Metastatic stage 4 prostate cancer

This page was reviewed under our medical and editorial policy by

Maurie Markman, MD, President, Medicine & Science

This page was updated on May 10, 2022.

In many cases, prostate cancer cells are less aggressive and grow more slowly than cells found in other cancers. As a result, prostate cancer is often diagnosed before it has had a chance to spread, or metastasize, to other parts of the body. In 69 percent of cases, the disease is diagnosed while the cancer is confined to the prostate.

When diagnosed in early stages, prostate cancer is highly treatable. In metastatic or stage 4 prostate cancer, cancer cells break away from the tumor in the prostate and establish new tumors in other parts of the body. An initial diagnosis of metastatic prostate cancer is very rare.

Stage 4 prostate cancer metastatic sites

Prostate cancer cells may travel through the lymphatic system or the bloodstream to other areas of the body. Common prostate cancer metastasis sites include:

  • Bones
  • Lungs
  • Liver
  • Brain
  • Lymph nodes outside the pelvis
  • Other organs

This article will cover:

Stage 4 prostate cancer substages

Stage 4 prostate cancer is classified into substages, and the subcategory the oncologist assigns helps guide the treatment options.


Stage 4A: Cancer cells have been found in nearby lymph nodes and may have spread into local tissue.


Stage 4B: Cancer has spread to areas farther away from the prostate, such as distant lymph nodes or bones.

Symptoms of metastatic prostate cancer

With metastatic prostate cancer, the patient may notice different symptoms than those generally associated with other stages of the disease. Some of the most frequently occurring stage 4 prostate cancer symptoms include:

  • Bone pain, particularly in the pelvis, ribs, skull and spine (prostate cancer most commonly spreads to the bones)
  • Unexplained weight loss
  • Fatigue
  • General feeling of being unwell
  • Changes in urinary habits, such as needing to go more often
  • Cough, breathlessness or other changes involving the lungs and chest
  • Constipation

Not everyone with metastatic prostate cancer will experience each of these symptoms, but patients should speak with their care teams if they notice any such changes.

Metastatic prostate cancer PSA levels

As part of patients' ongoing treatment, the care team regularly tests PSA levels. PSA stands for prostate-specific antigen, which may be high in men who have prostate cancer. PSA tests are used not only for the initial cancer diagnosis but also to observe the advancement of the disease over time.

Generally, PSA levels are higher in men with metastatic prostate cancer. However, in rare cases, it’s possible to have a low PSA even if a patient has metastatic disease. For these patients, disease progression is better measured in other ways, such as through imaging tests and biomarker tools.

Metastatic prostate cancer treatment

If a patient has been diagnosed with prostate cancer and he is concerned about prostate cancer metastasis, he should talk with a doctor about the risk of prostate cancer metastasis and treatment options.

Treatments for stage 4 prostate cancer may depend on where in the body the disease has spread. Options include those listed below.

Surgery for metastatic prostate cancer

Unlike with localized prostate cancer, surgery isn’t usually used to treat metastatic cancer. However, it may be used in some cases if it can help improve a patient’s quality of life, often to resolve urinary problems or stop bleeding.

If prostate cancer is locally advanced and hasn’t spread far, a radical prostatectomy may still be an option. This is a surgical procedure in which the prostate is removed, along with any nearby tissue that contains prostate cancer cells.

Radiation therapy for metastatic prostate cancer

Radiation therapy may be used to treat men with high-risk prostate cancer or stage 4A cancer (in which the cancer has spread to lymph nodes near the prostate but not to other parts of the body).

In these instances, external beam radiation therapy is commonly used, also known as EBRT (external beam radiation therapy). Using an external machine, a doctor sends targeted beams of radiation to the cancer site. It’s administered five days a week in an outpatient facility over several weeks.

Radiation may be targeted to prostate cancer that has spread to the bones as well, helping reduce pain.

Hormone therapy for metastatic prostate cancer

Metastatic prostate cancer patients may benefit from hormone therapy. Androgen suppression therapy, also known as androgen deprivation therapy (ADT), uses medication to lower androgens (male hormones such as testosterone) created in the testicles, which can fuel cancer growth. Radiation therapy and hormone therapy may be given together.

Side effects of hormone therapy

Hormone therapy may cause side effects associated with low testosterone, such as hot flashes, sweating, weight gain, reduced sexual desire and depression. Some men also may experience swollen breasts, depression, memory loss and heart problems. Eventually, the cancer may become resistant to hormone therapy. If hormone therapy stops working, doctors may switch treatments.

Learn more about hormone therapy for prostate cancer

Chemotherapy for metastatic prostate cancer

Chemotherapy may be used for patients with metastatic prostate cancer, with the aim of slowing any further spread of cancer and improving quality of life.

The most commonly used chemotherapy medications, typically given via an intravenous (IV) line, are docetaxel combined with prednisone. However, there are several chemotherapy drugs available, so ask a doctor which types may be most appropriate as an effective prostate cancer treatment.

In some cases, these treatments are considered palliative, intended to relieve difficult symptoms and improve quality of life.

Side effects of chemotherapy

Side effects of chemotherapy are common and may include:

  • Hair loss
  • Mouth sores
  • Decreased appetite
  • Digestive issues such as nausea, vomiting and diarrhea

While on chemotherapy, patients are also susceptible to infections because their white blood cell counts are lower. Other common side effects include bruising or bleeding due to fewer blood platelets and fatigue due to the lowered red blood cell count.

It’s also possible to experience a severe allergic reaction to some of the drugs used to treat prostate cancer, especially Taxotere® (docetaxel) and Jevtana® (cabazitaxel). The patient’s care team may recommend medicines before each session to help prevent a reaction.

The prostate chemotherapy drug mitoxantrone may cause leukemia later in life, but this is rare. The prostate chemotherapy drug Emcyt® (estramustine) may increase the risk for blood clots.

During chemotherapy, doctors may also offer supportive care services to help ease side effects. For example, naturopathic providers may suggest supplements to reduce nausea. Also, a mind-body therapist may recommend techniques to help the patient relax and feel less anxious during prostate cancer chemotherapy treatments.

Learn more about managing prostate cancer treatment side effects 

Targeted therapy

Targeted therapy cancer treatments involve drugs that may identify cancer cells without harming normal cells. Essentially, these new treatments change the way cancer cells function during their life cycle, while having less of an impact on a patient’s overall health and well-being than chemotherapy. These treatments for prostate cancer are oral medications, and are also known as PARP inhibitors.

Side effects of targeted therapy

Some men may experience side effects such as diarrhea, nausea and low red blood cell counts. Other possible side effects include:

  • Fatigue
  • Loss of appetite
  • Constipation
  • Cough
  • Shortness of breath
  • Skin rash

Liver blood tests may also be abnormal.

One of the targeted therapies for prostate cancer, Lynparza® (olaparib), may increase the risk for blood clots in the lungs and legs. These drugs may also cause a blood cancer such as myelodysplastic syndrome or acute myeloid leukemia, but this is rare.


Immunotherapy is a unique treatment that uses the body’s immune system to fight off cancer cells. It’s a promising treatment for prostate cancer, including advanced or recurrent forms of the disease. This treatment method may be used alone or in conjunction with other treatments such as radiation therapy and hormone therapy.

A cancer vaccine and immune checkpoint inhibitors have also been used when men with advanced prostate cancer no longer respond to hormone therapy, but show few or no symptoms.

Each vaccine is made specifically for the patient. A special machine is used to remove white blood cells (which are part of the immune system) from the blood. This procedure may take several hours. White blood cells are sent to a lab to be mixed with a protein (prostatic acid phosphatase) that protects the body against prostate cancer. The vaccine is then given to the patient by infusion. The process is repeated twice, two weeks apart for a total of three doses. This vaccine may help the immune system attack the prostate cancer. The vaccine may help men live longer, but it hasn’t been shown to stop the growth of cancer.

Immune checkpoint inhibitors are another way of using the immune system to prevent prostate cancer from growing. Checkpoint inhibitors may be used in men whose prostate cancer cells have tested positive for specific gene mutations and whose cancer recurs after being treated with chemotherapy or has spread throughout the body. They are called “checkpoints” because they act like switches that turn on a signal allowing an immune response in cells. They also may be designed to turn off an immune response.

Side effects of immunotherapy

Side effects of immunotherapy may include:

  • Fatigue
  • Nausea
  • Loss of appetite
  • Joint pain

Diarrhea, skin rash and itching are also possible.

When the immune system attacks other parts of the body, rare serious side effects may develop, such as problems in the lungs, gastrointestinal tract, kidneys and hormone-producing glands.


One emerging treatment for advanced prostate cancer involves the use of theranostics. This technology pairs diagnostic biomarkers with therapeutic agents to identify and target cancer cells for destruction.

The Food and Drug Administration has approved PLUVICTO® (Lu-PSMA-617) to treat advanced prostate-specific membrane antigen-positive metastatic castration-resistant prostate cancer in patients who have received other anticancer treatments.

Stage 4 prostate cancer survival rate

The prognosis for stage 4 prostate cancer varies for each patient, as each person’s medical circumstances are unique. For prostate cancer that is confined to the prostate or has spread to regional lymph nodes, the five-year relative survival rate is 100 percent, according to the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program.

For patients with metastatic prostate cancer that has spread to distant parts of the body, the five-year relative survival rate is 34.1 percent, according to SEER data.

Keep in mind that the survival rate for metastatic prostate cancer depends on a variety of factors, including the patient’s age, overall health and the extent of the disease, so always talk to the care team about the patient’s individual prognosis.

Supportive care

Treatments for metastatic prostate cancer often cause side effects that may impact quality of life. Side effects may include:

  • Digestive issues, such as diarrhea and vomiting
  • Pain
  • Hair loss
  • Fatigue

Prostate cancer experts work closely with the supportive care team to anticipate potential side effects and work proactively to address issues so patients can better tolerate treatments. Supportive care services designed to help manage side effects include:

Learn more about supportive care

Next topic: What are the stages of prostate cancer?

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Show references
  • Cancer Research UK (2019, June 26). Symptoms of Advanced Prostate Cancer.
  • National Cancer Institute (2021, February 24). Prostate-Specific Antigen (PSA) Test.
  • Lu Y. (2021). Association between low prostate-specific antigen levels and greater disease progression in high-grade locally-advanced prostate cancer. Journal of the Formosan Medical Association, 120(1), Part 2, 483–491.
  • American Cancer Society (2022, January 18). Initial Treatment of Prostate Cancer, by Stage and Risk Group.
  • American Cancer Society (2019, August 1). Chemotherapy for Prostate Cancer.
  • American Cancer Society (2022, March 1). Survival Rates for Prostate Cancer.