NCCN Guidelines for Patients® | Prostate Cancer - page 56

56
NCCN Guidelines for Patients
®
: Prostate Cancer
Version 1.2014
Part 5: Initial treatment by risk group
5.6 Metastatic disease
This chart lists the treatment options for men with
metastatic disease. Metastatic disease refers to cancer
that has spread to nearby lymph nodes, a distant site, or
both. The growth of these cancers can be controlled with
treatment.
Observation or ADT are options for cancer that has
spread to either the lymph nodes or distant sites. ADT for
first-time users can consist of surgical castration with a
bilateral orchiectomy or medical castration with an LHRH
antagonist or agonist. Both methods for castration work
equally well.
Some metastases can be seen with imaging tests.
When these overt metastases are treated with LHRH
agonists, there can be an increase in testosterone for
several weeks. This increase is called a “flare.” Flare
can cause pain if there are bone metastases, but the
pain doesn’t mean the cancer is growing. Flare can also
cause paralysis if metastases are located in weight-
bearing bones (legs or spine). To prevent the flare, an
antiandrogen can be given for 7 or more days, starting
before or along with the LHRH agonist.
Another option for first-line ADT is long-term use of an
antiandrogen with an LHRH agonist. This is a form of
CAB. However, CAB is no better than castration alone for
metastases. Moreover, it may lead to higher costs and
worse side effects.
If the cancer has only spread to nearby lymph nodes, a
second treatment option is EBRT with long-term ADT. For
ADT, an LHRH antagonist or LHRH agonist may be used.
However, doctors often use CAB. ADT is given before,
during, and after radiation therapy.
Treatment options
TNM scores
Any T
N1, M0
Radiation therapy + ADT for 2–3 years
ADT
• Orchiectomy,
• LHRH agonist ± antiandrogen for
≥7 days to prevent testosterone flare,
• LHRH agonist + antiandrogen, or
• LHRH antagonist
Observation
Any M1
ADT
• Orchiectomy,
• LHRH agonist ± antiandrogen for
≥7 days to prevent testosterone flare,
• LHRH agonist + antiandrogen, or
• LHRH antagonist
Observation, or
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