2024

NCCN
GUIDELINES
FOR PATIENTS
®

Advanced-
Stage Prostate
Cancer

®
NATIONAL COMPREHENSIVE CANCER NETWORK
Available online at
Presented with support from FOUNDATION
Guiding Treatment. Changing Lives.
NCCN.org/patientguidelines
 1
Prostate cancer basics

5 What is prostate cancer?

6 What are the symptoms of prostate cancer?

6 What causes prostate cancer?

10 What is advanced-stage prostate cancer?

10 Can prostate cancer be cured?

11 What’s the best treatment?

11 Key points

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Prostate
1 Prostate
cancer
cancer
basics
basics
» What
» What
is prostate
is prostate
cancer?
cancer?
» What is prostate cancer?

The prostate is a gland located reproductive system. Besides the prostate, the
male reproductive system includes the penis,
deep inside the pelvis. Everyone
seminal vesicles, and testicles.
with a prostate has a chance
Prostate cancer is one of the most common
of getting prostate cancer. This
types of cancer. Cancer is what happens when
chapter offers an overview of this something goes wrong with the natural cell
process, which causes some cells to grow out
common cancer.
of control.

Cancer cells don’t behave like normal cells.

Cancer cells develop genetic changes
What is prostate cancer? (mutations) that allow them to multiply and
make many more cancer cells. The cancer
cells crowd out and overwhelm normal cells.
Prostate cancer is a disease where cells in the
This can end up harming the body.
prostate gland grow out of control.
Cancer cells can survive much longer than
The prostate is a gland located just below
normal cells do. They can replace many
the bladder in the pelvis, deep inside the
normal cells and cause organs to stop working
area of your body between your hip bones.
well. Cancer cells can also spread outside the
The prostate is an important part of the male
prostate to other areas of the body.

The prostate gland is

an important part of
the male reproductive
system. It’s located in
the pelvis just below the
bladder and is typically
about the size of a ping-
pong ball.

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1 Prostate
cancer
cancer
basics
basics
» What
» What
are the
are symptoms
the symptoms
of prostate
of prostate
cancer?
cancer?

What are the symptoms of † Feeling like your bladder hasn’t fully
prostate cancer? emptied
† Dull pain in your groin or pelvis
A symptom is a feeling or problem that can
† Erectile dysfunction (difficulty getting an
indicate a disease or condition. Prostate
erection) or painful ejaculation
cancer often grows slowly and shows no
symptoms for a long time. You don’t have to
have symptoms to have prostate cancer.
What causes prostate
Symptoms, if they occur, may include: cancer?
† Blood in the urine or semen
Many people who develop prostate cancer
† Burning or pain while urinating wonder where it came from and how they got
it. Cancer researchers don’t know exactly what
† Unexplained weight loss
causes prostate cells to grow out of control
† Bone, hip, or back pain (become cancerous). The fact is, everyone
with a prostate has a risk of getting prostate
It’s important to know that prostate cancer has cancer.
many of the same symptoms as a condition
called enlarged prostate (also called benign But several factors are linked to a higher risk of
prostatic hyperplasia, or BPH). An enlarged prostate cancer. These are called risk factors.
prostate can push against the bladder and A risk factor is anything that increases your
compress the urethra, which slows the flow of chance of getting cancer. Risk factors don’t
urine and can cause a feeling that you haven’t necessarily cause prostate cancer, but people
fully emptied your bladder. with prostate cancer usually have one or more
of these risk factors:
BPH is much more common than prostate
cancer. It’s difficult to tell the difference
Age
between the two conditions based on
symptoms alone. Be sure to tell your health The biggest risk factor for prostate cancer
care providers if you have any of these is age. Prostate cancer is diagnosed most
symptoms, because you may need special often in those aged 65 years and above. Your
testing: chances of getting prostate cancer increase as
you become older.
† Urinating frequently, especially at night
† Weak or intermittent urine stream Family history
† Trouble urinating or straining to urinate Your family health history is information about
the diseases and health conditions in your
† Trouble holding in urine
family. A family history reflects a pattern of
certain diseases among family members.

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1 Prostate
cancer
cancer
basics
basics
» What
» What
causes
causes
prostate
prostate
cancer?
cancer?
» What causes prostate cancer?

Where does the prostate fit in?

The prostate is a gland located in the pelvis—the area between your hips. The
prostate is important for sexual reproduction.

Prostate: A gland in the male reproductive system. A gland is an organ that makes
fluids or chemicals the body needs. The prostate gland makes a fluid that nourishes
and helps transmit sperm. The prostate also contains muscles that help propel
semen through the urethra during ejaculation.

Semen: A fluid made up of liquids from the prostate and the seminal vesicles as
well as sperm from the testicles. During ejaculation, semen is released from the body
through the urethra and out through the penis.

Urethra: A tube that carries urine from the bladder and out of the body. The prostate
surrounds the urethra just beneath the bladder.

Seminal vesicles: Two glands that make and store another part of the fluid that
becomes semen. The seminal vesicles are located above the prostate and behind
the bladder.

Bladder: An organ that holds urine.

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1 Prostate
cancer
cancer
basics
basics
» What
» What
causes
causes
prostate
prostate
cancer?
cancer?
» What causes prostate cancer?

Having a close family member with prostate

cancer (a sibling or parent) increases the
chance of getting it yourself. Those with a
family history of certain other cancers (breast,
What does aggressive mean?
ovarian, colon, pancreatic, and other cancers)
may also be at higher risk for prostate cancer.
When health care professionals describe
cancer as aggressive, they mean the
Genetic factors cancer is likely to grow or spread more
When cancer “runs in the family,” genetic rapidly than average.
testing can be done to find specific genetic
changes (mutations) known to be linked Aggressive can also be used to describe
with prostate cancer and other cancers. For therapy that may be stronger or more
instance, having an inherited genetic change in intense than other treatment options.
the BRCA2 gene increases the risk of getting
prostate cancer.

There are also genetic abnormalities that don’t

run in families and aren’t inherited.
Black males may want to talk with their health
Race care providers about getting screening tests
earlier and perhaps more often than what’s
In the United States, Black males are more
recommended for other males.
likely than white males to develop prostate
cancer. Prostate cancer in Black males is also
more likely to occur at an earlier age and be Diet and lifestyle
more aggressive and more advanced when
No one particular diet has been found to cause
diagnosed. Black males are also twice as likely
prostate cancer or to prevent it. However,
to die from prostate cancer compared to white
eating food that’s high in fat, such as meat
males.
and dairy products, has been linked with an
increased risk of prostate cancer. Smoking and
Hispanic and Asian males are less likely than
obesity also increase the risks of developing
both white and Black males to be diagnosed
and dying from prostate cancer.
with prostate cancer.
On the other hand, those who eat more fruits
Several things contribute to these differences,
and vegetables have a lower risk of developing
such as barriers to accessing health care
advanced prostate cancer. Exercise and
(including early detection screening), as well
maintaining a healthy weight may also
as biological and genetic factors, and other
decrease the aggressiveness of prostate
causes. Researchers are trying to understand
cancer and the likelihood of dying from it.
the reasons for these differences and what can
be done to improve outcomes.

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1 Prostate
cancer
cancer
basics
basics
» What
» What
causes
causes
prostate
prostate
cancer?
cancer?
» What causes prostate cancer?

Early vs. advanced prostate cancer

Early-stage prostate cancer has not visibly spread beyond the prostate. It
usually grows slowly and stays in the prostate. This is also called localized prostate
cancer.

Advanced-stage prostate cancer has grown outside the prostate and spread to
other areas in the body such as distant lymph nodes (bottom left), bones, or organs
like the liver or lungs (bottom right). This is also called metastatic prostate cancer.

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1 Prostate
cancer
cancer
cancer
basics
basics
basics
»»
What
What
» isWhat
advanced-stage
is advanced-stage
is advanced-stage
prostate
prostate
prostate
cancer?
cancer?
cancer?
» Can prostate cancer be cured?

What is advanced-stage † Cancer that spreads beyond the prostate

prostate cancer? to other parts of the body is called distant
metastatic prostate cancer or simply
metastatic prostate cancer.
Prostate cancer can be grouped into early-
stage cancer or advanced-stage cancer.
How does prostate cancer spread? Cancer
cells use the bloodstream like a highway to
Early stage travel to distant areas in the body. Cancer cells
can also spread through the lymphatic system.
Early-stage prostate cancer has not spread
The lymphatic system is a network of organs
beyond the prostate. The cancer usually grows
and vessels that fights infections and circulates
slowly and stays in the prostate. Cancer that is
a clear fluid called lymph throughout the body.
contained entirely within the prostate is called
localized prostate cancer.
A normal and important part of the lymphatic
system are the lymph nodes. Lymph nodes are
More information about early-stage prostate
small, disease-fighting clusters that filter lymph
cancer can be found in the NCCN Guideline
fluid to remove germs. Lymph vessels and
for Patients: Early-Stage
nodes are found everywhere in the body.
Prostate Cancer at NCCN.
org/patientguidelines and on
Some patients have advanced-stage prostate
the NCCN Patient Guides for
cancer when they’re first diagnosed. Others
Cancer app.
develop advanced-stage cancer after having
treatment for early-stage cancer.
Advanced stage
Advanced stage means that the cancer has
spread beyond the prostate to other areas in Can prostate cancer be
the body. This spreading is called metastasis
or metastatic cancer. Metastatic prostate
cured?
cancer may spread to the lymph nodes, bones,
Advanced-stage prostate cancer is usually
liver, lungs, and other organs.
a life-long disease. But treatment can slow
down its growth, reduce symptoms, and
This book is all about advanced-stage prostate
prolong life. Treatments for advanced-
cancer.
stage prostate cancer include hormone
therapy, chemotherapy, radiation therapy,
† Cancer that grows from the prostate
immunotherapy, targeted therapy,
gland to nearby areas such as lymph
radiopharmaceuticals, surgery, and other
nodes, but no farther, is called regional
therapies.
prostate cancer. (It’s also called locally
advanced prostate cancer. This book will
It’s true that prostate cancer in the advanced
call it regional prostate cancer to avoid
stage can be fatal for some patients. But in the
confusion between localized and locally
past few years, improved detection methods
advanced.)

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Tests for advanced prostate
cancer
13 Common prostate tests

14 General health history

15 Diagnostic tests

20 Genetic tests

22 Tumor staging

23 What’s next?

23 Key points

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» Common
» Common
prostate
prostate
teststests
» Common prostate tests

If you haven’t yet been diagnosed PSA test

with prostate cancer, you may This is a blood test that measures the amount
of prostate-specific antigen (PSA) in your
need multiple tests and scans to
bloodstream. PSA is a protein made inside
find out if you have it and whether the prostate gland. Its job is to help semen
transport sperm. All prostate cells, both normal
it has spread. These tests and
cells and cancer cells, make PSA.
scans will help your team make
If there’s something wrong with the prostate—
the best plan to treat your prostate
like prostate cancer—the prostate may make
cancer. more PSA. While most PSA goes into semen,
a little bit ends up in the bloodstream, too. An
unusually high amount of PSA in the blood
may be a sign of prostate cancer. Likewise, an
Health care providers use a variety of tests
increase in PSA after treatment may indicate
to find prostate cancer and to determine how
that the treatment is losing effectiveness.
advanced the cancer is. Tests are used to
plan treatment, check how well treatment
However, age and other factors—such as an
is working, and monitor your health after
enlarged prostate or a urinary tract infection—
treatment ends. This chapter describes what
can also cause high levels of PSA. This
tests you might have and what to expect
means that a PSA test by itself can’t provide a
during testing. Not every person with prostate
diagnosis of prostate cancer. That’s why a PSA
cancer will receive every test listed here.
test is often paired with imaging or a digital
rectal exam, or both, to decide whether you
When you go for testing, bring someone with
need a biopsy.
you to listen, ask questions, and write down
the answers.
PSA level (also called total PSA) is measured
in nanograms of PSA per milliliter (ng/mL) of
blood.
Common prostate tests
Digital rectal exam
Common prostate cancer tests are used to
detect the possibility of prostate cancer in A digital rectal exam (also called a prostate
someone who’s undiagnosed. They’re also exam) may be an awkward and unpleasant
used to check and monitor prostate cancer in form of testing. But it’s the simplest and most
patients who have been diagnosed. direct way to check the size and texture of your
prostate.
Two common tests that look for prostate cancer
are the PSA test and digital rectal exam. For this test, the doctor will insert a gloved
finger into your rectum to feel your prostate for
any signs of cancer. An irregular or hardened
part of the prostate could be a sign of a tumor.

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» General
» General
health
health
history
history
» General health history

Not all parts of the prostate can be felt during may feel for enlarged glands (lymph nodes) in
a digital rectal exam, though. So it’s usually your groin, underarms, and neck.
paired with a PSA test and other factors—
your age, race, family history, and more—to
Family history
determine whether you need further testing.
Some cancers and other diseases can run
in families. Your care team will ask about the
General health history health history of family members who are
blood relatives. This information is called a
family history.
Health history and physical exam
It’s important to ask members from both
Your care team needs to have all your health
sides of the family about all cancers, not just
information. They’ll ask you about any health
prostate cancer. Ask family members if any
problems and treatments you’ve had in your
relatives had cancer, at what age they were
life. Be prepared to talk about any illness or
diagnosed, and if they died from it. Also ask
injury you’ve had and when it happened. Also
family members about other health issues like
tell your team about any symptoms you have.
heart disease, stroke, and diabetes. Share this
information with your care team and update
Bring a list of your regular medications and
your team with any changes to your family
any over-the-counter medicines, herbs, or
history.
supplements you take. Some of these (such
as saw palmetto or St. John’s wort) can cause
changes in your PSA level, so your care team Symptoms and quality of life
needs to know if you’re taking them.
Your doctor or another member of your care
team will ask you a series of questions about
A physical exam is a check of your body for
what symptoms you may have (such as peeing
any signs of disease. Your health care provider

Taking supplements?
Bring a list of your medicines to your
doctor’s office when you begin testing. It’s
also important to tell your treatment team if
you’re using any complementary medicines,
especially supplements, vitamins, or herbs.
Some of these can interfere with your cancer
tests or treatment. This may reduce the
effectiveness of treatment or cause more
side effects.

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frequently, difficulty peeing or pooping, or

sexual problems). You’ll also be asked how
these symptoms affect your quality of life. Diagnosis vs. prognosis
Quality of life refers to your overall satisfaction What’s the difference between your
with your well-being and your ability to diagnosis and your prognosis? These
participate in regular activities. It’s important two words sound alike but they’re very
to answer all these questions honestly and different.
completely so your care team has full and up-
to-date information about how you’re doing. Diagnosis is identifying an illness
based on tests. Your diagnosis names
what illness you have.
Diagnostic tests
Prognosis is the likely course and
Diagnostic tests are used to confirm you have outcome of a disease. Your prognosis
cancer. They’re also used to find out if the predicts how your illness will turn out.
cancer is localized or advanced. Diagnostic
tests can help plan treatment after you’ve been
diagnosed and can detect whether the cancer
is still growing or spreading after treatment.
Imaging can come before, during, or after a
Diagnostic tests include imaging scans,
biopsy. Imaging may also be used after cancer
biopsies, and genetic tests.
treatment to see how well it worked and to
check if the cancer comes back.
Imaging tests
Imaging methods for prostate cancer include
An imaging test takes pictures (images) of the
MRI, CT, PET, ultrasound, bone scan, or a
insides of your body. The images can reveal
combination of these.
cancer, including its size, location, and other
features such as the size of the prostate itself.
MRI scan
The images may show where the cancer
A magnetic resonance imaging (MRI) scan
started (primary tumor) and whether the
uses radio waves and powerful magnets to
cancer has spread (metastasized).
take pictures of the inside of the body. An MRI
can be used to get a more detailed view of the
After your scan, your images will be studied by
cancer within the prostate. It’s also used to see
a radiologist. A radiologist is a doctor who’s an
if cancer has spread to nearby lymph nodes or
expert in reading imaging tests. The radiologist
to the bones in your pelvis.
will send the results to your care team. This
information helps to plan the next steps of your
MRI scans can also help to plan treatment,
care. Your team will discuss the results with
and may be used after treatment to
you. Be sure to ask any questions you may
have.

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check whether the cancer has come back PET scan

(recurrence). A positron emission tomography (PET) scan
highlights cells in your body that may be
An appointment for an MRI scan can take cancerous. You may have a PET scan after
1 to 2 hours, including 30 to 60 minutes of you’ve been diagnosed to determine the extent
actual scanning time. You’ll need to remain as of your cancer or to see if it has metastasized.
motionless as possible during each scan. You PET imaging can also show how well
may be positioned with pillows or bolsters to treatment is working.
help you keep still.
A PET scan requires injecting a radioactive
Because an MRI uses magnets, you can’t substance called a tracer into your
bring any metal objects (such as jewelry, bloodstream. It takes about an hour for the
phones, wristwatches, or belts with metal tracer to circulate throughout your body. The
buckles) into the imaging room. tracer targets your cancer cells, which show
up as bright spots on the scan. Afterward, the
CT scan radiotracer is passed out of your body in your
A computed tomography (CT or CAT) scan urine.
uses x-rays and computer technology to take
pictures of the inside of the body. CT takes A PET scan appointment can take 1 to 2
many x-rays of the same body part from hours, including about 30 minutes of actual
different angles. The computer combines all scanning time.
the x-ray pictures to make a single detailed
image. A CT scan is usually completed in less Because PET uses a different imaging method,
than 30 minutes. it’s often combined with other types of imaging,
such as CT or MRI, to provide an even more

PET imaging
A positron emission tomography
(PET) scan highlights cells in your
body that may be cancerous. A
PET scan can determine the extent
of your cancer or see if it has
metastasized. PET imaging can also
show how well treatment is working.

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detailed image. This combined method is A bone scan uses a radioactive tracer to make
called a PET/CT or PET/MRI scan. pictures of the inside of bones. Before the
pictures are taken, the tracer is injected into
PSMA-PET your bloodstream. It can take a few hours for
PET scans use different types of tracers. The the tracer to enter your bones.
most common tracer in prostate cancer locates
a protein called prostate-specific membrane A special camera will take pictures of the
antigen (PSMA) on the surface of prostate tracer in your bones. Areas of bone damage
cancer cells. Prostate cancer cells can make a absorb more tracer than healthy bone. These
lot of PSMA, so doctors developed tracers that areas show up as bright spots in the scans.
target this specific protein.
Ultrasound
Not everyone with prostate cancer will need a Ultrasound imaging is commonly used to help
PSMA-PET scan. It’s mostly used to monitor guide a biopsy of the prostate. This is called
prostate cancer for recurrence. It’s also used to transrectal ultrasound (TRUS) imaging.
determine whether targeted therapy can treat
certain cases of metastatic prostate cancer. During a biopsy, an ultrasound probe is
inserted into the rectum. The probe is about
Bone scan the size of a finger. The device uses high-
A bone scan can detect whether cancer has energy sound waves to create a view of the
spread to your bones. A bone scan may be prostate from inside the body. These images
used if you have bone pain, have a high risk allow the surgeon to remove a small sample
for bone metastasis, or have changes in of the prostate without having to open up your
certain test results. Bone scans may also be abdomen.
used to monitor treatment.

PET/CT scan of
prostate cancer
This image combines PET and CT
scans to show a cross-section of a
patient’s pelvis. The greenish circle
identifies cancer in the prostate,
while the intense red dot indicates
cancer that has spread to a lymph
node in the pelvis.

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At some centers, your saved MRI images tests have some risk. The risks for a prostate
can be combined with real-time ultrasound biopsy include infection, bleeding, and pain.
to provide a more detailed view for a more Doctors use invasive tests only when needed.
precise biopsy. This is called MRI-TRUS You and your care team will decide when, or if,
fusion. you need a biopsy.

A biopsy sample may be taken from the

Biopsy
prostate, the metastasis (an area of cancer
A biopsy is a procedure in which a sample of that has spread outside of the prostate), or
cells, fluid, or tissue is removed from your body sometimes both.
and tested for cancer. It’s the main way to
confirm whether you have cancer. Biopsy of the prostate
A prostate biopsy is usually performed by
A biopsy is an invasive test, which means that a urologist. A urologist is a doctor who’s an
it goes into (invades) your body. All invasive

PSMA-PET scan of
prostate cancer
A CT scan for a patient treated for
prostate cancer shows a cross-
section of the body at the pelvis.
The CT pinpoints a lymph node
that appears normal (top image).

But a PMSA-PET scan of the same

lymph node highlights prostate
cancer cells (arrow in bottom
image).
Images: University of Chicago Medicine

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expert in treating diseases of the urinary take 12 or more core samples from different
system and the male reproductive organs. parts of the prostate. Checking different areas
provides a more complete evaluation of cancer
For this procedure, you’ll lie on your side throughout the gland.
with your knees curled up or you’ll lie on your
back with your legs raised. You’ll be given After the biopsy samples are removed, a
anesthesia to numb the pain or to make you specialist called a pathologist will examine the
fall asleep. The urologist will insert a lubricated samples under a microscope and test them for
probe into your rectum. The probe provides a cancer cells. The pathologist will find out how
visual image of the prostate. many of the core samples contain cancer and
will also measure the percentage of cancer in
The urologist will then insert a hollow needle each core.
into the prostate gland using the video display
to guide it. The needle is inserted either With this information, the pathologist can
through the perineum (the skin between the estimate the amount of cancer in the prostate
anus and scrotum) or through the rectum. and how aggressive it may be. Also, by
knowing where each core sample was
When the urologist removes the needle, it taken, the pathologist can tell if the cancer
will pull out a small sample of prostate tissue is concentrated in a certain section of the
called a core. A core sample is only about 1 prostate.
to 2 millimeters wide and 12 to 20 millimeters
long—about as wide as a toothpick and as The pathologist will put these results into a
long as a raisin. The urologist will usually report. Ask your doctor or another member of

Biopsy of the prostate

A biopsy removes a sample of
tissue that is tested for cancer.
This is a transperineal biopsy, in
which a needle is inserted through
the perineum and into the prostate.
An ultrasound probe, which goes
into the rectum, helps the doctor
guide the needle into the prostate.
MRI scans of your prostate may
be combined with the ultrasound
image to provide a highly accurate
picture of the cancer.

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your care team to review the pathology report Genetic tests

with you.
A genetic test is used to find harmful changes
Biopsy of the metastasis in your genes. Genes are small segments
A biopsy of a metastasis can be taken from of DNA inside every cell. Genes provide
a lymph node, an internal organ, or a bone. the instructions to tell the cell how to make
This biopsy is performed in a similar way to proteins, which carry out a lot of important
a prostate biopsy—using a hollow needle to functions in the body.
remove cores of tissue.
Once in a while, a gene will have or develop
Sometimes, a blood sample is taken, also a change, called a mutation, that damages
called a “liquid biopsy,” to look for cancer cells its function. As a result of this mutation, the
in the blood. gene isn’t able to make a normal protein so
the protein can’t do its necessary job. This can
Having a biopsy may cause complications. A affect the usual activities of the cell, which can
complication is an unwanted and unplanned lead to disease, such as cancer.
result from a procedure. Complications may
include infection, bleeding from the rectum, Mutations can be passed down in families,
or blood in the urine, stool, or semen. These in which case they occur in every cell in your
usually go away after a few days or, with body. Or mutations can occur spontaneously
semen, after a few weeks. It’s also important in just some of your cells. In other words, they
to know that a biopsy won’t cause prostate may be in your body before you’re born (called
cancer to spread or worsen. a hereditary or germline mutation) or occur by

Biopsy of the metastasis

Prostate cancer may
metastasize to lymph nodes,
bones, or internal organs. A
biopsy of a metastasis (as seen
here, taken from the liver) uses
a hollow needle to remove a
small core of tissue. The tissue
is tested in a lab to look for
cancer cells.
Removed liver
tissue

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chance or environmental factors later in life and other cancers in addition to prostate
(called an acquired or somatic mutation). cancer.

The two basic types of genetic tests used If an inherited cancer risk gene is suspected
for prostate cancer care are hereditary gene based on your family’s or your own health
testing and tumor testing: history, you should ask about genetic testing.
Your health care provider can talk to you about
testing or refer you to a genetic counselor.
Hereditary gene testing
A genetic counselor is an expert who has
Sometimes, mutations in genes inherited from special training in genetic diseases. A genetic
your parents can increase the risk of different counselor can help you decide whether you
cancers. You can pass these genes on to your would like to undergo germline testing and also
children. Your siblings or other family members help you interpret the results of these tests.
might also carry these mutations. If you have
a family history of cancer, your health care Inherited gene testing is recommended if you
provider might suggest genetic testing to find have prostate cancer and any of the following:
out if you have an inherited cancer risk. This is
also called germline testing. † Family members or relatives who have
or had prostate cancer, breast cancer,
The goal of this type of genetic testing is to ovarian cancer, intestinal cancer, and
look for inherited (germline) mutations that certain other cancers
occur in every cell in your body. Genetic
† Family history of mutations in certain
germline testing is done using a sample of
genes including BRCA1, BRCA2, ATM,
your blood, urine, or saliva.
CHEK2, and others
For prostate cancer, this testing typically looks † Very-high-risk, high-risk, regional (cancer
for characteristic changes in these genes: in a lymph node), or metastatic prostate
BRCA1, BRCA2, ATM, CHEK2, MLH1, MSH2, cancer regardless of family history
MSH6, PALB2, PMS2, and others.
† Ashkenazi Jewish ancestry
Having a hereditary mutation doesn’t mean
Talk to your medical providers and/or a genetic
you’ll automatically get cancer. It means your
counselor about your family history of cancer.
chances for developing certain cancers is
higher.
Tumor testing
Some mutations can put you at risk for more
Tumor testing (also called somatic testing,
than one type of cancer. Inherited mutations in
molecular tumor testing, or tumor profiling)
genes like BRCA1 or BRCA2 are also related
requires a tissue sample from the tumor itself
to breast cancer, ovarian cancer, pancreatic
or from a metastasis in a lymph node, bone,
cancer, and skin cancer (melanoma). Inherited
liver, lung, or other affected area. Or it may
mutations in MSH2, MSH6, MLH1, and PMS2
come a sample of your blood, which contains
are related to colorectal cancer, uterine cancer,
the tumor’s DNA.

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Tests
2 Tests
for advanced
for advanced
prostate
prostate
cancer
cancer
» Tumor
» Tumor
staging
staging
» Tumor staging

In this type of testing, the sample is analyzed In this system, the letters T, N, and M stand for
to look at its molecular components. Tumors different areas of cancer growth:
often release molecules that can be used as
clues for finding and learning about the cancer. † T (tumor) – Describes the size of the
This information helps figure out the likelihood main (primary) tumor and if it has grown
that your cancer could spread to other parts of outside the prostate
the body. It can also help predict whether the
† N (node) – Identifies whether cancer has
cancer could transform into a more aggressive
spread to lymph nodes
type.
† M (metastasis) – Indicates if cancer
Importantly, targeted therapies (PARP has spread (metastasized) to parts of the
inhibitors, for example) can be used against body outside of the pelvis
cancers that have particular molecular tumor
markers. So the testing looks for specific Your provider will assign a number to each
abnormalities in a number of genes involved in letter, based on your test results. The higher
DNA repair, including BRCA1, BRCA2, ATM, the number, the larger the tumor (T) or the
PALB2, FANCA, and others. more the cancer has spread (M). These scores
are combined to assign a “stage” to the cancer.

Tumor staging Staging is a way to describe how much cancer

is in your body and how far it has spread.
Knowing your stage is important for predicting
Tumors come in different shapes and sizes. So
the course of your disease and for making a
it’s not easy to compare one tumor to another.
treatment plan.
To solve this problem, cancer experts created
the tumor, node, metastasis (TNM) system to
Cancer staging is done when you’re first
describe any tumor. It’s based on the results of
diagnosed. It may also be done after treatment
your imaging scans, biopsies, and blood tests.
to confirm that the stage hasn’t changed.

How to read a TNM score

Let’s say your prostate cancer is given a TNM score of T4, N1, M1. This score means that
the tumor has grown outside the prostate gland (T4) and has spread to nearby lymph nodes
(N1) and to one or more distant parts of the body (M1).

Why know your TNM score? For one, it lets you know the extent of your cancer. It also helps
characterize your risk for the cancer to spread. Your level of risk helps indicate the most
appropriate treatment for you.

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 3
Prostate cancer treatments

25 Hormone therapy

29 Non-hormone therapy

32 Clinical trials

34 Supportive care

36 What’s next?

36 Key points

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3 Prostate
cancer
cancer
treatments
treatments
» Hormone
» Hormone
therapy
therapy
» Hormone therapy

There’s more than one treatment key word in ADT is “deprivation”—this therapy
“deprives” (starves) the cancer of its main fuel:
for advanced prostate cancer. This
androgens. This can shrink the tumor or slow
chapter describes the available tumor growth for a while.
treatment options and what you
You might hear the term “castration” used
might expect from them. Talk when describing prostate cancer or its
treatment. This term describes a drastic
with your care team about which
reduction of testosterone. Castration can be
treatment could be best for you. done with hormone-lowering medication or
by surgical removal of one or both testicles
(orchiectomy). Though orchiectomy is a
surgical procedure, it’s still considered
Prostate cancer is a complex disease with hormone therapy because it removes the
many treatment options. Treatments for primary source of testosterone: the testicles.
advanced-stage prostate cancer include While drug hormone therapy can be reversed
hormone therapy as well as non-hormone when the medication is stopped, orchiectomy
therapies like chemotherapy, immunotherapy, is permanent and can’t be reversed.
targeted therapy, and radiation therapy. Often,
hormone therapy is combined with one or more Surgical removal of the testicles is much
other therapies. Combining therapies can be less common these days because systemic
more effective than using either therapy alone.

Hormone therapy What is ADT?

Hormone therapy is a systemic (whole-body) Androgen deprivation therapy (ADT)

treatment that adds, blocks, or removes brings testosterone down to a very low
hormones. A hormone is a natural chemical level. ADT treatments include:
made by a gland in the body. Its job is to
activate cells or organs. • LHRH agonist (goserelin, leuprolide,
or triptorelin)
Male hormones are called androgens. The
main androgen is testosterone. Most of the • LHRH agonist + anti-androgen
testosterone in the body is made by the testicles. (nilutamide, flutamide, or
Testosterone helps produce sperm, among bicalutamide)
other functions. But testosterone also helps • LHRH antagonist (degarelix or
prostate cancer grow. A type of hormone therapy relugolix)
called androgen deprivation therapy (ADT) can
stop your body from making testosterone or • Surgical castration
block cancer cells from using testosterone. The

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3 Prostate
cancer
cancer
treatments
treatments
» Hormone
» Hormone
therapy
therapy
» Hormone therapy

hormone therapy is often just as effective at LHRH antagonist that comes as a tablet taken
blocking testosterone. once a day. Anti-androgens, corticosteroids,
and androgen synthesis inhibitors are also
Hormone therapies for prostate cancer include available as pills and taken 1 to 3 times a day,
luteinizing hormone-releasing hormone depending on the medication. See Guide 1.
(LHRH) agonists and LHRH antagonists,
both of which cause the testicles to stop
Newer hormone therapies
making testosterone. You may have heard of
leuprolide (Lupron), a commonly used LHRH Hormone therapy has been the main
agonist or degarelix (Firmagon), a commonly treatment for advanced prostate cancer for
used LHRH antagonist. Most LHRH agonists several decades. Longstanding hormone
and LHRH antagonists are injections. These therapies (such as bicalutamide, flutamide,
may be given monthly, or 2, 3, or 4 times a and nilutamide) are sometimes still used for
year. The exception is relugolix (Orgovyx), an treating prostate cancer.

Guide 1
Hormone therapy drugs for prostate cancer

apalutamide (Erleada), bicalutamide

Anti-androgens block receptors on prostate (Casodex), darolutamide (Nubeqa),
cancer cells from receiving testosterone. enzalutamide (Xtandi), flutamide (Eulexin),
nilutamide (Nilandron)

LHRH agonists prevent the release of luteinizing

goserelin (Zoladex), leuprolide (Lupron
hormone-releasing hormone (LHRH), which
Depot, Eligard), triptorelin (Trelstar)
causes the testicles to stop making testosterone.

LHRH antagonists block or stop the pituitary gland

(located in the brain) from making LHRH. This degarelix (Firmagon), relugolix (Orgovyx)
causes the testicles to stop making testosterone.

Androgen synthesis inhibitors block androgen abiraterone (Zytiga, Yonsa), ketoconazole

production. (Nizoral)

Corticosteroids (“steroids”) are synthetic

dexamethasone, hydrocortisone,
hormones made in a lab that can stop the adrenal
methylprednisolone, prednisone
glands and other tissues from making testosterone.

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3 Prostate
cancer
cancer
treatments
treatments
» Hormone
» Hormone
therapy
therapy
» Hormone therapy

However, newer hormone therapies are better worse. In Black patients, hormone therapy may
at delaying the spread of cancer and extending increase the risk of death from heart issues.
life. These newer drugs include abiraterone,
apalutamide, darolutamide, and enzalutamide. Ask your doctor about monitoring your blood
You may hear your treatment team refer to pressure and cholesterol levels. Also, let your
these as novel, advanced, or next-generation primary care physician know you’re being
hormone therapies. treated with ADT.

LHRH agonists can cause a surge in

Side effects of hormone therapy
testosterone for a few weeks before dropping
Hormone therapy can have significant side to an undetectable level. This increase is
effects. These vary from person to person called a testosterone flare. A testosterone flare
and from one type of hormone therapy to can cause bone pain and urinary problems.
another. Many other factors affect your risk for But these symptoms will go away after the
side effects including your age, your health first few weeks of treatment. You might be
before treatment, how long or often you have given an anti-androgen medicine to prevent
treatment, and other things. testosterone flare.

The good news is that your treatment team The sexual side effects of hormone therapy
can offer supportive care to lessen or reverse can be a significant cause of stress. Hormone
many of these effects. therapy may reduce your desire for sex and
cause erectile dysfunction.
In general, the longer you’re on hormone
therapy, the greater your risk for side effects. Erectile dysfunction means having difficulty or
These can include tiredness (fatigue), hot being unable to have an erection of the penis.
flashes, mood changes, weight gain, changes Erectile dysfunction medicines (such as Viagra
in penis length and testicle size, tenderness and Cialis) aren’t as effective for those on
and growth of your breasts, and loss of muscle hormone therapy. These drugs don’t restore
mass. the loss of sexual desire caused by lower
androgen levels.
Thinning and weakening of your bones
(osteoporosis) and bone fractures can also However, some treatments that may improve
happen. When you start ADT, you may have a erectile function include injections of
test to measure your bone density. If your bone medication into the penis, vacuum constriction
density is low, your care team can recommend devices (“penis pump”), or surgical implants
medications you can take to strengthen your that produce an erection.
bones.
Your sex drive and your ability to have an
Hormone therapy also increases the risk erection may gradually return after stopping
for diabetes and cardiovascular disease. If hormone therapy, though the process may
you already have either of these conditions, take up to a year or more. Some patients
hormone therapy can cause them to get never regain full ability to have an erection.

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3 Prostate
cancer
cancer
treatments
treatments
» Hormone
» Hormone
therapy
therapy
» Key points

Erectile dysfunction is a leading cause

of depression in patients with prostate
cancer. Ask your care team about therapy
or counseling if you’re having problems
due to erectile dysfunction or symptoms of
 TIP
depression. Help is available.
Regular exercise can lessen the
Talk to your care team about how to manage symptoms and side effects of
the side effects of hormone therapy. They hormone therapy, including:
have ways to lessen or soothe most of these
problems. Bones can be strengthened with • weight gain
medicine as well as with physical activity. • fatigue
Exercise and eating a healthy diet can also
help with fatigue, mood, and weight gain. • loss of bone and muscle mass
Physical activity can also improve your
Loss of sex drive, erectile dysfunction, and general health and make you feel better.
other sexual side effects usually go away after Ask your care team to recommend an
you stop hormone therapy. In the meantime, exercise program for you.
consider talking to your partner and/or a
therapist to help you deal with any problems
you’re having.

Hormone therapy resistance

It’s important to know that prostate cancer
Hormone therapy can be very effective that’s resistant to hormone therapy is still
at shrinking or slowing the growth of your treatable. So most people with hormone-
prostate cancer. But for people with metastatic resistant prostate cancer stay on ADT to keep
prostate cancer, hormone therapy can lose this their testosterone at a low level.
effect over time, even when their testosterone
is at a very low level. Other hormone-reducing drugs are also still
used. These hormone therapies are often
Why? Because the cancer eventually combined with non-hormone treatments
learns how to survive without using much like chemotherapy, targeted therapy, or
testosterone, which makes it unaffected by immunotherapy to help get better results.
hormone therapy. The cancer can “resist” the
hormone therapy. This is called hormone-
resistant prostate cancer (also called
castration-resistant prostate cancer).

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3 Prostate
cancer
cancer
treatments
treatments
» Non-hormone
» Non-hormone
therapy
therapy
» Non-hormone therapy

Non-hormone therapy live longer as well as reduce their pain and

other symptoms. Docetaxel is an option for
Hormone therapy may be the first treatment some who are taking ADT for the first time.
recommended for advanced prostate cancer, Docetaxel is also used to treat metastases
but it’s not the only one. Other systemic after ADT fails to stop cancer growth.
treatments that don’t use hormones can also
slow cancer growth, prevent cancer symptoms, Cabazitaxel
and prolong life. Cabazitaxel (Jevtana) is a chemotherapy
option if docetaxel isn’t effective. Cabazitaxel
If you’re given non-hormone therapy, you’ll can’t cure prostate cancer but it can help
likely also stay on ADT to make sure your people live longer and improve pain and other
testosterone remains at the lowest possible symptoms.
level. See Guide 2.
Carboplatin and cisplatin
Carboplatin and cisplatin are chemotherapy
Chemotherapy
drugs made from platinum. These are
Chemotherapy is a systemic drug treatment sometimes used for patients with very
that damages rapidly dividing cells throughout advanced or aggressive cancer. Usually,
the body. Cancer cells divide and multiply either carboplatin or cisplatin is combined
rapidly, which makes them a good target for with another chemotherapy medicine such as
chemotherapy. cabazitaxel or docetaxel.

But chemotherapy can harm healthy cells, too. Mitoxantrone

That’s how it can cause side effects. Because Mitoxantrone (Novantrone) is used to
chemotherapy can be a tough treatment to go relieve pain and decrease the need for pain
through, it’s recommended only for those who medications. It’s an option if you aren’t able to
are able to physically tolerate it. Despite the tolerate other therapies.
side effects, it can help people with metastatic
prostate cancer live significantly longer.
Immunotherapy
Chemotherapy for prostate cancer is a liquid The immune system is the body’s natural
medicine given by intravenous infusion. This defense against infection and disease.
means that it’s slowly injected into a vein for up Immunotherapy is a type of systemic therapy
to an hour. It’s given every 3 weeks for a total that boosts the ability of your immune
of 6 to 10 times (cycles), along with a daily system to find and destroy cancer cells.
steroid. Immunotherapy is usually given alone for
treating prostate cancer. Immunotherapy drugs
Docetaxel include sipuleucel-T and pembrolizumab.
Docetaxel (Taxotere) is the chemotherapy
medicine used most often to treat patients with Sipuleucel-T
advanced prostate cancer. Though docetaxel Sipuleucel-T (Provenge) is intended for those
can’t cure prostate cancer, it can help people with hormone-resistant metastatic prostate

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3 Prostate
cancer
cancer
treatments
treatments
» Non-hormone
» Non-hormone
therapy
therapy
» Non-hormone therapy

cancer who have few or no symptoms. This Pembrolizumab

drug is known as a “cancer vaccine.” First, Pembrolizumab (Keytruda) is a type of
immune cells are collected from your body immunotherapy called an immune checkpoint
and sent to a lab. The immune cells are then inhibitor. For a small percentage of people
activated to identify and target prostate cancer whose prostate cancer is due to specific
cells. Lastly, the immune cells are injected genetic mutations, pembrolizumab can restore
back into your body where they attack cancer the immune system’s ability to detect and
cells. destroy cancer cells.

Guide 2
Non-hormone systemic therapies for advanced prostate cancer

Type of therapy Brand name Generic name Drug form

Taxotere docetaxel

Jevtana cabazitaxel

Chemotherapies Paraplatin carboplatin infusion into a vein

Platinol cisplatin

Novantrone mitoxantrone

Provenge sipuleucel-T
Immunotherapies infusion into a vein
Keytruda pembrolizumab

Rubraca rucaparib
tablet
Lynparza olaparib (plus abiraterone)
Biomarker-targeted
therapies Akeega niraparib/abiraterone
talazoparib (plus
Talzenna capsule
enzalutamide)
Pluvicto lutetium-177
Radiopharmaceuticals infusion into a vein
Xofigo radium-223

Prolia, Xgeva denosumab

injection
Bone-targeted
Zometa zoledronic acid
therapies
Fosamax alendronate tablet

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3 Prostate
cancer
cancer
treatments
treatments
» Non-hormone
» Non-hormone
therapy
therapy
» Non-hormone therapy

Biomarker-targeted therapy Lutetium-177

Lutetium-177 (Pluvicto) is a targeted
This treatment targets specific biomarkers that
radiopharmaceutical that looks for a particular
are found through molecular tumor testing.
protein (prostate-specific membrane antigen,
Biomarker-targeted therapies are useful only
PSMA) on the surface of prostate cancer cells
in patients whose prostate cancer is due
anywhere in the body. When the drug finds
to specific genetic mutations. This includes
PSMA, it attaches itself to the cancer cells
mutations in BRCA1, BRCA2, and other
and implants a small amount of its radioactive
genes that repair damaged DNA. About 1 in
substance in them. The cancer cells absorb
4 patients with metastatic hormone-resistant
the radiation from the drug and die.
prostate cancer have this kind of genetic
mutation.
Lutetium-177 is an intravenous infusion given
once every 6 weeks for up to 6 doses. You’ll
Biomarker-targeted therapies (also known
need a PSMA-PET scan to find out if this
as PARP inhibitors) for advanced prostate
treatment may work for you.
cancer include rucaparib (Rubraca), olaparib
(Lynparza), niraparib and abiraterone
Radium-223
(Akeega), and talazoparib (Talzenna). Because
Radium-223 (Xofigo) is used to treat prostate
genetic mutations differ between people, a
cancer that has metastasized in bone but
treatment that helps one person may not help
hasn’t spread to other organs. Radium-223
another.
collects in bones and gives off radiation that
can kill prostate cancer cells there. It’s an
Radiopharmaceuticals injection given once a month for 6 months.
You’ll need to have blood tests before
A radiopharmaceutical is a medicine that
each dose. A bone-targeting therapy, either
contains a radioactive substance. This
denosumab or zoledronic acid, is often given
radioactive substance releases radiation to
with radium-223.
kill cancer cells. The radiation doesn’t travel
far from cancer cells so nearby healthy tissue
Radium-223 is also used to reduce pain from
remains mostly unharmed.
bone metastases.
Radiopharmaceuticals are injected into
a vein (intravenous injection). Because Radiation therapy
radiopharmaceuticals leave the body through
Radiation therapy uses high-energy rays, like
the gut, common side effects are nausea,
x-rays or gamma rays, to kill cancer cells and
diarrhea, and vomiting.
shrink tumors. Radiation therapy is given in
regular doses over a certain period of time.
Radiopharmaceutical drugs include
lutetium-177 and radium-223:
External beam radiation therapy (EBRT) is
the type of radiation used for prostate cancer.
EBRT uses a machine that aims radiation
precisely at cancer inside the body. The

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cancer
cancer
treatments
treatments
» Clinical
» Clinical
trialstrials
» Clinical trials

radiation beam focuses directly on the cancer

while trying to avoid healthy tissue. This
Clinical trials
technique delivers higher doses of radiation
Therapy may also be given as part of a clinical
more safely.
trial.
For metastatic prostate cancer, radiation
A clinical trial is a type of medical research
therapy is mainly used for treatment of
study. Clinical trials are a key way to assess
prostate cancer that returns after initial
new treatment approaches.
treatment (recurrence). Radiation therapy is
also used as palliative treatment to relieve the
After being developed and tested in a
pain of bone metastases.
laboratory, potential new ways of fighting
cancer need to be studied in people. If found
Radiation therapy (EBRT) is more commonly
to be safe and effective in a clinical trial, a
used along with hormone therapy as the initial
drug, device, or treatment approach may be
treatment for patients who have early-stage
approved by the FDA.
or regional prostate cancer. EBRT treats the
prostate as well as cancerous lymph nodes,
Everyone with cancer should carefully consider
while hormone therapy lowers testosterone
all the treatment options available for their
to a minimal level to prevent the cancer from
cancer type, including standard treatments and
getting worse.
clinical trials. Talk to your doctor about whether
a clinical trial may make sense for you.
Some of the possible side effects of radiation
therapy are urinary and bowel problems,
erectile dysfunction, and fatigue.

Black males have a higher risk of

developing and dying from prostate
cancer. But many may not know about
clinical trial opportunities. As a result,
not as much is known about whether new
treatments can work for Black males with
prostate cancer.

Everyone with cancer can ask for and

should be given information about clinical
trials. Knowing all the options means not
missing out on clinical trial opportunities
for promising new treatments.

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