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FOR PATIENTS
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Prostate Cancer
Presented with support from:

Available online at NCCN.org/patients

Ü
 Prostate Cancer

LEARNING that you have cancer

can be overwhelming.
Prostate cancer is the most common type of cancer in men living in the United
States. Learning that you have prostate cancer can feel overwhelming. The goal
of this book is to help you get the best cancer treatment. This book presents which
cancer tests and treatments are recommended by experts in prostate cancer.

The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit alliance

of 28 of the world’s leading cancer centers. Experts from NCCN have written
treatment guidelines for prostate cancer doctors. These treatment guidelines
suggest what the best practice is for cancer care. The information in this patient
book is based on the guidelines written for doctors.

This book focuses on the treatment of prostate cancer. Key points of the book are
summarized in the related NCCN Quick Guide™. NCCN also offers patient books
on colon and lung cancers, as well as other cancer types. Visit NCCN.og/patients
for the full library of patient books, summaries, and other resources.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 1
 About

These patient guidelines for cancer care are produced by the National
Comprehensive Cancer Network® (NCCN®).

The mission of NCCN is to improve cancer care so people can live better lives. At
the core of NCCN are the NCCN Clinical Practice Guidelines in Oncology (NCCN
Guidelines®). NCCN Guidelines® contain information to help health care workers
plan the best cancer care. They list options for cancer care that are most likely to
have the best results. The NCCN Guidelines for Patients® present the information
from the NCCN Guidelines in an easy-to-learn format.

Panels of experts create the NCCN Guidelines. Most of the experts are from
NCCN Member Institutions. Their areas of expertise are diverse. Many panels
also include a patient advocate. Recommendations in the NCCN Guidelines are
based on clinical trials and the experience of the panelists. The NCCN Guidelines
are updated at least once a year. When funded, the patient books are updated to
reflect the most recent version of the NCCN Guidelines for doctors.

For more information about the NCCN Guidelines, visit NCCN.org/clinical.asp.

Dorothy A. Shead, MS Laura J. Hanisch, PsyD Erin Vidic, MA

Director, Patient Medical Writer/Patient Medical Writer
Information Operations Information Specialist
Rachael Clarke
Alycia Corrigan Guidelines Data and
Medical Writer Layout Coordinator

NCCN Foundation was founded by NCCN to raise funds for patient education
based on the NCCN Guidelines. NCCN Foundation offers guidance to people
with cancer and their caregivers at every step of their cancer journey. This is done
by sharing key information from leading cancer experts. This information can be
found in a library of NCCN Guidelines for Patients® and other patient education
resources. NCCN Foundation is also committed to advancing cancer treatment
by funding the nation’s promising doctors at the center of cancer research,
education, and progress of cancer therapies.

For more information about NCCN Foundation, visit NCCNFoundation.org.

© 2018 National Comprehensive Cancer Network, Inc. Based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
Prostate Cancer (Version 4.2018, August 15, 2018).

All rights reserved. NCCN Guidelines for Patients® and illustrations herein may not be reproduced in any form for any purpose without the
express written permission of NCCN. No one, including doctors or patients, may use the NCCN Guidelines for Patients® for any commercial
purpose and may not claim, represent, or imply that the NCCN Guidelines for Patients® that has been modified in any manner is derived
from, based on, related to or arises out of the NCCN Guidelines for Patients®. The NCCN Guidelines are a work in progress that may be
redefined as often as new significant data become available. NCCN makes no warranties of any kind whatsoever regarding its content, use,
or application and disclaims any responsibility for its application or use in any way.

National Comprehensive Cancer Network (NCCN) • 3025 Chemical Road, Suite 100 • Plymouth Meeting, PA 19462 • 215.690.0300

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 2
 Supporters

Endorsed by

PCaAware Veterans Prostate Cancer Awareness

Guidelines for Patients plays a critical role in our outreach efforts Veterans Prostate Cancer Awareness commends the National
to help men and their partners gain a better understanding of the Comprehensive Cancer Network (NCCN) for developing the Patient
need for men to be aware and pro-active when it concerns the Guidelines for use as the standard in education and awareness for
subtle warning signs of early stage prostate cancer. Breaking down prostate cancer patients and providers. On behalf of all Veterans, VPCa
thanks the NCCN for providing this valuable tool to use as guidance on
the “wall of silence” surrounding men and prostate cancer is our
the journey through prostate cancer.
single mission. Success is achieved when men speak up, are
engaged in their personal health and are not afraid to take action.
pcaaware.org
ZERO – The End of Prostate Cancer
Every 19 minutes a man loses his battle with prostate cancer.
NCCN’s Guidelines for Patients is a premier resource in helping
Malecare Cancer Support
men and their families to be proactive and make informed
Malecare Cancer Support group members know that nothing is
decisions. By advancing research, encouraging action, and
more perplexing than prostate cancer treatment choice making.
providing educational support, we can create Generation ZERO —
The NCCN Patient Guidelines provides an excellent starting point
the first generation of men free from prostate cancer.
for discussion, particularly for African Americans who die from
zerocancer.org
prostate cancer at twice the rate as Caucasian men. malecare.org

Prostate Conditions Education Council (PCEC)

National Alliance of State Prostate Cancer Coalitions
Having a tool that helps to provide an overview of all the treatment
(NASPCC)
options available to patients is critical in winning the fight against
NASPCC strongly endorses the NCCN Guidelines for Patients:
prostate cancer. The NCCN guidelines aid in this important step.
Prostate Cancer, as an invaluable resource for patients and others.
prostateconditions.org
It is a reliable wealth of important information about prostate
cancer, in a readable and understandable format. naspcc.org

The California Prostate Cancer Coalition (CPCC)

CPCC is pleased to endorse this important resource. We believe it
to be the most understandable and comprehensive guide for men
diagnosed with prostate cancer who want to really understand what
the disease is about and what their specific treatment options are.
prostatecalif.org

With generous support from

Pamela Becker In Honor of Dr. Stanley Becker.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 3
NCCN Guidelines for Patients®:
Prostate Cancer, 2018 4
 Prostate Cancer

Contents
6 How to use this book 70 Part 7
Treatment guide:
7 Part 1 Systemic treatment
Prostate cancer basics Presents options that control the growth of
Explains how prostate cancer starts and how it advanced cancer.
spreads.
81 Part 8
12 Part 2 Making treatment decisions
Cancer staging Offers tips for choosing the best treatment.
Describes how doctors rate the growth of
prostate cancer. 90 Dictionary

24 Part 3 94 Acronyms
Treatment planning
Describes how doctors plan your treatment. 95 NCCN Panel Members for Prostate
Cancer
30 Part 4
Overview of cancer treatments 96 NCCN Member Institutions
Describes the treatments used to cure or
control prostate cancer. 98 Index

47 Part 5
Treatment guide:
Initial treatment
Presents the options when treating prostate
cancer for the first time.

62 Part 6
Treatment guide:
Treatment monitoring
Presents tests that check treatment results and
options if local treatment fails.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 5
 How to use this book

Who should read this book? NCCN experts base the recommendations in this
book on science and experience. However, these
This book is about treatment for adenocarcinoma of recommendations may not be right for your situation.
the prostate. About 98 out of 100 men with prostate Your doctors may suggest other tests and treatments
cancer have an adenocarcinoma. Women don’t get based on your health and other factors. If other
prostate cancer because they don’t have a prostate. recommendations are given, feel free to ask your
Patients and those who support them—caregivers, treatment team questions.
family, and friends—may find this book helpful. It may
help you discuss and decide with doctors what care
is best.
Help! What do the words
mean?
Are the book chapters in a In this book, many medical words are included.
certain order? These are words you will likely hear from your
treatment team. Most of these words may be new to
Yes, early chapters may help you with treatment you, and it may be a lot to learn.
options found in later chapters. Starting with Part 1
may be helpful. It explains what prostate cancer is. Don’t be discouraged as you read. Keep reading
Knowing more about prostate cancer may help you and review the information. Feel free to ask your
better understand its treatment. To learn how doctors treatment team to explain a word or phrase that you
plan treatment, read Parts 2 and 3. don’t understand.

Parts 4 through 7 address prostate cancer Words that you may not know are defined in the text
treatment. Part 4 briefly describes the treatments. or in the Dictionary. Acronyms are also defined when
Parts 5 through 7 are guides to treatment options. first used and in the Glossary. One example is PSA
Part 8 gives tips for making treatment decisions. for prostate-specific antigen.

Does this book include all

options?
This book includes information for many situations.
Thus, you will likely not get every test and treatment
listed. Your treatment team can help with options.
They can point out what sections apply to you. They
can also give you more information. As you read
this book, you may find it helpful to make a list of
questions to ask your doctors.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 6
 1
Prostate cancer basics
8 The prostate
8 A disease of cells
10 Cancer’s threat
11 Review

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 7
 1  Prostate cancer basics The prostate | A disease of cells

You’ve learned that you have prostate A disease of cells

cancer. It’s common to feel shocked and
confused. Part 1 may help you learn more Cancer is a disease of cells. Inside of cells are coded
about how this cancer starts in the body. instructions for building new cells and controlling
Once you know about prostate cancer, how cells behave. These instructions are called
your doctor and you can talk about tests genes. Genes are a part of DNA (deoxyribonucleic
and treatment options. acid), which is grouped together into bundles called
chromosomes. See Figure 2. Prostate cancer
occurs when normal cells begin to grow faster or die
slower. Either pattern causes a tumor to form. Some
prostate cancers occur from abnormal changes,
The prostate called mutations, in genes.

The prostate is a gland that makes a white-colored Doctors have learned that certain risk factors can
fluid. Sperm mixes with this fluid and other fluids be seen with these cancers. A risk factor is anything
to form semen. Semen is ejected from the body that increases your chances of having a disease like
through the penis during ejaculation. The fluid from cancer. Doctors are still learning what may cause
the prostate protects sperm from the acid inside a prostate cancer. Some risk factors for prostate
woman’s vagina. cancer are listed below:

As shown in Figure 1, the prostate is located below †† Aging, being of African-American descent, and
the bladder near the base of the penis. Urine from having family members with prostate cancer
the bladder travels through the urethra, which passes have been linked to a higher chance of getting
through the prostate and into the penis. Above the prostate cancer.
prostate and behind the bladder are two seminal
vesicles. Seminal vesicles are also glands that make †† Contact with Agent Orange, obesity, smoking,
a fluid that is part of semen. and poor diet have been linked with prostate
cancer. Not all men with these conditions get
Inside the prostate, 30 to 50 small sacs make and prostate cancer.
hold the white-colored fluid. The fluid travels in ducts
to the urethra during ejaculation. Around the sacs †† Prostate cancer is common among older men.
and ducts is connective tissue. However, prostate cancer in older men often
doesn’t become a problem.
The prostate begins to form while a baby is inside
his mother’s womb. After birth, the prostate keeps Almost all prostate cancers are adenocarcinomas.
growing and reaches nearly full size during puberty. Adenocarcinomas are cancers that start in cells that
At this point, it is about the size of a walnut. line glands and, in the case of prostate cancer, make
Testosterone causes the prostate to grow slowly semen. Adenocarcinomas of the prostate are the
in most men. However, the prostate may grow to a focus of this book.
large size in some men and cause problems passing
urine.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 8
 1  Prostate cancer basics The
A disease
prostate
of cells

Figure 1.
The prostate

The prostate gland makes a fluid bladder

that is part of semen. seminal vesicle

prostate

urethra

Illustration Copyright © 2018 Nucleus Medical Media, All rights reserved. www.nucleusinc.com

Figure 2.
Genetic material in cells

Most human cells contain the

“blueprint of life”—the plan by
which our bodies are made and
work. The plan is found inside of
chromosomes, which are long
strands of DNA. Genes are small
pieces of DNA. Humans have
about 24,000 genes. Some prostate
cancers occur from abnormal
changes in genes called mutations.

Illustration Copyright © 2018 Nucleus Medical Media, All rights reserved. www.nucleusinc.com

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 9
 1  Prostate cancer basics Cancer’s threat

Cancer’s threat
Cancer cells don’t behave like normal cells in three
key ways. First, prostate cancer cells grow more
quickly and live longer than normal cells. Normal
cells grow and then divide to form new cells when
What to know about needed. They also die when old or damaged as
prostate cancer shown in Figure 3. In contrast, cancer cells make
new cells that aren’t needed and don’t die quickly
when old or damaged. Over time, cancer cells form a

Most men with prostate cancer will not mass called the primary tumor.
die of this disease. However, prostate
The second way cancer cells differ from normal cells
cancer is the second most common is that they can grow into (invade) other tissues. If not
cause of death from cancer in men. treated, the primary tumor can grow large and take
over most of the prostate. It can also grow beyond
the prostatic capsule and invade nearby tissues. This
 Most prostate cancers grow slowly but growth is called extracapsular extension.
some grow and spread quickly. Cancer
Third, unlike normal cells, cancer cells can leave the
that spreads quickly is called aggressive prostate. This process is called metastasis. In this
cancer. process, cancer cells break away from the tumor and
merge with blood or lymph. Lymph is a clear fluid that
gives cells water and food and contains germ-fighting
 Why some prostate cancers grow fast blood cells. Then, the cancer cells travel in blood
or lymph through vessels to other sites. In other
is unknown and is being studied by
sites, the cancer cells may form secondary tumors,
researchers. called metastases, and replace many normal cells or
interfere with function, which can cause major health
problems.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 10
 1  Prostate cancer basics Review

Review
Figure 3.
Key differences between †† The prostate makes a fluid that is part of
normal cells and cancer cells semen.

†† Prostate cancer often starts in the cells that

make fluid.

†† Cancer cells may form a tumor since they don’t

die as normal cells do.

†† Cancer cells can spread to other body parts

through lymph or blood.

†† Most men with prostate cancer will not die from

it.
Normal cells Cancer cells
†† Some men have prostate cancer that grows
fast.

Make new cells Grow out of

as needed; die control, forming
if old/damaged a tumor over
time

Stop when they
get too close to Ignore other

other cells cells and invade
nearby tissues

Stay where they
belong in the Can spread

body and make new
tumors

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 11
 2
Cancer staging
13 Prostate-specific antigen
14 Digital rectal exam
14 Imaging tests
17 Prostate biopsy
18 Gleason score
20 TNM scores
23 Review

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 12
 2  Cancer staging Prostate-specific antigen

Part 2 discusses the tests and scoring †† PSA velocity is how much PSA levels change
system used for staging prostate cancer. A within a period of time.
cancer stage is a rating by your doctors of
how far the cancer has grown and spread. †† PSA doubling time is the time it takes for the
There are 4 stages of prostate cancer. PSA level to double.
Staging is based on test results. The test
results help your doctor and you decide The larger the prostate, the more PSA it can make.
on a treatment plan. Large prostates can be a result of cancer or other
health problems of the prostate. Some medicines
can also affect the PSA level. PSA increases after
ejaculations and vigorous exercise, especially
running or bicycling. Thus, your doctor may
Prostate-specific antigen recommend you refrain from sex and exercise for 3
days before a PSA test. This will allow the PSA test
PSA (prostate-specific antigen) is a protein made by to be more exact.
the fluid-making cells that line the small glands inside
the prostate. These cells are where most prostate
cancers start. PSA turns semen that has clotted after
ejaculation back into a liquid. PSA is made mostly
by prostate cancer cells and normal prostate cells.
However, a small amount of PSA is made by all cells,
even in women.

PSA can be measured using a blood sample, since

some of it enters the bloodstream. PSA values are
used for cancer staging, treatment planning, and
checking treatment results. PSA values discussed in
this book include the following:

†† PSA level is the number of nanograms of PSA

per milliliter (ng/mL) of blood.

†† PSA density is the PSA level in comparison

to the size of the prostate. It is calculated
by dividing the PSA level by the size of the
prostate. The size of the prostate is measured
by DRE (digital rectal exam) of the prostate, or
by using TRUS (transrectal ultrasound), or an
MRI (magnetic resonance imaging) scan of the
prostate.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 13
 2  Cancer staging Digital rectal exam | Imaging tests

Digital rectal exam Imaging tests

Doctors use a DRE to screen for cancer, rate the Imaging tests are used to take pictures (images) of
cancer stage, and assess treatment results. For the inside of your body. Imaging can be used to see
this exam, your doctor will put a glove on his or her if there is cancer in the body. Your doctor will want
hand and then put lubricant on his or her index finger to check the primary tumor, or original site of the
(See Figure 4). Next, your doctor will insert a finger tumor. MRI, CT (computed tomography) scans, and
into your rectum to feel your prostate as shown in bone scans are the recommended imaging tests for
Figure 4. Your prostate can be felt since it is on the staging prostate cancer. Each imaging test has a
other side of the rectal wall. Bear in mind that not all purpose and may occur at different times in your care
parts of the prostate can be felt on this exam. plan. Many people with prostate cancer do not need
imaging at diagnosis, but can go directly to treatment
after biopsy.

Figure 4.
Digital rectal exam
rectum
Your prostate can be felt through the
prostate
wall of your rectum. A digital rectal
exam is a procedure during which
your doctor will insert a finger into
your rectum to feel your prostate.

Illustration Copyright © 2018 Nucleus Medical Media, All rights reserved.

www.nucleusinc.com

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 14
 2  Cancer staging Imaging tests

MRI scan
Imaging tests make pictures (images) of the insides
of your body. MRI uses a magnetic field and radio
waves to make images. A 3T, multi-parametric MRI
of your prostate may help pinpoint where the cancer Early detection of
is in the prostate and assess features of the cancer.
The short name for this test is mpMRI. prostate cancer
Prostate MRI can be used at many points of care.
It is sometimes used for biopsies as discussed

NCCN experts recommend PSA testing
next. Prostate MRI may also be used to help decide and a DRE for men who are healthy and
whether to start and continue active surveillance. aware of the tests being used. For some
Active surveillance is briefly described in Part 4 on men, testing can start at age 45 and
page 31. A prostate MRI also examines lymph nodes continue until age 75.
within your pelvis to see if the cancer has spread
(metastasized). It does this as well as a CT scan.
Another use for prostate MRI is to assess if you 
The recommended age to start
have cancer when other tests, given after treatment, screening and how often the tests
suggest there’s cancer. Read Part 6 for more occur may vary. Doctors are still doing
information. research to know how to best screen for
prostate cancer.
For the MRI, you will need to lie on a table and be
fitted with coil devices that emit radio waves. An
endorectal coil may be used. However, the need for 
If you have an abnormal DRE and/or
endorectal coil is debated among experts. Instead of an elevated PSA level, you may have
using a coil, newer methods to improve images are repeat tests or a prostate biopsy to
being tested. An endorectal coil is a thin wire that is
check for cancer.
inserted into your rectum. To prepare for endorectal
MRI, you may be asked to eat less and clean your
bowel with an enema. A cover will be placed over the 
To confirm cancer, your doctor will
coil and gel will be applied before insertion. Once perform a biopsy of the prostate. This is
inserted, the device will be inflated to hold it in place. usually a TRUS-guided biopsy.

During the MRI, you will be inside the MRI machine.

Straps may be used to help you stay in place. You To learn more about early detection, visit
may be given a sedative beforehand if you feel the NCCN Clinical Practice Guidelines in
nervous about the test. The machine will make loud Oncology (NCCN Guidelines®) Prostate
noises, but you can wear earplugs. After the MRI Cancer Early Detection, available at
you will be able to resume your activities right away
unless you took a sedative. www.NCCN.org.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 15
 2  Cancer staging Imaging tests

CT scan
A CT scan uses x-rays to take pictures of the inside
of the body. It takes many x-rays of the same body
part from different angles. All the x-ray pictures are
combined to make one detailed picture of the body
What to know about part. A CT scan of your abdomen and/or pelvis may
imaging tests be one of the tests used to look for cancer that has
spread to other areas (metastasized). A CT scan is
not the best option for taking pictures of the prostate

Imaging tests can see if the cancer is in gland. An MRI is preferred for viewing this area.
more than one part of the body.
Getting a CT scan is like getting an MRI scan. Before
 These tests are used during treatment to CT, you may need to drink enough liquid to have a
full bladder. A full bladder helps to keep the bowel
see how the disease is responding. away so the prostate can be better seen. You may
also be given a contrast dye to make the pictures
 The tests can be used after treatment to clearer. You may drink the dye, have it injected into
check for signs of disease (recurrence). your vein, or both. It may cause you to feel flushed
or get hives. Rarely, serious allergic reactions occur.
Tell your doctors if you have had bad reactions in the
 You may not learn of the results of your past.
imaging tests for a few days since a
radiologist needs to see the pictures. Bone imaging
A bone scan is an imaging test that can show if
cancer has spread to your bones. This test is only
 A radiologist is a doctor who’s an expert used if you have certain symptoms such as bone
in reading the pictures from imaging pain or high levels of ALP (alkaline phosphatase)
tests. in your blood. These symptoms may signal that the
cancer has spread to your bones.

 A nuclear medicine specialist is a doctor A bone scan uses a radiotracer to make pictures
who’s an expert in imaging tests that use of the inside of bones. A radiotracer is a substance
radioactive substances. that releases small amounts of radiation. Before the
pictures are taken, the tracer will be injected into your
vein. It can take a few hours for the tracer to enter
your bones. For the scan, you will need to lie very
still on a table. A special camera will take pictures of
the tracer in your bones as it moves over your body.
Areas of bone damage use more radiotracer than
healthy bone and thus show up as bright spots on
the pictures. Bone damage can be caused by cancer
or other health problems.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 16
 2  Cancer staging Prostate biopsy

If you have a higher Gleason score, higher tumor Types of biopsies

stage, or higher PSA level, your doctor may consider The most common type of prostate biopsy is the
using a bone scan for staging disease. If the transrectal method. To make sure the best samples
results show disease, other tests like CT, MRI, or are removed, a TRUS probe will be inserted into your
PET/CT (position emission tomography/computed rectum. The TRUS uses sound waves to make a
tomography) or PET/MRI (position emission picture of your prostate that is seen by your doctor on
tomography/magnetic resonance imaging) may a screen.
be used to assess for metastatic disease. More
research is needed to understand the role of PET/CT A newer method uses MRI along with TRUS. Before
scans for prostate cancer. See Part 3 on page 24. the biopsy, images will be made with MRI. These
images will then be combined with TRUS during
the biopsy. This will allow for better tracking of the
movement of your prostate. It will also help doctors
Prostate biopsy pinpoint which area of tissue to sample.

Rising PSA levels and abnormal DRE findings may A spring-loaded needle will be inserted through
suggest cancer is present. However, the only way the TRUS. Your doctor will trigger the needle to go
to know if you have prostate cancer is to remove through the rectal wall and into your prostate. The
tissue from your body and have a pathologist look needle will remove tissue about the length of a dime
at it using a microscope. A biopsy removes small and the width of a toothpick. At least 12 samples—
samples of tissue for testing. Biopsies can also help called cores—are often taken. This is done to check
your doctor assess how far the cancer has grown. for cancer in different areas of the prostate. Prostate
A prostate biopsy is a type of biopsy that removes biopsies aren’t perfect tests. They sometimes miss
tissue from the prostate. cancer when it’s there. If no cause for the high PSA
is found, your doctor may order more biopsies.
Before the biopsy
To prepare for the biopsy, your doctor may say to
stop taking some medicines and start taking others.
Medicines to stop taking include blood thinners like
warfarin (Coumadin®) or antiplatelet drugs like aspirin
or Plavix®. Your doctor may prescribe antibiotics to
try to prevent an infection from the biopsy.

Right before the biopsy, local anesthesia may be

given to numb the area. You’ll feel a small needle
stick and a little burning with some pressure for less
than a minute. A numbing gel may also be applied
to the area. You may feel pressure and discomfort
during the biopsy, but there is often little to no pain.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 17
 2  Cancer staging Gleason score

Prostate biopsies often occur with no problems. cancer cells that look almost normal to 5 for very
However, side effects are possible. Some people abnormal cells that aren’t able to form glands.
have allergic reactions to anesthesia. Tell your doctor
if you’ve had any problems with anesthesia in the The primary and secondary grades are added
past. The prostate biopsy may cause: together to get the Gleason score. Gleason scores
range from 2 to 10, but most prostate cancers are
Often scored 6 to 10. Guide 1 briefly describes what
†† Blood in your semen (hematospermia) or urine the scores mean. Higher Gleason scores mean the
(hematuria) cancer is more likely to grow and spread.

†† Rectal bleeding Another factor used in regard to the Gleason score

is Grade Groups. The Gleason scores have been
Sometimes divided into groups ranging from 1 to 5. The Gleason
†† Infection score and Gleason pattern determine the group.
Doctors use Gleason scores and groups to select the
Rarely most appropriate treatment.
†† Swelling of your prostate (prostatitis) or
epididymis (epididymitis) Grade Group

†† Inability to empty your bladder †† 1 is Gleason score =6 and

(urinary retention) Gleason pattern =3+3

†† Require an overnight stay in the hospital †† 2 is Gleason score 7 and

Gleason pattern 3+4

†† 3 is Gleason score 7 and

Gleason score Gleason pattern 4+3

One grading system for prostate cancer is called †† 4 is Gleason score 8 and
the Gleason score. The Gleason score is used by Gleason pattern 4+4, 3+5, 5+3
doctors to plan treatment. Results from the biopsy
are used for scoring. †† 5 is Gleason score 9 or 10 and
Gleason pattern 4+5, 5+4, 5+5
First, the cancer is assigned two Gleason grades.
The primary grade is the most common Gleason
pattern. The secondary grade is the second most
common Gleason pattern.

Gleason grades are depicted in Figure 5. Glands

comprised of cells with a grade of 1 or 2 may not be
able to be scored on a prostate biopsy. Therefore,
Gleason grades range from 3 for glands made of

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 18
 2  Cancer staging Gleason score

Guide 1. Gleason score summary

Gleason score What does the score mean?

The cancer is likely to grow and spread very slowly. If the cancer is small, many years may
2–6
pass before it becomes a problem. Thus, you may never need cancer treatment.

The cancer is likely to grow and spread at a modest pace. If the cancer is small, several
7 years may pass before it becomes a problem. To prevent problems, treatment may be
needed.

The cancer is likely to grow and spread fast. If the cancer is small, a few years may pass
8–10
before the cancer becomes a problem. To prevent problems, treatment is needed now.

Glands are small, well-formed, and

close together. There are only small
signs of cancer.

Figure 5.
Gleason grades Glands are larger and have more
space in between them.
To obtain a Gleason
score, doctors first
assign the cancer two Glands are even further apart, are
Gleason grades. The darker, and have different shapes.
grades are combined to
obtain a Gleason score.
There are hardly any glands.
Gleason grades range
Cancer cells have lost their ability to
from 1 to 5. form glands. Clumps of cancer cells
are invading other tissue.

Often, there are no glands.

There are sheets of cancer cells
throughout the tissue.

Used with permission from Jonathan I. Epstein, M.D.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 19
 2  Cancer staging TNM scores

TNM scores
The AJCC (American Joint Committee on Cancer)
staging system is used to stage prostate cancer.
What to know about In this system, the letters T (tumor), N (node), and
M (metastasis) describe a different location of cancer
test results growth. Your doctors will assign a score to each
letter. These scores will be combined to assign a

The results from the PSA test, DRE, cancer stage.

imaging tests, and prostate biopsy will There are four cancer stages—I, II, III, and IV for
help your doctor determine your next each type of prostate cancer.
steps of care.
In this staging system, the letters T, N, and M
describe a different area of cancer growth. The T, N,

These results help doctors learn and M scores are combined to assign the cancer a
the cancer stage, and how well or stage.
aggressively the cancer may behave.
†† T score describes the growth of the primary
The cancer stage is based on how far tumor.
the cancer has grown and spread in
the body. How aggressive the cancer †† N score describes spread of cancer growth to
lymph nodes.
may be or the risk level is based on a
combination of 3 factors: the stage, the †† M score tells if the cancer has spread to distant
PSA level, and the Gleason grade. sites.

NCCN experts decide options for initial treatment


Once your doctors know more about partly based on these scores. See Part 5 on
your diagnosis, they can talk to you page 47.
about what to expect. Talking with your
T = Tumor
doctor about the risk level may help with The T score is a rating of the size and extent of the
treatment planning. primary tumor. TX means the primary tumor cannot
be assessed. T0 means there is no evidence of a

Your treatment team will come together primary tumor. T1 tumors can’t be felt or seen with
imaging tests. They are found in tissue removed by
and decide on a treatment plan. A biopsies or surgical treatment. For example, prostate
treatment plan is a written course of cancer may be found in men who had an abnormal
action that covers every aspect of the PSA level or who had an operation for urinary
problems caused by an enlarged prostate. Prostate
treatment process. cancer discovered as a result of an operation for
voiding problems is called an incidental finding.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 20
 2  Cancer staging TNM scores

• T1a means that incidental cancer was found N = Nodes

in 5% or less of the removed tissue. Lymph drains from around prostate cells into vessels
that transport it to the bloodstream. As lymph travels,
• T1b means that incidental cancer was found it passes through small, oval-shaped structures
in more than 5% of the removed tissue. called lymph nodes. Lymph nodes remove germs
from lymph. As shown in Figure 7 on the next page,
• T1c tumors are found by needle biopsy in lymph nodes and vessels are found throughout the
one or both sides of the prostate. body. The N category reflects if cancer cells have
spread through lymph to nearby lymph nodes.
T2 tumors can be felt by your doctor during a DRE. Nearby lymph nodes include the hypogastric,
They also may be seen with an imaging test. T2 obturator, internal and external iliac, and sacral
scores are based on cancer growth within the lymph nodes. Most often, prostate cancer spreads to
lobes—the left and right halves of the prostate. T2 the external iliac, internal iliac, or obturator nodes. N
tumors haven’t grown outside the prostate gland. scores for prostate cancer include:

• T2a tumors haven’t grown beyond half of • NX means it is unknown if there is cancer in
one lobe. lymph nodes.

• T2b tumors have grown beyond half of one • N0 means that there is no cancer within the
lobe but not to the other lobe. nearby lymph nodes.

• T2c tumors have grown into both lobes. • N1 means that the cancer has spread into
the nearby lymph nodes.
T3 tumors have grown outside the prostate. They
have reached the connective tissue around the M = Metastasis
prostate, the seminal vesicles, or the neck of the The M category tells you if the cancer has spread
bladder. See Figure 6 on the next page. to distant sites. Para-aortic, common iliac, inguinal,
supraclavicular, scalene, and cervical lymph nodes
• T3a tumors have grown outside the prostate are distant from the prostate. Prostate cancer tends
but not into the seminal vesicle(s). to metastasize to bone then the lungs and liver. M
scores for prostate cancer include:
• T3b tumors have grown outside the prostate
and into the seminal vesicle(s). • M0 means that there is no growth to distant
sites.
T4 tumors are fixed to or have invaded other nearby
tissues. Such tissues include the external sphincter, • M1 means that the cancer has spread to
rectum, bladder, levator muscles, and/or pelvic wall. distant sites.

• T4 tumors are fixed to or have grown into • M1a is cancer that has spread to distant
nearby tissues other than seminal vesicles. lymph nodes.

• M1b is cancer that has spread to bone(s).

• M1c is cancer that has spread to distant

NCCN Guidelines for Patients®: organs.
Prostate Cancer, 2018 21
 2  Cancer staging TNM scores

Figure 6.
Areas of tumor growth bladder
outside the prostate seminal vesicle
bladder neck

The primary tumor may grow rectum

through the prostate and external sphincter
into nearby organs.

Illustration Copyright © 2018 Nucleus Medical Media, All rights reserved.

www.nucleusinc.com

Figure 7. cervical
Cancer spread to lymph scalene
supraclavicular
nodes

Throughout your body is

a network of vessels that sacral
external iliac
transport lymph to the internal iliac
bloodstream. Lymph is a clear obturator
hypogastric
fluid that contains germ-
fighting blood cells. As lymph para-aortic
common iliac
travels in vessels, it passes inguinal
through lymph nodes, which
remove germs from lymph.
Prostate cancer can spread
to lymph nodes near to and
distant from the prostate.
nearby distant

Illustration Copyright © 2018 Nucleus Medical Media, All rights reserved.

www.nucleusinc.com

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 22
 2  Cancer staging Review

Review
†† Prostate cancer is grouped into 4 stages.
Your medical records:
†† Cancer stages are defined by the growth and
spread of the tumor. üYour doctors will order tests and
schedule visits to talk about your
†† PSA, DRE, and a prostate biopsy can help care plan.
doctors assess the size of a tumor. üIt is helpful to keep track of your
test results at all times. Ask your
†† The Gleason score is a grading system for how doctors questions about the
much prostate cancer cells retain their ability to
results.
form glands.
üYour treatment team will go over
†† Doctors rate the extent of prostate cancer with your test results and suggest
T, N, and M scores. The T score is a rating treatment options.
of size and extent of the primary tumor. The
N score reflects if the cancer has spread to
nearby lymph nodes. The M score reflects if the
cancer has spread to distant sites.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 23
 3
Treatment planning
25 Life expectancy
25 Risk assessment
26 Imaging for metastases
29 Review

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 24
 3  Treatment planning Life expectancy | Risk assessment

Part 3 includes a few more sources of This method may correctly predict length of life for
information your doctor uses to plan a large group of men, but it can’t predict without a
treatment. Other sources include test doubt what will happen to you. Even so, it gives a
results, as well as the grading and staging starting point for suggesting treatment options.
systems that were described in Part 2.
Your personal needs are also an important
factor when it comes to your plan. It is Risk assessment
helpful to talk to your treatment team
about your treatment options. To plan the best treatment for you, your doctors will
like to know:

†† If and how far the cancer has spread

Life expectancy †† How fast the cancer will grow

To help assess what tests and treatments you will †† How the cancer will respond to treatment
need, your doctor may determine the number of
years you will likely live. These years are called †† Whether cancer will re-appear on tests after
your life expectancy. It may be hard to talk with your treatment (called a recurrence)
doctor about how long you might live. However, this
information is very important for your health care. However, this information often can only be known
over time or after cancer treatment has started.
Prostate cancer often grows slowly. If you’re likely to As such, your doctors will assess your chances
die of other causes, having more tests and cancer (also called risk) for such events. Risk groups and
treatment may have little or no benefit. Likewise, if nomograms are two tools that doctors use. Molecular
the cancer isn’t causing symptoms, there may be no testing is a newer tool that needs more research.
benefit to having more tests.

How many years you may live is estimated with two

Prostate cancer
sources of information. First, research on the general
population tells how long the average man may live growth
based on his age. See Part 8 on page 81 for more
information. The second source is your general Most prostate cancers diagnosed
health. in the United States are found
using PSA and are slow growing.
If you’re in excellent health, the number of life years Growth of prostate cancer can be
from the general population research is increased by estimated with tests. You and your
half. If you’re in poor health, the number of years is doctor should begin talking about
decreased by half. If you are of average health, no
prostate cancer by comparing your
change is made.
life expectancy versus the threat to
you by the prostate cancer.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 25
 3  Treatment planning Imaging for metastases

Risk groups These tests include Decipher, Oncotype DX Prostate,

Risk groups divide people with cancer into smaller Prolaris, and ProMark.
subsets based on their chances of an event. Some
risk groups are based on one piece of information Molecular testing is performed on prostate tissue
while others use multiple pieces of information. In removed by biopsy for diagnosis. It can be
Part 5 on page 47, treatment options are presented considered when active surveillance is an option.
by risk groups for prognosis. Risk is based on Molecular tests should be used with standard tests,
TNM scores, Gleason score, and PSA values. NCCN including PSA, Gleason grade, cancer stage, and
experts recommend that these risk groups be used imaging.
as a foundation to start talking about treatment
options. Molecular tests of prostate cancer have not been
assessed in randomized clinical trials. Such clinical
Nomograms trials would assign men to research groups by
A nomogram uses data from a large number of men chance. Also, molecular testing would be done first
and complex math to predict risk. It can predict one and then outcomes would be assessed over time.
person’s risk better than a risk group. A nomogram Without such studies, there are major limits to how
predicts an event by taking into account similarities useful molecular tests are for making treatment
and differences among pieces of information. In decisions. Still, more research is needed for these
this book, test and treatment recommendations are molecular tests.
sometimes based on nomograms that predict how
likely the cancer has spread to lymph nodes. Also,
NCCN experts advise that nomograms be used
in addition to risk groups to better plan treatment. Imaging for metastases
Websites with information on nomograms are listed
in Part 8 on page 88. Imaging tests can help show if the cancer has spread
to the lymph nodes or bones. If your life expectancy
Molecular testing is more than 5 years or you have cancer symptoms,
Any of your body’s molecules that can be measured testing for metastases may help with treatment
to assess your health are called biomarkers. An planning. Signs of metastases are listed in Guide 2.
example of a biomarker is PSA for detecting prostate If you have these signs, you may get a 1) bone scan
cancer. There are also biomarkers for predicting how or 2) CT or MRI scan of your pelvis and possibly
fast cancer will grow and treatment results. Molecular your abdomen. Imaging tests for metastatic disease
(or biomarker) testing assesses for such biomarkers. should not be performed if you have very-low-risk
or low-risk features. Your doctor may change his or
There are several molecular tests that may help her rating of the cancer stage based on these test
assess how aggressive localized prostate cancer results.
is. Localized cancer includes tumors that have
not grown through the prostate and into nearby Most men have minor, if any, problems with imaging
structures. There is also no spread to nearby lymph tests. There are usually no side effects. Depending
nodes or distant sites. For some men with low or on the test, you may need to stop taking some
favorable intermediate risk disease, doctors may medicines, stop eating and drinking for a few hours,
consider using the following molecular tests to better and take off any metal objects from your body. After
predict how a cancer will behave. an imaging test, you will be able to resume your
activities right away unless you took a sedative.
NCCN Guidelines for Patients®:
Prostate Cancer, 2018 26
 3  Treatment planning Imaging for metastases

Guide 2. Deciding factors for imaging tests

Disease status Imaging tests

• T2b-T2c
or
• Get a CT or MRI of the pelvis ± abdomen if
• Gleason score 3+4=7/grade group 2
or ª nomogram predicts >10% probability of pelvic
lymph node involvement
• PSA 10–20 ng/mL and
• Percentage of positive biopsy cores <50%

• T2b-T2c
or
• Gleason score 3+4=7/grade group 2 or • Get a bone scan if T2 and PSA >10 ng/mL
Gleason score 4+3=7/grade group 3 • Get a CT or MRI of the pelvis ± abdomen if
or ª nomogram predicts >10% probability of pelvic
• PSA 10–20 ng/mL lymph node involvement
or
• Percentage of positive biopsy cores ≥ 50%

• T3a
or • Get a bone scan
• Gleason score 8/grade group 4 or Gleason • Get a CT or MRI of the pelvis ± abdomen if
score 4+5=9/grade group 5 ª nomogram predicts >10% probability of pelvic
or lymph node involvement
• PSA >20 ng/mL

• T3b-T4
or • Get a bone scan
• Primary Gleason pattern 5 • Get a CT or MRI of the pelvis ± abdomen if
or
ª nomogram predicts >10% probability of pelvic
lymph node involvement
• >4 cores with Gleason score 8–10/ grade
group 4 or 5

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 27
 3  Treatment planning Imaging for metastases

Bone imaging CT or MRI

Bone imaging is advised if you have signs or A CT or MRI of your abdomen and/or pelvis may
symptoms of bone metastases. For a bone scan, show if your lymph nodes are enlarged. It can also
a radiotracer will be injected into your vein. Areas show if there is other disease in the area. Both scans
of bone repair take up more of the radiotracer were described in Part 2 on pages 15 and 16. MRI
than healthy bone and thus show up as bright or images are made with a magnetic field and radio
“hot” spots in the pictures. However, other health waves. A CT scan takes many pictures of a body
conditions besides cancer can cause bone repair. A part from different angles using x-rays. A computer
radiologist can often tell what is and is not cancer on combines all the x-rays to make detailed pictures.
an abnormal bone scan.
If the CT or MRI scan suggests that the cancer has
Figure 8 shows a bone scan machine that is used spread into your lymph nodes, an FNA (fine-needle
to take the pictures. You will need to lie still on the aspiration) can confirm if cancer is present. An FNA
padded table to complete the pictures. Prostate is a type of biopsy. It uses a very thin needle to
cancer in bone can damage the bone causing the remove very small pieces of tissue. A CT scan, MRI,
bone to struggle to repair itself. or ultrasound machine is used to guide the needle
into the lymph node. With a local anesthetic, this test
causes little discomfort and doesn’t leave a scar.

Figure 8.
Bone scan machine

Doctors use bone scans to assess if

cancer has spread to the bones.

Gamma Camera by Brendaicm available at commons.wikimedia.org/wiki/File:Gam-

ma_camera.jpg under a Creative Commons Attribution-Share Alike 3.0 Unported.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 28
 3  Treatment planning Review

A biopsy of the bone is sometimes recommended.

Cancer cells don’t change how they look when they
move to a new location in the body, so a pathologist
can look at the biopsy and determine whether there
are prostate cancer cells in the biopsy. They can
also check if the abnormal cells are another kind of
Newer tests cancer or not cancer (benign).


Doctors are still learning about newer
tests for imaging the bones and lymph Review
nodes.
†† Doctors plan treatment using many sources of
information.
Some of the newer tests that
are under study may include a †† Life expectancy is the number of years you
will likely live. It is sometimes used to plan
PET/CT or PET/MRI scan using treatment.
different radiotracers such as 18F-NaF
†† Risk groups can be used to start talking about
(sodium fluoride), 68 Ga PSMA
initial treatment options.
(prostate-specific membrane antigen),
F-18 fluorodihydrotestosterone, or †† Nomograms predict one person’s risk better
than risk groups and might also be useful in
C-11 acetate. planning treatment.

These newer tests appear to detect †† Imaging tests may be used to see if the cancer
has spread beyond the prostate.
prostate cancer in certain cases.
However, more research is needed †† An FNA may be done to test for cancer in lymph
to learn the best way to use the nodes.

information from these tests.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 29
 4
Overview of cancer treatments
31 Active surveillance 41 Immunotherapy
31 Surgical treatment 42 Chemotherapy
35 Radiation therapy 43 Radiopharmaceuticals
38 Cryosurgery 43 Clinical trials
38 High-intensity focused 44 Understudied treatments
ultrasound 46 Review
39 Hormone therapy

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 30
 4  Overview of cancer treatments Active surveillance | Surgical treatment

Part 4 briefly describes the main Radical prostatectomy

types of treatment for prostate cancer. A radical prostatectomy is an operation that removes
Knowing what a treatment is will help the entire prostate, seminal vesicles, and sometimes
you understand your treatment options other tissue. It is often used when the tumor appears
listed in Parts 5 through 7. Not every not to have grown outside the prostate—T1 and T2
man with prostate cancer will receive tumors.
every treatment listed here. Before any
treatment, it is helpful to talk with your Results of a prostatectomy may be related to the
doctor about sperm banking if you plan to experience of the surgeon. Surgeons who are
have children. experienced have better results. When choosing
your surgeon, ask how many of these operations
he or she has done. Going to a surgeon who has
and continues to do many radical prostatectomies
may result in a better outcome. It may be helpful to
Active surveillance talk to other men with prostate cancer about their
experiences.
Small prostate tumors often have been found with
PSA screening tests. They have also been found There are a few steps to prepare for an operation.
in prostates removed because of benign prostatic You may need to stop taking some medications to
hyperplasia. If small tumors grow slowly, they may reduce the risk of severe bleeding. You will need
not ever cause health problems, especially if you’re to eat less, change to a liquid diet, or use enemas
older. Thus, some men would suffer needlessly from or laxatives to empty your bowel. Right before the
treatment side effects if all men with prostate cancer operation, you will be given anesthesia. Anesthesia
were treated. Another option is active surveillance. may be general, spinal, or epidural.
Active surveillance involves ongoing testing until
cancer treatment is needed. More information about After a radical prostatectomy, a catheter will be
this option can be found in the next chapter. inserted into your urethra to allow your urethra to
heal. It will stay in place for 1 to 2 weeks. You will be
shown how to use it while you’re at home. If removed
too early, you may lose control of your bladder
Surgical treatment (urinary incontinence) or be unable to urinate due to
scar tissue.
Surgical treatment may be an option if you are
healthy enough to have an operation. The goal of an Open radical prostatectomy
operation is to remove all the cancer from your body. Open radical prostatectomy removes the prostate
To do so, the tumor will be removed along with some through one large cut. Your surgeon can make the
normal-looking tissue around its rim. The normal- cut in one of two places (retropubic or perineal). This
looking tissue is called the surgical margin. Other operation itself may take a few hours to complete.
tissue may be removed along with your prostate as You may stay in the hospital for a couple of days and
described next. resume all normal activities in about 4 to 6 weeks.
Your doctor or nurse will talk to you in more detail
about what to expect before and after the operation.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 31
 4  Overview of cancer treatments Surgical treatment

It is helpful to know which method your doctor may Your cavernous nerve bundles are on both sides of
use for the open radical prostatectomy. Below are 2 your prostate. They are needed for natural erections.
methods that are used for prostate cancer. A nerve-sparing prostatectomy will be done if your
cavernous nerves are likely to be cancer-free.
Radical retropubic prostatectomy However, if the cancer involves them, one or both
This surgery removes tissue through a cut that runs bundles of nerves will be removed. If removed, good
from your belly button down to the base of your erections are still possible with aids, and orgasms
penis. During the operation, you will lie on your back can occur with or without these nerves.
on a table with your legs slightly higher than your
head. Radical perineal prostatectomy
This surgery removes tissue through a cut in your
Before removing your prostate, some veins and your perineum. The perineum is the area between your
urethra will be cut to clear the area. Your seminal scrotum and anus as shown in Figure 9. During the
vesicles will be removed along with your prostate. operation, you will lie on your back with your legs
After removing your prostate, your urethra will be spread open and supported with stirrups.
reattached to your bladder.
Your prostate and seminal vesicles will be removed
after being separated from nearby tissues. Nerve
sparing is possible but more difficult.

Figure 9.
Open methods to radical
prostatectomy

Your prostate may be removed

through one large cut in your
pelvis or between your legs.

Illustration Copyright © 2018 Nucleus Medical Media, All rights reserved.

www.nucleusinc.com

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 32
 4  Overview of cancer treatments Surgical treatment

Lymph nodes can’t be removed. After your

prostate has been removed, your urethra will be Figure 10.
re-attached to your bladder. Robotic-assisted radical
prostatectomy
Laparoscopic radical prostatectomy
A newer method for removing the prostate is the Your prostate may be removed by your surgeon
laparoscopic radical prostatectomy. This operation with “robotic” arms that hold surgical tools.
requires five small cuts, called ports, be made in Your surgeon will move the robotic arms
your pelvis. Tools will be inserted into these cuts through a computer system instead of with his
to see and remove tissue. It may take between 90 or her hands. The surgical tools will be inserted
minutes and 4 hours to complete this operation. into your body through small cuts made into
You will likely leave the hospital the next day. It your abdomen.
may take another 2 weeks to recover at home.

Robotic-assisted radical prostatectomy

A laparoscopic radical prostatectomy can be done
with the help of a “robot.” During this operation,
the surgeon will be in the room with you but not
by your side. Instead, he or she will be at a desk
that is equipped with a computer system. This
system allows the surgeon to move robotic arms
that hold the surgical tools used to perform the
operation. See Figure 10. Robotic arms make
more precise cuts compared to a surgeon’s hand.
However, surgeons can detect changes in the
tissue by touching your organs during an open
prostatectomy. Surgeons who perform robotic
surgery go through special training to perform this
type of operation.

Pelvic lymph node dissection

A PLND (pelvic lymph node dissection) is an
operation that removes lymph nodes from your
pelvis. As described in Part 5, PLND is advised
if you choose to have a radical prostatectomy
and either 1) you have high-risk or very-high-risk
prostate cancer or 2) a nomogram predicts you
have a 2% or greater risk for cancer in your lymph
Laproscopic Surgery Robot by Nimur
nodes. Using a 2% cutoff, nearly half of men (48 Laproscopic Surgery Robot by Nimur available at commons.wikimedia.org/
out of every 100) will be spared having a PLND. wiki/File:Laproscopic_Surgery_Robot.jpg under a Creative Commons Attribu-
tion-Share Alike 3.0 Unported

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 33
 4  Overview of cancer treatments Surgical treatment

See Figure 11. Also, almost all men in this group and require a blood transfusion. Serious risks of
who have cancer in their lymph nodes will be staged anesthesia and prostatectomy include heart attack
and treated correctly. and blood clots.

An extended PLND removes more lymph nodes than After the operation, general anesthesia may cause
a limited PLND. It finds metastases about two times a sore throat from a breathing tube, nausea with
as often as a limited PLND. It also stages cancer vomiting, confusion, muscle aches, or itching. You
more completely and may cure some men with very will have pain and swelling, though this will often
tiny metastases that haven’t spread far. Therefore, an fade away within weeks. The PLND may rarely cause
extended PLND is advised if you’re to have a PLND. swelling in the legs due to the buildup of lymph
It can be done with an open retropubic, laparoscopic, (lymphedema) that will resolve over several weeks.
or robotic method.
Almost every man has urinary incontinence and
Side effects of surgical treatment erectile dysfunction after a radical prostatectomy.
Side effects are unhealthy or unpleasant physical These two side effects may be short lived, but for
or emotional responses to treatment. You may some men they are lifelong issues.
experience side effects from the general anesthesia,
radical prostatectomy, or the PLND. During the
operation, you may have a serious loss of blood

Figure 11.
Nomogram results for PLND

Primary tumors that are rated T1 or

T2 have not grown outside of the
prostate. However, the cancer may
have spread to nearby lymph nodes.
To receive the best treatment, your
doctor needs to know if cancer is
present in lymph nodes. When using
a ≥2% risk cutoff, most men with
cancer in their lymph nodes will
be correctly staged because they
received a PLND.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 34
 4  Overview of cancer treatments Radiation therapy

You’re at higher risk for erectile dysfunction if 1) Radiation therapy

you’re older; 2) you have erectile problems before
the operation, or 3) your cavernous nerves are Radiation therapy is a cancer treatment that uses
damaged or removed during the operation. If your high-energy rays. The rays damage DNA. This either
cavernous nerves are removed, there is no good kills the cancer cells or stops new cancer cells from
proof that nerve grafts will help restore your ability to being made. Radiation can also harm normal cells.
have erections. Aids are still needed.
Radiation therapy is an option for many men with
Removing your prostate and seminal vesicles prostate cancer. Radiation therapy may be given to
will cause you to have dry orgasms. You will no your pelvic lymph nodes as well as to your prostate.
longer be able to father children through sex. Your The different ways to give radiation are discussed
prostatectomy essentially includes a vasectomy. next.
This is an operation men may choose to have
in order to stop being able to have children. External beam radiation therapy
Although not as common as erectile dysfunction, Most often, EBRT (external beam radiation therapy)
other sexual changes may include pain during is the method used to treat prostate cancer. This
orgasm (dysorgasmia), inability to have an orgasm method delivers radiation from outside your body
(inorgasmia), curving of your penis (penile curvature using a large machine. The radiation passes through
or Peyronie’s disease), and a smaller penis (penile your skin and other tissue to reach the tumor.
shrinkage).
Simulation
Bladder control often returns within months after Treatment planning with a simulation session is
the operation, but you may not have full control. needed. During simulation, pictures of the tumor will
Stress incontinence is leakage of a little urine when be taken with an imaging scan. Pictures are taken
coughing, laughing, sneezing, or exercising. It is after your body is moved into the position needed for
caused by damage to the muscle at the base of the treatment.
bladder. Overflow incontinence occurs when there
is too much urine in the bladder because scarring Using the scans, your treatment team will plan the
blocks the full release of urine. Some men also have best radiation dose, number and shape of radiation
problems with bowel movements (defecating) after beams, and number of treatment sessions. Beams
the operation. are shaped with computer software and hardware
added to the radiation machine. Radiation beams are
Not all side effects of surgical treatment are listed aimed at the tumor with help from ink marks on the
here. Please ask your treatment team for a complete skin or marker seeds in the tumor.
list of common and rare side effects. If a side effect
bothers you, tell your treatment team. There may be Receiving treatment
ways to help you feel better. During treatment, you will lie on a table in the same
position as done for simulation. Devices may be used
to keep you from moving so that the radiation targets
the tumor. You will be alone while the technician
operates the machine from a nearby room. He or she
will be able to see, hear, and speak with you at all
times.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 35
 4  Overview of cancer treatments Radiation therapy

As treatment is given, you may

hear noises. One session often
takes less than 10 minutes. EBRT
is given 5 days a week for about
8 to 9 weeks, although there is
growing interest in shortening the
Newer treatment
length of treatment.
In recent years, some cancer centers have built radiation
Often, ADT (androgen deprivation machines that use proton beams. Proton beams are a stream
therapy) is used with EBRT. ADT of positively charged particles that emit energy within a short
is described later in this chapter. distance. Some doctors think that proton treatment is better
Many studies have shown that than x-ray–based treatment. One benefit would be less severe
adding ADT to EBRT improves
side effects.
treatment outcomes when prostate
cancers are more aggressive. ADT
has side effects so it shouldn’t be To date, research hasn’t shown that proton treatment is
used unless needed. Some men any better or worse for treating cancer or causing side
require short-term (4 to 6 months) effects. Well-designed research comparing IMRT and
ADT. Other men are on ADT for 1 proton treatment is ongoing. Thus, NCCN experts advise
to 3 years. There are multiple types that proton treatment can be an option if received at cancer
of EBRT to treat prostate cancer:
centers with the proper equipment and experience. It is also
helpful to ask about insurance coverage for this treatment
†† 3D-CRT (three-dimensional
conformal radiation therapy) since it may cost much more than EBRT. Your doctor may
uses beams matched to the suggest you receive proton therapy in a clinical trial. More
shape of the tumor. data is are being collected to fully understand how this type
of therapy can be used to treat prostate cancer.
†† IMRT (intensity-modulated
radiation therapy) uses small SBRT (stereotactic body radiotherapy) is a newer
beams of different strengths. technique. It treats cancer with very precise, high-dose
beams. Receiving SBRT is much like getting other EBRTs
In 3D-CRT, the radiation beams
except treatment is finished in about 5 or less fewer doses.
match the shape of your tumor
to avoid healthy tissues. IMRT is Research thus far has shown that SBRT and IMRT are
a more precise type of 3D-CRT alike in treating cancer, but the side effects are different.
that may be used especially for SBRT may cause more side effects than IMRT. However,
more aggressive prostate cancer. well-designed research of SBRT is needed to understand
The radiation beam is divided into the side effects and assess long-term results. Thus, NCCN
smaller beams, and the strength of
experts advise that treatment with SBRT be be received
each beam can vary.
only at cancer centers with the proper equipment and
The prostate can slightly shift within experience.
the body. Tumors may also change

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 36
 4  Overview of cancer treatments Radiation therapy

shape and size between and during treatment visits. seeds usually consist of either radioactive iodine or
IGRT (image-guided radiation therapy) can improve palladium. They will remain in your prostate to give
how well 3D-CRT and IMRT target the tumor. low doses of radiation for weeks or months. The
radiation travels a very short distance. This allows for
IGRT uses a machine that delivers radiation and also a large amount of radiation within a small area while
takes pictures of the tumor. Pictures can be taken sparing nearby healthy tissue. Over time, the seeds
right before or during treatment. These pictures are will stop radiating.
compared to the ones taken during simulation. If
needed, changes will be made to your body position For LDR brachytherapy, seed placement is harder if
or the radiation beams. you have a very large or small prostate, your urine
flow is blocked, or you’ve had TURP (transurethral
There are different types of radiation beams. 3D-CRT resection of the prostate). If your prostate is large,
and IMRT are x-ray–based treatments. They use you may be given ADT before LDR brachytherapy
photon radiation beams. Photon beams are a stream to shrink it. After the seeds are implanted, your
of particles that have no mass or electric charge. doctor should measure the radiation dose for quality
assurance.
Brachytherapy
Brachytherapy is another standard radiation HDR brachytherapy uses seeds made of
therapy for prostate cancer. This treatment involves iridium-194 that are contained inside soft catheters.
placing radioactive seeds inside your prostate. The catheters are removed after radiation has been
Brachytherapy is also called interstitial radiation—a given. This treatment requires staying in the hospital
seed treatment. Brachytherapy may be used alone or for 1 to 2 days. Either type of brachytherapy may
combined with EBRT, ADT, or both. be given along with EBRT in men with unfavorable
intermediate-, high-, or very-high-risk prostate
The seeds are about the size of a grain of rice. They cancer.
are inserted into your body through the perineum
and guided into your prostate with imaging tests. Side effects of radiation therapy
Treatment planning is done beforehand to design the Similar to surgical treatment, a common side effect
best course of treatment. You will be under general of EBRT and brachytherapy is erectile dysfunction.
or spinal anesthesia when the seeds are placed. Unlike surgery, erectile dysfunction may develop
several years after radiation therapy. Although not
Brachytherapy alone may be an option for men with as common as erectile dysfunction, other sexual
very low, low, or favorable intermediate-risk prostate changes may include difficulty achieving orgasm,
cancer. Brachytherapy can be given either as: thicker semen, dry orgasm, discolored semen, and
a decreased sperm count. These less common side
†† Permanent LDR (low dose-rate) brachytherapy effects often stop after a short period of time.

†† Temporary HDR (high dose-rate) You may develop urinary problems. Urinary problems
brachytherapy right after EBRT may include frequent urination,
a burning feeling while urinating, blood in urine
LDR brachytherapy uses thin needles to place (hematuria), and feeling the need to rush to a
40 to 100 seeds into your prostate. Placement of bathroom or you’ll leak urine (urge incontinence).
the seeds is done as an outpatient procedure. The After brachytherapy, you may have burning with

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Prostate Cancer, 2018 37
 4  Overview of cancer treatments
treatments Cryosurgery
Cryosurgery | High-intensity focused ultrasound

urination, a slow or weak urinary stream, urinary be used to place the needles. Argon gas will flow
retention, overflow incontinence, and hematuria. through the needles and freeze your prostate to
These side effects go away. Several years later, below-zero temperatures. Freezing kills the cancer
radiation injury to the bladder can cause urinary cells. Your urethra will be spared by use of a catheter
incontinence, although this isn’t common for either filled with warm liquid.
EBRT or brachytherapy. However, your risk after
brachytherapy is higher if you have had a TURP. Side effects of cryotherapy
The full range of side effects from cryotherapy is
Despite the best treatment planning and delivery, unknown. More research is needed. Known short-
your rectum will be exposed to some radiation during term side effects include urinary retention, painful
EBRT or brachytherapy. You may have rectal pain, swelling, and “pins and needles” feeling in the penis
diarrhea, blood in the stool, and inflammation of the (penile paresthesia). Long-term side effects include
colon. These side effects will go away over several erectile dysfunction, stress incontinence, fistulas,
months. and blockage of the urethra with rectal scar tissue. It
is helpful to ask your doctor about the possible side
Several years later, radiation injury to the rectum effects of cryosurgery.
can cause rectal bleeding and irritation, but these
symptoms are rare.

EBRT may cause changes in your skin. Your treated High-intensity focused
skin will look and feel as if it has been sunburned. It
will likely become red and may also become dry and
ultrasound
sore and feel painful when touched. You may also
feel extremely tired despite sleep (fatigue) and not HIFU (high-intensity focused ultrasound) is treatment
feel hungry. Exercise may help reduce fatigue. option if radiation therapy fails. HIFU treats prostate
tumors by using heat. HIFU uses high-intensity
Not all side effects of radiation therapy are listed sound waves (ultrasound) to heat and kill the cancer
here. Please ask your treatment team for a complete cells. HIFU is done as an outpatient procedure.
list of common and rare side effects. If a side effect A probe is inserted into the rectum and the high-
bothers you, tell your treatment team. There may be intensity sound waves are aimed directly at the
ways to help you feel better. cancer.

Side effects of HIFU

The full range of side effects from HIFU is unknown.
Cryosurgery More research is needed. Some side effects may
include urinary retention, urinary incontinence, or
Cryosurgery is a treatment option if radiation therapy erectile dysfunction. It is helpful to ask your treatment
fails. Cryosurgery treats prostate tumors by freezing team for a full list of side effects.
them. This treatment is often done as an outpatient
procedure.

Very thin needles will be inserted through your

perineum into your prostate. Imaging tests will

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 38
 4  Overview of cancer treatments Hormone therapy

Hormone therapy †† Androgen synthesis inhibitors are drugs

that block the making of androgen at different
Prostate cancer cells need hormones called sites. Ketoconazole is an antifungal drug that
androgens to grow. The main male androgen is stops the adrenal glands and other tissues from
testosterone. Hormone therapy will stop your body making testosterone. Abiraterone acetate works
from making testosterone or will stop the action of similarly but is more potent and less toxic.
testosterone. It can slow tumor growth or shrink the
tumor for a period of time. The term “hormone therapy” can be confusing
because of the many names it is called. Some
The types of hormone therapy are: people refer to all hormone therapy as androgen
suppression therapy or ADT. However, to be
†† Bilateral orchiectomy is the surgical removal exact, only orchiectomy and LHRH agonists and
of both testicles. They are removed since they antagonists are ADTs.
make most of the testosterone in the body.
Sometimes, antiandrogens are used with LHRH
†† LHRH (luteinizing hormone-releasing agonists or following an orchiectomy. This type
hormone) agonists are drugs used to stop the of treatment is called CAB (combined androgen
testicles from making testosterone. They are blockade). However, CAB is no better than castration
either injected into a muscle or implanted under alone for metastases. Moreover, it may lead to higher
the skin every 1, 3, 4, 6, or 12 months. LHRH costs and worse side effects.
agonists include goserelin acetate, histrelin
acetate, leuprolide acetate, and triptorelin Finasteride or dutasteride used with CAB is called
pamoate. triple androgen blockade. The benefit of triple
androgen blockade is probably small if any benefit
†† LHRH antagonists are drugs used to stop the exists. If you will be on long-term ADT, your doctor
testicles from making testosterone. They are may consider intermittent treatment to reduce side
injected under the skin usually every month. effects. Intermittent treatment is alternating periods
Degarelix is an LHRH antagonist. of time on and off treatment. It can provide similar
cancer control to continuous hormone therapy.
†† Antiandrogens are drugs that block receptors
on cancer cells from receiving testosterone. Side effects of hormone therapy
Antiandrogens include bicalutamide, flutamide, Hormone therapy has multiple side effects. It can be
nilutamide, enzalutamide, and apalutamide. hard to know whether you will get a side effect. Many
factors play a role. Such factors include your age,
†† Estrogens can stop the adrenal glands and your health before treatment, how long or often you
other tissues from making testosterone. take treatment, and so forth.
One type of estrogen is called DES
(diethylstilbestrol). Side effects differ between the types of hormone
therapy. In general, ADT may reduce your desire for
†† Corticosteroids can stop the adrenal sex and cause erectile dysfunction. These sexual
glands and other tissues from making side effects don’t seem to lessen with time.
testosterone. Hydrocortisone, prednisone, and
dexamethasone are corticosteroids.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 39
 4  Overview of cancer treatments Hormone therapy

Guide 3. Drug treatment for prostate cancer

Generic name Brand name (sold as) Type of treatment

Abiraterone acetate Zytiga®, Yonsa® Hormone therapy

Apalutamide Erleada™ Hormone therapy
Bicalutamide Casodex® Hormone therapy
Cabazitaxel Jevtana® Chemotherapy
Degarelix Firmagon® Hormone therapy

Dexamethasone; Dexamethasone
– Hormone therapy
sodium phosphate

Diethylstilbestrol (DES) – Hormone therapy

Docetaxel Taxotere® Chemotherapy
Enzalutamide Xtandi® Hormone therapy
Flutamide – Hormone therapy
Goserelin acetate Zoladex® Hormone therapy
Histrelin acetate Vantas® Hormone therapy
Hydrocortisone Cortef® Hormone therapy
Ketoconazole Nizoral® Hormone therapy
Leuprolide acetate Eligard®, Lupron Depot® Hormone therapy
Methylprednisolone Medrol® Hormone therapy
Mitoxantrone hydrochloride Novantrone® Chemotherapy
Nilutamide Nilandron® Hormone therapy
Pembrolizumab Keytruda® Immunotherapy
Prednisone – Hormone therapy
Sipuleucel-T Provenge® Immunotherapy
Triptorelin pamoate Trelstar® Hormone therapy

The longer you take ADT, the more your risk for A side effect specific to orchiectomy is the loss of
thinning and weakening bones (osteoporosis), your testicles. Implants that look like testicles can be
bone fractures, weight gain, loss of muscle mass, inserted into your scrotum. Your testicles won’t be
diabetes, and heart disease increases. Other side removed with LHRH agonists but these drugs will
effects of ADT include hot flashes, mood changes, shrink your testicles over time.
and fatigue.

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Prostate Cancer, 2018 40
 4  Overview of cancer treatments Immunotherapy

Side effects of antiandrogens are like those of Apalutamide the newest hormone therapy and may
ADT. When an antiandrogen is used with an LHRH be used to treat men with non-metastatic CRPC. This
agonist, diarrhea is a major side effect. Other side is cancer that has not spread in the body and is not
effects include nausea, liver problems, breast growth responding to ADT. A rare but severe side effect of
and tenderness, and tiredness. Estrogens also apalutamide is seizures. Common side effects may
increase risk for breast growth and tenderness as include extreme tiredness, hot flashes, diarrhea,
well as blood clots. Ketoconazole can cause low pain, not feeling hungry, swelling, weight loss,
cortisol levels and cause health problems when headache, and high blood pressure. Apalutamide
taken with other drugs. puts you are risk for falling. This drug may cause
your muscles and bones to be weak and put you at
Abiraterone acetate with prednisone or risk for a broken bone (fracture).
methylprednisolone is a newer hormone therapy. It
may be an option for men with M0 or M1 castration- Not all of the side effects of hormone therapy are
naïve prostate cancer, or as a secondary hormone listed here. Please ask your treatment team for a
therapy for metastatic (M1) CRPC (castrate complete list of common and rare side effects. If a
resistant-prostate cancer) disease. While taking side effect bothers you, tell your treatment team.
abiraterone acetate, you should be tested for high There may be ways to help you feel better. Some
blood pressure (hypertension), low potassium ways to reduce risks of hormone therapy are
(hypokalemia), fluid buildup (edema), and problems discussed in Part 6, but your treatment team can tell
with your adrenal glands, heart, and liver. You could you more.
also have hot flashes, fatigue, diarrhea, vomiting,
constipation, coughing, shortness of breath, joint or
muscle pain, and lung or urinary infections.
Immunotherapy
Enzalutamide and apalutamide are new anti-
androgens. They try to prevent testosterone from The immune system is the body’s natural defense
having its normal effect, turning on prostate growth. against infection and disease. The immune system
Enzalutamide may be given to men with non- includes many chemicals and proteins. These
metastatic CRPC, or before or after docetaxel for chemicals and proteins are made naturally in your
metastatic CRPC. It may also be considered when body.
you have metastatic CRPC and chemotherapy
is not an option. A rare but severe side effect of Immunotherapy increases the activity of your immune
enzalutamide is seizures. Common side effects may system. By doing so, it improves your body’s ability
include extreme tiredness, hot flashes, diarrhea, to find and destroy cancer cells. Immunotherapy may
headaches, pain, not feeling hungry, constipation, be option for some men with prostate cancer.
lung infections, swelling, shortness of breath, weight
loss, headache, high blood pressure, dizziness, and Sipuleucel-T
a feeling that things are spinning around (vertigo). Sipuleucel-T is a drug that uses your white blood
The chance that you may fall is greater when taking cells to destroy prostate cancer cells. In a lab,
enzalutamide. your white blood cells from a blood sample will be
changed by a protein so they will find and destroy
prostate cancer cells. This drug is a known as a
cancer vaccine. It is given as an injection.

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Prostate Cancer, 2018 41
 4  Overview of cancer treatments Chemotherapy

Common side effects of sipuleucel-T include chills, of DNA. Other drugs interfere with cell parts that are
fever, nausea, and headache. These effects don’t needed for making new cells.
appear to last for long. Serious heart problems rarely
occur. Docetaxel and cabazitaxel are chemotherapy drugs
used to treat advanced prostate cancer. They may
Pembrolizumab improve survival, delay or relieve symptoms, and
Pembrolizumab is a newer immunotherapy drug reduce tumor growth and PSA levels. Mitoxantrone
approved for cancers with certain DNA changes, hydrochloride may relieve symptoms caused by
which occur in fewer than 5% of prostate cancer advanced cancer. Read Part 7 for more details on
patients. Thus, your doctor may recommend a test chemotherapy.
to check if you have MSI-H (microsatellite instability-
high) or mismatch repair (MMR)-deficient tumor cells See Guide 3 on page 40 for a list of drugs used to
to determine if pembrolizumab could be helpful, but treat prostate cancer. The chemotherapy drugs used
it would typically not be used until other treatments to treat prostate cancer are liquids that are injected
have been used. into a vein. The drugs travel in the bloodstream to
treat cancer throughout the body. Chemotherapy is
This type of immunotherapy is called a PD-1 given in cycles of treatment days followed by days of
(programmed death receptor-1) inhibitor. PD-1 is a rest. This allows the body to recover before the next
protein found on immune system cells called T cells. cycle.
This type of drug blocks the PD-1 protein and boosts
the immune system response against the cancer. Docetaxel is an option for some men who are taking
Pembrolizumab is given every few weeks as a liquid ADT for the first time. In this case, 3-week cycles
that is injected into a vein. Pembrolizumab may be are advised. These 3-week cycles may occur 6
an option for treating prostate cancer that continues times. Side effects may include fatigue, weakness
to through at least one line of systemic therapy for or numbness in the toes or fingers (neuropathy),
metastatic CRPC. inflammation of the mouth (stomatitis), diarrhea,
and low counts of neutrophils (neutropenia) with or
The most common side effects of pembrolizumab without fever. Neutrophils are a type of white blood
may include skin rash, itchy skin, extreme tiredness, cell.
nausea, vomiting, diarrhea, and bone, joint, and/or
muscle pain. This drug can also cause inflammation Docetaxel is also used to treat metastases after
of the liver, kidney, or lungs. Not all of the side effects ADT fails to stop cancer growth. Three-week cycles
are listed here. It is helpful to ask for a complete list are also advised. The number of cycles you receive
of side effects. should be based on how much the drug is helping
and the severity of side effects.

Cabazitaxel is an option if docetaxel fails to work.

Chemotherapy However, the benefits of cabazitaxel are small and
the side effects can be severe. You should not take
Chemotherapy, or “chemo,” is the use of drugs to kill cabazitaxel if your liver, kidney, or bone marrow is
cancer cells. Some chemotherapy drugs kill cancer not working well or if you have severe neuropathy.
cells by damaging their DNA or disrupting the making

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 4  Overview of cancer treatments
treatments Radiopharmaceuticals
Radiopharmaceuticals | Clinical trials

You may have a severe allergic reaction within a Clinical trials

few minutes of receiving cabazitaxel. Common side
effects are fatigue, neuropathy, hematuria, back pain, Clinical trials are research studies that people
bruising, shortness of breath, cough, joint pain, and choose to take part in. Because of clinical trials,
hair loss. Severe stomach and intestinal problems, doctors learn how to prevent, diagnose, and treat
illness from too few white blood cells, and kidney diseases like cancer. Because of clinical trials, the
failure may occur. tests and treatments in this book are now widely
available to help men with prostate cancer.
Not all of the side effects of chemotherapy are listed
here. Please ask your treatment team for a complete One of your treatment choices may be to join a
list of common and rare side effects. If a side effect clinical trial. NCCN experts strongly support clinical
bothers you, tell your treatment team. There may be trials as a treatment option. Clinical trials are an
ways to help you feel better. important option for men with prostate cancer at all
stages. For example, some trials are testing whether
using treatments that work for prostate cancer work
better in combination, or when used in earlier stages
Radiopharmaceuticals of the disease. Newer treatments can also be tested
to see if they work better for prostate cancer.
Radiopharmaceuticals are drugs that contain
a radioactive substance. Radium-223 is a Phases of a clinical trial
radiopharmaceutical that is injected into the body to Clinical trials go through levels or phases of testing
treat prostate cancer that has spread to the bone. It to find safe and helpful ways to manage prostate
may improve survival time. It may also delay bone cancer. These phases help move the research along
problems and the need for radiation to treat pain. to find out what works best for patients with prostate
cancer.
Since the chemical makeup of radium-223 is similar
to calcium, it travels to bone damaged by cancer. †† Phase I looks at how much drug to give, its side
Once it reaches the bone, it delivers radiation that effects, and how often to give the treatment.
kills the nearby cancer cells. The radiation doesn’t
travel far so healthy tissue is spared. †† Phase II tests for side effects and how cancer
responds to treatment.
Radium-223 may lower blood cells counts. Thus, you
may get infections and bruises and have unusual †† Phase III compares the new treatment (or new
bleeding or fatigue. Since radium-223 leaves the use of treatment) to what is commonly used.
body through the gut, other common side effects are
nausea, diarrhea, and vomiting. †† Phase IV follows late side effects and if the
treatment still works after a long period.
89Sr (strontium-89) and 153Sm (samarium-153) also
are radiopharmaceuticals. They haven’t been shown
to extend life. However, they may relieve pain caused
by cancer metastases in the bone. They also may
cause a decrease in the number of blood cells.

NCCN Guidelines for Patients®:

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 4  Overview of cancer treatments Understudied treatments

Taking part in a clinical trial Understudied treatments

All clinical trials have a plan and are carefully led by
a medical team. Patients in a clinical trial are often The treatments described so far are those
alike with their cancer type and general health. You recommended by NCCN experts. These treatments
can join a clinical trial when you meet certain terms have been proven in clinical trials to be safe
(eligibility criteria). and work well. You may have heard about other
treatments. Some treatments that are of great
If you decide to join a trial, you will need to review interest but need more research are addressed next.
and sign a paper called an informed consent
form. This form describes the clinical trial in detail, Cryosurgery or high-intensity focused
including the risks and benefits. Even after you sign ultrasound
consent, you can stop taking part in a clinical trial at Cryosurgery is a treatment option following failure of
any time. radiation therapy. It causes many of the same side
effects in the prostate region as surgery or radiation.
Some benefits of a clinical trial: The effects of cryosurgery are still uncertain.
More research is needed to learn more about this
†† You’ll have access to the most current cancer treatment.
care.
Vascular-targeted photodynamic therapy
†† You will be closely watched by your medical VTP (vascular-targeted photodynamic therapy)
team. destroys blood vessels of prostate tumors. It consists
of a drug that is first injected into your vein. The drug
†† You may help other patients with cancer. is then activated by light. The light is emitted from
tiny laser fibers that are inserted into your prostate.
Some risks of a clinical trial: VTP isn’t recommended by NCCN experts at this
time unless it’s part of a clinical trial.
†† Like any test or treatment, there may be side
effects

†† New tests or treatments may not work.

†† You may have more clinic visits for treatment

and blood or imaging tests.

Next steps 
Ask your doctor or nurse if a clinical trial may be an
option for you. There may be clinical trials where
you’re getting treatment or at other treatment centers
nearby. You can also find clinical trials through the
websites listed in Part 8 on page 88.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 44
 4  Overview of cancer treatments Complementary and alternative medicine

Complementary and alternative medicine

Complementary medicines are

meant to be used alongside standard
therapies, most often for relaxation, to
improve your health, or to prevent or
reduce side effects.

Alternative medicine is treatment

or techniques that are used instead of
standard treatments such as chemotherapy
or radiation. Some are sold as cures even
though they haven't been proven to work in
clinical trials.

Many cancer centers or local hospitals

have complementary therapy programs
that offer acupuncture, yoga, and other
CAM (complementary and
types of therapy.
alternative medicine) is a group
of treatments sometimes used by
It's important to tell your treatment team
people with cancer. Many CAMs
if you are using any complementary
are being studied to see if they medicines, especially supplements,
are truly helpful. vitamins, or herbs. Some of these things
can interfere with your cancer treatment.
For more information about CAM, ask your
doctor and visit the websites listed in Part 8.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 45
 4  Overview of cancer treatments Review

Review
†† A radical prostatectomy removes the prostate
and the seminal vesicles. A PLND removes
lymph nodes near the prostate.

†† Radiation from a machine or “seeds” is used to

kill cancer cells or stop new cancer cells from
being made.

†† Cryosurgery kills cancer cells by freezing them

and HIFU kills cancer cells by heating them.

†† Hormone therapy treats prostate cancer by

either stopping testosterone from being made
or stopping the action of testosterone.

†† Immunotherapy activates your body’s disease-

fighting system to destroy prostate cancer cells.

†† Chemotherapy stops cancer cells from

completing their life cycle so they can’t increase
in number.

†† Radiopharmaceuticals are radioactive drugs

used to treat cancer in the bones.

†† Clinical trials give men with prostate cancer

access to new tests and treatments.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 46
 5
Treatment guide:
Initial treatment
49 Very low risk
51 Low risk
54 Favorable intermediate risk
56 Unfavorable intermediate risk
58 High risk or very high risk
60 Regional cancer
61 Review

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 47
 5  Initial treatment Treatment guide

Part 5 is a guide to the initial treatment

options for men with prostate cancer.
The risk groups are used to recommend
treatment options. These groups have
been tested and have been found to
predict treatment outcomes well. They
provide a better basis for treatment
recommendations than just using the Helpful tips for reading
cancer stage.
the treatment guides in
the next 4 chapters 
This information is taken from the
treatment guidelines written by NCCN
experts for prostate cancer doctors. Your The treatment guides (the colored
doctors may suggest other treatments charts) are numbered and list test or
than those listed in Part 5 based on your
health and personal wishes. treatment options.

It is helpful to read the guides from left to

right, using the arrows to follow a path.
The titles of the guides are important.

The symbol ± means “with or without.”

This is used to show when a test or
treatment is given with or without another
test or treatment.

Acronyms (a group of letters using the

first letters of words or phrases) found
in the treatment guides are defined on
page 94.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 48
 5  Initial treatment Very low risk

Very low risk

Guide 4. Primary treatment

Expected years to live What are the options?

<10 years ª • Observation

• Active surveillance:
◦◦ PSA no more often than every 6 months as needed
◦◦ DRE no more often than every 12 months as needed
10–20 years ª ◦◦ Repeat prostate biopsy no more often than every 12 months as
needed
◦◦ Consider mpMRI to help stage and grade the cancer if PSA
increases and biopsy samples had no cancer

• Active surveillance:
◦◦ PSA no more often than every 6 months as needed
◦◦ DRE no more often than every 12 months as needed
◦◦ Repeat prostate biopsy no more often than every 12 months as
needed
◦◦ Consider mpMRI to help stage and grade the cancer if PSA
increases and biopsy samples had no cancer
≥20 years ª • Radiation therapy:
◦◦ EBRT
◦◦ Brachytherapy

• Surgical treatment:
◦◦ Radical prostatectomy ± PLND if ≥2% risk of cancer in lymph
nodes

Guide 4 lists the treatment options for men at very be the cause of death. The cancer itself may never
low risk of recurrence. This tumor can’t be felt with a cause any problems. Observation consists of testing
DRE but is found because of high PSA levels. NCCN on a regular basis so that supportive care with ADT
experts are concerned about overtreatment of this can be given if symptoms from the cancer are likely
early cancer. to start. Tests during observation include PSA and
DRE.
Observation
NCCN experts advise starting observation if you’re Active surveillance
expected to live less than 10 years. Other health Active surveillance is advised if you are a younger
issues may be affecting you more than the prostate male with slow-growing disease, and are likely to live
cancer. In the long run, prostate cancer may not more than 10 years. Active surveillance consists of

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 49
 5  Initial treatment Very low risk

testing on a regular basis so that treatment can be There is debate over which events during active
started when and if needed. Treatment is given when surveillance should signal the start of treatment. The
there is still an excellent chance for a cure. decision to start treatment should be based on your
doctor’s judgment and your personal wishes. NCCN
Active surveillance consists of multiple tests. In experts suggest the following triggering events:
general, PSA testing should occur no more often
than every 6 months. DRE should occur no more • Cancer from the repeat biopsy has a
often than every 12 months. Gleason grade of 4 or 5, or

Doctors don’t agree on the need for and frequency • There is a larger amount of cancer within
of repeat biopsies. Some doctors do repeat biopsies biopsy samples or a greater number of
each year and others do them based on test results. biopsy samples have cancer.
Examples of such test results include a rise in PSA
level, change in DRE, or an MRI that shows more Radiation therapy
aggressive disease. If you will likely live more than 20 years, you may
want treatment now instead of active surveillance.
A decision to do a repeat biopsy should balance the In time, the cancer may grow outside your prostate,
potential benefits and risks. Risks include infection cause symptoms, or both. Since there is no way
and other side effects. If 10 or fewer cores were to know for sure, radiation therapy is an option.
removed or MRI showed concern for more disease, Very-low-risk cancers can be treated with EBRT or
you may have a repeat biopsy within 6 months to brachytherapy alone.
make sure your cancer was correctly classified as
low risk. If you’re likely to live less than 10 years Surgical treatment
and are on observation, you may not have a repeat Surgical treatment is another option if you will likely
prostate biopsy. live more than 20 years and prefer treatment over
active surveillance. It should consist of a radical
A prostate biopsy may be done under the guidance prostatectomy. Your pelvic lymph nodes may also be
of MRI images combined with real-time ultrasound removed if your risk for them having cancer is 2% or
images. This type of biopsy is called an MRI-US higher. Your doctor will determine your risk using a
fusion biopsy. It may help detect higher-grade nomogram, which was described in Part 3.
cancers. Higher-grade cancers include those with
Gleason score 7 through 10. The tissue that will be removed from your body
during the operation will be sent to a pathologist. He
The use of mpMRI may help to assess whether the or she will assess how far the cancer has spread
cancer is still very low risk. Your doctor may suspect within the tissue. After the operation, your PSA level
that the cancer is in the front part of your prostate will also be tested. You may receive more treatment
that can’t be felt during DRE. This is called anterior after surgery. See Guide 6 on page 53 for more
prostate cancer. Your doctor may also or instead information.
suspect that an aggressive cancer is now present.
mpMRI may help stage and grade the cancer when
the PSA level increases but no cancer was found in
biopsy samples.

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Prostate Cancer, 2018 50
 5  Initial treatment Low risk

Low risk
Guide 5. Primary treatment

Expected years to live What are the options?

<10 years ª • Observation

• Active surveillance:
◦◦ PSA no more often than every 6 months as needed
◦◦ DRE no more often than every 12 months as needed
◦◦ Repeat prostate biopsy no more often than every 12 months as needed
◦◦ Consider mpMRI to help stage and grade the cancer if PSA increases
and biopsy samples had no cancer

≥10 years ª • Radiation therapy:

◦◦ EBRT
◦◦ Brachytherapy

• Surgical treatment:
◦◦ Radical prostatectomy ± PLND if ≥2% risk of cancer in lymph nodes

Guide 5 lists the treatment options for men at low testing on a regular basis so that treatment can be
risk of recurrence. Treatment options are based on started when and if needed. Treatment is given when
how many years a man is expected to live. there is still an excellent chance for a cure.

Observation Active surveillance consists of multiple tests. In

NCCN experts advise starting observation if you’re general, PSA testing should occur no more often
expected to live less than 10 years. The cancer than every 6 months. DRE should occur no more
itself may never cause any problems. Observation often than every 12 months.
consists of testing on a regular basis so that
supportive care with ADT can be given if symptoms Doctors don’t agree on the need for and frequency
from the cancer are likely to start. Tests during of repeat biopsies. Some doctors do repeat biopsies
observation include PSA and DRE. each year and others do them based on test results.
Examples of such test results include a rise in PSA
Active surveillance level, change in DRE, or an MRI that shows more
Active surveillance is advised if you are a younger aggressive disease.
male with slow-growing disease, and are likely to live
more than 10 years. Active surveillance consists of

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 5  Initial treatment Low risk

A decision to do a repeat biopsy should balance the

potential benefits and risks. Risks include infection
and other side effects. If 10 or fewer cores were Order of treatments
removed and the results are not clear, you may have
a repeat biopsy within 6 months of being diagnosed
with prostate cancer. If you’re likely to live less than Some men with prostate cancer may
10 years and are on observation, you may not have receive more than one type of treatment.
a repeat prostate biopsy.
It is helpful to talk to your doctor about the
A prostate biopsy may be done under the guidance order of your treatment plan. The terms that
of MRI images combined with real-time ultrasound describe the order of treatments are:
images. This type of biopsy is called MRI-US fusion
biopsy and may help detect higher-grade cancers.
Higher-grade cancers include those with Gleason
score 7 through 10. Neoadjuvant treatment is
The use of mpMRI may help to assess whether given to shrink the tumor before
the cancer is still low risk. Your doctor may suspect surgery or radiation.
that the cancer is in the front part of your prostate
that can’t be felt during DRE. This is called anterior
prostate cancer. Your doctor may also or instead Primary treatment is the main
suspect that an aggressive cancer is now present. treatment given to rid the body of
mpMRI may help stage and grade the cancer when cancer.
the PSA level increases but no cancer was found in
biopsy samples.
Adjuvant treatment is given
There is debate over which events during active after surgery or radiation to kill any
surveillance should signal the start of treatment. The
decision to start treatment should be based on your remaining cancer cells.
doctor’s judgment and your personal wishes. NCCN
experts suggest the following triggering events:

• Cancer from the repeat biopsy has a

Gleason grade of 4 or 5, or

• There is a larger amount of cancer within

biopsy samples or a greater number of
biopsy samples have cancer.
cause symptoms, or both. Since there is no way
Radiation therapy to know for sure, radiation therapy is an option.
If you will likely live more than 10 years, you may Low-risk cancers can be treated with EBRT or
want treatment now instead of active surveillance. brachytherapy alone.
In time, the cancer may grow outside your prostate,

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 5  Initial treatment Low risk

Surgical treatment • Cancer in the seminal vesicle(s)

Surgical treatment is another option if you will likely
live more than 10 years and prefer treatment over • Detectable PSA levels
active surveillance. It should consist of a radical
prostatectomy. Your pelvic lymph nodes may also be If test results find no high-risk features or cancer in
removed if your risk for them having cancer is 2% or the lymph nodes, no more treatment is needed. You
higher. Your doctor will determine your risk using a may start observation. You will see Part 6.
nomogram, which was described in Part 3.
EBRT or observation is an option for when there
The tissue that will be removed from your body are high-risk features but no cancer in lymph nodes.
during the operation will be sent to a pathologist. He EBRT will target areas where the cancer cells have
or she will assess how far the cancer has spread likely spread. Treatment will be started after you’ve
within the tissue. After the operation, your PSA level healed from the prostate operation.
will also be tested. You may receive more treatment
after surgery. There are two treatment options if cancer is found
in lymph nodes. The first option is to start ADT now.
Guide 6 lists options for adjuvant treatment after a EBRT may be given with ADT. If your PSA levels are
radical prostatectomy. Adjuvant treatment helps to undetectable, a second option is to start observation.
stop the cancer from returning. Options are based Supportive care with ADT can be started if the levels
on the presence of high-risk features and cancer rise.
in the lymph nodes. High-risk features create the
possibility that not all of the cancer was removed by For adjuvant ADT, an LHRH antagonist or LHRH
the operation. High-risk features include: agonist is advised. It can be given on an intermittent
schedule to reduce its side effects. However, the
• Cancer in surgical margins benefits of ADT in this case are unclear. Your doctor
can tell you how long to use ADT.
• Cancer outside the prostatic capsule

Guide 6. Adjuvant treatment after prostatectomy

Test results What are the options?

No high-risk features or cancer in lymph nodes ª • see Part 6, Treatment monitoring

• EBRT
High-risk features but no cancer in lymph nodes ª or
• Observation

• ADT ± EBRT
Cancer in lymph nodes ª or
• Observation

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 5  Initial treatment Favorable intermediate risk

Favorable intermediate risk

Guide 7. Primary treatment

Expected years to live What are the options?

• Radiation therapy

<10 years*
ª ◦◦ EBRT
◦◦ Brachytherapy

ª • Observation

• Active surveillance:
◦◦ PSA no more often than every 6 months as needed
◦◦ DRE no more often than every 12 months as needed
◦◦ Repeat prostate biopsy no more often than every 12 months as
needed
◦◦ Consider mpMRI to help stage and grade the cancer if PSA
increases and biopsy samples had no cancer
≥10 years
• Radiation therapy
◦◦ EBRT
◦◦ Brachytherapy alone

• Surgical treatment:
◦◦ Radical prostatectomy ± PLND if ≥2% risk of cancer in lymph nodes

*Men with “favorable” cancer may start active surveillance but more research on outcomes is needed.

Guide 7 lists the treatment options for men in the Active surveillance
favorable intermediate risk group. Treatment options Active surveillance is an option, especially if only
are based on how many years a man is expected to 1 core contained a certain amount of cancer and
live. you are likely to live more than 10 years. Active
surveillance consists of testing on a regular basis
Observation so that treatment can be started when needed. For
Observation is an option for men expected to live favorable intermediate-risk disease, you should be
less than 10 years. The cancer is unlikely to cause watched carefully for any change in the disease
problems. Observation consists of testing on a status. Treatment is given when there is still an
regular basis so that supportive care with ADT can excellent chance for a cure.
be given if symptoms from the cancer are likely to
start. Tests during observation include PSA and DRE.

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 5  Initial treatment Favorable intermediate risk

Radiation therapy
A treatment option for some men with favorable
intermediate risk is radiation therapy. This may
include EBRT or brachytherapy alone.

Surgical treatment
If you are expected to live 10 or more years, a
radical prostatectomy may be an option. Your pelvic
lymph nodes may also be removed if your risk for
them having cancer is 2% or higher. Your doctor will
determine your risk using a nomogram, which was
described in Part 3.

The tissue that will be removed from your body

during the operation will be sent to a pathologist. He
or she will assess how far the cancer has spread
within the tissue. After the operation, your PSA level
will also be tested. You may receive more treatment
after the operation. See Guide 9 on page 57 for more
information.

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 5  Initial treatment Unfavorable intermediate risk

Unfavorable intermediate risk

Guide 8. Primary treatment

Expected years to live What are the options?

• Radiation therapy

<10 years*
ª ◦◦ EBRT + ADT for 4–6 months
◦◦ EBRT + brachytherapy ± ADT for 4–6 months

ª • Observation

• Surgical treatment:
ª ◦◦ Radical prostatectomy ± PLND if ≥2% risk of cancer in lymph
nodes
≥10 years
• Radiation therapy
ª ◦◦ EBRT + ADT for 4–6 months
◦◦ EBRT + brachytherapy ± ADT for 4–6 months

*Men with “favorable” cancer may start active surveillance but more research on outcomes is needed.

Guide 8 lists the treatment options for men in the intermediate-risk cancers but will likely cause more
unfavorable intermediate risk group. Treatment side effects.
options are based on how many years a man is
expected to live. Your doctor may want to add a short course of ADT
to EBRT. Research has shown that adding ADT to
Observation radiation can increase the likelihood of cure. For
Observation is an option for men expected to live ADT, an LHRH agonist alone or with an antiandrogen
less than 10 years. The cancer may not progress may be used. If you will receive ADT, it will be given
quickly enough to cause problems within 10 years. before, during, and after radiation therapy for 4 to 6
Observation consists of testing on a regular basis months.
so that supportive care with ADT can be given if
symptoms from the cancer are likely to start. Tests Surgical treatment
during observation include PSA and DRE. Active If you are expected to live 10 or more years, a
surveillance is not recommended for patients in this radical prostatectomy is a second option. Your pelvic
risk group. lymph nodes may also be removed if your risk for
them having cancer is 2% or higher. Your doctor will
Radiation therapy determine your risk using a nomogram, which was
A treatment option for all men with unfavorable described in Part 3.
intermediate risk is radiation therapy. LDR or
HDR brachytherapy can be used with EBRT for

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 5  Initital treatment Unfavorable intermediate risk

Guide 9. Adjuvant treatment after radical prostatectomy

Test results What are the options?

No high-risk features or cancer in lymph nodes ª • See Part 6, Treatment monitoring

• EBRT
High-risk features but no cancer in lymph nodes ª • Observation

• ADT ± EBRT
Cancer in lymph nodes ª • Observation

The tissue that will be removed from your body EBRT or observation is an option for when there
during the operation will be sent to a pathologist. He are high-risk features but no cancer in lymph nodes.
or she will assess how far the cancer has spread EBRT will target areas where the cancer cells have
within the tissue. After the operation, your PSA level likely spread. Treatment will be started after you’ve
will also be tested. You may receive more treatment healed from the prostate operation.
after surgery.
There are two treatment options if cancer is found
Guide 9 lists options for adjuvant treatment in lymph nodes. The first option is to start ADT now.
after a prostatectomy for favorable or unfavorable EBRT may be given with ADT. If your PSA levels
intermediate risk. Adjuvant treatment helps to stop are undetectable, a second option is observation.
the cancer from returning. Options are based on Treatment with ADT and radiation can be started if
the presence of high-risk features and cancer in the levels rise.
the lymph nodes. High-risk features suggest that
not all of the cancer was removed by the operation. For adjuvant ADT, an LHRH antagonist or LHRH
High-risk features include: agonist is advised. It can be given on an intermittent
schedule to reduce its side effects. However, the
• Cancer in surgical margins benefits of ADT in this case are unclear. Your
physician will discuss length of treatment with you.
• Cancer outside the prostatic capsule

• Cancer in the seminal vesicle(s)

• 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.

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 5  Initial treatment High risk or very high risk

High risk or very high risk

Guide 10. Primary treatment

What are the options?

• EBRT + ADT for 2–3 years

• EBRT+ brachytherapy + ADT for 1–3 years

• Radical prostatectomy + PLND

Guide 10 lists the treatment options for men in the The tissue removed from your body will be sent to a
high-risk or very-high-risk group who are expected pathologist. He or she will assess how far the cancer
to live for at least another 5 years. There are a few has spread within the tissue. Your PSA level will also
treatment options based on your level of risk. The be tested.
first option is EBRT to the prostate and pelvic lymph
nodes and long-term ADT. Docetaxel may be given
after EBRT for six 3-week cycles. You will continue to
take ADT during this time. When used with radiation,
ADT may consist of an LHRH agonist or an LHRH
agonist with an antiandrogen. If you will receive ADT,
it will be given before, during, and after radiation
therapy for a total of 2 to 3 years.

The second treatment option is EBRT plus

brachytherapy and long-term ADT. The time ADT
is given may be reduced when EBRT is given with
brachytherapy. When used with radiation, ADT may
consist of an LHRH agonist or an LHRH agonist with
an antiandrogen. If you will receive ADT, it will be
given before, during, and after radiation therapy for a
total of 1 to 3 years.

If the tumor can be fully removed, a radical

prostatectomy with removal of your pelvic lymph
nodes (PLND) may be considered. This may be an
option for men who are younger and have no other
health issues.

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 5  Initial treatment High risk or very high risk

Guide 11. Adjuvant treatment

After radiation therapy

What are the options?

• See Part 6, Treatment monitoring

After prostatectomy

Test results What are the options?

No high-risk features or cancer in lymph nodes ª • Observation

• EBRT
High-risk features but no cancer in lymph nodes ª • Observation

• ADT ± EBRT
Cancer in lymph nodes ª • Observation

Guide 11 lists options for adjuvant treatment. EBRT or observation is an option for when there
Adjuvant treatment helps to stop the cancer from are high-risk features but no cancer in lymph nodes.
returning. Options for adjuvant treatment after a EBRT will target areas where the cancer cells have
prostatectomy are based on the presence of high-risk likely spread. Treatment will be started after you’ve
features and cancer in the lymph nodes. High-risk healed from the operation.
features may include:
There are two treatment options if cancer is found
• Cancer in surgical margins in lymph nodes. The first option is to start ADT now.
EBRT may be given with ADT. If your PSA levels are
• Cancer outside the prostatic capsule undetectable, a second option is to start observation.
Supportive care with ADT can be started if the levels
• Cancer in the seminal vesicle(s) rise.

• Detectable PSA levels For adjuvant ADT, an LHRH agonist or orchiectomy

may be an option. It can be given on an intermittent
If test results find no high-risk features or cancer in schedule to reduce its side effects. However, the
the lymph nodes, no more treatment is needed. You benefits of ADT in this case are unclear.
may start observation.

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 5  Initial treatment Regional cancer

Regional cancer
Guide 12. Treatment options

What are the options?

• EBRT + ADT for 2–3 years ± abiraterone and prednisone

or
• EBRT + ADT for 2–3 years ± abiraterone and methylprednisolone

• ADT ± abiraterone and prednisone

or
• ADT ± abiraterone and methylprednisolone

• Intermittent ADT

• Observation

Guide 12 lists the treatment options for men with ADT can consist of surgical castration with a bilateral
regional cancer. Regional cancer has spread to orchiectomy or medical castration with an LHRH
nearby lymph nodes but not to distant sites. agonist. Both methods for castration work equally
well. Observation may also be an option if your PSA
An option is EBRT with long-term ADT. ADT given is undetectable, or the level is low and stable.
with EBRT may consist of an LHRH agonist with
or without an antiandrogen. If you will receive
long-term ADT, it will be given before, during, and
after radiation therapy for a total of 2 to 3 years.
Along with ADT, you may receive abiraterone
acetate and prednisone, or abiraterone acetate and
methylprednisolone.

Other options for regional cancers consist of using

ADT alone. You may receive intermittent ADT.
Intermittent treatment is alternating periods of time
on and off ADT. You may also receive the ADT
with abiraterone acetate with either prednisone
or methylprednisolone. ADT can stop much of the
cancer, but it is not able to completely eliminate it
therefore, ADT alone cannot cure prostate cancer.

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 5  Initial treatment Review

Review
†† One option for some men with very-low-, low-
risk, and favorable intermediate-risk cancers
is not to start treatment since the cancer might
never cause problems. Otherwise, radiation
therapy and surgical treatment are options.

†† For favorable intermediate-risk or unfavorable

intermediate-risk cancers, treatment options
may include observation, radiation therapy, or
surgical treatment. Certain men with favorable
intermediate-risk cancer may be able to do
active surveillance.

†† High- and very-high-risk cancers may be

treated with radiation or an operation.
Sometimes long-term ADT, docetaxel, or both
are added to radiation therapy.

†† Regional cancers may be treated with radiation

therapy plus ADT or ADT alone, or observation.

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 6
Treatment guide: Treatment
monitoring
63 Reducing ADT risks
65 Initial treatment results
66 Treatment after prostatectomy
68 Treatment after radiation
therapy
69 Review

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 6  Treatment monitoring Reducing ADT risks

Part 6 is a guide to monitoring after initial Calcium and vitamin D3 taken every day may help
treatment. You can learn about the ways prevent or control osteoporosis. NCCN experts
to reduce some of the health risks of ADT. recommend that men on ADT take calcium and
Monitoring also includes assessing if initial vitamin D. Your blood should be tested to ensure the
treatment was successful. The tests used proper levels.
to assess treatment results are listed. If
local treatments don’t succeed in treating If you are at high risk for bone fracture, there are
the cancer, the next treatments you can drugs that may strengthen your bones. Before ADT
receive are explained. is planned to last more than 6 months, you should
receive a DEXA (dual energy x-ray absorptiometry)
scan to measure your bone density. Denosumab,
This information is taken from the zoledronic acid, or alendronate are recommended
treatment guidelines written by NCCN if your bone density is low. Denosumab is injected
experts for doctors who treat prostate under the skin. Zoledronic acid is injected into a vein.
cancer. Your doctors may suggest other Alendronate is a pill that is swallowed. One year
treatments than those listed in Part after treatment has started, another DEXA scan is
6 based on your health and personal recommended.
wishes.
Denosumab, zoledronic acid, and alendronate have
possible side effects. They have been linked to a
rare side effect called osteonecrosis—bone tissue
death—of the jaw. Other side effects are low blood
Reducing ADT risks calcium levels and arthritis type aches. You may be
at higher risk of jaw osteonecrosis if you already
Guide 13 lists some risks of ADT and ways to have dental problems. Thus, it’s important to get a
reduce them. One known risk of ADT is the thinning dental exam and dental treatment before starting any
and weakening of bones (osteoporosis). of these drugs.

Guide 13. Health care for ADT risks

Health risk What are the options?

• Calcium and vitamin D3

Osteoporosis • Denosumab, zoledronic acid, or alendronate if at high risk for
bone fracture

Diabetes • Follow guidelines for general population

Heart (cardiovascular) disease • Follow guidelines for general population

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 6  Treatment monitoring Reducing ADT risks

Diabetes and cardiovascular disease are common in

older men. ADT increases the risk for these diseases.
Thus, screening and treatment to reduce your risk
for these diseases are advised. You should tell your
primary care physician if you are being treated with
ADT. He or she can do everything possible to help
keep you from getting diabetes.

ADT and other hormone therapies can have other

side effects as discussed in Part 4. These risks
included erectile dysfunction, fatigue, hot flashes,
breast tenderness and growth, diarrhea, weight gain,
liver inflammation, and so forth. There are ways to
prevent or treat many of these side effects. Examples
include exercise for fatigue, diet modification to
reduce weight gain, antidepressant drugs for hot
flashes or emotional changes, and radiation to
prevent breast growth. Talk to your treatment team
about ways to manage risks of hormone therapy.

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 6  Treatment monitoring Initial treatment results

Initial treatment results

Guide 14. Tests used

Initial treatment Test How often is this test needed?

Radiation therapy • Every 6–12 months for 5 years

or ª PSA ª • If normal results, then PSA every year
Surgery if no disease in
lymph noddes ª DRE ª • Every year unless PSA is undetectable

Still on ADT for lymph

node metastases
ª Physical exam ª • Every 3–6 months

or
Local disease while on ª PSA ª • Every 3–6 months
observation • Every 6–12 months and if you have
ª Bone imaging ª symptoms

Guide 14 lists the tests used to assess the results 5 years, then PSA testing can be done every year.
of initial treatment or to watch men who are on long- A DRE can also help to find a recurrence of prostate
term ADT because of disease in the lymph nodes. The cancer early as well as cancer in the rectum or colon.
test may also occur for men who are being observed If your PSA is undetectable, your doctor may not do
without treatment because of a shorter life expectancy. a DRE.
For many men, the goal of initial treatment is to cure
the cancer. A cure is possible when the cancer has If your initial treatment controls but doesn’t cure
not spread far. The cancer may have been cured the cancer or if you are being observed without
if tests find no signs of cancer after treatment. An treatment, you should be checked often by a doctor.
undetectable PSA level after treatment is a good sign. In addition to PSA testing, a complete physical exam
However, prostate cancer returns in some men after is recommended. A physical exam may tell if the
having no signs of cancer for a period of time. cancer is still growing despite undergoing treatment.

DRE and PSA testing done on a regular basis may After a radical prostatectomy, your PSA level should
catch a recurrence early. A DRE can find a recurrence fall to near zero since the whole prostate was
near or in the prostate. An increase in the PSA level removed. If this doesn’t happen, it may be a sign of
can be a sign of recurrence either near or in the persistent cancer. Persistent cancer is cancer that
prostate or in other areas. Besides PSA level, your was not completely removed or destroyed by initial
doctor will assess the PSA doubling time and velocity. treatment. If tests find that your PSA level increases
twice in a row after falling to near zero, the cancer may
If the goal of your initial treatment was to cure the have returned (recurrence). However, some men have
cancer, PSA testing every 6 to 12 months for 5 years low levels of PSA that may result from benign prostate
is recommended. However, PSA testing every 3 tissue left behind or PSA made by other organs,
months may be needed if you have a high risk of especially the small or large bowel (intestines), parotid
recurrence. If PSA levels remain normal during the or salivary glands, or dental disease.

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 6  Treatment monitoring Treatment after prostatectomy

Treatment after prostatectomy

Guide 15. Treatment by M stage

Health tests Test results What are the options?

Main tests:
• PSA doubling time No distant • EBRT ± ADT
Possible tests: ª metastases
(M0 stage)
ª • Observation
• Chest x-ray or CT chest
• Bone imaging
• CT or MRI of abdomen
and pelvis, TRUS, or
both
• C-11 choline or F-18
• ADT ± EBRT to site of metastases, if
fluciclovine PET/CT or Distant cancer in weight-bearing bones or if there
PET/MRI
• Decipher molecular test
ª metastases
(M1 stage)
ª is bone pain
• Observation
• Biopsy of the prostate
bed

Guide 15 lists the tests and treatment options If there is little reason to suspect distant metastases,
when PSA scores or a DRE suggest there’s cancer EBRT to the prostate bed and sometimes the pelvic
after you were treated with an operation. An elevated lymph node regions may be recommended, with or
PSA may tell us that there is still cancer in your without ADT. However, observation may be a choice
body. Once the PSA reaches a high enough level, depending on your overall health and personal
your doctor may order imaging tests to try and find wishes. For ADT, an LHRH agonist may be used with
where the cancer cells are in the body. A fast PSA or without an antiandrogen. If you will receive ADT,
doubling time is associated with an earlier risk of it will be given before, during, and after radiation
finding disease has spread to the bone, and imaging therapy for a total of 6 months to 2 years. ADT is the
may be ordered at lower PSA levels when the PSA is main treatment for known or highly suspected cancer
doubling quickly. that has spread to distant areas in the body.

A chest x-ray, CT, MRI, PET/CT or PET/MRI, or After treatment, testing to monitor treatment results
TRUS may be used to look for cancer spread to will start again. These tests include PSA with either
lymph nodes or other organs. A bone scan shows if a DRE or physical exam. If the tests suggest the
the cancer has spread to the bone. It is usually done cancer is growing or spreading, imaging tests are
when there are symptoms of bone metastases or advised.
when your PSA level is rising quickly.

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 6  Treatment monitoring Treatment after prostatectomy

Imaging tests should include a chest x-ray, bone

scan, and CT or MRI of your abdomen and pelvis. CT
and MRI should be done with and without contrast.

A PET scan may also be helpful although it is not

considered standard by all insurance plans. For
prostate cancer, a radiotracer called C-11 choline or
F-18 fluciclovine or F-18 sodium fluoride will first be
injected into your body. The radiotracer is detected
with a special camera during the scan. Prostate
cancer cells appear brighter in images than normal
cells because they use a lot of choline to quickly
build their membrane or use a lot of fluciclovine while
making proteins. The radiotracer sodium fluoride is
seen because it is incorporated into prostate cancer
growing in the bones. Thus, PET can show even
small amounts of cancer. However, it is unclear 1) if
such PET scans improve outcomes in this setting;
and 2) how results should be used for decisions
about health care.

After radiation therapy, PSA levels usually fall to 0.3

ng/mL or below. If your PSA increases by at least
2 ng/mL after falling to low levels, the cancer may
have returned. There are other changes in PSA that
may be a sign of recurrence. Thus, your doctor may
assess if the cancer has returned before the PSA
level increases by 2 ng/mL. Signs of cancer also may
be found by a DRE.

Next section 
The next section lists what health care is advised
when PSA scores or a DRE suggest there’s cancer.
Options are based on if you may be able to have
local treatment. Local treatment is an option if: 1) the
clinical stage was T1 or T2; 2) initial tests found no
lymph node metastases or weren’t done; 3) you’re
likely to live at least another 10 years; and 4) your
current PSA level is below 10.

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 6  Treatment monitoring Treatment after radiation therapy

Treatment after radiation therapy

Guide 16. Local treatment isn’t an option

What are the options?

• ADT (especially if disease on bone scan)

• Observation

Guide 17. Local treatment may be an option

Health tests Test results What are the options?

Cancer isn’t • Observation

Main tests: found in
• PSA doubling time ª prostate or ª • ADT
• Chest x-ray or CT chest other areas • Clinical trial
• Bone imaging
• Prostate MRI
• TRUS biopsy • Observation
Cancer is • Radical prostatectomy + PLND
found in
Possible tests:
• Abdominal and pelvic
ª prostate but ª • Cryosurgery
hasn’t spread • HIFU
CT/MRI
• Brachytherapy
• C-11 choline or F-18
fluciclovine PET/CT or
PET/MRI
ª Metastases ª • ADT listed in Part 7

Guide 16 lists treatment options for when local of your abdomen and pelvis, and a C-11 choline or
treatment isn’t an option. In this case, your options F-18 fluciclovine PET scan.
include ADT or observation. Read Part 7 for more
information. For PET scans, a radiotracer called C-11 choline or
F-18 fluciclovine will first be injected into your body.
Guide 17 lists test and treatment options for when The radiotracer is detected with a special camera
local treatment may be an option. To confirm that during the scan. Prostate cancer cells appear
local treatment is right for you, your doctors will brighter in images than normal cells because they
assess where the cancer has grown. A fast PSA use a lot of choline to quickly build their membrane or
doubling time suggests spread beyond the prostate. use a lot of fluciclovine while making proteins.
A chest x-ray, bone scan, TRUS biopsy of your
prostate, and MRI of your prostate should also be
done. Possible other tests include a CT or MRI scan

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 6  Treatment monitoring Review

Thus, PET can show even small amounts of cancer. Review

However, it is unclear 1) if such PET scans improve
outcomes in this setting; and 2) how results should †† ADT can increase your chances of
be used for decisions about health care. osteoporosis, diabetes, and heart disease. Take
steps to prevent or decrease the severity of
Sometimes the prostate biopsy and imaging tests these health problems.
find no cancer despite rising PSA levels. One option
in this case is to continue observation until cancer †† The results of initial treatment should be
growth is confirmed. Another option is to start checked on a regular basis.
ADT. When to start ADT should be influenced by
PSA velocity, your anxiety as well as your doctor’s †† If local treatments don’t succeed, there are
concern about cancer growth, and your feelings more options for treating the cancer.
about side effects. A third option is to enroll in a
clinical trial.

There are five options if cancer has returned in the

prostate but has unlikely spread to distant sites. The
first option is to continue observation until further
cancer growth is found. Another option is radical
prostatectomy with PLND. Be aware that the side
effects of radical prostatectomy following radiation
therapy are worse than when it used as initial
treatment. Other options for local treatment include
cryotherapy, HIFU, and brachytherapy. However, less
is known about the effectiveness of these treatments.
Which treatment you will receive needs to be based
on your chances of further cancer growth, treatment
being a success, and the risks of the treatment.

After treatment, testing to monitor treatment results

will start again. These tests include PSA with either
a DRE or physical exam. If the tests suggest the
cancer is growing or spreading, imaging tests are
advised. Imaging tests should include a chest CT
scan, bone scan, and CT or MRI of your abdomen
and pelvis. CT and MRI should be done with and
without contrast. A PET scan may also be helpful.

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 7
Treatment guide:
Systemic treatment
71 Castration-naïve prostate
cancer
74 Castration-resistant prostate
cancer
80 Review

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 7  Systemic treatment Castration-naïve prostate cancer

Part 7 is a guide to systemic treatment If an LHRH agonist is given alone it may include
for advanced disease. Advanced disease goserelin, histrelin, leuprolide, or triptorelin. For
can’t be cured by surgical treatment or some men, an LHRH agonist may be also added to
radiation therapy. Instead, treatments a first-generation antiandrogen such as nilutamide,
are given that travel throughout the body flutamide, or bicalutamide. The LHRH antagonist that
that control the growth of cancer for long may be given is degarelix. See more details about
periods of time. the types of treatment below for M0 and M1 disease.

Orchiectomy
This information is taken from the When talking about prostate cancer, castration is a
treatment guidelines written by NCCN term that means the testicles are making little or no
experts for doctors who treat prostate testosterone. It can be achieved by an operation or
cancer. Your doctors may suggest other by medicines. Surgical castration that removes both
treatments than those listed in Part testes is called a bilateral orchiectomy. This surgery
7 based on your health and personal is a type of ADT. Orchiectomy is a treatment option
wishes. for both M0 and M1 cancers.

LHRH agonist and antagonist

Medical castration works equally as well as surgical
castration. Medicines used to cause castration
Castration-naïve prostate include an LHRH antagonist or agonist. They are a
cancer type of ADT. As discussed next, an antiandrogen may
be added to an LHRH agonist.
In this section, options for castration-naïve prostate
cancer are discussed. This means you were not The risk for side effects can be reduced by
taking ADT when the prostate cancer progressed or intermittent use of your medicine. Intermittent
you were diagnosed at the start with prostate cancer treatment improves quality of life without affecting
that had already spread (metastasized). Options are survival. It often begins with continuous treatment
based on if the cancer is M0 or M1 stage. Treatment that is stopped after about 1 year. Treatment is
for M0 and M1 is listed in Guide 18 on the next page. resumed when a certain PSA level is reached or
Surgical and medical castration may be considered. symptoms appear. PSA levels that trigger restarting
Ask your doctor more about your options. treatment may depend on rate of rise, time off
therapy, PSA level at prior treatment, or other factors
Guide 18 (on page 72) list types of ADT that specific to the person.
may be considered for M0 or M1 castration-naïve
prostate cancer. This includes an orchiectomy, Antiandrogen
LHRH agonists, and an LHRH antagonist. Your LHRH agonists can cause an increase in
doctor may also combine some of these methods, testosterone for several weeks. This increase
such as abiraterone acetate with prednisone or is called a “flare.” Flare can cause pain if bone
methylprednisolone or with docetaxel. For some men metastases can be seen on imaging tests (overt
with M0 disease, observation may be an option. metastases). The pain doesn’t mean the cancer is
growing.

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 7  Systemic treatment Castration-naïve prostate cancer

Guide 18. Treatment by M stage

M0 stage
What are the options?

• Orchiectomy

• LHRH agonist ± antiandrogen

• LHRH antagonist

• Observation

M1 stage

What are the options?

• ADT and docetaxel

• ADT and abiraterone with prednisone

• Orchiectomy

• LHRH agonist ± antiandrogen for ≥7 days to prevent testosterone flare

• LHRH agonist + antiandrogen

• LHRH antagonist

• ADT + abiraterone with methylprednisolone

Flare can also cause major problems if the with you whether or not you should receive an
metastases are located in weight-bearing bones antiandrogen.
(legs or spine). To prevent the flare, an antiandrogen
(ex: bicalutamide) can be given for 7 or more days, Observation
starting before or along with the LHRH agonist. Observation is an option for men without metastases
(M0). Observation consists of testing on a regular
Another treatment option is long-term use of an basis so that supportive care with ADT can be given
antiandrogen with an LHRH agonist. This is a form if symptoms from the cancer are likely to start. Tests
of CAB. CAB may be better than castration alone during observation include PSA and DRE.
for metastases. However, it may lead to higher costs
and worse side effects. Your doctor will discuss

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 7  Systemic treatment Castration-naïve prostate cancer

ADT with docetaxel

Another option for metastatic disease is continuous
ADT with 6 cycles of docetaxel. This combination
Next section 
is given with a steroid, either dexamethasone or In the next section, options for CRPC are discussed.
prednisone. More research is needed to learn if this CRPC is also known as castrate-recurrent prostate
option can help control low-volume cancers. Low- cancer, and means that the prostate cancer is
volume disease is defined as 1) no metastases in growing or spreading even though testosterone
internal organs (no visceral disease); and 2) fewer levels are low from ADT. Options are based on if
than four bone metastases. the cancer is M0 or M1 stage. Treatment for M0
is addressed below. Treatment for M1 is listed in
ADT with abiraterone acetate Guides 22, 23, and 24.
A newer option for both M0 and M1 disease is
ADT and abiraterone acetate. This combination Despite low testosterone levels, CRPC may
should be given with a steroid, either prednisone occur because androgen receptors in the cancer
or methylprednisolone, to replace the amount cells become active again. Changes in androgen
your body does not make due to the abiraterone, receptors, called mutations, allow cancer cells to
and to reduce side effects of blood pressure and receive signals from unusual sources that activate
potassium level changes. If the cancer progresses growth. One unusual source is antiandrogens.
while taking abiraterone acetate on either steroid, Activation of androgen receptors may also occur
the steroid should be discontinued when abiraterone because the cancer cells or nearby cells start to
is discontinued. Talk with your physician about make testosterone.
how to stop the steroid, as sometimes a taper is
recommended. Despite that the cancer has returned during ADT,
it is important to keep taking this therapy. To treat
Monitoring the cancer, your testosterone levels need to stay at
While on hormone therapy, your doctor will monitor castrate levels (less than 50 ng/dL). To do so, your
treatment results. A rising PSA level suggests doctor may keep you on your current treatment or
the cancer is growing. This increase is called a may switch the type of hormone therapy you are
biochemical relapse. If PSA levels are rising, your using.
testosterone levels should be tested to see if they
are at castrate levels (<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 assess for new metastases.

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 7  Systemic treatment Castration-resistant prostate cancer

Castration-resistant prostate cancer

Guide 19. Secondary Hormone Therapy for M0 or M1 CRPC

Secondary Hormone Therapy for M0 or M1 CRPC

Continue LHRH agonist or antagonist to maintain castrate serum levels of testosterone (<50 ng/dL) and add:

• Second-generation antiandrogen
◦◦ Apalutamide (for M0)
◦◦ Enzalutamide (for M0 or M1)
• Androgen metabolism inhibitor
◦◦ Abiraterone with prednisone (for M1)
◦◦ Abiraterone with methylprednisolone (for M1)
• First-generation antiandrogen
◦◦ Nilutamide, flutamide, or bicalutamide

• Ketoconazole

• Ketoconazole plus hydrocortisone

• Corticosteroids (hydrocortisone, prednisone, dexamethasone)

• DES or other estrogen

Guide 19 lists the possible secondary hormone Your doctor may also suggest starting apalutamide or
therapy options for M0 and M1 CRPC. You enzalutamide if your PSA doubling time is 10 months
will typically continue taking an LHRH agonist or less. Both drugs are the newest treatment options
or antagonist as new treatments are added or for men with non-metastatic CRPC. Enzalutamide
subtracted. Your doctor will consider options for may also be offered to men with M1 CRPC. They are
secondary hormone therapy including antiandrogens, secondary hormone therapies. Secondary hormone
ketoconazole with or without hydrocortisone, therapy may help control cancer growth if the
corticosteroids, DES, or other estrogen. Newer androgen receptors are active.
hormone therapy options include abiraterone
acetate, enzalutamide, and apalutamide. Other options include other secondary hormone
therapies as shown in Guide 19, especially if the
Guides 20 and 21 (on the next page) list PSA doubling time is less than 10 months. However,
treatments for CRPC with no metastases. One option secondary therapies haven’t been shown to extend
is observation. Instead of changing your treatment, life when given to men without metastases.
you may want to continue observation until the proof
for cancer growth is stronger. This is especially true if If your first hormone therapy was surgical or
the PSA doubling time is 10 months or longer. medical castration, starting CAB may help. Adding
an antiandrogen may lower testosterone levels.

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 7  Systemic treatment Castration-resistant prostate cancer

Guide 20. Treatment for M0 stage CRPC

Test results What are the options?

• Observation, especially if PSA doubling

time is >10 months
• Continue ADT to • Apalutamide, especially if PSA doubling
maintain castrate time is ≤10 months
Negative for distant
metastases ª serum levels
of testosterone
ª • Enzalutamide, especially if PSA doubling
time is ≤10 months
(<50 ng/dL)
• Other secondary hormone therapy,
especially if PSA doubling time is ≤ 10
months

Guide 21. Disease monitoring and further treatment for M0 stage CRPC
Disease monitoring What are the options?

• No metastases (M0) on imaging: Change or maintain current

treatment and continue disease monitoring
PSA increasing ª
• Metastases (M1) on imaging: See systemic therapy in Guide 22

PSA is not
increasing ª • Maintain current treatment and continue disease monitoring

Other secondary hormone therapies that may lower

testosterone levels include ketoconazole with or
without hydrocortisone, steroids, DES, and other
estrogens.

If you’re already on CAB, stopping your use

of the antiandrogen—known as antiandrogen
withdrawal—may help if the cancer cells are using
the antiandrogen to grow. This effect is called the
antiandrogen withdrawal response and usually lasts
several months.

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 7  Systemic treatment Castration-resistant prostate cancer

Guide 22. Treatment for M1 stage CRPC

First-line immunotherapy

Treatment conditions

• Sipuleucel-T is an option if these statements describe you:

◦◦ The cancer is causing few or no symptoms,
◦◦ There are no liver metastases,
◦◦ You are expected to live more than 6 months, and
◦◦ You are in good health other than having cancer

Other first-line treatment

Options if no metastases in internal organs Options if metastases in internal organs

• Abiraterone acetate with prednisone • Docetaxel

• Docetaxel • Enzalutamide

• Enzalutamide • Abiraterone acetate with prednisone

• Radium-223 for bone metastases causing

• Abiraterone acetate with methylprednisolone
symptoms

• Abiraterone acetate with methylprednisolone • Clinical trial

• Clinical trial • Mitoxantrone with prednisone

• Other secondary hormone therapy • Other secondary hormone therapy

Guide 22 addresses treatment for CRPC with Prostate cancer often spreads to the bones. When
metastases. Despite that the cancer has returned prostate cancer invades your bones, they are at risk
during hormone therapy, it is important to keep taking for injury and disease. Such problems include bone
it. To treat the cancer, your testosterone levels need fractures, bone pain, and spinal cord compression.
to stay at castrate levels. Castrate levels are less Denosumab every 4 weeks or zoledronic acid every
than 50 ng/dL. To do so, your doctor may keep you 3 to 4 weeks may help to prevent or delay these
on your current treatment or may switch the type of problems.
hormone therapy you are using. You should keep
taking hormone therapy even if given other types of If you have painful bone metastases, there are
treatment, such as immunotherapy. treatments that may help to lessen the pain.
EBRT may be used when pain is limited to a

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 7  Systemic treatment Castration-resistant prostate cancer

specific area or your bones are about to fracture. Enzalutamide and abiraterone acetate
Radiopharmaceuticals 89Sr (strontium) or 153Sm Enzalutamide and abiraterone acetate are
(samarium) may relieve pain from widely spread newer hormone therapies. See page 39 for more
bone metastases that isn’t responding to other information about these therapies. Enzalutamide
treatments. Be aware that these treatments can is an antiandrogen that may work better than other
cause your bone marrow to make fewer blood cells, antiandrogens. In clinical trials, it lowered PSA levels
which could prevent you from being treated with and extended life by an average of about 5 months.
chemotherapy. Abiraterone acetate is taken on an empty stomach
with a steroid. The steroid may be prednisone or
Radiation therapy used to relieve pain is called methylprednisolone.
supportive care. Supportive care (also called
palliative care) doesn’t aim to treat cancer but aims Docetaxel and other chemotherapy
to improve quality of life. Ask your treatment team for Chemotherapy with hormone therapy is another
a supportive care plan to address any symptoms you treatment option. Docetaxel with prednisone on an
have and other areas of need. every-3-week schedule is the preferred treatment
option if the cancer is causing symptoms. It is not
Sipuleucel-T often used when the cancer isn’t causing symptoms.
Sipuleucel-T is an immunotherapy created from your However, your doctor may suggest it if the cancer is
own immune cells that was tested among men with growing fast or may have spread to your liver.
metastatic CRPC. Research found that men who
took sipuleucel-T lived, on average, 4 months longer If your PSA level rises while taking docetaxel, it
than men not taking this drug. Your results may doesn’t mean that the treatment has failed. Your
be the same, better, or worse. Sipuleucel-T is only doctor may suggest that you keep taking docetaxel
advised for men who meet the conditions listed in the until it is clear that the cancer has grown or side
Guide 22. Sipuleucel-T has not been tested among effects are too severe. If docetaxel’s side effects
men with metastases to the internal organs (visceral are too severe, you may be given mitoxantrone.
disease). Mitoxantrone is a chemotherapy drug. It may improve
your quality of life, but it isn’t likely to increase how
For treatments other than sipuleucel-T, a drop long you will live.
in PSA levels or improvement in imaging tests
occurs if treatment is working. Be aware that these Radium-223
signs typically don’t occur immediately following Newer research supports use of radium-223 if the
sipuleucel-T. Thus, don’t be discouraged if your test cancer has metastasized to the bone but not to the
results don’t improve. internal organs. In clinical trials, radium-223 was
shown to extend the lives of men by an average
There are other options if sipuleucel-T is not right of about 4 months. Your results may be the same,
for you. These options for metastatic CRPC are better, or worse. Radium-223 also reduced the pain
based on whether the cancer is or isn’t in the internal caused by the bone metastases and the use of pain
organs. Some options in the two groups overlap. medication.
However, the order of options differ based what’s
best for that group.

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 7  Systemic treatment Castration-resistant prostate cancer

Guide 23. Treatment after abiraterone or enzalutamide

Options if no metastases in internal organs Options if metastases in internal organs

• Docetaxel • Docetaxel
• If not taken before:
• Radium-223 for bone metastases
◦◦ Abiraterone acetate with prednisone
◦◦ Abiraterone acetate with methylprednisolone
• Pembrolizumab for MSI-H or dMMR ◦◦ Enzalutamide
◦◦ Cabazitaxel
• If not taken before:
◦◦ Abiraterone acetate with prednisone • Pembrolizumab for MSI-H or dMMR
◦◦ Abiraterone acetate with methylprednisolone
◦◦ Enzalutamide • Clinical trial
◦◦ Sipuleucel-T
• Other secondary hormone therapy
• Clinical trial
• Best supportive care
• Other secondary hormone therapy

• Best supportive care

Clinical trial estrogens. See Guide 19 on page 74 for a list of

A clinical trial is a type of research that studies how secondary hormone therapy options.
well a treatment works. Because of clinical trials, the
treatments in this book are now widely used to help Guide 23 lists treatment options for M1 disease
men with prostate cancer. There may be a clinical following abiraterone acetate or enzalutamide. These
trial that you may join. options are based on whether the cancer is or isn’t in
the internal organs. Some options in the two groups
Other secondary hormone therapy overlap. However, the order of options differs based
Compared to the newer secondary hormone what’s best for that group.
therapies, abiraterone acetate and enzalutamide,
older ones have only minor benefits. If your first Docetaxel with a steroid (prednisone or
hormone therapy was surgical or medical castration, dexamethasone) on an every-3-week schedule
starting CAB or switching to a new antiandrogen is preferred for cancer that is causing symptoms.
may help. If you’re already on CAB, stopping your Abiraterone acetate with prednisone or
use of the antiandrogen—known as antiandrogen methylprednisolone may be offered if you took
withdrawal—may help if the cancer cells are using enzalutamide before and enzalutamide can be
the antiandrogen to grow. This effect is called the offered if you took abiraterone acetate before.
antiandrogen withdrawal response and usually lasts
several months. Other medicines that may lower Radium-223 is an option for metastases that occur
testosterone levels include ketoconazole with or mostly in the bones and not in the internal organs.
without hydrocortisone, steroids, DES, and other Sipuleucel-T may also be used for CRPC that

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 7  Systemic treatment Castration-resistant prostate cancer

Guide 24. Treatment after docetaxel

Options if no metastases in internal organs Options if metastases in internal organs

• Abiraterone acetate with prednisone • Abiraterone acetate with prednisone

• Cabazitaxel • Enzalutamide

• Enzalutamide • Cabazitaxel
• Radium-223 for bone metastases causing
symptoms • Abiraterone acetate with methylprednisolone

• Abiraterone acetate with methylprednisolone • Pembrolizumab for MSI-H or dMMR

• Pembrolizumab for MSI-H or dMMR • Clinical trial

• Sipuleucel-T if none before • Docetaxel rechallenge

• Clinical trial • Mitoxantrone with prednisone

• Consider docetaxel rechallenge • Other secondary hormone therapy

• Mitoxantrone with prednisone • Best supportive care

• Other secondary hormone therapy

• Best supportive care

hasn’t spread to internal organs. Pembrolizumab treatment. Abiraterone acetate with prednisone or
may be an option for MSI-H or dMMR tumors after methylprednisolone or enzalutamide has been shown
the cancer has progressed on abiraterone acetate to slightly prolong life when used after docetaxel.
or enzalutamide. Another option to consider is a Similar results were found with cabazitaxel plus a
different secondary hormone therapy. All men with steroid (prednisone or dexamethasone). However,
CRPC should also receive best supportive care. cabazitaxel can cause severe side effects, so close
Joining a clinical trial is strongly supported at any monitoring is needed. You shouldn’t use cabazitaxel
stage of disease. It may give you access to new if you have liver problems.
treatments.
Radium-223 is an option for men whose metastases
Guide 24 lists options for M1 disease if docetaxel are only in the bones. Pembrolizumab may be an
fails. These options are based on whether the cancer option for MSI-H or dMMR tumors. Sipuleucel-T may
is or isn’t in the internal organs. Some options in the also be used for CRPC that hasn’t spread to internal
two groups overlap. However, the order of options organs and has not be taken before.
differ based what’s best for that group. There is
no strong agreement on what is the next best

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 7  Systemic treatment Review

After docetaxel fails, your doctor may want you Review

to take docetaxel again. This is called docetaxel
rechallenge. Whether or not you took docetaxel †† Advanced disease is often first treated with
a second time, other recommendations include a ADT.
different chemotherapy, called cabazitaxel, and
secondary hormone therapy such as abiraterone or †† CRPC is prostate cancer that grows even
enzalutamide if you have not taken those before. If though testosterone is at very low levels.
you can’t take a taxane-based chemotherapy like
cabazitaxel, mitoxantrone is an option. Mitoxantrone †† Newer treatments for CRPC without
and other chemotherapy drugs haven’t extended the metastases are apalutamide and enzalutamide.
lives of men after docetaxel failure but may help you A clinical trial, observation, and other secondary
feel better by reducing symptoms. hormone therapy are other options.

All men with CRPC should also receive best †† Newer treatments for CRPC with metastases
supportive care that includes bone supportive include sipuleucel-T, abiraterone acetate,
therapy when indicated. Best supportive care alone enzalutamide, and radium-223. Chemotherapy
may be the right choice for some men. Joining a with hormone therapy, clinical trials, and other
clinical trial is strongly supported at any stage of secondary hormone therapy are other options.
disease. It may give you access to new treatments.
†† All men with CRPC should receive best
supportive care.

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 8
Making treatment decisions
82 It’s your choice
82 Questions to ask your doctors
87 Deciding between options
88 Websites
88 Decision aids
88 Review

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 8  Making treatment decisions It’s your choice

Having cancer can feel very stressful. On the other hand, you may want to take the lead or
While absorbing the fact that you have share in decision-making. In shared decision-making,
cancer, you must also learn about tests you and your doctors share information, discuss the
and treatments. And, the time you have to options, and agree on a treatment plan. Your doctors
decide on a treatment plan may feel short. know the science behind your plan but you know
your concerns and goals. By working together, you
can decide on a plan that works best for you when it
Parts 1 through 7 described prostate comes to your personal and health needs.
cancer along with the tests and treatment
options recommended by NCCN experts.
These options are based on science and
agreement among these experts. Part 8 Questions to ask your doctors
aims to help you make decisions and talk
with your treatment team about your next You will likely meet with experts from different
steps of care. fields of medicine. It is helpful to talk with each
person. Prepare questions before your visit and ask
questions if the information isn’t clear. You can get
copies of your medical records. It may be helpful to
have a family member or friend with you at these
It’s your choice visits to listen carefully and even take notes. A patient
advocate or navigator might also be able to come.
The role patients want in choosing their treatment They can help you ask questions and remember
differs. You may feel uneasy about making treatment what was said.
decisions. This may be due to a high level of stress.
It may be hard to hear or know what others are The questions below are suggestions for information
saying. Stress, pain, and drugs can limit your ability you read about in this book. Feel free to use these
to make good decisions. You may feel uneasy questions or come up with your own personal
because you don’t know much about cancer. You’ve questions to ask your doctor and other members of
never heard the words used to describe cancer, your treatment team.
tests, or treatments. Likewise, you may think that
your judgment isn’t any better than your doctors’.

Letting others decide which option is best may make

you feel more at ease. However, whom do you
want to make the decisions? You may rely on your
doctors alone to make the right decisions. However,
your doctors may not tell you which to choose if you
have multiple good options. You can also have loved
ones help. They can gather information, speak on
your behalf, and share in decision-making with your
doctors. Even if others decide which treatment you
will receive, your treatment team may still ask that
you sign a consent form.

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 8  Making treatment decisions Questions to ask your doctors

Questions about testing and the results

1. What tests will I have for this type of cancer?

2. Where and when will the tests take place?

3. How long will they take?

4. What are the risks?

5. How do I prepare for testing?

6. How soon will I know the results and who will explain them to me?

7. Would you give me a copy of the pathology report and other test results?

8. Where did the cancer start? In what type of cell?

9. What is the cancer stage? Does this stage mean the cancer has spread far?

10. What is the grade of the cancer? Does this grade mean the cancer will grow and spread fast?

11. Can the cancer be cured? If not, how well can treatment stop the cancer from growing?

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 8  Making treatment decisions Questions to ask your doctors

Questions about treatment options

1. What treatment options do I have?

2. What will happen if I do nothing?

3. Can I just carefully monitor the cancer?

4. Can I join a clinical trial?

5. Do you consult NCCN recommendations when considering options?

6. Are you suggesting options other than what NCCN recommends? If yes, why?

7. How do my age, health, and other factors affect my options?

8. Which option is proven to work best?

9. Which options lack scientific proof?

10. What are the benefits of each option? Does any option offer a cure? Are my chances any better for
one option than another? Is any option less invasive? Less time-consuming? Less expensive?

11. What are the risks of each option? What are possible complications? What are the rare and
common side effects? Short-lived and long-lasting side effects? Serious or mild side effects?

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 8  Making treatment decisions Questions to ask your doctors

Questions about clinical trials

1. What clinical trial is right for me?

2. How many people will be on the clinical trial?

3. What are the tests and treatments for this study? And how often will they be?

4. How long will I be on the clinical trial?

5. Will I be able to get other treatment if this doesn’t work?

6. How will you know the treatment is working?

7. Who will help me understand the costs of the clinical trial?

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 8  Making treatment decisions Questions to ask your doctors

Questions about a doctor’s experience

1. Are you board certified? If yes, in what area?

2. How many patients like me have you treated?

3. How many procedures like the one you’re suggesting have you done?

4. Is this treatment a major part of your practice?

5. How many of your patients have had complications?

6. How many of your patients have had side effects such as urinary incontinence or erectile
dysfunction?

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 86
 8  Making treatment decisions Deciding between options

Deciding between options Getting support

Support groups often include people at different
Deciding which option is best can be hard. Doctors stages of treatment. Some may be in the process of
from different fields of medicine may have different deciding while others may be finished with treatment.
opinions on which option is best for you. This can be At support groups, you can ask questions and hear
very confusing. Your spouse or partner may disagree about the experiences of other people with prostate
with which option you want. This can be stressful. In cancer. If your hospital or community doesn’t have
some cases, one option hasn’t been shown to work support groups for people with prostate cancer,
better than another, so science isn’t helpful. Some check out the websites on the next page.
ways to decide on treatment are discussed next.
You can also reach out to a social worker or
Getting a 2nd opinion psychologist. They can help you find ways to cope
Even if you like and trust your doctor, it is helpful or refer you to support services. These services may
to get a 2nd opinion. You will want to have another also be available to your family, friends, and to those
doctor review your test results. He or she can with children, so they can connect and get support.
suggest a treatment plan or check the one you
already heard about.

Things you can do to prepare:

Keep in mind:
†† Check with your insurance company about its
rules on 2nd opinions. You want to know about
out-of-pocket costs for doctors who are not part ü
Every treatment option has
of your insurance plan. benefits and risks. Consider
these when deciding which
†† Reach out to patient advocacy organizations
option is best for you.
(see websites on the next page) for help with
2nd opinions. Some may also give referrals to
hospitals or cancer centers who specialize in ü
Talking to others may help
treating prostate cancer. identify benefits and risks you
hadn’t thought of.
†† Make plans to have copies of all your records
sent to the doctor you will see for your 2nd
opinion. Do this well before your appointment.
ü
It is helpful to ask your doctor
If you run into trouble having records sent, pick about his or her personal results
them up and bring them with you. with treatment, not only about
the results based on medical
If the new doctor offers other advice, make an
appointment with your first doctor to talk about the findings.
differences. Do whatever you need to feel confident
about your diagnosis and treatment plan.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 87
 8  Making treatment decisions
decisions Websites
Websites | Review

Websites Review
American Cancer Society †† Shared decision-making is a process in which
cancer.org/cancer/prostatecancer/index you and your doctors plan treatment together.

California Prostate Cancer Coalition (CPCC) †† Asking your doctors questions is vital to getting
prostatecalif.org the information you need to make informed
decisions.
Malecare Cancer Support
malecare.org and cancergraph.com †† Getting a 2nd opinion, attending support groups,
and comparing benefits and risks may help you
National Alliance of State Prostate Cancer decide which treatment is best for you.
Coalitions (NASPCC)
naspcc.org

National Coalition for Cancer Survivorship

Canceradvocacy.org/toolbox

National Prostate Cancer Awareness

(PCaAware) Foundation
pcaaware.org

Nomograms
nomograms.mskcc.org/Prostate/index.aspx

Prostate Conditions Education Council

(PCEC)
prostateconditions.org

Prostate Health Education Network (PHEN)

prostatehealthed.org

ZERO - The End of Prostate Cancer

zerocancer.org

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 88
Glossary
90 Dictionary
94 Acronyms
 Dictionary

Dictionary
active surveillance epididymis
Frequent and ongoing testing to watch for changes in A tube-shaped structure through which sperm travel after
cancer status so cancer treatment can be started if it’s leaving the testicles.
needed.
erectile dysfunction
androgen deprivation therapy (ADT) A lack of blood flow into the penis that limits getting or
A treatment that removes the testes or stops them from staying hard.
making testosterone.
external beam radiation therapy (EBRT)
antiandrogen A cancer treatment with radiation received from a machine
A drug that stops the action of the hormone testosterone. outside the body.

bilateral orchiectomy extracapsular extension

An operation that removes both testicles. The growth of prostate cancer beyond its outer edge.

biopsy fatigue
A procedure that removes fluid or tissue samples to be Severe tiredness despite getting enough sleep that limits
tested for a disease. one’s ability to function.

brachytherapy fine-needle aspiration

A treatment with radiation from an object placed near or in A procedure that removes tissue samples with a very thin
the tumor. Also called internal radiation. needle.

castration-resistant prostate cancer (CRPC) fistula

A worsening of prostate cancer despite treatment that A passage between two organs that should not be joined.
lowered testosterone. Also known as castrate-recurrent
prostate cancer.
flare
An increase in testosterone after starting treatment to
combined androgen blockade (CAB) reduce its level.
A cancer treatment that stops the making and action of
testosterone.
gene
Coded instructions in cells for making new cells and
computed tomography (CT) controlling how cells behave.
A test that uses x-rays from many angles to make a picture
of the insides of the body.
Gleason grade
A rating of how much prostate cancer cells look like
cryosurgery normal cells. A score from 1 (best) to 5 (worst) made by
A treatment that kills cancer cells by freezing them. Also a pathologist based on the ability of prostate cells to form
called cryoablation. glands. The primary grade is the most common pattern, and
the secondary grade is the second most common pattern.
digital rectal exam (DRE) The two grades are summed to give a Gleason score.
A study of the prostate by feeling it through the wall of the
rectum. Gleason score
The grading system for prostate cancer.
dry orgasm
A sexual climax without the release of semen. high-dose rate (HDR) brachytherapy
Treatment with radioactive objects that are removed at the
dual energy X-ray (DEXA) end of the treatment session.
A test that uses small amounts of radiation to make a picture
of bones. Also called bone densitometry.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 90
 Dictionary

high-intensity focused ultrasound (HIFU) lymph node

Treatment using high-intensity sound waves that make heat A small, bean-shaped disease-fighting structure.
to kill the cancer cells.
magnetic resonance imaging (MRI)
hormone therapy A test that uses radio waves and powerful magnets to make
A cancer treatment that stops the making or action of pictures of the insides of the body.
hormones. Also called endocrine therapy when used for
women’s cancer. Also called androgen deprivation therapy
magnetic resonance imaging-ultrasound (MRI-US)
when used for men’s cancers.
fusion biopsy
A procedure that removes tissue samples with a needle
image-guided radiation therapy (IGRT) guided with two types of imaging.
A treatment with radiation that is aimed at tumors using
imaging tests during treatment.
metastasis
The spread of cancer from the first tumor to a new site.
immunotherapy
A treatment with drugs that help the body find and destroy
multi-parametric magnetic resonance imaging
cancer cells.
(mpMRI)
A test that makes pictures that show many features of body
intensity-modulated radiation therapy (IMRT) tissue.
Treatment with radiation that uses small beams of different
strengths.
mutation
An abnormal change.
intermittent treatment
Alternating periods of time on and off treatment.
nerve-sparing radical prostatectomy
An operation that removes the prostate and one or neither
interstitial radiation cavernous nerve bundle.
Treatment with radioactive objects placed in the tumor. Also
called brachytherapy.
nomogram
A graphic tool that uses health information to predict an
laparoscopic radical prostatectomy outcome.
An operation that removes the prostate with tools passed
through small cuts near the belly button.
nuclear medicine specialist
A doctor who’s an expert in tests that use radioactive
life expectancy substances.
The number of years a person is likely to live.
observation
low-dose rate (LDR) brachytherapy A period of testing for changes in cancer status while not
Treatment with radioactive objects that are placed in the receiving treatment.
tumor and left to decay.
open radical prostatectomy
luteinizing hormone-releasing hormone (LHRH) An operation that removes the prostate through one large
agonist cut made in one of two places.
A drug that acts in the brain to stop the testicles from
making testosterone.
overflow incontinence
Leakage of urine due to an overly full bladder.
luteinizing hormone-releasing hormone (LHRH)
antagonist pathologist
A doctor who’s an expert in testing cells and tissue to find
A drug that acts in the brain to stop the testicles from
disease.
making testosterone.

lymph
A clear fluid containing white blood cells.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 91
 Dictionary

pelvic lymph node dissection (PLND) radiologist

An operation that removes lymph nodes between the hip A doctor who specializes in reading imaging tests.
bones.
radiopharmaceutical
perineum A drug that contains a radioactive substance.
The body region in men between the scrotum and anus.
recurrence
persistent cancer The return of cancer after a disease-free period.
Cancer that is not fully treated.
risk group
positron emission tomography (PET) A set of people who will likely have the same outcome.
A test that uses radioactive material to see the shape and
function of body parts.
robotic-assisted radical prostatectomy
An operation that removes the prostate with a machine
primary grade controlled by the surgeon.
The most common pattern of how prostate cancer cells look.
secondary grade
primary treatment The second most common pattern of how prostate cancer
The main treatment used to rid the body of cancer. cells look.

prognosis seminal vesicle

The likely course and outcome of a disease based on tests. One of two male glands that makes fluid used by sperm for
energy.
prostate
A male gland that makes fluid, which protects sperm from side effect
the acid in the vagina. An unhealthy or unpleasant physical or emotional response
to a test or treatment.
prostate-specific antigen (PSA)
A protein mostly made by the prostate. stress incontinence
Leakage of urine when pressure is placed on the bladder.
prostate-specific antigen (PSA) density
The level of PSA—a prostate-made protein—in relation to supportive care
the size of the prostate. Health care that includes symptom relief but not cancer
treatment. Also called palliative care.
prostate-specific antigen (PSA) doubling time
The time during which the level of PSA—a prostate-made surgical margin
protein—doubles. The normal-looking tissue around a tumor that was removed
during an operation.
prostate-specific antigen (PSA) level
The number of nanograms per milliliter of PSA—a prostate- testosterone
made protein. A hormone that helps the sexual organs in men to work.

prostate-specific antigen (PSA) velocity three-dimensional conformal radiation therapy

How much the level of PSA—a prostate-made protein— (3D-CRT)
changes over time. A treatment with radiation that uses beams matched to the
shape of the tumor.
radical perineal prostatectomy
An operation that removes the prostate through one cut transrectal ultrasound (TRUS)
made between the scrotum and anus. A test that sends sound waves through the rectum to make
pictures of the prostate.
radical retropubic prostatectomy
An operation that removes the prostate through one large transurethral resection of the prostate (TURP)
cut made below the belly button. A procedure that removes prostate tissue samples through
the urethra.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 92
 Dictionary

triple androgen blockade

A treatment that stops the making and action of testosterone
with three methods.

ultrasound
A test that uses sound waves to take pictures of the inside
of the body.

urethra
A tube-shaped structure that carries urine from the bladder
to outside the body; it also expels semen in men.

urge incontinence
A health condition in which urine is leaked during a sudden,
strong need to urinate.

urinary incontinence
A health condition in which the release of urine can’t be
controlled.

urinary retention
A health condition in which urine can’t be released from the
bladder.

visceral disease
The spread of cancer from the first tumor to the organs
within the belly.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 93
 Acronyms

Acronyms
3D-CRT LDR
three-dimensional conformal radiation therapy low dose-rate

ADT LHRH
androgen deprivation therapy luteinizing hormone-releasing hormone

AJCC PSA
American Joint Committee on Cancer prostate-specific antigen

ALP PSMA
alkaline phosphatase prostate-specific membrane antigen

CAB mg
combined androgen blockade milligram

CAM mpMRI
complementary and alternative medicine multi-parametric magnetic resonance imaging

CRPC MRI
castration-resistant prostate cancer magnetic resonance imaging

CT MRI-US
computed tomography magnetic resonance imaging-ultrasound

DES PET
diethylstilbestrol positron emission tomography

DEXA PLND
dual-energy x-ray absorptiometry pelvic lymph node dissection

DNA SBRT
deoxyribonucleic acid stereotactic body radiotherapy

DRE TRUS
digital rectal exam transrectal ultrasound

EBRT TURP
external beam radiation therapy transurethral resection of the prostate

HDR VTP
high dose-rate vascular targeted photodynamic therapy

HIFU
high-intensity focused ultrasound

IGRT
image-guided radiation therapy

IMRT
intensity-modulated radiation therapy

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 94
 NCCN Panel Members

NCCN Panel Members for

Prostate Cancer
James L. Mohler, MD/Chair Edward Schaeffer, MD, PhD
Roswell Park Cancer Institute Christopher J. Kane, MD Robert H. Lurie Comprehensive Cancer
UC San Diego Moores Cancer Center Center of Northwestern University
Emmanuel S. Antonarakis, MD
The Sidney Kimmel Comprehensive Michael Kuettel, MD, MBA, PhD Ahmad Shabsigh, MD
Cancer Center at Johns Hopkins Roswell Park Cancer Institute The Ohio State University Comprehensive
Cancer Center - James Cancer Hospital
Andrew J. Armstrong, MD Joshua M. Lang, MD and Solove Research Institute
Duke Cancer Institute University of Wisconsin
Carbone Cancer Center Eric J. Small, MD
Anthony Victor D’Amico, MD, PhD UCSF Helen Diller Family
Dana-Farber/Brigham and Women’s Jesse McKenney, MD Comprehensive Cancer Center
Cancer Center | Massachusetts General Case Comprehensive Cancer Center/
Hospital Cancer Center University Hospitals Seidman Cancer Center
and Cleveland Clinic Taussig Cancer Institute Daniel Spratt, MD
Brian J. Davis, MD, PhD University of Michigan
Mayo Clinic Cancer Center Rogel Cancer Center
George Netto, MD
Tanya Dorff, MD University of Alabama at Birmingham Sandy Srinivas, MD
City of Hope National Medical Center Comprehensive Cancer Center Stanford Cancer Institute

James A. Eastham, MD * David F. Penson, MD, MPH Jonathan Tward, MD, PhD
Memorial Sloan Kettering Cancer Center Vanderbilt-Ingram Cancer Center Huntsman Cancer Institute
at the University of Utah
Elizabeth R. Plimack, MD, MS
Charles A. Enke, MD Fox Chase Cancer Center
Fred & Pamela Buffett Cancer Center
Julio M. Pow-Sang, MD NCCN Staff
Thomas A. Farrington Moffitt Cancer Center
Patient Advocate Dorothy A. Shead, MS,
Prostate Health Education Network (PHEN) Thomas J. Pugh, MD Director, Patient Information Operations
University of Colorado Cancer Center
Celestia S. Higano, MD Deborah Freedman-Cass, PhD
Fred Hutchinson Cancer Research Center/ Sylvia Richey, MD Oncology Scientist/Senior Medical Writer
Seattle Cancer Care Alliance St. Jude Children’s Research Hospital/
University of Tennessee
Eric Mark Horwitz, MD Health Science Center
Fox Chase Cancer Center
Mack Roach, III, MD
Michael Hurwitz, MD, PhD UCSF Helen Diller Family
Yale Cancer Center/Smilow Cancer Hospital Comprehensive Cancer Center

Joseph E. Ippolito, MD, PhD Stan Rosenfeld

Siteman Cancer Center at Barnes- Patient Advocate
Jewish Hospital and Washington University of California San Francisco
University School of Medicine Patient Services Committee Chair

* Reviewed the clinical content of this book.

For disclosures, visit www.nccn.org/about/disclosure.aspx.

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 95
 NCCN Member Institutions

NCCN Member Institutions

Abramson Cancer Center The Sidney Kimmel Comprehensive Stanford Cancer Institute
at the University of Pennsylvania Cancer Center at Johns Hopkins Stanford, California
Philadelphia, Pennsylvania Baltimore, Maryland 877.668.7535
800.789.7366 410.955.8964 cancer.stanford.edu
pennmedicine.org/cancer hopkinskimmelcancercenter.org
University of Alabama at Birmingham
Fred & Pamela Buffett Cancer Center Robert H. Lurie Comprehensive Cancer Comprehensive Cancer Center
Omaha, Nebraska Center of Northwestern University Birmingham, Alabama
800.999.5465 Chicago, Illinois 800.822.0933
nebraskamed.com/cancer 866.587.4322 www3.ccc.uab.edu
cancer.northwestern.edu
Case Comprehensive Cancer Center/ UC San Diego Moores Cancer Center
University Hospitals Seidman Cancer Mayo Clinic Cancer Center La Jolla, California
Center and Cleveland Clinic Taussig Phoenix/Scottsdale, Arizona 858.657.7000
Cancer Institute Jacksonville, Florida cancer.ucsd.edu
Cleveland, Ohio Rochester, Minnesota
800.641.2422 • UH Seidman Cancer Center 800.446.2279 • Arizona UCSF Helen Diller Family
uhhospitals.org/seidman 904.953.0853 • Florida Comprehensive Cancer Center
866.223.8100 • CC Taussig Cancer Institute 507.538.3270 • Minnesota San Francisco, California
my.clevelandclinic.org/services/cancer www.mayoclinic.org/cancercenter 800.689.8273
216.844.8797 • Case CCC cancer.ucsf.edu
case.edu/cancer Memorial Sloan Kettering
Cancer Center University of Colorado Cancer Center
City of Hope National Medical Center New York, New York Aurora, Colorado
Los Angeles, California 800.525.2225 720.848.0300
800.826.4673 mskcc.org coloradocancercenter.org
cityofhope.org
Moffitt Cancer Center University of Michigan
Dana-Farber/Brigham and Tampa, Florida Rogel Cancer Center
Women’s Cancer Center 800.456.3434 Ann Arbor, Michigan
Massachusetts General Hospital moffitt.org 800.865.1125
Cancer Center mcancer.org
Boston, Massachusetts The Ohio State University
877.332.4294 Comprehensive Cancer Center - The University of Texas
dfbwcc.org James Cancer Hospital and MD Anderson Cancer Center
massgeneral.org/cancer Solove Research Institute Houston, Texas
Columbus, Ohio 800.392.1611
Duke Cancer Institute 800.293.5066 mdanderson.org
Durham, North Carolina cancer.osu.edu
888.275.3853 University of Wisconsin
dukecancerinstitute.org Roswell Park Comprehensive Carbone Cancer Center
Cancer Center Madison, Wisconsin
Fox Chase Cancer Center Buffalo, New York 608.265.1700
Philadelphia, Pennsylvania 877.275.7724 uwhealth.org/cancer
888.369.2427 roswellpark.org
foxchase.org Vanderbilt-Ingram Cancer Center
Siteman Cancer Center at Barnes- Nashville, Tennessee
Huntsman Cancer Institute Jewish Hospital and Washington 800.811.8480
at the University of Utah University School of Medicine vicc.org
Salt Lake City, Utah St. Louis, Missouri
877.585.0303 800.600.3606 Yale Cancer Center/
huntsmancancer.org siteman.wustl.edu Smilow Cancer Hospital
New Haven, Connecticut
Fred Hutchinson Cancer St. Jude Children’s Research Hospital 855.4.SMILOW
Research Center/Seattle The University of Tennessee yalecancercenter.org
Cancer Care Alliance Health Science Center
Seattle, Washington Memphis, Tennessee
206.288.7222 • seattlecca.org 888.226.4343 • stjude.org
206.667.5000 • fredhutch.org 901.683.0055 • westclinic.com

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 96
 Notes

Notes

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 97
 Index

Index
active surveillance 15, 26, 31, 49–56 prostate-specific antigen 13, 15, 17, 20, 23, 25, 27,
31, 42, 49–60, 65–75, 77
androgen deprivation therapy 36–42, 49, 51,
53–69, 71–73, 75, 80 radiopharmaceuticals 43, 46, 77
biopsy 14–15, 17–18, 20–21, 23, 26–29, 49–52, 54, stereotactic body radiotherapy 36
66, 68–69
bone scan 14, 16–17, 26–28, 66–69
brachytherapy 37, 49–58, 69
chemotherapy 40–43, 45–46, 77–78, 80
clinical trial 26, 36, 43–46, 69, 76–80, 84–85
computed tomography 14–16, 26–29, 66–69
cryosurgery 38, 44
digital rectal exam 13–15, 17, 20–21, 23, 49–52, 54,
56, 65–67, 69, 72
external beam radiation therapy 35–38, 49–60, 66,
76
fine-needle aspiration 28, 29
Gleason score 17–19, 23, 26–27, 50, 52
hormone therapy 39–41, 46, 64, 73–80
immunotherapy 40–42, 46, 76–77
life expectancy 25–26, 29, 65
magnetic resonance imaging 13–17, 26–29, 49–52,
54, 66–69
molecular testing 25-26
NCCN Member Institutions 96
NCCN Panel Members 95
nomogram 25–26
observation 49–61, 65–66, 68–69, 71–72, 74–75, 80
pelvic lymph node dissection 33–34, 46, 49, 51,
54, 56, 58, 69
prostatectomy 31–35, 46, 49–51, 53–59, 65–66, 69

NCCN Guidelines for Patients®:

Prostate Cancer, 2018 98
Ü
 NCCN
GUIDELINES
FOR PATIENTS
®

Prostate Cancer
2018

NCCN Foundation® gratefully acknowledges our industry supporters Genomic Health, Inc., Pfizer, and Sanofi-Genzyme Oncology
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