NCCN Guidelines for Patients
: Prostate Cancer
Part 7: Treatment for advanced cancer
7.1 ADT for first-time users
ADT for first-time users includes surgical or medical
castration. Surgical castration is done with a bilateral
orchiectomy. Medical castration is done using an LHRH
antagonist or agonist. Both castration methods work
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 is long-term use of an antiandrogen with
an LHRH agonist. This is one form of CAB. However, CAB
is no better than castration alone for metastases.
Moreover, it may lead to higher costs and worse side
For advanced cancer, the risks of ADT can be reduced
by using ADT intermittently rather than continuously.
Intermittent ADT improves quality of life without affecting
survival. Intermittent ADT often begins with about 1 year
of continuous ADT and then is stopped. ADT is resumed
when a certain PSA level is reached or symptoms
appear. PSA levels that trigger restarting ADT usually are
10, 20, or 40 ng/mL.
Besides ADT, observation is an option. Observation
consists of testing on a regular basis so that supportive
care with ADT can be given if symptoms from the cancer
are likely to start. Tests during observation include PSA
While on ADT, your doctor will monitor
treatment results (see Parts 6.1 and 6.2). A rising PSA
level during ADT suggests the cancer is growing. This
increase is called a biochemical relapse. If PSA levels
are rising, your testosterone levels should be tested to
see if they are at castrate levels (less than 50 ng/dL). If
the levels aren’t very low, the dose of your ADT will likely
be increased. If the levels are very low, you may receive
imaging tests to look for metastases. Cancer growth
while taking ADT is called castration-recurrent cancer.
Treatment recommendations for castration-recurrent
cancer with no metastases are listed in Part 7.2, and with
metastases in Part 7.3.
LHRH agonist ± antiandrogen for ≥7 days
to prevent testosterone flare,
LHRH agonist + antiandrogen,
LHRH antagonist, or