NCCN Guidelines for Patients
Prostate Cancer, Version 1.2016
Treatment guide: Systemic treatment
Castration-recurrent prostate cancer
addresses treatment for CRPC with
metastases. Despite that the cancer has returned
during hormone therapy, it is important to keep taking
it. To treat the cancer, your testosterone levels need
to stay at castrate levels. Castrate levels are less
than 50 ng/dL. To do so, your doctor may keep you
on your current treatment or may switch the type of
hormone therapy you are using. You should keep
taking hormone therapy even if given other types of
treatment, such as immunotherapy.
Prostate cancer often spreads to the bones. When
prostate cancer invades your bones, they are at risk
for injury and disease. Such problems include bone
fractures, bone pain, and spinal cord compression.
Denosumab every 4 weeks or zoledronic acid every
3 to 4 weeks may help to prevent or delay these
If you have painful bone metastases, there are
treatments that may help to lessen the pain.
EBRT may be used when pain is limited to a
specific area or your bones are about to fracture.
Radiopharmaceuticals 89Sr (strontium) or 153Sm
(samarium) may relieve pain from widely spread bone
metastases that isn’t responding to other treatments.
Be aware that these treatments can cause your
bone marrow to make fewer blood cells, which could
prevent you from being treated with chemotherapy.
Radiation therapy used to relieve pain is called
supportive care. Supportive care (also called
palliative care) doesn’t aim to treat cancer but aims
to improve quality of life. Ask your treatment team for
a supportive care plan to address any symptoms you
have and other areas of need.
Sipuleucel-T is an immunotherapy drug that was
tested among men with metastatic CRPC. Research
found that men who took sipuleucel-T lived, on
average, 4 months longer than men not taking this
drug. Your results may be the same, better, or worse.
Sipuleucel-T is only advised for men who meet the
conditions listed in the Guide. Sipuleucel-T has not
been tested among men with metastases to the
internal organs (visceral disease).
For treatments other than sipuleucel-T, a drop in
PSA levels or improvement in imaging tests occurs if
treatment is working. Be aware that these signs don’t
occur during sipuleucel-T. Thus, don’t be discouraged
if your test results don’t improve.
There are other options if sipuleucel-T is not right for
you. These options for metastatic CRPC are based on
whether the cancer is or isn’t in the internal organs.
Some options in the two groups overlap. However,
the order of options differ based what’s best for that
Enzalutamide and abiraterone acetate
Enzalutamide and abiraterone acetate are newer
hormone therapies. Enzalutamide is an antiandrogen
that may work better than other antiandrogens. In a
clinical trial, it lowered PSA levels and extended life
by an average of about 5 months. Abiraterone acetate
is taken on an empty stomach with prednisone.
This drug has been shown to slow cancer growth.
Enzalutamide and abiraterone acetate have only
been tested among men with few or no cancer
Docetaxel and other chemotherapy
Chemotherapy with hormone therapy is another
treatment option. Docetaxel with prednisone on an
every-3-week schedule is the preferred treatment
option if the cancer is causing symptoms. It is not
often used when the cancer isn’t causing symptoms.
However, your doctor may suggest it if the cancer is
growing fast or may have spread to your liver.
If your PSA level rises while taking docetaxel, it
doesn’t mean without doubt that the treatment has
failed. Your doctor may suggest that you keep taking
docetaxel until it is clear that the cancer has grown or