Prostate-specific antigen (PSA) testing has become easily available and widely used, and more men are getting tested. For those with elevated PSAs, the diagnosis of prostate cancer is almost uniformly made when the cancer is in the early stages. The overwhelming majority of my new patients have early- stage prostate cancer. Nevertheless, I do on occasion see a patient who presents initially with metastatic disease. I should mention here that my practice is composed predominantly of African American men.

Most of my patients with advanced disease had their localized prostate cancer definitively treated with a radical prostatectomy or radiation therapy and have experienced treatment failure as evidenced by rising PSA values (over a nadir of <0.1 ng/mL); this rise in PSA may be significant. On occasion I make the diagnosis of advanced disease in other ways, such as finding a palpable prostate nodule or disease that palpably extends beyond the capsule of the prostate.

Informing patients that their prostate cancer has progressed is best approached with sensitivity and compassion, as many men find this diagnosis devastating. In my practice, this discussion often takes more than one visit. I try to keep the discussion at about a high school level to help them grasp the concepts. I give them reading materials about advanced prostate cancer to take with them. They frequently don't hear everything I tell them at this visit because they are so upset. I bring them back to talk about the fact that their prostate cancer is advanced. My experience is that patients who have already had the diagnosis of localized prostate cancer and need to be told it has advanced have a much better understanding of the disease and its treatment and are more accepting of their diagnosis than those who are primarily diagnosed with advanced prostate cancer. I ask caregivers to join these discussions. Caregivers often are the ones who take notes and ask questions. Male patients tend to try to handle things on their own and it's important to have their support system be aware of their needs. In addition, as the disease progresses and patients become disabled, the caregivers become the caretakers. They need to be involved in treatment decisions because the burden of care eventually falls on them.

I encourage my patients to have other support systems as well. I recommend that they join a survivors group. For my patient population in New York City, I recommend “Brother to Brother”. I feel strongly that urologists should be aware of the support groups in their area and direct their patients to them.

The therapeutic options that I recommend for advanced prostate cancer depend on the type of disease. I might suggest that they first undergo pelvic lymph node dissection to clarify the stage of the cancer. Therapies I might suggest include cryoablation surgery, radiation therapy, or hormonal therapy, depending on the stage of the disease and other aspects of the patient's situation.

For patients who are candidates for hormonal therapy, I describe the usefulness of luteinizing hormone-releasing hormone (LHRH) agonists as well as the side effects. I talk with them about the sexual side effects, hot flashes, gynecomastia, weight gain, and hair loss. The side effects that seem to be the most bothersome to my patients are gynecomastia, hot flashes, central obesity, and fatigue. While patients are on treatment, I monitor PSA. If the patient has bone metastases, I monitor his alkaline phosphatase levels as well.