STEP 6: Managing recurrent, residual or metastatic disease

Patients who present with recurrent or metastatic disease should be managed by a multidisciplinary team and offered timely referral to appropriate physical, practical and emotional support.

Step 6 is concerned with managing recurrent or local residual and metastatic disease. The likelihood of recurrence depends on many factors usually related to the type of cancer, the stage of cancer at presentation and the effectiveness of treatment. Some cancers cannot be eradicated even with the best initial treatment. But controlling disease and disease-related symptoms is often possible, depending on the clinical situation.

Some patients will have metastatic disease on initial presentation. Others may present with symptoms of recurrent disease after a previous cancer diagnosis. Access to the best available therapies, including clinical trials, as well as treatment overseen by a multidisciplinary team, are crucial to achieving the best outcomes for anyone with locally recurrent or metastatic disease.

Signs and symptoms will depend on the type of cancer initially diagnosed and the location of metastatic disease. They may be discovered by the patient or by surveillance in the post-treatment period. Patients with locally recurrent disease can present asymptomatically with a rising PSA, or with symptoms such as urinary symptoms. Symptoms such as pain, loss of energy or weight loss can occur in men with metastatic disease.

Imaging (pelvic MRI and PSMA PET/CT) may help to differentiate local recurrence, which may be curable with salvage therapy, from metastatic disease.

Managing recurrent or metastatic disease is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate. From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A and B, and in the special population groups section should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.

Survivorship care should be considered and offered at an early stage. Many people live with advanced cancer for many months or years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.

If there is an indication that a patient’s cancer has returned, care should be provided under the guidance of a treating specialist. Each patient should be evaluated to determine if referral to the original multidisciplinary team is necessary. Often referral back to the original multidisciplinary team will not be necessary unless there are obvious aspects of care involving different therapeutic and supportive care disciplines not otherwise accessible. The multidisciplinary team may include new members such as palliative care specialists.

Treatment will depend on the location, extent of recurrent or metastatic disease, previous management and the patient’s preferences. Accordingly, imaging may be important to define these parameters. When the identification of metastatic disease is deemed likely to change management, PSMA PET/CT is generally recommended as a preferred imaging investigation (Fendler et al. 2019).

In managing men with prostate cancer, treatment may include these options:

  • surgery
  • radiation therapy
  • ADT
  • cytotoxic chemotherapy (e.g. docetaxel)
  • novel androgen receptor signalling inhibitors (e.g. enzalutamide or abiraterone)
  • radionuclides (e.g. radium 223)
  • supportive therapies such as bisphosphonates or RANK ligand inhibitors to manage bone metastatic disease or ADT-induced osteoporosis.

In the case of a rising PSA post-prostatectomy or a defined local recurrence (in the absence of metastatic disease), patients should be referred to a radiation oncologist to consider curative intent, salvage pelvic radiation therapy. All patients with metastatic prostate cancer should be reviewed, if possible, by a medical oncologist prior to or soon after starting ADT to assess their suitability for combination treatment. Patients who go on to develop metastatic castration resistant disease should be offered a referral to a medical oncologist to discuss whether other systemic treatments are appropriate. Patients with local symptoms should also be referred to a radiation oncologist to consider the benefit of palliative radiation therapy for symptom control.

The potential goals of treatment should be discussed, respecting the patient’s cultural values. Wherever possible, written information should be provided.

Encourage early referral to clinical trials or accepting an invitation to participate in research.

Advance care planning is important for all patients with a cancer diagnosis but especially those with advanced disease. Patients should be encouraged to think and talk about their healthcare values and preferences with family or carers, appoint a substitute decision-maker and consider developing an advance care directive to convey their preferences for future health care in the event they become unable to communicate their wishes (AHMAC 2011).

More information

Refer to section 4.3 ‘More information’ for links to resources.

Refer patients and carers to Advance Care Planning Australia or to the Advance Care Planning National Phone Advisory Service on 1300 208 582.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). The treatment team should emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers. Refer to section 4.3 for more detailed information.

The lead clinician should ensure timely and appropriate referral to palliative care services. Referral to palliative care services should be based on the patient’s need and potential for benefit, not prognosis.

More information

Refer to the end of section 4.3 ‘Palliative care’ for links to resources.

The treatment team should support the patient to participate in research and clinical trials where available and appropriate.

For more information visit the Cancer Australia website.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise at this time for patients:

  • assistance for dealing with emotional and psychological distress resulting from fear of death or dying, existential concerns, anticipatory grief, communicating wishes to loved ones, interpersonal problems and sexuality concerns
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • cognitive changes as a result of treatment and disease progression such as altered memory, attention and concentration (a patient may appoint someone to make medical, financial and legal decisions on their behalf – a substitute decision-maker – before and in case they experience cognitive decline)
  • mood lability or depression as a result of ADT, which may benefit from referral to a psychologist or consideration of mood-stabilising medication
  • physical symptoms including pain, fatigue, incontinence, urinary retention or voiding difficulties and bladder outlet obstruction
  • erectile and ejaculation dysfunction and impotence as a result of treatment, which will require referral to a medical specialist and clinicians skilled in this area of counselling
  • urinary dysfunction, including urinary incontinence, requiring pads, referral to a continence nurse and/or pelvic floor physiotherapist
  • bowel dysfunction or rectal bleeding, which may require referral for endoscopic evaluation and dietitian review
  • rectal complications, which may require the involvement of a continence nurse and stomal therapist
  • weight gain and fluid retention as a result of ADT, which may require referral to a dietitian and exercise physiologist for review
  • decline in mobility or functional status as a result of recurrent disease and treatments (referral to physiotherapy or occupational therapy may be required)
  • coping with hair loss and changes in physical appearance (refer to the Look Good, Feel Better program– see ’Resource List’)
  • appointing a substitute decision-maker and completing an advance care directive
  • financial issues as a result of disease recurrence such as gaining early access to superannuation and insurance
  • legal issues (completing a will, care of dependent children) and making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Rehabilitation may be required at any point of the metastatic care pathway, from preparing for treatment through to palliative care. Issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, returning to work and ongoing adjustment to cancer and its sequels.

Exercise is a safe and effective intervention that improves the physical and emotional health and wellbeing of cancer patients. Exercise should be embedded as part of standard practice in cancer care and be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment.

The lead clinician should ensure there is adequate discussion with patients and carers about the diagnosis and recommended treatment, including treatment intent and possible outcomes, likely adverse effects and the supportive care options available.

More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.