Chemotherapy is used when the cancer has spread out-with the prostate into other parts of the body . At this stage it isn’t possible to kill all the cancer cells so advanced prostate cancer can’t be cured but it can be controlled very successfully often for many years.
What is chemotherapy?
Chemotherapy uses certain drugs to kill cancer cells wherever they are in the body so it acts throughout the whole body and it isn’t limited to particular sites or areas (this is called systemic treatment).
Cancer cells in the body divide very quickly. Chemotherapy works by targeting, and killing rapidly growing cancer cells as they divide, wherever they are in your body. Because cancer cells divide more quickly than healthy cells, chemotherapy drugs kill more cancer cells than healthy cells. This should help shrink and slow down the growth of the cancer.
The benefits of chemotherapy may be that you are not in as much pain, make you feel better generally and may help you live longer with a better quality of life.
The drawbacks are that chemotherapy may also damage healthy cells in your body so you might have side-effects like losing hair, feeling sick and being very tired.
Is chemotherapy the right treatment?
Chemotherapy may not be the right treatment for all men though. The oncologist looking after you will need to consider:
- If you would benefit from having this type of treatment;
- If you are fit enough to deal with any side-effects.
- How the side-effects would affect your quality of life;
So, before starting this kind of treatment you will probably find that that the doctor will check on your general health by making sure that your heart, liver, lungs and kidneys are working properly.
You might also want to think about whether to start chemotherapy and talk this over with your family. In some areas, there are prostate cancer support groups and it may help to talk to other men and their families who have been in similar circumstances.
Chemotherapy and hormone treatment
The way that chemotherapy is being used has been changing and nowadays you might be offered chemotherapy at the same time as having hormone therapy. If you’ve just been diagnosed with advanced prostate cancer using chemotherapy in this way may help some men live longer.
This means that if you’re having hormone therapy such as Zoladex ®, Prostap® Decapeptyl® or Firmagon®, you will have chemotherapy along with your hormone therapy.
How is chemotherapy given?
The dose of chemotherapy drugs used varies from person to person. The doctor will take into account things like your height and weight, stage of your cancer and how healthy you are in general and will plan your treatment, and times for your treatment, very carefully. So, it’s important that you attend all your treatment dates. Let the oncologist or CNS know in plenty of time if there are any times (such as a special celebration) that you think you can’t manage any the dates given.
Chemotherapy is given as cycles of treatment. This is to make sure that as the new cancer cells try to grow they are killed off every few weeks. It also gives your body some time to recover between cycles.
You will most likely have to go into the hospital clinic or day area as a day patient to have your treatment. The treatment will be given by a specialist chemotherapy nurse. A typical chemotherapy session might be:
- Your blood being checked before you have each chemotherapy treatment to make sure that your blood count is satisfactory, so you can safely have the treatment. Often this is arranged for the day before at your local GP surgery;
- The staff keeping a close eye on how you are for the first minutes of the infusion starting. It’s important to let the doctor or nurse know if you are not feeling well when the drip starts
A nurse putting a drip (a needle attached to a small flexible tube) into a vein and allowing the drug to gently run into your body (infusion) for about an hour.
This may help prevent certain side-effects of the chemotherapy and you will usually be given steroid tablets to take at home before your chemotherapy session. As the way of taking steroid tablets can vary, it’s important to take these as the oncologist or CNS has told you to. Tell the oncologist or nurse if you haven’t taken the tablets.
Treatments for feeling or being sick
The CNS may give you anti-sickness medicine through a needle in your vein to help. Afterwards, you may be given anti-sickness tablets to take at home to help prevent feeling or being sick. The nurse will tell you how to take the tablets and it’s important that you follow what you’ve been told.
Are there different types of chemotherapy?
There are 3 different drugs used when treating advanced prostate cancer; Docetaxel, Mitoxantrone and Cabazitaxel.
Docetaxel (Taxotere®) This is the most commonly used drug for men with advanced prostate cancer. Depending on individual circumstances, it may be started soon after you’ve been diagnosed with advanced prostate cancer and given at the same time as hormone therapy with around 6 cycles of treatment about 3 weeks apart.
It is also used for those men who have had hormone therapy but the hormone therapy isn’t working any longer. In this case the man may have around 10 cycles of Docetaxel about 3 weeks apart.
Mitoxantrone (Novatrone®) If your oncologist thinks that you are not fit and healthy enough, and so might not be able to cope with the side-effects of Docetaxel, then Mitoxantrone might be an option that you are offered. Although it’s not usually the first option for prostate cancer, it might be offered as a 2nd line treatment.
Cabazitaxel (Jevtana®) Cabazitaxel is now available for men with advanced prostate cancer when hormone therapy and Docetaxel chemotherapy isn’t working for them any longer. As this has been given after Docetaxel you may hear this type of treatment called 2nd line treatment.
What about side-effects?
The side-effects you may have are linked to the way the chemotherapy drug works. Understanding that it kills some of the healthy dividing cells in the skin, hair follicles, bone marrow and digestive system (gut) explains some of the side-effects.
With side-effects remember:
- How chemotherapy affects you may be different from other men who have had chemotherapy. Some men get a lot of side-effects while others have very few. It’s something no-one can predict but it’s important to let your oncologist or CNS know about, they may be able to offer something to help;
- There is a lot of information on how the treatment might make you feel, but pay attention to how you feel, note it down then tell the oncologist or CNS.
|The most common side effects are:
|What can be done to help
|More difficult to fight off infections Chemotherapy can reduce the number of white blood cells being made by the bone marrow, making you more at risk of catching an infection.
Please see section on neutropenic sepsis below
|Washing your hands thoroughly to kill off any germs. Keeping away from others who have colds, coughs, sore throats or any other illnesses so that you don’t pick up any infection.
You may feel that you have very little energy, are tired all the time and can’t be bothered with the things you enjoyed doing before
|Although it may sound strange try taking some gentle, regular exercise like going for short walks
Sitting down or resting whenever you feel tired at whatever time that might be
Trying to get enough sleep at night – if this is a problem ask your doctor for more advice
Getting help with everyday jobs like cleaning, work, shopping, gardening.
|Bruising or bleeding
Chemotherapy can impair your blood clotting mechanisms
|Let your CNS or oncologist nurse know immediately about any bruising, nosebleeds or if your gums bleed
This can make you feel tired and breathless
|If necessary, your oncologist may suggest a blood transfusion or prescribe iron tablets
|Feeling or being sick
|Your CNS or oncologist will prescribe drugs (anti-emetics) that can help.
Because the treatment can affect your mouth and gums you might notice small mouth ulcers
|Brush your teeth regularly but gently in the morning, after eating and at bedtime using a very soft toothbrush. Ask the specialist nurse for more advice about using a mouthwash
|Not having much of an appetite
You may find that food doesn’t taste the same – more salty, bitter or metallic
|Try having small regular meals and snacks throughout the day. If this is a real concern the doctor might refer you to a specialist dietitian.
Hair thinning is quite common and for some there may be total hair loss. Because of this, you may find you will be quite cold going outside
|Wearing a hat may help or in some instances it might be possible to get a wig. The good news is that your hair should start to grow back after your treatment finishes.
It’s quite common to feel a bit down in the dumps or unhappy around this time. You might find that your mood gets better and you feel happier after your treatment finishes
|The CNS or oncologist may be able to help if this continues after your treatment finishes. Joining a support group or contacting organisations who provide telephone helplines may help
You may difficulties with diarrhoea or difficulty in emptying your bowels.
|The CNS or oncologist may be able to give some medication to help with this.
Make sure you are drinking enough fluid so you don’t become dehydrated.
Your skin may become dry
|Ask for advice from your CNS about the type of cream to use to help with dryness
|Changes to nails
Nails may become brittle, weak, darker in colour and have ridges or lines on them
|These changes usually disappear in a few months after your treatment finishes
|Tingling in hands and feet or numbness
You might notice it’s difficult to do things like fastening buttons
|Let the CNS or oncologist as they may be able to change your chemotherapy dose to help with this.
|Build-up of fluid
You may notice that your ankles and legs may swell because of build up of fluid
The steroid tablets should help prevent thi.s
When you start on chemotherapy your CNS or oncologist will almost certainly give you special advice about a very important potential side-effect of chemotherapy called neutropenic sepsis. For more information, please see Treatments for Advanced Prostate cancer explained page 42
What is neutropenic sepsis? Bone marrow normally produces different types of blood cells – red cells, white cells and platelets. The growth of all these types of blood cells will be reduced when you start chemotherapy.
Neutrophils are one of the types of white blood cells and are very important in protecting the body against infection. Neutropenic or neutropenia means that there are a low number of neutrophils in your blood.
So what does this mean?
It means that you will be more prone to catching an infection and your body won’t be able to fight the infection as well as before. Catching an infection can have very serious consequences, so it is important that you know what to look out for and what you should do.
Signs you should look out for:
- High temperature of 37.5 degrees C or above. As it is important to be able to check your temperature accurately, it is a good idea to buy a digital thermometer from a chemist;
- Shivering or sweating;
- Feeling hot or flushed;
- Feeling generally unwell;
- Have a headache, cough or sore throat;
- If you notice any of these signs especially 7-10 days after your chemotherapy treatment.
What should you do? It’s a good idea to make a record of your GP, CNS, oncologist, your contact details, what your chemotherapy treatment is and when you last had it. Possibly let your wife, partner or a friend know these details too in case they have to make the call on your behalf.
Can anything be done about the pain?
Pain shouldn’t be a normal part of living with cancer; controlling pain is part of your cancer treatment. Some days though, you might find that your pain is worse than on other days. Pain from cancer or bone pain can usually be well controlled although it can take time to find the best type of pain relief for you. You may also find that you have aches and pains that are nothing to do with your cancer.
However, when you don’t have pain, you will probably be able to sleep and eat better, carry on with your normal day-to-day activities such as work and hobbies, and enjoy being with your family and friends.
Talking with your doctor about pain
The first step in getting your pain under control is to let your doctor know about the pain. Tell your doctor things like:
• Where you have pain;
• What it feels like (sharp, dull, throbbing, constant, burning or shooting);
• How much pain you have;
• How long it lasts.
What can your doctor do to help with pain?
Your doctor may prescribe medicine(s) to help with your pain – this will be based on the kind of pain you have and how severe it is. You might hear these called analgesics. There are 3 steps that your doctor can take to help get your pain under control. You may find that your doctor combines some of the medicines to help get any pain under control. More information about pain issues see the Treatments for Advanced Prostate cancer page 20
Radiotherapy for bone pain
Radiotherapy may be given to help relieve pain from the cancer that has spread to the bone, to help you feel better generally and slow down the growth of the cancer cells in the area being treated; but it may not be the right kind of treatment for all men. The doctors treating you will explain all about the treatment and why it may or may not be a suitable choice for you.
A special machine produces high-energy x-ray beams, which are then very accurately aimed at the area of cancer cells in the bone. The aim is to destroy these cancer cells while trying not to damage healthy cells. Very low doses of radiation are used and you may have only one or a few radiotherapy treatments.
You may have this treatment as a single dose all at once or it may be divided into smaller doses called fractions which are given over a period of time. For further information see Treatments for Advanced Prostate cancer page 22
How long might it be before I start to feel better?
For the first few days after treatment you might find that the pain becomes slightly worse before starting to get better. You can ask your CNS or oncologist for advice on what you can take to help with the pain during this time. As the radiotherapy works quickly, you could feel the benefits within a few weeks and maximum benefit can be up to six weeks. This treatment may go on relieving pain for about 3 months.
What about side-effects?
Side-effects from the treatment can vary from man to man with most men finding that they have few side-effects with this type of radiotherapy. Some of the more common ones are; slight reddening or itchiness of the skin, being more tired, feeling a bit sick or possibly some diarrhoea.
Radium 223 dichloride brand name Xofigo®
It is a radioactive, therapeutic drug that is given by injection. Radium 223 is used for men with hormone-resistant prostate cancer that has spread chiefly to the bones, there it helps to control the effect of cancer in your bones and may help you live longer.
If prostate cancer has spread to bones, then these are areas of bone that are growing very quickly. Radium 223 collects at these areas killing the cancer cells and allowing the therapy to be delivered exactly where it is needed while limiting damage to normal healthy cells. The radium will work if there are cancer cells in more than one area of bone to destroy the cancer cells. This helps to reduce the cancer growths and the pain that these growths can cause. Radium 223 is not suitable for all and the CNS or oncologist will discuss whether this might be an option in your particular circumstances.
How is it given?
Radium 223 is given by injection and as an out-patient. To make sure that your blood counts are normal or satisfactory, you will have to have a sample of blood taken before your treatment/injection can go ahead. You may have to attend an out-patient/GP appointment to have blood taken;
The dose/amount of radium 223 you will have will be calculated for you by the oncologist looking after you. A small needle/tube (you may hear this called a cannula) is put into a vein in your hand or arm and is first of all flushed through with saline. Then the drug is given slowly, over a minute, through this needle and finally flushed through with saline again. So, the whole procedure should only take a few minutes and shouldn’t cause any discomfort.
How long will I have this treatment for?
This will be given once every 4 weeks up to a total of 6 injections. To get the most benefit from your treatment, it’s important that you attend all your appointments – for your blood tests and to have your 4 weekly injection. If you can’t manage appointments for any reason, it’s important to let the clinic/ day unit know as soon as possible.
How long might it to take to make me feel better?
For a couple days after your injection, you might find you have a bit more pain than usual. If this happens continue with your usual pain-killing medicine. Sometimes it may be necessary to take more pain-killers or you might have to take a stronger pain-killer. Your consultant, CNS or GP will be able to guide you on this. This should settle as the treatment starts to work and the pain should improve.
What about side-effects?
Probably the most common side-effects are nausea (feeling sick), being sick, diarrhoea and your legs, ankles, feet or arms swelling. If these are troublesome everyday, then your oncologist or GP may be able to prescribe something to help.
Temporary reduction in the number of certain blood cells in your body .
This is the reason for you having blood samples taken before your treatments so the oncologist can check that your blood count is satisfactory. It’s essential that you have these before your treatment appointment.
Strontium 89 (Metastron)
If hormone therapy isn’t working any longer, and your prostate cancer has spread to the bones causing pain, then your doctor may suggest treating you with Strontium 89. Bones are made of calcium, and Strontium 89 acts like calcium in the body. You will need to go into a hospital clinic or day area to have Strontium 89. When it is injected it will collect in the metastases and deliver radiation directly to the affected area, giving relief from pain. For further information see Treatments for Advanced Prostate cancer , page 24
How long before it starts to work?
It often takes around 2 weeks before the treatment really starts to work and it may take slightly longer before you notice any benefit. Some men find that the pain gets slightly worse, called a ‘flare’, for the first few days after the injection. Once it starts to work, you should have the benefit of pain relief for several months and Strontium 89 can be given again in the future if it helped.
Is there anything I have to do after the injection?
The effect of Strontium 89 is kept to the small area where it collects in the bones and helps with pain. However, for the first 2 weeks after the injection there will be some Strontium 89 in your urine so you must take extra care when passing urine. The CNS or oncologist will most likely give more guidelines on this.
You should be given a treatment card which you should carry with you all the time for the first three months after you have had this treatment. You should show this card to any medical staff that may be treating you, so that they know you have had this kind of radiotherapy treatment.
What are bisphosphonates?
Bisphosphonates are drugs that, in certain situations, can help protect your bones against some of the effects of cancer such as pain, thinning, weakness, possible breaks and may help improve the man’s quality of life. They can’t treat the cancer itself but work by strengthening the bones. There is zoledronic acid (Zometa®) and a new medicine called denosumab (Xgeva®) For further information see Treatments for Advanced Prostate cancer, page 27.
When are bisphosphonates used?
These are used when hormone therapy has stopped working as effectively and the cancer has spread to the bones and can also be used to treat high levels of calcium in the blood, called hypercalcaemia.
How do these help?
In healthy bone, there is a balance between two types of bone cells osteoclasts and osteoblasts. They work together constantly to shape, rebuild and strengthen bones:
• Osteoclasts – destroy old bone
• Osteoblasts – build new bone
When a bone is affected by cancer, the osteoclasts work harder, breaking down more bone and so it becomes weaker. Bisphosphonates stop osteoclasts from doing this.
How are bisphosphonates given?
You will need to go to a day unit or outpatients ward at hospital every 3 to 4 weeks. A thin tube (cannula) will be put into a vein in your arm then a fluid containing the drug will run through this tube into the vein. The treatment usually takes about 15 minutes but may take slightly longer. You might feel a little discomfort at first but it shouldn’t last long.
What about side-effects?
Although Bisphosphonates may help with pain or help prevent bones breaking, just as with other drugs, there may be some minor side-effects, but after a short time most men cope with this treatment quite well. Probably the most common side-effects are: the bone pain gets slightly worse when you first start taking a bisphosphonate, some flu-like symptoms, feeling sick, being tired, constipation and red sore eyes.
If these side-effects are troublesome let your CNS or oncologist know as they may be able to suggest what might help with these. While you are on this treatment you may find that the doctor will check that your kidneys are working properly, measure the levels of calcium, magnesium and potassium in your blood and keep a check on your blood pressure. For more information about side-effects see Treatments for Advanced Prostate cancer, page 29.
Osteonecrosis of the jaw
This doesn’t happen very often. It is more usual if you have bisphosphonates for longer than a year and if you have any dental treatment whilst taking bisphosphonates. It means that the healthy bone in the jaw dies and it may cause the following symptoms:
• Pain, swelling, or redness in the gums;
• Gum infections;
• Teeth becoming loose or falling out;
• Gums not healing properly after dental treatment;
• A heavy or numb feeling in your jaw.
You can still go ahead with normal dental check-ups but let your dentist know that you are having bisphosphonates. If you need any dental work, it’s best to have this done before starting bisphosphonates or you may have stop taking the bisphosphonate for a few months in order to have dental treatment done. If you have any of the symptoms listed above, then let the CNS, oncologist or dentist know as soon as possible.
Spinal cord compression
What is spinal cord compression?
Spinal cord compression is caused by pressure on the spinal cord because:
• The cancer has spread to the bones or the spine
• This secondary tumour grows causing compression of the spinal cord
As a result, there is swelling and pressure on the spinal cord and nerve roots. Although this is not a very common problem, it is something you need to be aware of and let your CNS or oncologist know immediately if you experience any symptoms that may indicate it is happening.
What should you look out for?
- Pain in your back: This can be anywhere from your neck down, particularly if it is associated with any numbness or tingling in the legs. People often say that the pain feels like a ‘band’ around their chest or tummy or describe the pain as burning or shooting.
- Numb feeling: A numbness or ‘pins and needles’ in your toes, fingers or over your bottom.
- Unsteady: You might notice that you are a bit more unsteady on your feet, walking might become a bit more difficult and your legs may feel weak.
- Problems passing urine: You might find that it is a bit more difficult to hold urine in your bladder or that you don’t pass very much urine or sometimes none at all.
- Bowel: You might find that you have difficulty controlling your bowels.
If you have any of the following you should contact your CNS, oncologist or GP immediately:
• Any new difficulty walking;
• Reduced power/altered sensation;
• Bowel/bladder disturbance;
• Shooting pain that goes down your leg or new pain that feels like a band around your chest or stomach.
What might the doctor do?
To be sure of what is causing these symptoms your doctor may want you to have some tests.
How can it be treated? As soon as the doctor confirms that you have spinal cord compression then treatment is started straight away, this aims to shrink the tumour and so ease the pressure on the nerves. The quicker the treatment is given, the sooner your symptoms will start to improve and the less likely it will be for permanent injury to the nerves in the spinal cord.
Treating spinal cord compression (SCC)
As far as possible and as soon as possible, it is important to get you back to the way you were before.
Steroids These are usually started straight away as they help reduce swelling, ease the pressure around the spinal cord and this helps reduce any pain. The steroid most commonly used is dexamethasone. Once your symptoms have started to get better, the doctor will gradually reduce the dose of the steroid until you no longer need it. For some men, dexamethasone will be continued after radiotherapy has started, then the dose will gradually be tapered off.
Radiotherapy Radiotherapy is the usual way to treat spinal cord compression (SCC). This means that high energy x-ray beams from outside the body are aimed at the tumour in or near the spine, to kill the cancer cells. Before radiotherapy can begin the doctors work out a treatment plan. To make sure that the correct area is treated there will be a tiny, permanent mark made on your skin. Although treatment takes just a few minutes and you won’t feel anything, you may have to stay in hospital.
Surgery Very occasionally, it may be necessary to treat spinal cord compression with an operation. This would involve removing part, or all, of the tumour in the spine to relieve pressure on the nerves.
After treatment One of the most troubling symptoms is often pain. Your oncologist will prescribe pain-killers for you. Let the CNS or oncologist know whether these are controlling your pain well. Another option may be to see a doctor who specialises in controlling pain.
In certain circumstances, the oncologist may advise you to rest in bed. Ask for more advice on this.
You may see a physiotherapist or occupational therapist to help get you moving again. They may suggest exercises for you to do to help build up your strength.