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63

NCCN Guidelines for Patients

®

Prostate Cancer, Version 1.2016

5

Treatment guide: Initial treatment

Regional cancer | Metastatic cancer

Guide 12

lists the treatment options for men with

regional cancer. Regional cancer has spread to

nearby lymph nodes but not to distant sites.

The first option is EBRT with long-term ADT. Long-

term 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.

Other options for regional cancers consist of only

using ADT. ADT is used to control cancer growth.

It 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. LHRH antagonists and agonists

can be given on an intermittent schedule to reduce

side effects.

Guide 13

lists the treatment options for men with

metastatic cancer. Metastatic cancer has spread to

distant sites. The growth of these cancers can be

controlled with treatment.

ADT is advised for metastases. It 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.

LHRH agonists can cause an increase in testosterone

for several weeks. This increase is called a “flare.”

Flare can cause pain if bone metastases can be seen

on imaging tests (overt metastases). The pain doesn’t

mean the cancer is growing. Flare can also cause

paralysis if the 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 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.

The risks for side effects can be reduced by

intermittent use of ADT. Intermittent treatment

improves quality of life without affecting survival. It

often begins with continuous treatment that is stopped

after about 1 year. ADT is resumed when a certain

PSA level is reached or symptoms appear. PSA levels

that trigger restarting treatment usually are 10, 20, or

40 ng/mL.

A newer option for metastatic disease is continuous

ADT with docetaxel. Prednisone may or may not be

given with these drugs. More research is needed

to learn if this option can help control low-volume

cancers. Low-volume disease is defined as 1) no

metastases in internal organs (visceral disease); and

2) fewer than four bone metastases.