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NCCN Guidelines for Patients


Prostate Cancer, Version 1.2016


Treatment guide: Initial treatment

High risk

Guide 8

lists the treatment options for men in the

high-risk group. The criteria for high risk include T3a

tumors. For high-risk cancers, research supports

treatment unless you’re likely to live less than 5 years

when observation is the best choice.

There are four treatment options for high-risk

tumors. The first option is EBRT to the prostate and

pelvic lymph nodes and long-term ADT. The second

treatment option is EBRT plus HDR brachytherapy

and maybe ADT.

A third option is EBRT with long-term ADT and

docetaxel. However, the role of docetaxel for high-risk

cancer is still being studied. There is more to learn

about the benefits and risks. Docetaxel is given after

radiation for typically six 3-week cycles.

When used with radiation, ADT may consist of an

LHRH antagonist or LHRH agonist. However, doctors

often use CAB, which includes an antiandrogen. CAB

may increase side effects but may also control the

growth of prostate cancer for a longer period of time.

If you will receive ADT, it will be given before, during,

and after radiation therapy for a total of 2 to 3 years.

A fourth option is a radical prostatectomy with PLND,

which removes your pelvic lymph nodes. The tissue

that will be removed from your body will be sent to a

pathologist. He or she will assess how far the cancer

has spread within the tissue. Your PSA level will also

be tested.

Guide 9

lists options for adjuvant treatment.

Adjuvant treatment helps to stop the cancer from


If you had radiation therapy, you may have started

ADT. ADT is recommended for 2 to 3 years, so you

will need to keep taking these drugs after radiation

therapy has ended.

Options for adjuvant treatment after a prostatectomy

are based on the presence of high-risk features

and cancer in the lymph nodes. High-risk features

suggest that not all of the cancer was removed by the

operation. High-risk features include:

• Cancer in surgical margins,

• Cancer outside the prostatic capsule,

• Cancer in the seminal vesicle(s), and

• Detectable PSA levels.

If test results find no high-risk features or cancer in

the lymph nodes, no more treatment is needed. You

may start observation.

EBRT or observation is an option for when there

are high-risk features but no cancer in lymph nodes.

EBRT will target areas where the cancer cells have

likely spread. Treatment will be started after you’ve

healed from the operation.

There are two treatment options if cancer is found

in lymph nodes. The first option is to start ADT now.

EBRT may be given with ADT. If your PSA levels are

undetectable, a second option is to start observation.

Supportive care with ADT can be started if the levels


For adjuvant ADT, an LHRH antagonist or LHRH

agonist is advised. It can be given on an intermittent

schedule to reduce its side effects. However, the

benefits of ADT in this case are unclear.