NCCN Guidelines for Patients
Prostate Cancer, Version 1.2016
Treatment guide: Initial treatment
Very high risk
lists the treatment options for men in the
very-high-risk group. Men at very high risk include
those with T3b and T4 tumors, primary Gleason
grade 5, or more than 4 biopsy cores with Gleason
scores between 8 and 10. There are five treatment
options for very-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 very-
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.
If the tumor isn’t fixed to nearby organs, a fourth
option is a radical prostatectomy with PLND. When a
tumor isn’t fixed, it is more likely to be fully removed.
In this case, an operation may be able to cure the
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.
The fifth option is ADT for very-high-risk cancer that
can’t be cured. The goal of ADT is to control the
growth of the cancer. In this case, ADT includes an
LHRH antagonist or LHRH agonist. If these drugs
don’t suppress your testosterone level, your doctor
may want you to take CAB.
lists options for adjuvant treatment. 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.