for family members and loved ones. Most people prepare a
legal will to pass on their material possessions but many want to leave
more than just things. They want to leave a sense of themselves, of their
love, their beliefs, their memories and their experiences. They want to
leave a will from their heart, a heart will.
This is not difficult to do and can take any form you like. You could leave
letters for your loved ones, record a tape, make a video, compile a CD of
your favourite songs, create something online or just buy a notebook
from the newsagent and put down thoughts, bits of family wisdom or
life advice for the next generation. You could get a shoe-box and fill it
with significant photos and cards for special birthdays in the future. You
can use your own creative ideas to leave behind a lasting gift of love. A
heart will is a way to be heard when your voice is still.
12.5 Conclusions
In this chapter, we have described some of the care options and
resources that can help you to be comfortable and active as long as
possible. Planning and preparation can help deal with some of the issues
that may arise. It is a time to let others family, friends and your care
team take on things that have become difficult.
Your loved ones can also draw on your care team should they need them.
Palliative care professionals understand fully the participation of your
family in providing you with support and care and it is their goal to make
sure your family is treated with understanding and compassion for as
long as is needed.
12.6 Resources
Palliative care organisations
Nationwide contact telephone number is 1800 660 055
Palliative Care Council of NSW
T: 0403 699 491
E: info@palliativecarensw.org.au
W: ww.palliativecarensw.org.au
Palliative Care Council of SA

T: (08) 8291 4137
E: pallcare@pallcare.asn.au
W: www.pallcare.asn.au
Palliative Care Queensland

T: 07 36330096
E: info@pallcareqld.com
W: www.palliativecareqld.org.au
Tasmanian Association for

Hospice and Palliative Care
T: 03 6234 7577
E: enquiries@palliativecareqld.org.au
E: tahpc@associationoffices.com.au
12.4 Advance care planning

In most states and territories you can make advance plans for your
care that can be implemented if you are unable to make your own
decisions. These plans are known by various names: wills, enduring
powers of attorney, guardianship orders, advance directives, living
wills, medical powers of attorney, etc. Some of these terms are
taken from applicable legislation; others are standard terms in
everyday use. See Appendix 8 for descriptions of these terms, how to
implement them, and other legal and financial topics.
0199
0200
Palliative Care Victoria

T: 03 9662 9644
E: info@pallcarevic.asn.au
W: www.pallcarevic.asn.au
Palliative Care WA
T: 08 9212 4330
E: pcwainc@palliativecarewa.asn.au
W: www.palliativecarewa.asn.au
Palliative Care ACT

T: 02 6273 9606
E: actpc@bigpond.com
Palliative Care NT
T: 08 8922 8824
E: moq13026@hcinternet.com.au
Other resources
Aged Care Australia: www.agedcareaustralia.gov.au
Commonwealth Governments Aged Care Website
Caresearch: www.caresearch.com.au/Caresearch/Default.aspx
Website for information on all aspects of palliative care
Peer Support
Books and guides

A caregivers guide: a handbook about end-of-life care. Palliative Care
Council of SA Inc. 2007. 202 Greenhill Rd, Eastwood, 5063
Food and cancer: a guide to nutrition for people with cancer. Cancer
Council NSW. Available at www.cancercouncil.com.au/editorial.
asp?pageid=192
Managing Cancer Pain, Pain Relief Foundation.
Available at www.painrelieffoundation.org.uk
Overcoming and controlling cancer pain. Booklet from Cancer
Council NSW available at: www.cancercouncil.com.au/html/
patientsfamiliesfriends/livingwithcancer/cancerpain/downloads/
overcoming_cancer_pain.pdf
Understanding palliative care: a guide for people with cancer, their
families, carers and friends: Cancer Council NSW. Available at:
What is anorexia? Canadian Virtual Hospice: www.virtualhospice.ca
0201
0202
Appendix 1: Staging and the TNM System
Appendix 1: Staging and the TNM

System
Staging refers to finding out how far the cancer has spread.
This is investigated in a number of different ways. Initially, at the digital
rectal examination, the surgeon notes whether he or she can feel the
tumour as a nodule or irregularity on the prostate, and if so, whether it
extends beyond the prostate itself. This is referred to as clinical staging.
However, the exact stage is not easy to determine from a clinical
examination. Sometimes the number of biopsy cores with cancer in them
is reported by the pathologist, and gives an indication of the extent of
the cancer. If surgery is completed and the prostate removed, staging
can be determined more precisely by pathological (using a microscope)
examination of the prostate tissue and surrounding organs that have
been removed. This is called pathological staging.
Stage NX Regional lymph nodes cannot be assessed
Stage N0 No regional lymph node metastasis
Stage N1 Regional lymph node(s) metastasis
Stage MX Distant metastasis cannot be assessed.
Stage M0 No distant metastasis
Stage M1 Distant metastasis
Stage M1a Distant metastasis other than regional lymph nodes
Stage M1b Metastasis to bone(s)
Stage M1c Other site(s)
Stage pM1c Metastasis to more than one site
TNM system
This is a system for recording how far the cancer has spread. T refers to
tumour, N to node and M to metastasis. The system is used around the
world to stage cancers that develop as tumours and metastasise. In the
TNM system for prostate cancer, this more detailed version shows the
stages for advanced prostate cancer. Prostate cancer does not necessarily
progress in a sequential manner, as this implies, however.
Stage T1T2c Organ-confined disease
Stage T3a Extracapsular extension of the tumour
Stage T3b Invasion of the seminal vesicle(s)
Stage T4 Tumour fixed or tumour invading adjacent structures

other than seminal vesicles (eg, bladder neck, external sphincter,
rectum, levator muscles, and/or pelvic floor)
0203
0204
Appendix 2: The Gleason Grading System
Appendix 2: The Gleason Grading

System
Grading systems score how abnormal the tissue looks under the
microscope. This is also related to how fast the cancer is likely to grow.
Sometimes a pathology report refers to tissue as poorly differentiated.
This is another way of saying that the tissue does not look like the
normal tissue (fully differentiated).
The main system for grading tissue taken at biopsy is the Gleason grading
system. The higher the Gleason score, the more aggressive the cancer,
and the faster it is likely to grow. The pathologist identifies the two most
common tissue patterns and gives them a score from 1 (most normal or
differentiated) to 5 (most abnormal or poorly differentiated). The Gleason
score is given as two numbers added together to give a score out of 10
(for example, 3 + 4 = 7). The first number is the most common pattern
seen under the microscope and the second number is the next most
common. This means that a Gleason 4 + 3 is more aggressive than 3 + 4.
A total Gleason score of less than 6 is rarely reported.
Gleason scores reflect the risk posed by the cancer.
Low risk: low grade, well-differentiated tumour, Gleason score 26
Intermediate risk: intermediate grade, moderately differentiated,

Gleason score 7
High risk: high grade, poorly differentiated, Gleason score 810
These risk categories are those adopted in the American Urological

Association 2006 Clinical Practice Guidelines for Localised Prostate
Cancer and the National Cancer Control Network Practice Guidelines in
Oncology version 2.2009 Prostate Cancer:
www.nccn.org/professionals/physician_gls/PDF/prostate.pdf
0205
0206
Appendix 3: PSA rising What Does It Mean?
Appendix 3: PSA rising What Does It

Mean?
After surgery or radiotherapy for localised prostate cancer, the PSA
usually stays low for many years or indefinitely. But if it starts to rise
again, some men say they wonder what it means. Does it mean Ill be
dead tomorrow? they ask. The answer is definitely No. In fact a low PSA,
even if rising, usually means the cancer is still at an early stage, and it
can be many years before it progresses to the next stage. Several studies
have looked at this question
For those who are interested in prognosis, a number of nomograms

are available. These are statistical equations that assess the likelihood
of an event given your particular clinical details. Some of these can
be accessed online at www.mskcc.org/mskcc/html/10088.cfm. You can
download a worksheet, which you and your doctor can complete, then
feed this information in to the program to calculate your risk of PSA
recurrence and other outcomes after surgery and radiotherapy.
One study of men undergoing radical prostatectomy found that at 15

years, 82% of them remained free of metastasis. For those men who did
develop metastases, the median time after the first signs of PSA rising
to the development of metastases was 8 years.6 Two other studies found
that for men who did ultimately died from prostate cancer, the median
time this occurred after surgery was 1416 years (median means 50%
experienced longer, 50% shorter times).7, 97
This means there is often ample time to make changes in lifestyle and
undertake the treatments that may alter the course of the disease. We
discuss these in Chapters 4, 5 and 6.
0207
0208

Resistance or strength training aims to develop the size and strength of
skeletal muscle by performing effort against an opposing force. These
exercises increase muscular fitness and muscle mass. Additional benefits
include improving bone density and functional capacity (ability to enjoy
activities requiring strength such as gardening).
Ask your doctor for guidance in choosing the right type and amount
of exercise for you. If you have unstable bone lesions (areas of bone
weakness) or other medical problems such as cardiovascular disease
you may not be able to do all kinds of exercise.
Figure A4.1: Examples of resistance exercises
A workout aims to work all the major muscle groups and so may have
as many as 810 exercises (see Figure A4.1). A biceps curl exercises the
muscles at the front of the upper arm and a triceps extension the back of
the upper arm and so on.
A repetition maximum (RM) is the maximum weight you can lift once.
It is always safer to warm up, rather than go straight to the maximum
training intensity, so we recommend that you begin with 1215
repetitions at just under half your RM. Then increase that to 6070% of
your RM and repeat it 812 times. In a complete workout, you would do
23 sets of these repetitions for each muscle group and aim to workout
at least twice a week.
This is just an example however. It is important for you to choose the
level that best suits you and wise to do it in consultation with your
doctor or an exercise professional.
The table shows examples of resistance exercises that you can do in your
own home. For each muscle group:
Step 1: work out your Repetition Maximum by gradually increasing

the weight to be lifted until a maximum weight is identified
Step2: warm up with 1215 repetitions at 4050% of your RM
Step 3: exercise with 812 repetitions at 6070% of your RM
Step 4: do two to three sets of Step 3.
0209
0210
Figure A4.1: Examples of resistance exercises (continued)
0211
0212
Appendix 5: Body Mass Index (BMI)

Calculator
The graph below (Figure A5.1) provides a simple way of determining
if you have a healthy body weight for your height. Just measure
your height (cm) and weight (kg) and see which category you are
in underweight, normal, overweight or obese. Many Australians are
overweight or obese if you are in either of these categories talk to your
doctor about losing some weight.
Figure A5.1: Weight status based on BMI
Source: American College of Sports Medicine (ACSM) Recommendations and

Position Stand, www.exrx.net/WeightTraining/Guidelines.html
Author: Tim Morris, Physiotherapist, Repatriation General Hospital
Source: www.chartsgraphsdiagrams.com/HealthCharts/bmi-status.htm
Permission received 26.3.09 josephbcasey@gmail.com
0213
0214
Appendix 5: Body Mass Index (BMI) Calculator
Appendix 6: Models of Resistance to Androgen Deprivation Therapy
Appendix 6: Models of Resistance to

Androgen Deprivation Therapy
Understanding the events that occur in the cell at the molecular level
can be helpful in understanding why prostate cancer stops responding
to Androgen Deprivation therapy despite low-circulating testosterone
levels. A protein in the prostate cancer cell, called the androgen receptor
is active at every stage in the progression of prostate cancer.
We are not sure of the exact way in which the cell continues to function
without normal circulating levels of testosterone, but the following
models have been proposed.98 All suggest that changes occur in the way
the androgen receptor in the prostate cancer cell operates. These are
shown in the diagram and explained below.
Free testosterone in the circulation enters prostate cells and is converted
to dihydrotestosterone (DHT) by the enzyme 5 alpha-reductase. DHT then
binds to the androgen receptor (AR), a protein that resides initially in the
cytoplasm of the cell (the jelly-like substance that surrounds the nucleus).
The AR complex is then translocated or moved to the nucleus where it
activates genes responsible for cell growth and survival (AR genes).
There are currently five models of changes which happen during the
prolonged absence of testosterone and DHT that can lead to cancer
re-growth.
a.
0215
b.
Promiscuous. The AR gene becomes mutated so that AR protein

can bind steroid hormones other than testosterone. Cells with
this mutation survive and grow normally even if testosterone
levels are low.
c.
Outlaw. The AR can be short-circuited into an active state by

other pathways such as by growth factors and cytokines (proteins
that serve as messengers between cells).
d.
Bypass. Prostate cancer cells that are deprived of androgens

develop new ways in which to make, accumulate or prevent
degradation of testosterone, thus bypassing the dependence on
circulating levels produced by the testes.
e.
Lurker cells. Altered expression of co-activators or corepressors of the AR. A very large number of molecules within the
nucleus can influence activity of the AR. Changes in the level of
these co-regulators may lead to a super-active AR and contribute
to androgen independence.
There is some evidence supporting all of these mechanisms.

Understanding these pathways can lead to the development of
drugs which target key steps in the process. For example a new drug,
abiraterone, is currently being trialed with some success. This drug
targets a key enzyme necessary for the synthesis of androgens in cells,
including in cancer cells (mechanism d).98
Hypersensitive. The AR gene is amplified (so that there are many

copies) resulting in more AR receptor protein in the cytoplasm. This
causes increased sensitivity to low levels of testosterone or DHT.
0216

In its fact sheet 34 on Prostate Cancer and Depression/Anxiety,
beyondblue gives the following check list:
You may be depressed if for more than TWO WEEKS you have
Felt sad, down or miserable most of the time
Lost interest or pleasure in most of your usual activities
If you answered YES to either of these questions, complete the symptom

checklist below. If you did not answer YES to either of these questions, it
is unlikely that you have a depressive illness.
Have you:
The androgen receptor (AR) is shown in the cytoplasm of the cell. When
an androgen such as DHT (comes from testosterone) binds to it, the AR
enters the nucleus of the cell and combines with target genes on the
DNA in the nucleus that trigger cell growth and multiplication.
Had a change in weight?

Or Had a change in appetite?
Experienced sleep disturbances?
Felt slowed down, restless or excessively busy?
Felt tired or had no energy?
Felt worthless, excessively guilty OR
Felt guilt about things without a good reason?
Had poor concentration OR
Had difficulties thinking? OR been very

indecisive?
Had recurrent thoughts of death?
With androgen independence, this may happen in many different ways,

shown as a) to e) in the diagram and explained in the text.
Adapted by permission from Macmillan Publishers Ltd: Nature Reviews Cancer 1:
3445 copyright 2001 License 2009.
Reference: Feldman, B. and D. Feldman, The development of androgen-independent
prostate cancer. Nature Reviews Cancer 2001. 1(October): p. 3445.
0217
Tick if yes
Add up the number of ticks for the total score
0218
Appendix 6: Models of Resistance to Androgen Deprivation Therapy
Figure A6.1: Models of androgen independence
4 or less: You are unlikely to be experiencing a depressive illness

5 or more: It is likely that you may be experiencing a depressive illness
Its important to note that scores provide only a rough guide as to
whether you may have depression. If you have ticked five or more of
these statements, consult a health professional as you may have a
depressive illness
Source: beyondblue Fact Sheet 34: Prostate cancer and Depression/Anxiety
www.beyondblue.org.au
References: American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, 4th ed (DSM-IV). Washington, DC: APA,1994; and, International
classification of diseases and related health problems, 10th revision. Geneva, World
Health Organization, 19921994.
It is important to prepare for decision-making regarding your care if you

are unable to make your own decisions. The various options for this are
described below. This appendix also describes some of the legal, financial
and care matters you may need to consider while you are feeling well.
It can be helpful to plan these at an early stage, so you dont need to be
bothered if the cancer progresses.
Decision making advance care planning
This section will briefly outline the basic sorts of plans that you can
make. You will need to check the state of the law where you live your
local palliative care association, your GP, aged care provider or palliative
care team can help you do this. It is important to discuss your advance
care plans with those who are close to you so that they understand
why you have made certain decisions this can help lessen confusion or
conflict later.
Guardianship
When you are not able to make decisions for yourself, for example,
about your lifestyle, your healthcare and your daily needs, an appointed
guardian can make these decisions on your behalf. Your guardian may
need to exercise these powers for several years if you live a long time
without the capacity to make informed choices about your lifestyle,
financial and healthcare needs.
In some places you can appoint your own guardian in advance, and this
is recommended whenever possible. In most states and territories a court
or a board convened by government applicable to where you live, will
appoint a guardian, when required, if you have not already appointed
one in advance
0219
0220
What does your score mean?

Assuming you answered YES to questions 1 and/or question 2
Advance care directive

In some states and territories advance directives are known as living wills
or anticipatory directions. Using an advance directive you can specify
the medical care you would like when you are dying and unable to make
or communicate your decisions. People commonly direct that they want
futile medical treatments withdrawn at this time. Some make general
statements eg. I do not want any treatment that will delay my dying
process, while others provide details e.g. I do not want artificial feeding.
Not all states and territories have legislation governing the use of these
documents. In some places you can register your advance directive or
medical power of attorney with a central office, which then makes this
information available to doctors and other healthcare providers. It is
important that your professional caregivers and your spouse/partner
have copies of your advance directive.
If in doubt about what you need to do ask your health care
professional who will have knowledge of local courses of action and
availability of contacts.
Medical power of attorney
There is wide variation between Australian jurisdictions on how to
appoint a medical agent or a medical attorney the name itself
is different in various parts of the country and the medical agents
legislated powers also differ. The basic concept is that you are able to
appoint in advance a person or people who are empowered to make
healthcare decisions on your behalf when you are no longer to able to
make those decisions for yourself. You can also specify conditions which
your agent or agents must observe when they make decisions.
Typically a medical agent would be your spouse or partner, a son,
daughter or other family member or a close friend who is familiar with
your wishes. Doctors will ask this person to make decisions about your
0221
healthcare if you are unable to make those decisions yourself and in

this case it is legitimate for medical agents to refuse futile medical
treatments on your behalf when you are dying, consistent with your
expressed wishes.
Legal and financial matters
Enduring Power of Attorney
An Enduring Power of Attorney is a document that appoints a person
to act on your behalf in financial matters if you become unable to
act for yourself. In some Australian states and territories you are able
to complete a simple pro-forma document to appoint your financial
attorney . In others its best to consult with a solicitor or accountant to
ensure the format of the document is valid and correct.
When completing an Enduring Power of Attorney you must be of sound
mind, alert and be able to make decisions a document completed by a
person who does not understand the implications of the appointment
is invalid and anyone acting on the Power of Attorney order is acting
without authority.
Will
A will is a plan, made while you are alive, which stipulates what should
happen to your property after you die. If you die without a willthis is called
intestateyour state or territory government, working through the office of
the Public Trustee, will divide your property according to set formulas.
Make your own will kits are available in many places and if your plans
are simple or straightforward, these will suffice. If your plan or financial
situation is more complex, its probably best to consult with a trusted
professional advisor about your will this could be a solicitor or an
accountant. Its also helpful to discuss your will with those around you.
0222
In Australia there are reputable Public Trustees that can assist. See local
guides/phone books/Google for your area.
otherwise require full-time nursing care, should a carer not be available

to provide this.
When you appoint an Executor to see your wishes are carried out after
your death, this person or persons has (have) no powers to speak or act
on your behalf until after your death.
Carer Allowance may be backdated for up to 12 weeks prior to the claim

being lodged.
Carer Payment
A Will can also be a place where you write down specific wishes for
your funeral.
Financial aid
There will be costs attached to many of the services that you can access
as you receive palliative care. Dont be afraid to ask any member of
your healthcare team about the costs of services: its better to know in
advance than to receive a bill you werent expecting! In some cases you
may be able to negotiate a cost reduction if you feel your circumstances
warrant it. If you are having financial difficulties, a social worker can
give you advice.
Carer Payment is an income support payment for carers who, because

of the demands of their caring role, are unable to support themselves
through substantial paid employment. This payment is income and assets
tested both for the carer and the person being cared for.
A doctor or health care professional must also assess the person you
care for.
Carer Payment is granted from the date the claim was made with Centrelink.
Note: If you currently get an income support payment from Centrelink
you need to decide which payment is best for you. If you need advice on
which payment is best for you call Centrelink on 13 2717.
What financial support is available?
There are two Australian government-funded support payments that you

may be able to access. Centrelink administers both:
If you get a Carer Payment, you can work, train or study for up to 25
hours per week, including travel time.
You can also get a Pensioner Concession Card that entitles you to
low cost medicines and you may also be entitled to Rent Assistance,
Telephone Allowance and Utilities Allowance.
To claim Carer Allowance and/or Carer Payment, you and the person
you care for must be Australian residents.
You can access forms from your GP or from the visiting nurse,
domiciliary care or community health service and also from
Centrelink on 13 2717.
www.centrelink.gov.au/internet/internet.nsf/forms/sa336.htm
Carer Allowance
You may obtain a Carer Allowance if you personally provide care and
attention on a daily basis to a person who needs a lot of additional
care due to a severe medical condition. To qualify, the care can be
provided in either your home or the home of the person. The payment
of Carer Allowance is not income or asset-tested, and is not taxable.
Carer Allowance can be paid in addition to Carer Payment or any other
Centrelink payment. The condition of payment is that the person would
0223
0224
Tax free lump sum superannuation

The federal government has announced that it will allow tax-free
treatment of lump sum payments from both taxed and untaxed funds
paid to persons with terminal medical conditions this applies to
payments after July 2007.
www.ato.gov.au/superprofessionals/content.asp?doc=/content/00132334.
htm&mnu=46101&mfp=001/149
Equipment costs
Equipment can be made available through most domiciliary and
community health care services who may charge fees for services, but
these may be waived if financial hardship is assessed. In many cases if
your domiciliary equipment provider cannot supply the equipment needed,
private hire agencies that charge reasonable fees can be recommended.
Medications
Some prescribed medications are not available from the local community
pharmacy. In extreme circumstances a hospital may supply what is
needed with the help of a palliative care doctor or specialist. In the case
of more expensive medications, the doctor, visiting nurse or palliative
care worker may help you find a supplier who charges less than the local
pharmacy or you may also be able to negotiate the cost with the local
pharmacist. Dont hesitate to discuss medication costs if they are proving
to be a financial burden. Your visiting nurse or GP can make suggestions
and investigate options that are more financially accessible in your case.
Doctors visits at home

General practitioners
Many will bulk bill for the visit, but some may charge a fee in excess of
this amount.
You need to check with the doctor about their billing arrangements.
Specialists
In certain circumstances a specialist will undertake a home visit and you
will need to check what the cost will be.
Visiting Nurses
Most visiting nurse services will charge a Health Service Fee to all clients
eligible to pay. The fee is a contribution towards the costs of services
provided and is usually a set amount per 28 days.
Private home nurses
Fees vary between agencies. Some health insurers will cover the cost of
a visiting nurse service which may include overnight nursing care when
needed. With permission, contact can be made with the patients health
insurer to find out if a palliative care financial package is available.
However, the person or family may wish to use his or her own funds for
these services. Please ask your palliative care team member for a referral
to a service that is experienced in palliative nursing care.
Other financial help

In South Australia the Palliative Care Council has some funds available
for specialised home nursing. In your area check with your visiting nurse
for availability of other funds to help you care at home.
Eligible veterans and war widows can seek assistance from the Department
of Veterans Affairs for services, equipment and, in some cases, medications.
Some GPs will visit at home, patients who are unable to attend their surgery.
Your visiting nurse or palliative care team member can organise this for you.
0225
0226
Commonwealth Carer Respite Centres coordinate access to respite

services in your local area. They can give you advice about respite
services and find the service closest to you. They can also help get the
right respite services. Commonwealth Carer Respite Centres work with
carers to plan sensible approaches to respite and other support needs
and also arrange 24 hour emergency respite care.
Appendix 9: What Questions Could I

Ask?
Commonwealth Government Carer Respite
The following questions were contributed by one of our consumer

members and may help you raise issues with your care team.
What is best for me at this stage?
Tell me the risks of no further treatment.
Is further treatment likely to be any advantage to me?
If no further treatment is undertaken, how is the disease likely to

affect me?
Centrelink, on behalf of the Commonwealth Department of Family and

Community Services, help people coping with bereavement. Payments
can be in the form of Bereavement Payments, Bereavement Allowance
and Widow Allowance.
What is the estimated rate of progression of the disease?
Can rate of progression be retarded?
How much longer do I have to live?
What, if any, are the choices of treatments available?
People may also be able to claim a supplementary payment such as

Rent Assistance, Remote Area Allowance, Pharmaceutical Allowance and
Telephone Allowance. For more detailed information, contact Centrelink
Tel. 13 2300
What complications are likely to arise, and what are the likely effects
from treatment thereof?
What are the likely effects on quality of life, and how may I maintain
such quality of life?
Internet: www.centrelink.gov.au/internet/internet.nsf/site_help/az.htm to
check the payment required.
Are co-morbidities (or existing illnesses) significant in the proposed

treatment of advanced disease?
Access to the deceaseds bank accounts (other than joint accounts) is

not available until probate has been granted. However, banks will release
funds to meet funeral expenses (contact your bank to understand their
requirements). The executor must sign a statutory declaration and the
bank will pay the money directly to the funeral director.
What about pain management?
Are there any clinical trials in which I could participate?
Telephone 1800 059 059 from anywhere in Australia.

Bereavement Payments
0227
0228
How do I prepare them for the last stages of my life? (assuming

death from prostate cancer)
How do they manage their stress?
Palliative/hospice care
Who identifies the critical point in my care, particularly when
hospice care is necessary?
Who will be involved in this stage?
How much time is there to make this decision?
Is there any counselling or literature available to help my family?
Appendix 10: Steering Committee and

Reviewers
Steering Committee for the Guide to Advanced Prostate Cancer
We are grateful to members of the steering committee who generously
volunteered their time to develop this Guide:
Professor Tom Reeve, Australian Cancer Network
Professor Dianne OConnell, Cancer Council NSW
Jill Margo, journalist and author
Dr David Smith, Cancer Council NSW
Professor Suzanne Chambers, Australian Prostate Cancer Collaboration,
Cancer Council Queensland
Suzanne Hughes, Cancer Council NSW
Hayley Griffin, Cancer Council NSW
Dr Carole Pinnock, Australian Prostate Cancer Collaboration, Repatriation
General Hospital Daw Park (Chair)
Past and present members of the Support and Advocacy Committee
of the Prostate Cancer Foundation of Australia
Don Baumber
Trevor Hunt (dec)
Bill McHugh
Max Shub
0229
0230
Carers/family
Who will look after them when I am unable to look after myself?
Reviewers
We are grateful to the following people who provided very helpful
feedback on the content.
Particular sections
Associate Professor Mark Frydenberg, Urologist, Centre for Urological

Research, Monash Institute of Medical Research
Associate Professor Tom Shakespeare, Radiation Oncologist, member
NHMRC Clinical Practice Guidelines on Locally Advanced and Metastatic
Prostate Cancer Steering Committee
Kathy Chapman, Cancer Council NSW

Vivienne OCallaghan, Cancer Council NSW
Professor Villis Marshall, Chair NHMRC Clinical Practice Guidelines on

Locally Advanced and Metastatic Prostate Cancer Steering Committee
Dr John Litt, Associate Professor in the Department of General Practice,

Flinders University
Mrs Sheila Duke, PCFAs Carers brochure working group
Mrs Elizabeth Allen, PCFAs Carers brochure working group
Mrs Trish Bartlett, PCFAs Carers brochure working group
Sylvia Milner, Nurse Counsellor, Cancer Council Queensland
Helen Crowe, Nurse Practitioner, Urology
Professor David Clarke, Associate Professor in Psychological Medicine,
Monash University
Whole text
Members of peer support groups affiliated with PCFA
Professor Christopher Sweeney, Medical Oncologist, member NHMRC
Clinical Practice Guidelines on Locally Advanced and metastatic Prostate
Cancer Steering Committee
Dr Bruce Kynaston (retd)
Associate Professor Phillip Stricker, Urologist, member NHMRC Clinical
Practice Guidelines on Locally Advanced and Metastatic Prostate
Cancer Steering Committee
0231
0232
AA
ADT
Androgen deprivation therapy
CAB
Complete androgen blockade
CT
External beam radiotherapy
HIFU
High-intensity focused ultrasound
LHRH
Leuteinising hormone releasing hormone
Lower urinary tract symptoms
MDC
Multi-disciplinary care
NHMRC
The destruction of tissue by surgical means

or some form of energy such as heat, cold or
radiation.
adjuvant therapy
A treatment given in conjunction with or

shortly after another treatment to enhance its
effectiveness.
adenocarcinoma
A cancer originating in glandular tissue.

Glandular tissue is part of a larger tissue
category known as epithelial tissue, which
includes skin, glands and a variety of other tissue
that lines the cavities and organs of the body.
advanced prostate
cancer
Prostate cancer that has spread outside the

prostate. If it has spread outside the prostate
but not to distant tissues, it is called locally
advanced.
anaesthetic
A drug given to stop a person feeling pain. A

local anaesthetic numbs part of the body; a
general anaesthetic causes temporary loss of
consciousness.
androgen
independent
prostate cancer
This is an old term that refers to the ability of

prostate cancer cells to continue to develop
despite withdrawal of circulating testosterone. It
is no longer preferred because there is evidence
that the cancer is not hormone resistant there
is still a variety of hormones, including
androgens, available to stimulate growth within
the cancer cells. The cancer cells have developed
their own ways of making testosterone available.
Magnetic resonance imaging

National Health and Medical Research Council
ONJ
Osteonecrosis of the jaw
PBS
Pharmaceutical Benefit Scheme
PBAC
ablation
Luteinising hormone
LUTS
MRI
Most of the words listed here are used in this guide; others are words
you are likely to hear used by doctors and other health workers.
Computerised tomography
EBRT
LH
0233
Anti-androgens
Glossary
Glossary
Abbreviations
Abbreviations
Pharmaceutical Benefits Advisory Committee
PIN
Prostatic intraepithelial neoplasia
PSA
Prostate-specific antigen
TRUS
Trans-rectal ultrasound
TURP
Trans-urethral resection of the prostate
0234
Glossary
androgen receptor
A complex of proteins within the cell that

binds androgens (male hormones such as
testosterone), translocates into the nucleus and
regulates genes controlling prostate cell growth
and reproduction.
androgen
withdrawal
therapy
Also called androgen ablation, androgen

deprivation or hormone therapy. Treatment to
remove the male hormone, testosterone or its
effects.
androgens
Male sex hormones. The most active male

hormone, testosterone, is produced by the
testicles. Other male hormones are produced by
the adrenal glands.
angiogenesis
The formation of new blood vessels to support

tissue. Angiogenesis enables tumours to develop
their own blood supply, which helps them to
survive and grow.
anti-androgen
withdrawal
phenomenon
A reduction in tumour growth caused when

anti-androgen drugs are discontinued. It may be
caused when these drugs change from being an
off switch to an on switch due to changes in
the androgen receptor.
anti-androgens
Drugs which slow the growth of prostate cancer

by blocking the action of the male hormone,
testosterone, in the prostate.
anus
The opening at the end of the rectum through

which faeces pass to the outside.
apoptosis
A type of cell death in which the cell uses

specialised cellular machinery to kill itself. Also
called programmed cell death.
0235
autologous
(blood)
Where the donor and recipient are the same.

You can donate your own blood before prostate
surgery so that it is available if you need a
transfusion.
benign
Not cancerous.
benign prostate
enlargement
Non-cancerous enlargement of the prostate.

An overgrowth of normal prostate tissue. It is
caused by a condition known as benign prostate
hyperplasia.
biopsy
Removal of small pieces of tissue for

examination. When prostate cancer is suspected,
tissue samples are taken from different areas
of the prostate then examined under the
microscope to see if they are cancerous.
bisphosphonate
A class of drugs that can slow pain and bone loss

due to prostate cancer bone metastases.
bladder
The hollow organ that stores urine.
bone scan
A test in which a radioactive chemical is injected,

then x-rays trace its path throughout the body.
The chemical goes to parts of the bone that are
abnormal, such as areas of cancer, infection or
arthritis. Bone scans can be unreliable, and so
are often used to give guidance, rather than
answers, to a problem.
brachytherapy
Radiotherapy given from within the prostate.

Low-dose brachytherapy involves the insertion
of radioactive seeds directly into the prostate,
which are retained. High-dose brachytherapy
involves the temporary insertion of radioactive
substances into the prostate.
0236
Glossary
castrate-resistant
prostate cancer
Cancer that continues to grow despite treatment

to lower the levels of testosterone. Old terms for
this condition are androgen-independent or
hormone-resistant prostate cancer
catheter
A hollow, flexible tube through which fluids can

be passed into the body or drained from it.
cells
The building blocks of the body. A human is

made of millions of cells, which are adapted for
different functions. Cells are able to reproduce
themselves exactly, unless they are abnormal or
damaged, as are cancer cells.
chemotherapy
A treatment of cancer cells with cytotoxic

chemicals (cytotoxic means toxic to cells).
clinical staging
Staging of prostate cancer by digital rectal

examination.
clinical trial
A trial of a new treatment, conducted by medical

researchers on patients who have agreed to take
part. Clinical trials must be conducted ethically
and in keeping with internationally accepted
principles.
CT scan
confined to
0237
A CT (computerised tomography) scan uses

x-rays and computers to produce an image of
a cross-section of the body. This image allows
your doctor to check for swollen or enlarged
lymph nodes, which might mean that cancer has
spread. Also called CAT scan.
In the example of prostate cancer, when we
say that the cancer is confined to or confined
within the prostate, we mean that cancer cells
have not spread from the prostate gland into
other tissues or organs.
conformal
radiotherapy
A type of radiotherapy where the beams of

radiation are shaped so that the area where they
overlap follows the same shape as the prostate.
cryotherapy
A method of killing cancerous cells by freezing

the tissue.
cystoscopy
A procedure in which an instrument is

introduced into the urethra under local
anaesthetic, to view the bladder and prostate.
cytotoxic
Any substance that affects cells in a negative

way. This term is commonly used to describe
special medications that are used to kill
cancerous cells in the body.
DEXA scan
Dual energy x-ray absorptiometry, or DEXA

scanning, a widely used method to measure bone
mineral density in men considering hormone
treatment.
digital rectal
examination (DRE)
An examination of the prostate through the

wall of the rectum. The doctor inserts a finger in
the rectum and feels the shape of the prostate.
Irregularities may be caused by cancer.
doubling time
The time taken for the PSA level to double, for

example from 4ng/ml to 8ng/ml. It is a measure
of how fast the cancer is growing.
dry ejaculation
After a radical prostatectomy, a man may

achieve orgasm, but produce no ejaculate (fluid).
This is because the glands that produce much of
the fluid in the ejaculate are removed. See also
reverse ejaculation.
dysuria
Difficult or painful urination.
0238
Glossary
ejaculate
Fluid produced at ejaculation, which contains

sperm and secretions from the prostate, seminal
vesicles and testicles.
epididymis
a long tube that lies atop each testicle and

functions as a reservoir of sperm produced by
the testes.
erectile
dysfunction
Inability to achieve an erection firm enough for

penetration.
erection
The sexually active state of the penis, when it is

enlarged and rigid.
external beam
radiation (EBRT)
Radiotherapy given from outside the body.
fertility
The ability to conceive children naturally.
five-year survival
rate
A scientific measure used to determine the

success of a treatment, because it is hard to
know if someone is cured or not. It measures
the number of people alive five years after a
particular treatment. It does not necessarily
mean you will only live for five years after
having treatment.
flare
When an LHRH agonist is first started, it

paradoxically causes a rise in the pituitary
hormone LH. The LH rise stimulates the testicles
to make testosterone during the first 512 days
after initiation of the LHRH agonist. This increase
in testosterone stimulates prostate cancer cell
growth and is termed flare. It can be prevented
by taking an antiandrogen a drug which blocks
the testosterone receptors for two weeks prior to
LHRH therapy.
0239
fractionation
The delivery of a radiation dose in several small

doses or fractions.
free to total PSA

ratio
In both healthy men and those with prostate

cancer, the prostate specific antigen (PSA) in the
bloodstream latches onto protein. In men with
benign prostatic enlargement (BPE), there tends
to be more free or unbound PSA. This test
compares the ratio of unbound PSA to total PSA
in the bloodstream.
gene
The tiny factors that govern the way the bodys

cells grow and behave. Each person has a set of
many thousands of genes inherited from both
parents. Genes are found in every cell of the
body.
Gleason score
A way of grading cancer cells. Low-grade cancers

(Gleason score 2, 3, 4) are slower growing than
high-grade (Gleason scores 8, 9, 10) cancers. The
pathologist identifies the two most common
tissue patterns and grades them from 1 (least
aggressive) to 5 (most aggressive). The Gleason
score is given as two numbers added together
to give a score out of 10 (for example, 3 + 4 =
7). The first number is the most common pattern
seen under the microscope and the second
number is the next most common.
grade/grading
A score that describes how abnormal the cancer

cells look, and consequently how aggressive or
fast-growing the cancer is likely to be. The most
commonly used grading system is the Gleason
score, which ranges from 210 (see above).
Gray (Gy)
The international system (SI) unit of radiation

dose expressed in terms of absorbed energy per
unit mass of tissue.
0240
Glossary
HIFU
High Intensity Focused Ultrasound. A method for

killing cancer cells. The high intensity ultrasound
is focused in the prostate causing heat that kills
the tissue.
hormone
resistance
Prostate cancer cells are dependent on

testosterone or male hormone for growth.
Withdrawal of male hormone by surgery or
by means of drugs is therefore a means of
controlling its growth. However cancer cells
may develop which do not need testosterone for
growth. The cancer is then said to be `hormone
resistant.
hormone therapy
In prostate cancer, treatment with drugs that

minimise the effect of testosterone in the body,
which can slow or stop the growth of prostate
cancer.
hormones
Natural chemical substances that are produced

by one body organ, and travel through the
bloodstream to other organs where they exert
their effects. A well-known example is insulin,
which regulates the blood sugar level.
hot flush
A sudden rush of heat to the face, neck,

sometimes chest and back. It can be associated
with hormone therapy for prostate cancer.
impotence
See erectile dysfunction.
incontinence
Involuntary passing of urine (urinary

incontinence) or faeces (faecal incontinence).
indolent
Means lazy, usually referring to the type of

cancer cells which grow only slowly.
infertility
Inability to conceive naturally.
0241
intermittent
hormone therapy
Hormone therapy that is started and stopped

in cycles. Typically, it is continued for several
months until PSA has reached a low level, and
then discontinued. Once the PSA level in blood
rises to a particular level again (and this can take
many months), hormone therapy is re-started.
The main expected benefit in this approach is
reduction in side effects.
laparoscopic
surgery
Minimally invasive surgery to remove the

prostate. Small cuts are made in the abdomen.
Surgery is conducted using telescopic
instruments inserted through these cuts.
leuteinising
hormone releasing
hormone (LHRH)
Stimulates leuteinising hormone production by

the pituitary.
leuteinising
hormone (LH)
Stimulates testosterone production by the

testicles.
libido
Sex drive.
localised prostate
cancer
Prostate cancer that is at an early stage, and has

not spread beyond the prostate gland.
locally advanced
prostate cancer
Prostate cancer that has spread beyond the

prostate capsule and may include the seminal
vesicles, but is confined to the prostate region.
Stage T3, or C.
locally recurrent
Cancer that has recurred (come back) after

treatment, but which is confined to the prostate
or nearby tissues only.
0242
Glossary
lower urinary tract

symptoms (LUTS)
Symptoms related to the flow or passing of

urine, such as poor stream, frequent urination,
needing to get up at night two or more times to
urinate, incontinence and incomplete emptying
of the bladder. They are often caused by benign
enlargement of the prostate, but can also be
caused by advanced prostate cancer.
leuteinising
hormone releasing
hormone (LHRH)
agonist
a substance that resembles LHRH which controls

the production of sex hormones. The LHRH
agonists keep the testicles from producing
hormone (testosterone).
lymph nodes
Also known as lymph glands. Small, generally

pea-sized pieces of tissue found all over the
body but easier to feel in the neck, armpits and
groin. They act as filters for foreign substances
and commonly become inflamed if there is an
infection nearby. They can also harbour cancer
cells that have spread from elsewhere.
lymphoedema
Swelling in the limbs caused by blockage of

lymph nodes and lymph drainage system. In
prostate cancer, blockage in the pelvic lymph
nodes can cause swelling in the legs and ankles.
magnetic
resonance
imaging (MRI)
A way of imaging the inside of the body using

magnetic forces and without using x-rays.
malignant
Cancerous.
margin positive
After surgery to remove the prostate, if cancer

cells are present at the cut edge (Margin) of the
removed prostate, it is termed margin positive.
medical oncologist
0243
A specialist in the treatment of cancer using

chemotherapy.
metastasis/
metastasise
The spread of cancer away from the place where

it began.
metastatic
prostate cancer
When small groups of cells have left the primary

tumour site and started to grow in other parts of
the body.
micro-metastases
Small deposits of cancer cells, not large enough

to be detected by the usual means.
monitoring
The process in which patients are followed up

after initial diagnosis and treatment. It may
include clinical examination and/or the regular
performance of tests.
MRI scan
Magnetic resonance imaging, a test that

produces very clear pictures of the human body
without the use of x-rays. Instead, MRI uses a
large magnet, radio waves, and a computer to
produce these images. It is used to distinguish
benign and cancerous tissue.
nadir
The lowest PSA reading before it starts to rise,

occurring some months after radiotherapy to
cure prostate cancer.
neo-adjuvant
therapy
A treatment given before another treatment to

enhance its effectiveness.
nerve-sparing
operation
Surgery for prostate cancer that aims to preserve

the nerves which are needed for erections. These
nerves are on either side of the prostate gland.
The technique is not always possible because
cancer can affect the areas around the nerves.
oncologist
A specialist in the treatment of cancer (see

medical oncologist and radiation oncologist).
orchidectomy
(also orchiectomy)
A type of operation that removes the testicles,

but usually leaves the scrotal sac or scrotum.
0244
Glossary
osteoblasts
osteoclasts
One of two cell types (with osteoclasts) that

the human body uses in the creation and
maintenance of bones. Osteoblasts are the cells
that actually create bone.
Osteoclasts are highly specialised cells that must
work in perfect synchronisation with osteoblasts
to maintain the skeletal system. Osteoclasts are
the cells that resorb, or break down and absorb,
bone tissue back into the body.
osteonecrosis of
the jaw
Areas of dead bone, not covered by gum

in the jaw (thought to be associated with
treatment by drugs controlling bone loss called
bisphosphonates).
osteoporosis
A condition that affects bones, making them

thinner and weaker than normal and liable to
fracture and break.
palliative care
Care of persons whose disease is not responsive

to curative treatment. The goal of palliative care
is to achieve the best possible quality of life for
the person and their family.
paraesthesis
Tingling in the skin, often of the extremities. Also

called pins and needles.
pathologist
A doctor who specialises in the examination of

cells and tissues removed from the body.
pelvic
The area of the body located below the waist and

surrounded by the hip and pubic bones.
penis
Male reproductive organ consisting of a body

or shaft which starts deep inside the body and
extends externally to the end of the penis at
the glans.
0245
perineal
(perineum)
Area of body between the anus and the scrotum.
Pharmaceutical
Benefit Scheme
(PBS)
An Australian government program designed

to provide effective, subsidised drugs for
Australians (see Chapter 9).
PIN
Prostate intraepithelial neoplasia. The cells are

dividing more rapidly than normal cells but are
not yet cancerous.
pituitary
Part of the brain that produces hormones which

stimulate the testicles to produce testosterone
(male hormone).
positive surgical
margin
Where cancer cells extend to the cut margin

of the surgically removed tissue. It implies that
some tumour tissue may be left behind.
potency
The ability to have and maintain erections firm

enough for penetration.
priapism
A painful, prolonged erection lasting 3 hours or

more.
primary cancer
The original cancer. At some stage, cells from the

primary cancer may break away and be carried to
other parts of the body, where secondary cancers
may form.
prognosis
The course and likely outcome of a disease, as

estimated by a persons doctor or treatment
team.
prostate cancer:
localised
The cancer is confined within the prostate gland.
prostate cancer:
locally advanced
The cancer is contained within the prostate

region but extends beyond the prostate gland
and may include seminal vesicles.
0246
Glossary
prostate cancer:
advanced
The cancer has spread to adjacent organs such

as bladder, rectum, pelvic wall.
prostate cancer:
metastatic
The cancer has spread to distant parts of the

body such as bone.
prostate gland
The gland that sits just below the bladder and

opens into the urethra. It produces a fluid that
forms part of semen.
prostate specific
antigen (PSA)
A protein produced by the cells in the prostate,

which is usually found in the blood in larger
than normal amounts when prostate cancer
is present. It can be used as a test for prostate
cancer or to monitor its recurrence.
prostatectomy
prostatitis
PSA bounce
radiation
Energy in the form of waves or particles,

including x-rays. This energy can injure or
destroy cells by damaging their genetic material.
This ability is harnessed for good when it is
used in radiotherapy.
radiation
oncologist
A specialist in the treatment of cancer using

radiation techniques.
radical
prostatectomy
An operation that removes the prostate, part of

the urethra, a small part of the vas deferens and
the seminal vesicles. This is usually done through
a cut in the lower abdomen.
radiotherapy
The use of radiation, for example, x-rays, to kill

cancer cells.
An operation to remove all or part of the

prostate.
rectum
The last part of the bowel, leading to the anus,

through which faeces pass.
Inflammation of the prostate. It can be caused by

bacteria.
recurrence
The re-occurrence of cancer some time after it

was first treated.
remission
(Also known as complete response) The term

used when, after treatment, there is no sign
of any cancer. It is not necessarily the same as
cure, as some cancer cells may be hidden. In
partial remission, signs of the disease process
have partly resolved but have not disappeared
completely.
response
A change in the size or extent of the disease due

to treatment.
Temporary rise in PSA reading that can occur

during the first 24 months after radiotherapy to
cure prostate cancer. It is commonly seen after
seed brachytherapy.
PSA doubling time
The time taken for the PSA level to double, for

example from 4ng/ml to 8ng/ml. It is a measure
of how fast the cancer is growing
psychosocial
Referring to the emotional, psychological, social

and spiritual aspects of life.
quality of life
Your overall appraisal of your situation and your

wellbeing.
0247
0248
Glossary
reverse ejaculation
seminal vesicles
Glands that lie very close to the prostate

and produce secretions that form part of the
ejaculate.
spinal cord
compression
Growth of cancer in the vertebra so that the

nerves in the spinal cord are squeezed. It leads to
symptoms such as pins and needles or numbness
in other areas of the body. In extreme cases it
can cause paraplegia.
stage/staging
Treatment, in prostate cancer usually

radiotherapy, to try to destroy cancer cells that
escaped the initial treatment.
The process of determining the extent of the

disease. A system for describing how far the
cancer has spread. The most common is the TNM
system described in Appendix 1.
stent (urinary)
Testing an at-risk population for an illness, to

find people who have the illness, although they
dont yet have obvious symptoms.
A specially designed hollow tube, made of a

flexible plastic material inserted into a ureter to
maintain flow of urine from the bladder.
stress incontinence
A pouch of skin that contains the testicles and

some other parts of the male reproductive
system. It hangs outside the body and behind
the penis.
Uncontrolled loss of a small amount of urine

as a result of any strenuous activity, laughing,
coughing, sneezing or lifting heavy objects.
stricture
Scar tissue which obstructs fluid flow; in

the case of a urethral stricture, urine flow is
obstructed.
second line
chemotherapy
agents
Chemotherapy agents used to prolong remission

after first line (initial) chemotherapy agents are
no longer effective
surgical margins
secondary cancer
See metastasis.
secondary
hormone
manipulation
After a radical prostatectomy, the edges of the

tissue that has been removed are examined to
see if cancer cells are present. If they are not
(negative surgical margins) the chance is higher
that all of the cancer has been removed.
Treatments designed to reduce testosterone

levels after primary (initial) androgen withdrawal
(hormone therapy) ceases to be effective.
Survival
(biochemical)
semen
The fluid ejaculated from the penis at sexual

climax.
Biochemical survival refers to the proportion of

people surviving without an increase in PSA levels
(this can be defined in different ways) in a given
time, such as five years.
Disease free survival refers to the proportion of
people surviving without evidence of disease to a
given time, such as five years.
robotic
prostatectomy
salvage treatment
screening
scrotum
0249
Also called retrograde ejaculation. This may

occur after surgery for benign conditions of
the prostate. The ejaculate travels back into the
bladder instead of exiting through the penis. This
means a man is usually infertile (cannot produce
offspring in the conventional way), but he can
still achieve orgasm.
A form of laparoscopic surgery where telescopic
instruments inserted through small cuts in the
abdomen are controlled remotely by the surgeon
with the aid of a computerised robot.
Survival
(disease-free)
0250
Glossary
survival (prostate
cancer specific)
systemic therapy
testicles
testosterone
thrombocytopenia
tissue
TNM system
trans-rectal
ultrasound (TRUS)
trans-urethral
resection of the
prostate (TURP)
tumour
TURP
0251
Prostate cancer specific survival refers to the

proportion of people who do not die of prostate
cancer in a given period, such as five years.
Treatment which extends throughout the body.
Glands that produce sperm and the male
hormone, testosterone. They are found in the
scrotum.
The major male hormone. It is produced by the
testicles.
Fewer clotting cells in blood caused by mild
suppression of bone marrow, so that it produces
of these cells.
A collection of cells.
A system for staging cancer, depending on the
size and invasiveness of the tumour, whether
lymph nodes are affected, and whether there is
metastasis. See Appendix 1.
A means of imaging the prostate in order to
locate cancer. The ultrasound probe is placed in
the rectum.
A common operation for benign enlargement of
the prostate, but only occasionally used to treat
prostate cancer. An instrument is inserted, under
anaesthetic, along the urethra (urine tube) and
removes prostate tissue that may be blocking the
flow of urine.
Any swelling. In the context of cancer, the word
usually refers to malignant (cancerous) lumps.
Trans urethral resection of the prostate. An
operation to remove prostate growth obstructing
urine flow in the urethra (tube carrying
urine from the bladder to the outside). See
transurethral resection of the prostate.
urethra
urinary retention
urologist
vas deferens
watchful waiting
x-ray
The tube that carries urine and ejaculate along

the length of the penis and to the outside of the
body.
The outflow of urine stops due to a blockage in
the outflow tube below the bladder (urethra) or
between the bladder and kidneys (ureters). It can
be temporarily relieved by insertion of a catheter,
prior to removal of the blockage surgically or by
other means.
Surgeon who specialises in treating urogenital
tract diseases.
Ducts that take sperm to the urethra on
ejaculation.
Not treating a disease, but monitoring it to see
whether or how fast it is worsening.
A form of electromagnetic radiation.
0252
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93. Terry, W., L.G. Olson, L. Wilss, and G. Boulton-Lewis, Experience of dying: concerns of dying
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97. Makarov, D.V., E.B. Humphreys, L.A. Mangold, M.A. Carducci, A.W. Partin, M.A. Eisenberger, et al.,
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85. Jatoi, A., N. Ellison, P.A. Burch, J.A. Sloan, S.R. Dakhil, P. Novotny, et al., A phase II trial of green
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0259
0260
Index
Index
digital rectal examination (DRE) 7, 21,

22, 230
disease free survival 242
bisphosphonate 116, 117, 228
abiraterone 128, 129, 133, 208
bodyweight 57, 61
adenocarcinoma 13, 226
bone metastases 64, 91, 103, 106, 114,

116, 128, 130, 174, 228
adjuvant radiotherapy 44, 45

adjuvant therapy 46, 226, 236
advanced prostate cancer 6, 7, 24, 26,
28, 30, 32, 33, 35, 39, 40, 41, 42, 43, 44,
46, 47, 56, 101, 102,119, 126, 135, 136,
138, 142, 146, 159, 195, 226, 234, 235,
247, 250, 251
bone pain 55, 64, 73, 79, 84, 91, 103,

105, 106, 116
bone scan 7, 18, 21, 23, 51, 73, 74, 91,
228
bone thinning 72, 91, 106, 110, 116
brachytherapy 44, 50, 51, 228, 239, 245
aerobic exercise 59, 99
docetaxel 113, 114, 121, 128, 131, 133,

251
hormone therapy 34, 39, 43, 46, 49, 50,

55, 59, 72, 76, 81, 92, 94, 103, 119, 126,
127, 128, 142, 143, 145, 159, 227, 233,
234, 241, 252
hospice 173, 19, 193, 221
doubling time 23, 26, 52, 53, 54, 73,

105, 230, 239, 246, 248, 250
hot flushes 27, 43, 72, 84, 87, 89, 90,

96, 142
endothelins 130
immunotherapies 119, 133
epididymis 231
impotence 55, 89, 233
erectile dysfunction 43, 47, 54, 87, 91,

96, 231, 233, 247
incontinence 33, 34, 54, 55, 75, 189,

233, 235, 242
external beam radiation 231, 245, 254
intensity-modulated radiotherapy 42,

126
extra-prostatic extension 52
alternative therapies 71
extraprostatic extension 127
androgen independent 14, 104, 226,

251, 253
castrate-resistant prostate cancer 103,

131, 229
intermittent androgen deprivation 83,

85, 86, 87, 89, 96
intermittent hormone therapy 234
androgen independent prostate cancer

226
catheter 107, 189, 229, 244
fentanyl 177, 179
chemotherapy 33, 49, 55, 64, 103, 113,

114, 115, 119, 122, 126, 128, 129, 131,
133, 187, 229, 235, 241, 251, 253, 256
fertility 83, 231
clinical staging 195, 229
fractionated 115
clinical trial 9, 70, 114, 118, 119, 120,

121, 122, 123, 124, 135, 137, 229
fractionation 232
androgen receptor 11, 14, 104, 108,

109, 111, 129, 207, 209, 227
androgens 76, 79, 81, 84, 85, 87, 90, 96,
97, 109, 111, 129, 208, 225, 226, 227
androgen withdrawal therapy 59, 104,
227
angiogenesis 133, 227
anti-androgens 79, 81, 84, 85, 87, 90,
96, 97, 109, 111, 129, 225, 227
combined androgen blockade 85, 87

complementary therapies 57, 68, 69,
70, 71, 103, 119, 133, 167, 180
cryotherapy 54, 230
finasteride 81
flare 82, 83, 84, 87, 231
fractions 115, 232

free to total PSA ratio 232
cyproterone 79, 111
goserelin 79, 82
apoptosis 76, 104, 227
cytotoxic 229, 230
green tea 119, 127, 135, 251
bicalutamide 79, 84, 97, 109, 111

biochemical recurrence 15, 246, 251
biopsy 33, 51, 52, 195, 197, 228
0261
DEXA scan 99, 230
localised prostate cancer 3, 15, 24, 49,

199, 234, 254
lower urinary tract symptoms 225, 235
gynaecomastia 43, 84, 97
magnetic resonance imaging 23, 74,

225, 235, 236
margin positive 235
haematuria 41
massage 57, 67, 68, 69, 71, 107
HIFU 54, 225, 233
MDV3100 129, 133, 251
hormone refractory 103, 104, 250
medical oncologist 32, 33, 35, 108, 160,

168, 235, 236
D
depression 6, 10, 34, 67, 69, 87, 89, 92,
93, 95, 99, 141, 142, 143, 149, 150, 151,
152, 162, 163, 165, 166, 171, 183, 210,
211, 249, 252
leuteinising hormone releasing hormone

77, 78, 225, 234, 235
lymph nodes 14, 19, 20, 21, 24, 40, 41,

46, 52, 73, 74, 107, 196, 229, 235, 243
CT scan 18, 21, 23, 41, 74, 81, 229
benign prostate hyperplasia 228
leuteinising hormone 77, 78, 82, 225,

234, 235
lycopene 64, 127, 247
anti-androgen withdrawal phenomenon

109, 227
leuprorelin 79, 82
G
Gleason score 18, 21, 26, 52, 53, 55,
105, 127, 197, 232
autologous (blood) 228
hormone resistance 233
0262
Index
meditation 27, 57, 67, 68, 161, 180, 255
phyto-oestrogens 60, 61, 64, 65
metastasis/metastasise 236
PIN 13, 225, 238
metastatic 9, 15, 20, 22, 24, 43, 46, 49,

55, 72, 73, 75, 82, 84, 96, 101, 223, 236,
239, 248, 250, 251, 252, 255
pituitary 12, 77, 78, 79, 82, 83, 111, 231,

234, 238
metastatic prostate cancer 15, 22, 24,

43, 46, 72, 73, 75, 84, 96, 101, 128, 236,
250, 252
potency 87, 238
micro-metastases 42, 51, 74, 236

mitoxantrone 114, 251
morphine 177, 179, 185
MRI scan 21, 23, 52, 236
multivitamin supplements 66
N
neo-adjuvant therapy 236
nilutamide 79, 84, 109
nocturia 40
positive surgical margin 41, 52, 238

prognosis 25, 26, 50, 52, 53, 105, 156,
200, 238
prostate cancer: advanced 239
prostate cancer: localised 238
prostate cancer: locally advanced 238
prostate cancer: metastatic 239
prostate gland 24, 39, 91, 229, 234, 236,
238, 239
prostate specific antigen 13, 232, 239,
245, 248
prostatitis 239
PSA bounce 50, 51, 239, 245
O
obesity 61, 62, 247
oncologist 30, 32, 33, 34, 35, 108, 115,
117, 160, 168, 172, 223, 224, 235, 236,
240
opioids 179, 185
orchiectomy 79, 82, 236, 249
osteonecrosis of the jaw 116, 117, 225,
237, 250
osteoporosis 81, 89, 91, 99, 116, 237,
247
oxycodone 177, 179, 185
P
palliative care 10, 27, 32, 33, 158, 159,
160, 164, 167, 168, 169, 170, 171, 172,
173, 174, 181, 191, 192, 193, 194, 212,
215, 217, 218, 237
Pharmaceutical Benefit Scheme 35, 82,
116, 225, 238
phase 3 trials 120, 121, 125, 126, 128
0263
PSA doubling time 23, 26, 52, 53, 54,

73, 105, 239, 246, 250
psychosocial support 119, 136
Q
quality of life 5, 18, 25, 27, 33, 43, 46,
54, 58, 69, 81, 85, 86, 89, 92, 95, 101,
102, 105, 114, 131, 135, 141, 161, 169,
170, 174, 220, 237, 239, 249, 250
R
radiation oncologist 30, 32, 115, 160,
168, 172, 236, 240
radical prostatectomy 41, 46, 52, 54, 81,
126, 127, 199, 230, 240, 242, 245, 246,
247, 250, 251, 252
recurrence 15, 24, 26, 31, 39, 40, 49,
51, 52, 53, 54, 55, 61, 85, 126, 127, 135,
138, 149, 158, 200, 239, 240, 245, 246,
250, 251
remission 27, 240, 241
resistance exercise 57, 58, 59, 94, 96,

99, 101, 246
TURP 39, 47, 107, 225, 243
U
S
urinary retention 107, 244
salvage radiation therapy 54, 127, 250

salvage treatment 54, 241
scrotum 79, 236, 238, 241, 243
secondary cancer 241
V
viagra 91
vitamin D 43, 57, 62, 63, 64, 91, 92, 96,
99, 101, 131, 247
secondary hormone manipulation 108,

241
second line 241, 256
x-ray 23, 42, 74, 230, 244
second line chemotherapy agents 241

Selenium 65, 66, 248
Z
zoledronic acid 116
seminal vesicles 13, 20, 39, 40, 41, 45,

52, 127, 195, 231, 234, 238, 240, 242
Sipuleucel-T 130, 133, 251
spinal cord compression 87, 106, 187,
242
SSRIs 90
stage 11, 13, 14, 18, 19, 22, 25, 26, 33,
40, 50, 55, 56, 62, 73, 77, 92, 103, 105,
106, 107, 119, 122, 125, 136, 160, 168,
170, 174, 185, 195, 199, 207, 212, 220,
221, 234, 238, 242, 256
statin 135, 251
stent 39, 47, 242
stricture 242
survival (biochemical 242
survival (disease-free) 242
T
testicles 12, 77, 81, 82, 83, 84, 227, 231,
234, 235, 236, 238, 241, 243
thrombocytopenia 115, 243
TNM system 18, 19, 195, 242, 243
trans-rectal ultrasound 225, 243
trans-urethral resection of the prostate
39, 46, 47, 75, 107, 225, 243
Triple androgen blockade 81
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Prepared by the Australian Cancer Network and

a guide for men

Copyright Cancer Council Australia (2009)

brochure working group, who generously

We would like to thank Andrology Australia and

shared their ideas and experience.

the Prostate Cancer Foundation of Australia

who, as major sponsors of the Clinical Practice

Guidelines, generously provided funding for

their development. We are also grateful to the

National Seniors Foundation working with

Website: www.cancer.org.au. Email: info@cancer.org.au.

the GM & JA Whitehouse Foundation who

funded the printing of this Guide. beyondblue

Professor Dianne OConnell and the guidelines

funding towards the production of the Guide. We

We are grateful to Cancer Council NSW for

are particularly grateful to members of support

permission to use material from their booklet:

groups affiliated with the PCFA who gave us

Understanding Clinical Trials.

invaluable feedback on the Guide content.

Lastly we would like to thank the reviewers

The chapter for carers and family members was

and the hardworking members of the steering

developed with the help of Sheila Duke, Trish

committee (listed in Appendix 10) who so

Bartlett and Elizabeth Allen of the Prostate

generously volunteered their time and saw this

Cancer Foundation of Australias carers

project through to completion.

Copies of this guide can be ordered through:

to you. We provide resources for further information at the end of

A message from beyondblue

3.6 Changing doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

6.8 Confused about terms? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

10.5 Resources and further help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Appendix 2: The Gleason Grading System

Appendix 3: PSA rising What Does It Mean?

Appendix 4: Resistance Exercises

Appendix 5: Body Mass Index (BMI) Calculator

Appendix 6: Models of Resistance to Androgen Deprivation Therapy 207

Appendix 8: Planning Ahead

Appendix 9: What Questions Could I Ask?

Appendix 10: Steering Committee and Reviewers

Chapter 1: Introduction to Advanced Prostate Cancer

Chapter 1: Introduction to Advanced

accompany you throughout the cancer journey. This guide aims to

1.1 Key points

The prostate is a small gland at the base of the bladder. It

Prostate cancer arises in the tiny glands within the prostate.

Prostate cancer is the second most common cancer in men after

About 15% of prostate cancers are diagnosed at the advanced stage.

If you are diagnosed with prostate cancer at an early age

1.2 After a diagnosis

Chapter 1: Introduction to Advanced Prostate Cancer

1.4 What is prostate cancer?

1.5 How common is prostate cancer?

Chapter 1: Introduction to Advanced Prostate Cancer