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61

NCCN Guidelines for Patients

®

Prostate Cancer, Version 1.2016

5

Treatment guide: Initial treatment

Very high risk

Guide 10

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

cancer.

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.

Guide 11

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

rise.

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.