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NCCN Guidelines for Patients


Prostate Cancer, Version 1.2016


Treatment guide: Systemic treatment

Castration-naïve prostate cancer

Guide 19

lists options for advanced cancer that has

never been treated with castration methods. Options

are grouped by whether the cancer is staged M0 or



When talking about prostate cancer, castration is a

term that means the testicles are making little or no

testosterone. It can be achieved by an operation or

by medicines. Surgical castration that removes both

testes is called a bilateral orchiectomy. This surgery is

a type of ADT. Orchiectomy is a treatment option for

both M0 and M1 cancers.

LHRH agonist and antagonist

Medical castration works equally as well as surgical

castration. Medicines used to cause castration

include an LHRH antagonist or agonist. They are a

type of ADT. As discussed next, an antiandrogen may

be added.

The risk for side effects can be reduced by

intermittent use of your medicine. Intermittent

treatment improves quality of life without affecting

survival. It often begins with continuous treatment that

is stopped after about 1 year. Treatment 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.


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 treatment option 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.


Observation is an option for men without metastases

(M0). 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 and DRE.

ADT with docetaxel

A newer option for metastatic disease is continuous

ADT with 6 cycles of docetaxel. Prednisone may or

may not be given with docetaxel. 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 (no visceral

disease); and 2) fewer than four bone metastases.


While on hormone therapy, your doctor will monitor

treatment results. A rising PSA level 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 treatment will likely

be increased. If the levels are very low, you may

receive imaging tests to look for metastases.