End-Stage Prostate Cancer: What to Expect

At this stage, the focus of treatments shifts from trying to cure the cancer to managing symptoms, maintaining comfort, and preserving your dignity and quality of life for as long as possible.

Understanding what to expect in the final months of life can help guide treatment and care decisions and provide comfort during this journey.

• Bone Pain “The biggest problem that men with metastatic prostate cancer face is bone pain,” says Ken Pienta, MD, co-director of the Prostate Cancer Research Program at the Sidney Kimmel Comprehensive Cancer Center in Baltimore. “Over 90 percent of guys who die of prostate cancer are going to have prostate cancer that spreads to their bones.”
• Fatigue Since treatment for metastatic prostate cancer removes testosterone, persistent tiredness and loss of muscle mass are common, says Dr. Pienta. The cancer itself and the toll of cancer treatments and their side effects also contribute to exhaustion, he says.
• Urinary and Bowel Changes Prostate cancer that has spread to the bladder or rectum can cause difficulty urinating, incontinence, or constipation.
• Weight Loss and Appetite Changes Appetite loss, nausea, and weight loss often occur as the body absorbs fewer nutrients at this stage, says Pienta.
• Shortness of Breath and Nausea If cancer has spread to the lungs, breathing may become difficult and a persistent cough might appear.
• Emotional and Mental Changes Anxiety, depression, confusion, or withdrawal from social interaction may develop due to disease progression or from pain medications.

At this point, most people will need to take one day at a time. Oftentimes, there will be good days alternating with not-so-great days. There’s no one standard answer for how someone should be treated and cared for in their final months, or even days, with this disease.

“Every patient has their own priorities in terms of how they'd like that process to go,” says Michael J. Morris, MD, a genitourinary medical oncologist and Prostate Cancer Section Head at Memorial Sloan Kettering Cancer Center in New York City. “The first step is to listen to the patient and see what their goals are.” Some men wish to stay in a home setting for as long as possible, receiving treatment for pain, anxiety, and nausea, or other discomfort, while others opt for inpatient hospice care, he says.

“Others may not need or not be considering hospice, and they may say ... ‘I'll live my life to its fullest now and when I'm more symptomatic and need more support, then I'll be in touch,’” Dr. Morris says.

Treatment at this stage is not focused on curing the cancer but on treating symptoms and providing comfort. The choices will depend on your goals and the state of your overall health.

Palliative Care

“We [also] work with psychologists and psychiatrists in order to treat the emotional aspects of being at that point in your life,” Morris says. “The particular blend [of care] depends on the patient himself and how they're feeling and what they would like that experience to look like.”

• Pain medications like steroids, nonsteroidal anti-inflammatory drugs (NSAIDs), drugs for nerve pain, opioids, or muscle relaxants
• Anti-nausea medications
• Radiation therapy to treat areas that are causing pain

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• Relaxation techniques like guided imagery, deep breathing, and progressive muscle relaxation to reduce stress, anxiety, pain, and even nausea and vomiting
• Talk therapy

Hospice Care

“When you've exhausted all therapeutic options for prostate cancer, or any cancer, the number one thing I advocate for is for my patients to get into hospice as early as possible,” Pienta says. “In this country, we utilize hospice way later than we should.”

Getting into hospice early means more support at home or in a facility to handle problems as they come up, like pain and loss of body function. “That optimizes the quality of their lives for the life they have left to live,” Pienta says.

The decision to stop prostate cancer treatment is a deeply personal one to be made with the guidance of your doctors, and is influenced by many factors.

When to Consider Stopping Treatment

Men might consider ending active treatment for prostate cancer if it no longer improves their quality of life, if side effects outweigh benefits, or if the disease continues to progress despite multiple therapies, Pienta says. This doesn’t mean your medical team will stop all care. Rather, the type of care and attention you receive will change.

This is a time for “adding support, not taking support away,” says Morris. At this point, your medical team’s role transitions from trying to cure the cancer to “being there and assuring the patient that if they have a need it will be met,” he says.

Informing Your Healthcare Team

Communicate openly with your doctors so that everyone is aligned with your goals, Morris says. This will ensure that all your needs are addressed.

Remember that you are not alone. “[Your healthcare team] brings a lot of expertise to the bedside and that expertise will be there,” Morris says.

You and your family should feel empowered to ask questions about transitioning to comfort care and the kinds of support that are available.

Talking to Family

Preparing Legal and Medical Documents

If you haven’t already, this is the time to complete advance directives, designate a healthcare proxy, and finalize a will. Doing so provides clarity for your loved ones and helps honor your wishes.

As the body winds down, eating and drinking decline, and people often sleep more. Mental sharpness may fade.

“They find that they're getting more fatigued, less functional, less participatory in life,” Morris says. “Appetite declines.”

Healthcare and hospice teams will work to ensure comfort during this time, managing pain and helping loved ones prepare for the natural process of dying.

“Just about everybody with this particular disease [has] bone pain and is going to need support with narcotics.” Pienta says. “What I tell my guys is that eventually with so much narcotics, you're just going to be asleep and you're going to pass away in your sleep.”

This is another reason why he emphasizes the value of hospice. “It's much harder on the family,” Pienta says. “If you're asleep, you're not in pain. It's the family that has to watch that happen, which is why hospice is such an important thing to have support for the patient and the family.”

• When prostate cancer no longer responds to treatment, it becomes even more important to focus on your comfort and quality of life.
• Palliative care and hospice can provide important support for managing pain, fatigue, and emotional challenges. Starting these services early can help both patients and their families.
• The decision to stop active treatment is personal and should be made in partnership with your healthcare team, ensuring that your care aligns with your goals and values.
• Advance planning, including legal and medical directives, can give you and your loved ones peace of mind and ensure your wishes are respected during the final stage of your life.