An Overview of Non-Metastatic Castration-Resistant Prostate Cancer

Non-metastatic castration-resistant prostate cancer (nmCRPC) is a potentially dangerous form of the cancer that’s resistant to therapy but has not spread to other parts of the body (metastasized). Testosterone promotes the growth of this cancer in this gland (located between the bladder and the penis), and androgen deprivation treatment (ADT) is often used to lower levels of this hormone and thereby shrink the growth.

In nmCRPC cases, the cancer has developed a resistance to this kind of treatment and continues to grow. This is in contrast to metastatic castration-resistant prostate cancer (mCRPC), where these cancer cells start to spread to lymph nodes, bones, and other organ systems.

Prostate cancer is the second most common form of cancer in men, and while early detection and treatment is highly successful, the development of nmCRPC is an area of significant concern.

Symptoms

This type of prostate cancer is essentially an earlier stage of the disease (it’s considered stage I or II), and what’s troubling about it for caregivers is that it’s often asymptomatic at this point. The growth of the cancer itself is not felt by patients, which underscores the importance of regular evaluation. What is essential for those with nmCRPC is to recognize the symptoms that arise when the cancer starts to metastasize:

• Blood in urine: One of the most prominent signs of trouble is that the urine is reddish in color and contains blood. In addition, semen may also contain blood.
• Pain in urination: Pain or burning sensations during urination, due to inflammation in the area, is a less frequent but telltale symptom.
• Frequent urination: The progression of prostate cancer also leads to a more frequent need to urinate.
• Pain while sitting: The cancer causes significant inflammation of the prostate, which can make sitting uncomfortable.  
• New onset of erectile dysfunction: An inability to maintain an erection—erectile dysfunction—can also arise as prostate cancer gets more serious.

Notably, additional symptoms can arise based on where the cancer has spread to and its size.

Causes

Prostate cancer, in general, arises due to mutations in that organ’s cells that lead to the growth of cancerous tumors. Cancer cells tend to divide and grow at a faster rate than healthy ones, which is, in part, why it’s so dangerous. In many respects, you could refer to nmCRPC as “man-made” because it’s a stage of the cancer defined by its reaction to ADT. Drugs that reduce testosterone levels—and thereby halt cancerous growth—like Erleada (apalutamide) and Xtandi (enzalutamide)—are sometimes unsuccessful. The cancer cells bind to androgen receptors in the prostate and are fed by them, and these drugs work by binding to and blocking these areas. However, some types of the cancer can essentially develop the ability to work around this issue, leading to nmCRPC.

Diagnosis

Since nmCRPC is only evident after attempts at ADT, it’s primarily detected during the necessary follow-up sessions. The idea is that doctors assess for signs that the cancer is still growing. Broadly speaking, there are five stages of cancer growth; since stages I and II are those in which the cancer has not yet spread beyond the prostate, those are the ones seen in nmCRPC cases. There are several methods for this detection:

• Blood tests: The prostate-specific antigen (PSA) test can check for the levels of a protein (antigen) secreted only by prostatic cells, which is increased when those cells are cancerous. Because it measures the levels of antigens in blood, it’s often used to track progress of the condition. In nmCRPC cases, doctors may also need to detect testosterone levels.
• Digital rectal exam (DRE): This is a manual examination for the presence of inflammation or irregular growth in the prostate, and it’s often indicated alongside blood tests. It entails the doctor wearing gloves and accessing the organ by inserting a lubricated finger into the rectum.
• Magnetic resonance imaging (MRI): MRI scans are often used to assess if cancer is spreading out of the prostate to surrounding tissues. This type of imaging employs radio waves instead of X-ray, and a contrast dye injected into the veins allows more details to be seen.
• Computed tomography (CT) ccan: This method employs detailed X-ray imaging to provide careful analysis of multiple angles of the affected area. It’s most often used to detect the spread of cancer to the urinary tract and is not quite as effective for assessment of the prostate itself.
• Positron emission tomography (PET): Similar in nature to MRI, PET scans employ a special drug is used to sharpen images. It’s used to track any growth of the cancer.
• Bone scan: Prostate cancer is particularly troubling once it starts spreading. Bone scans help doctors assess if it is starting to develop in bone marrow.

Treatment

By definition, nmCRPC is resistant to prostate cancer treatments, with ADT therapy proving ineffective in stopping the disease’s progression. Depending on the case, treatment options are: 

• Orchiectomy: Testosterone, the male sex hormone, is produced in the testicles, so one approach to nmCRPC involves surgically removing these with a procedure called orchiectomy. ADT is at first delivered via medications, but when they don’t work, this irreversible outpatient procedure, a surgical form of the treatment, is considered an option.
• Hormone therapies: Depending on the case, the doctor may consider alternative approaches to ADT that still involve medication. The goal is always to lower testosterone levels because this hormone boosts cancer development.
• Active surveillance: Men with nmCRPC who do not have pronounced symptoms of prostate cancer and want to avoid the side-effects of hormone therapy can consider an approach that involves close monitoring of the disease progression. Cases in which the cancer is less likely to spread from the prostate are tracked in this way.

Naturally, the actual treatment plan will depend on the recommendations of the doctor and the wishes of the patient.

Coping

Taking on prostate cancer, as with any serious medical condition, can be a real challenge. For both those affected and their families, there may be a serious emotional fallout. What’s perhaps most important for those with nmCRPC is trust and open communication with the medical staff. Beyond that, mental health counseling and support groups can be helpful in taking on the burden of this disease. In addition, advocacy groups such as the Prostate Cancer Foundation, Us, Too, and Male Care can connect people with the condition and their families with resources and information about the condition.

Prognosis

Prostate cancer can function differently in different people, and the same can be said for nmCRPC. The good news is that ADT approaches and therapies taking on the condition have been shown to be effective in delaying progression of the disease, decreasing mortality among those who have this cancer. Individual results vary, but it’s largely accepted that the current first and second-line treatments delay the growth and spread of nmCRPC and can prevent deaths as a result of this cancer.

A Word From Verywell

There’s no such thing as an easy cancer, but since prostate cancer is the second most common cancer in men (behind skin cancer), treatments have evolved a great deal and are getting better all the time. It’s encouraging to know that the five-year survivability rate for prostate cancers that have not spread to other parts of the body (like nmCRPC) defined as the percentage of those who are still alive five years after diagnosis, is close to 100 percent. While treatments aren’t able to completely eradicate this cancer, they can certainly fight it. And as the medical community continues to learn more about this condition and improve existing approaches to it, prognosis will only improve.