Metastatic castration-resistant prostate cancer (mCRPC)

Diagnosis

Healthcare professionals may suspect that a prostate cancer is castration resistant based on blood tests, imaging tests and your symptoms. To know whether the cancer is metastatic castration-resistant prostate cancer (mCRPC), healthcare professionals use imaging tests to look for signs that the cancer has spread.

PSA test

A PSA test measures the amount of prostate-specific antigen (PSA) in the blood. PSA is a protein that's made by healthy prostate cells and cancerous prostate cells. A high level of PSA can be a sign of cancer. Other conditions that aren't cancer also can raise the level of PSA.

Sometimes the first sign of castration resistance is a rising PSA level in someone who is taking hormone therapy for prostate cancer.

There isn't a certain PSA level that says you might have castration-resistant prostate cancer. Instead, your healthcare team decides this based on your particular situation and results of imaging tests. Your level might be affected by your previous treatments and any hormone therapy medicines you take.

Testosterone test

A testosterone test measures the amount of testosterone hormone in the blood. If your PSA level starts going up, your healthcare professional also might test your testosterone level.

A testosterone level below 50 nanograms per deciliter (ng/dL) is considered castration level. If your testosterone is at castration level and the cancer is growing, this may be a sign of castration-resistant prostate cancer.

If your testosterone level has risen, it may be a sign that your hormone therapy treatment isn't working as expected. Your healthcare team might adjust your treatment to lower the level. This might help stop the cancer from growing.

Imaging tests

Imaging tests can make pictures of the body that the healthcare team uses to look for signs of cancer. Sometimes the first sign that the cancer is castration resistant is an imaging test that shows a new area of cancer or growth in an existing area of cancer in someone who is taking hormone therapy. If imaging tests show the cancer has spread away from the prostate, it's considered metastatic cancer.

Imaging tests might include:

• Bone scan. A bone scan uses nuclear imaging to make pictures. Nuclear imaging involves using small amounts of radioactive substances, called radioactive tracers. A special camera that can detect the radioactivity also is used along with a computer. The tracer may highlight areas of cancer within the bones. A bone scan may be used to detect prostate cancer that spreads to the bones.
• CT scan. A computerized tomography (CT) scan is a type of imaging that uses X-ray techniques to create detailed images of the body. Then a computer creates cross-sectional images, also called slices, of the bones and soft tissues inside the body. A CT scan can detect prostate cancer that has spread to the lymph nodes, organs or other places in the body.
• MRI scan. A magnetic resonance imaging (MRI) scan uses a magnetic field and radio waves to create pictures of the inside of the body. MRI can detect cancer that spreads to the lymph nodes or other places in the body.
• PET scan. A positron emission tomography (PET) scan is a nuclear imaging test. It uses a radioactive tracer that's injected into a vein. The tracer contains a substance that helps it stick to the cells that the test is looking for. The PET images show the places where the tracer builds up. A PET scan can look at the whole body to detect cancer.
• PSMA PET scan. A prostate-specific membrane antigen (PSMA) PET scan is a kind of PET scan. It uses a tracer that has a substance that helps it stick to prostate cancer cells. The substance attaches to a protein that's found on the surface of prostate cancer cells. The protein is called prostate-specific membrane antigen. A PSMA PET scan can detect prostate cancer that has spread anywhere in the body.
• Choline C-11 PET scan. A choline C-11 PET scan is a kind of PET scan. Like other PET scans, this test uses a radioactive tracer. Prostate cancer cells take up more of the tracer than do most other cells in the body. This test might be used if other imaging tests haven't found the cancer.
• FDG PET scan. A fluorodeoxyglucose (FDG) PET scan is a kind of PET scan. It uses a tracer that contains a radioactive substance and glucose, which is a simple sugar. Prostate cancer cells take up more of the tracer than do most other cells in the body. This test might be used if other imaging tests haven't found the cancer.

Biopsy

A biopsy is a procedure to remove a sample of tissue for testing in a lab. For metastatic castration-resistant prostate cancer, the kind of biopsy you have depends on where the cancer has spread. Often a healthcare professional puts a needle through the skin and into the cancer to get some cells.

In the lab, tests can show whether the concerning growth of cells is made up of prostate cancer cells. Other tests on the cells might give more information. The healthcare team may use the information to create a treatment plan.

Genetic testing

Genetic testing uses a sample of blood or saliva to look for variations in the DNA. Your healthcare team might recommend genetic testing if you haven't had it before. Some metastatic castration-resistant prostate cancer treatments work better in people who are born with or who develop certain DNA variations. Sometimes genetic tests provide information about cancer risk that can be helpful for blood relatives.

Treatment

Treatment for metastatic castration-resistant prostate cancer may help manage the disease and extend your life. Treatments aren't likely to cure the cancer. Options may include hormone therapy, chemotherapy, targeted therapy, radiopharmaceutical treatments, immunotherapy and radiation therapy.

Your healthcare team may choose your treatment plan based on:

• Other cancer treatments you had in the past.
• Cancer medicines you're currently taking.
• Any symptoms you're having.
• Where the cancer has spread.
• How many places in your body have cancer.
• Your overall health.
• Any other serious health conditions you have and their treatments.
• Your personal preferences and other concerns you have about cancer treatment.

Treatments for managing metastatic castration-resistant prostate cancer are an active area of cancer research. Researchers are looking at new medicines, new ways of using existing medicines and the order in which to give prostate cancer treatments for the best results. You might choose to take part in a clinical trial to study the latest prostate cancer treatments. Talk with your healthcare team about your options.

Hormone therapy

Hormone therapy for prostate cancer is a treatment that stops the hormone testosterone either from being made or from reaching prostate cancer cells. This treatment also is called androgen deprivation therapy (ADT).

Most people with castration-resistant prostate cancer already take hormone therapy medicines. If the cancer starts growing or spreads, the treatment often continues. Stopping hormone therapy could make the cancer grow or get worse. The care team might switch the medicines or add new ones. A change in medicines might slow the growth of the cancer.

Hormone therapy treatments for prostate cancer include:

• Medicines that stop the body from making testosterone. Some medicines block the signals that tell the testicles to make testosterone. These medicines are called luteinizing hormone-releasing hormone (LHRH) agonists and antagonists. Another name for them is gonadotropin-releasing hormone (GnRH) agonists and antagonists. Medicines that work in this way include degarelix (Firmagon), leuprolide (Eligard, Lupron Depot, others) and others, which are given as shots. Relugolix (Orgvyx) comes in pill form.
• Medicines that stop testosterone from acting on cancer cells. Medicines called antiandrogens block the actions of testosterone in the body. Newer forms of antiandrogens are sometimes called androgen receptor pathway inhibitors (ARPIs) or androgen receptor signaling inhibitors (ARSIs). Medicines that work in this way include apalutamide (Erleada), darolutamide (Nubeqa), enzalutamide (Xtandi) and abiraterone (Yonsa, Zytiga).
• Surgery to remove the testicles. Surgery to remove both testicles, called orchiectomy, lowers testosterone levels in the body quickly.

Side effects of hormone therapy include hot flashes, mood swings, memory loss, loss of muscle and increase in body fat. There may be a loss of sex drive, and it can be more difficult to get an erection. Other risks include an increased chance of getting diabetes and heart disease.

Chemotherapy

Chemotherapy treats cancer with strong medicines. Chemotherapy medicines are sometimes used with hormone therapy medicines for metastatic castration-resistant prostate cancer. Chemotherapy also helps treat the cancer when hormone therapy is no longer working.

Chemotherapy medicines commonly used for prostate cancer include docetaxel (Beizray, Docivyx, Taxotere), cabazitaxel (Jevtana) and other medicines. A healthcare professional gives these medicines through a vein. The treatments typically happen once every three weeks. Side effects of these medicines include feeling very tired, easy bruising and more-frequent infections. They also can damage the nerves in the fingers and toes, a condition called peripheral neuropathy. This can cause numbness, tingling or pain in the fingers and toes.

Other chemotherapy medicines exist. If one stops working, your healthcare team might try other chemotherapy medicines.

Targeted therapy

Targeted therapy for cancer is a treatment that uses medicines that attack the cancer cells in a specific way that causes the cells to die. For metastatic castration-resistant prostate cancer, targeted therapy medicines might be used when hormone therapy is no longer working.

The most common targeted therapy medicines used for prostate cancer are called poly(ADP-ribose) polymerase (PARP) inhibitors. They include:

• Niraparib (Zejula).
• Olaparib (Lynparza).
• Rucaparib (Rubraca).
• Talazoparib (Talzenna).

These medicines come as pills or capsules you swallow. PARP inhibitors block the action of enzymes in the cancer cells that help repair breaks in the DNA. These targeted therapy medicines work best in people with certain DNA changes in their cells. To find out if these changes are present in your cells, your healthcare team may test a sample of your blood or saliva, as well as some of your cancer cells. For every 10 people with advanced prostate cancer, research finds that 2 to 3 people may have cells that might respond to treatment with PARP inhibitors.

Side effects of these medicines include nausea, loss of appetite and feeling very tired. Other side effects include diarrhea, cough and easy bruising.

Immunotherapy

Immunotherapy for cancer is a treatment with medicine that helps the body's immune system kill cancer cells. The immune system fights off diseases by attacking germs and other cells that shouldn't be in the body. Cancer cells survive by hiding from the immune system. Immunotherapy helps the immune system cells find and kill the cancer cells.

For metastatic castration-resistant prostate cancer, immunotherapy treatments most often involve medicines called immune checkpoint inhibitors. These medicines help immune system cells find cancer cells. Some cells can send signals called immune checkpoints to the immune system. Immune checkpoints tell the immune system cells not to attack. Usually, immune checkpoints help keep the immune system from hurting healthy cells. But some cancer cells also send these signals. Immune checkpoint inhibitor medicines stop cancer cells from sending a signal to not attack.

One example of an immune checkpoint inhibitor used for prostate cancer is pembrolizumab (Keytruda). It only works in people with cancer cells that have certain DNA changes. Most prostate cancers don't respond to this treatment. For every 100 people with advanced prostate cancer, research finds that 2 to 5 people may have cells that might respond to immune checkpoint inhibitors.

Side effects of immunotherapy can include itchy skin, diarrhea, loss of appetite, rash and feeling very tired. Sometimes this treatment causes the immune system to attack the organs, leading to serious complications.

Radiopharmaceutical therapy

Radiopharmaceutical therapy uses medicines that contain a radioactive substance, called radiopharmaceuticals. Radiopharmaceutical treatments used for cancer can deliver radiation to cancer cells.

Radiopharmaceutical therapy treatments used for metastatic castration-resistant prostate cancer include:

• Treatment that targets PSMA. Radiopharmaceutical treatments can target a protein that's common on prostate cancer cells called prostate-specific membrane antigen (PSMA). One radiopharmaceutical medicine that works in this way is lutetium Lu-177 vipivotide tetraxetan (Pluvicto). This medicine contains a molecule that finds and sticks to the PSMA on prostate cancer cells. The medicine also contains a radioactive substance. A healthcare professional gives this medicine through a vein. The medicine finds the prostate cancer cells and releases the radiation directly into the cells. It can treat prostate cancer anywhere in the body. PSMA therapy only works if the prostate cancer cells have the PSMA protein, which most do. Side effects include dry mouth, dry eyes, nausea and feeling very tired.
• Treatment that targets the bones. Some radiopharmaceutical medicines contain a radioactive substance that is attracted to bones. When a healthcare professional puts this medicine into a vein, it travels to the bones and releases the radiation. One medicine that works in this way is radium Ra-223 dichloride (Xofigo). Healthcare professionals sometimes use it when prostate cancer spreads to the bones, but not to other parts of the body. Side effects include diarrhea and feeling very tired.

Radiation therapy

Radiation therapy treats cancer with powerful energy beams. The energy can come from X-rays, protons and other sources. During radiation therapy, you lie on a table while a machine directs radiation to precise points on your body.

Radiation therapy can help manage metastatic castration-resistant prostate cancer that spreads to the bones. Radiation to the affected bone can help with pain and lower the chances that the bone might break.

Radiation for cancer that spreads to the bones often uses a kind of treatment called stereotactic body radiotherapy (SBRT). This treatment aims beams of radiation from many angles at the cancer. The point where the beams meet gets a very large dose of radiation. SBRT is often given in one or a few treatments.

Palliative care

Palliative care is a special type of healthcare that helps you feel better when you have a serious illness. If you have cancer, palliative care can help relieve pain and other symptoms. A team of healthcare professionals gives palliative care. This team can include doctors, nurses and other specially trained professionals. Their goal is to improve the quality of life for you and your family.

Palliative care specialists work with you, your family and your healthcare team to help you feel better. They provide an extra layer of support while you have cancer treatment. You can have palliative care at the same time as treatment for cancer, such as surgery, chemotherapy or radiation therapy.

When palliative care is used with all of the other appropriate treatments, people with cancer may feel better and live longer.

Coping and support

Finding out your prostate cancer is no longer responding to hormone therapy can cause a range of feelings. People with metastatic castration-resistant prostate cancer sometimes describe feeling distress, fear, anger and sadness. With time, each person may figure out a way to cope. Until you find what works for you, here are some ways of coping that you can try.

Learn enough to make treatment decisions

Learn as much as you need to know about your cancer and its treatment to feel comfortable talking about your options with your healthcare team. Ask your healthcare professional to recommend some reliable sources of information.

Find a good listener

Finding someone who is willing to listen to you talk about your hopes and fears can be helpful. This could be a friend or family member. A counselor, medical social worker or clergy member also may offer helpful guidance and care.

Connect with other cancer survivors

Other people with prostate cancer sometimes are best at knowing what you're going through. They can provide a unique network of support. Ask your healthcare team about support groups or community organizations that can connect you with other people with cancer. Find support online through Mayo Clinic Connect, which is a community where you can connect with others for support, practical information and answers to everyday questions.

Preparing for your appointment

If you have symptoms that worry you, start by making an appointment with a doctor or other healthcare professional. If you're still having checkups with the healthcare team that treated your cancer, tell the team about your symptoms. If you're no longer seeing that care team, tell your usual healthcare professional about your concerns.

Because appointments can be brief, it's a good idea to be prepared. Here's some information to help you get ready.

What you can do

• Be aware of any restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
• Write down any symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medicines, vitamins and supplements that you're taking.
• Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information you get during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Write down questions to ask your healthcare professional.

Some questions to ask about metastatic castration-resistant prostate cancer include:

• What's my prostate-specific antigen (PSA) level?
• Has hormone therapy stopped working for me?
• Where is the prostate cancer in my body?
• Has my prostate cancer spread beyond my prostate?
• Will I need more tests?
• What are my treatment options?
• Is there a clinical trial available for me?
• Is there one treatment option you think is best for me?
• Do I need cancer treatment right away, or is it possible to wait and see if the cancer grows?
• What are the potential side effects of each treatment?
• What is the chance that my prostate cancer will be cured with treatment?
• If you had a friend or family member in my situation, what would you recommend?
• Should I see a specialist? What will that cost, and will my insurance cover it?
• Are there brochures or other printed material that I can take with me? What websites do you recommend?

In addition to the questions that you've prepared, don't hesitate to ask other questions during your appointment.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.