Prostate cancer: how to fight bone metastases

Prostate cancer can also involve the bones, but thanks to specific therapies it is also possible to deal with this situation.

Prostate cancer (a small male organ located between the base of the bladder and the urogenital diaphragm, in front of the last stretch of intestine, the rectum) is one of the most common in men over 50 years of age. When the cancer develops, the cells of the prostate gland multiply uncontrollably, leading to an increase in the volume of the same.

This enlargement causes symptoms, due to the pressure by the prostate mass on the surrounding structures, in some ways similar to those of other disorders, such as prostatitis and benign prostatic hypertrophy (also characterized by an enlarged gland, but which has no tumor nature). The most common symptoms can therefore include urinary disorders (such as difficulty urinating, the presence of frequent stimulus or pain when urinating), sexual (difficulty achieving and maintaining an erection, premature ejaculation), fatigueweight and appetite loss, pain in the backpelvis or pelvic area. Sometimes you may also notice blood in your urine and/or semen.

Often tumors that develop in the prostate remain localized within this gland. However, there are also forms of carcinoma in which the tumor is more aggressive, which can then invade the surrounding tissues, extend to the lymph nodes and get to involve other body districts, including bones. At this point, prostate cancer may be associated with more severe symptoms, which include bone pain and other complications, such as fractures and excess calcium in the blood.

For this reason, one of the fundamental objectives of prostate cancer therapy – in addition, of course, to the elimination or at least the reduction of the tumor itself – must be the prevention or slowing down of the development of bone metastases. If bone metastases are already present, it is also necessary to control pain and other possible complications related to them.

Protect bones from cancer

The first step to decrease the risk of developing bone metastases is, of course, the prevention of the tumor itself. Although the molecular causes of prostate cancer are not yet well defined (an element that makes it difficult to screen completely effectively), some risk factors have been identified, in addition to age, which allow to suggest some prevention strategies:

– positive family history: it has been shown that the risk of developing this pathology doubles if there have been cases in the family among blood relatives (father, brothers); The risk is also increased in the case of family members who have had breast or ovarian cancer

– high levels of testosterone and IGF1 hormone, involved in the growth of prostate cells

– obesity, determined in many cases by a diet rich in saturated fats and low in fiber and antioxidants. In particular, it has been shown that this condition determines an increased risk of developing fast-spreading forms of cancer, because the adipose layer surrounding the prostate gland secretes proteins that ‘attract’ cancer cells, favoring the dissemination of the neoplasm in the surrounding tissues.

Another element that can help in the prevention of bone metastases related to prostate cancer, thus improving the prognosis and life expectancy of the patient, is the early diagnosis of the tumor. It is therefore advisable to undergo, after the age of 40, routine examinations (analysis of PSA values and rectal exploration); In case of doubt, more in-depth analyzes can then be used, such as transrectal prostate ultrasound, magnetic resonance imaging and biopsy, which consists of taking a small amount of prostate tissue. In case of positive outcome, i.e. presence of tumor, it is important to evaluate the degree of differentiation of prostate cells (i.e. the level of similarity between cancer cells and normal ones). To do this, the so-called Gleason scale is usually used, which assigns the tumor a score from 1 to 5 (the lower it is, the lower the differentiation and therefore the risk of tumor progression and spread outside the prostate).

Alongside this evaluation, the staging of the tumor is also carried out with the TNM system, which indicates whether the lymph nodes are affected by the neoplasm and whether metastases, including bone ones, are present. To identify the presence of the latter – an element that indicates a pathology that is at an advanced stage – bone scintigraphy can be used, in some cases.

Once the gradeaggressiveness and spread of the tumor are defined, it is important to decide how to deal with it. There are essentially two treatment options for prostate cancer: hormone therapy (also called androgen deprivation) and prostate ablation surgery. It is important to remember that there is no “right” treatment by definition: both have advantages and side effects, which it is good to discuss with your trusted oncologist, in order to identify the correct approach, case by case. These treatments can then be associated with one or more cycles of radiotherapy, to reduce the risk of metastasis or recurrence, and / or chemotherapy.

As far as metastatic prostate cancer is concerned, in recent years there has been a progressive increase in the use of a class of drugs, bisphosphonates, to treat bone metastases: initially used as additives for toothpastes, these molecules, which bind to some bone cells, have proven to be able to counteract the growth of metastases, prevent fractures and reduce levels of hypercalcemia (high concentrations of calcium in the blood) typically associated with bone metastases. It is a class of drugs that tend to be safe, that is, with few or no side effects (usually limited to fever and muscle and joint pain).

An effect similar to that exerted by bisphosphonates can also be obtained with another active ingredient that targets osteoclasts, denosumab, which can be useful even when bisphosphonates are no longer effective. Let’s see how they act.

Bisphosphonates They work by slowing down osteoclasts, the cells that degrade the scaffolding. mineral of the bones and that often become overactive in the presence of bone metastases
Denosumab In addition to counteracting fractures, it can also slow the spread of bone cancer.

In both cases, however, it is necessary that the administration of the drug is associated with the intake of calcium and vitamin D to prevent the risks of a calcium deficiency.

Friendly radioactivity

Nuclear medicine exploits the action of so-called radiopharmaceuticals, molecules containing radioactive elements that, once injected into a vein, are located in the areas of the bones where the tumor has spread. Here they kill cancer cells thanks to the radioactivity they emit.

Until recently, radiopharmaceuticals used in oncology were emitters of beta particles: their radiation penetrates deeply, sometimes causing damage even to healthy cells surrounding cancer cells, thus affecting other tissues and causing important side effects. In addition, due to their physical characteristics, they induce limited damage to cancer cells: this can sometimes be repaired by the cell itself, which therefore does not die, but continues to grow.

Radium-223 is instead the first radiopharmaceutical that emits alpha radiation: the rays penetrate modestly into the tissues, without damaging healthy cells. Radium-223 accumulates in areas where bone tissue grows uncontrollably and therefore its effect is targeted on cancer cells obtaining, in most cases, the death of the cells themselves. In addition, alpha radiation does not have a high range, on the contrary. They are shielded by a sheet of paper or skin, and therefore do not expose relatives and friends of the patient to the risk of irradiation.

Side effects are usually modest: the most common are diarrheanausea and vomiting, decrease in the number of platelets (or, more rarely, white blood cells). In any case, it is recommended to undergo, during treatment with Radio-223, tests aimed at assessing the level of both PSA and alkaline phosphatase (an enzyme involved in bone metabolism), in order to keep bone health well monitored.

Radio-223 is indicated in particular for patients with symptomatic bone metastases who do not respond to therapies that aim to inhibit the synthesis or function of androgen hormones (by removal of testicles or hormone therapy): in this case we speak of metastatic prostate cancer resistant to castration.

A battle against pain

Bisphosphonates can also help to counteract the pain caused by metastasis, thus contributing to significantly improve the patient’s quality of life. From this point of view, painkillers such as ibuprofencorticosteroids or morphine can also be useful. It is important to remember, however, that each of these classes of drugs can present, especially if the treatment is prolonged, important side effects: corticosteroids, for example, can cause hypertension, opioid drugs such as morphine addiction and addiction, and so on. It is therefore important to discuss all treatment options with your doctor, and perform treatment in a controlled regimen.

Another treatment that can be used to counteract pain is radiation therapy. The latter helps reduce pain especially if it is limited to one or a few areas. In addition, radiotherapy can help counteract other symptoms by reducing tumor masses located in other parts of the body, and is therefore also used as a therapeutic approach associated with surgery, hormone therapy or chemotherapy.

Joycelyn Elders is the author and creator of EmpowerEssence, a health and wellness blog. Elders is a respected public health advocate and pediatrician dedicated to promoting general health and well-being.

The blog covers a wide range of topics related to health and wellness, with articles organized into several categories.

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