Metastatic cancer is widely perceived as an invariably terminal diagnosis. Yet prostate cancer remains an exception. In Korea, the five-year survival rate for stage IV prostate cancer is about 50 percent, and outcomes continue to improve as new treatments emerge.
Prostate cancer most often spreads to the bone. “Because bones with bone marrow extend throughout the body, prostate cancer tends to metastasize to areas rich in marrow,” said Professor Han Hyun-ho of Severance Hospital’s Department of Urology on the hospital’s YouTube channel. Common sites include the spine, ribs, and pelvic bones. Despite this spread, many patients experience no symptoms.
“It’s like changes in bone density—symptoms are uncommon,” Han explained. “The cancer disrupts hematopoietic function slightly but doesn’t interfere with the hard bone’s structure.” Severe metastasis can trigger pain, and in rare cases, spinal fractures or mechanical instability may occur.
Diagnosis typically begins with a prostate-specific antigen (PSA) blood test. After prostate removal, PSA levels should approach zero; a rising value may signal recurrence or treatment failure. In metastatic disease, PSA also helps measure response to hormone therapy.
Advanced imaging with PSMA PET-CT can pinpoint prostate cancer with high accuracy. “PSMA is expressed only in prostate cancer, and when we inject a tracer that binds to it, PET-CT reveals the exact tumor location,” Han said. The test outperforms CT and MRI in detecting metastatic lesions.
Hormone therapy remains the first-line treatment for metastatic prostate cancer. “Blocking male hormones can halt disease progression in many cases,” Han noted. Treatment has become more convenient as injections now range from monthly to six-month schedules. Hormone therapy is also used as a second-line option when the disease progresses. Chemotherapy is generally introduced later, alongside targeted therapies and immunotherapies guided by genetic testing.
Clinical studies are expanding treatment possibilities. Triple therapy—which combines chemotherapy, androgen deprivation therapy, and secondary hormone therapy—has extended survival and improved quality of life, especially in patients with “high-volume” disease. High-volume cases involve extensive spread, including to internal organs. Low-volume cases involve fewer than ten lesions or bone-only metastasis. Because high-volume disease carries a poorer prognosis, early chemotherapy is often recommended, while low-volume patients can often manage their condition with medication, similar to chronic diseases like hypertension.
“When triple therapy is used upfront, high-volume patients live longer and better,” Han said. “The gains outweigh the risks of side effects.” He added that new therapies are being introduced every quarter, reinforcing optimism about future curative potential.
However, hormone therapy carries a major downside: loss of muscle mass. “Suppressing male hormones helps control the cancer, but also decreases muscle and bone density,” Han warned. This raises the risk of metabolic and musculoskeletal disorders.
For this reason, Han stressed the importance of exercise for all patients receiving treatment. Core strengthening and pelvic exercises targeting the thighs and sphincter muscles are recommended, along with aerobic activity to maintain overall health.
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