NCCN Guideline Prostate Cancer 2020

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
Prostate Cancer
Version 2.2020 — May 21, 2020
NCCN.org
NCCN Guidelines for Patients®
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Version 2.2020, 05/21/20 © 2020 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
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Table of Contents
Prostate Cancer Discussion
Edward Schaeffer, MD, PhD/Chair ω Xin Gao, MD † Þ Julio M. Pow-Sang, MD ω

Robert H. Lurie Comprehensive Cancer Dana-Farber/Brigham and Women's Moffitt Cancer Center
Center of Northwestern University Cancer Center | Massachusetts General
Hospital Cancer Center Sylvia Richey, MD †
Sandy Srinivas, MD/Vice-Chair † ω St. Jude Children’s Research Hospital/The
Stanford Cancer Institute Celestia S. Higano, MD, FACP † ω University of Tennessee Health Science Center
Fred Hutchinson Cancer Research Center/
Emmanuel S. Antonarakis, MD † Seattle Cancer Care Alliance Mack Roach, III, MD §
The Sidney Kimmel Comprehensive UCSF Helen Diller Family
Cancer Center at Johns Hopkins Eric Mark Horwitz, MD § Comprehensive Cancer Center
Fox Chase Cancer Center
Andrew J. Armstrong, MD † Stan Rosenfeld ¥
Duke Cancer Institute Joseph E. Ippolito, MD, PhD ф University of California San Francisco
Siteman Cancer Center at Barnes- Patient Services Committee Chair
Justin E. Bekelman, MD § Jewish Hospital and Washington
Abramson Cancer Center University School of Medicine Ahmad Shabsigh, MD ω
at the University of Pennsylvania The Ohio State University Comprehensive
Christopher J. Kane, MD ω Cancer Center - James Cancer Hospital
Heather Cheng, MD, PhD † UC San Diego Moores Cancer Center and Solove Research Institute
Fred Hutchinson Cancer Research Center/
Seattle Cancer Care Alliance Michael R. Kuettel, MD, MBA, PhD § Daniel E. Spratt, MD §
Roswell Park Comprehensive Cancer Center University of Michigan
Anthony Victor D’Amico, MD, PhD § Rogel Cancer Center
Dana-Farber/Brigham and Women’s Joshua M. Lang, MD †
Cancer Center | Massachusetts University of Wisconsin Carbone Cancer Center Benjamin A. Teply, MD
General Hospital Cancer Center Fred & Pamela Buffett Cancer Center
Jesse McKenney, MD ≠
Brian J. Davis, MD, PhD § Case Comprehensive Cancer Center/ Jonathan Tward, MD, PhD §
Mayo Clinic Cancer Center University Hospitals Seidman Cancer Center Huntsman Cancer Institute
and Cleveland Clinic Taussig Cancer Institute at the University of Utah
Tanya Dorff, MD †
City of Hope National Cancer Center George Netto, MD ≠
O'Neal Comprehensive Cancer Center at UAB
James A. Eastham, MD ω
Memorial Sloan Kettering Cancer Center David F. Penson, MD, MPH ω
Vanderbilt-Ingram Cancer Center
Thomas A. Farrington ¥ NCCN
Prostate Health Education Network (PHEN) Deborah Freedman-Cass, PhD
Dorothy A. Shead, MS
ф Diagnostic/Interventional ¥ Patient advocate
§ Radiotherapy/Radiation oncology
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radiology NCCN Guidelines Panel Disclosures
Þ Internal medicine w Urology
† Medical oncology * Discussion Section Writing
≠ Pathology Committee

Table of Contents
NCCN Prostate Cancer Panel Members Principles of Life Expectancy Estimation (PROS-A)
Clinical Trials: NCCN believes that
Summary of Guidelines Updates Principles of Genetics (PROS-B) the best management for any patient
Initial Prostate Cancer Diagnosis (PROS-1) Principles of Imaging (PROS-C) with cancer is in a clinical trial.
Initial Risk Stratification and Staging Workup for Principles of Active Surveillance and Observation Participation in clinical trials is
Clinically Localized Disease (PROS-2) (PROS-D) especially encouraged.
Very Low Risk Group (PROS-3) Principles of Radiation Therapy (PROS-E) To find clinical trials online at NCCN
Low Risk Group (PROS-4) Principles of Surgery (PROS-F) Member Institutions, click here: nccn.
org/clinical_trials/member_institutions.
Favorable Intermediate Risk Group (PROS-5) Principles of Androgen Deprivation Therapy (PROS-G)
aspx.
Unfavorable Intermediate Risk Group (PROS-6) Principles of Immunotherapy and Chemotherapy
High or Very High Risk Group (PROS-7) (PROS-H)
NCCN Categories of Evidence and
Genetic and Molecular Biomarker Analysis for Staging (ST-1)
Consensus: All recommendations
Advanced Prostate Cancer (PROS-8) are category 2A unless otherwise
Regional Risk Group (PROS-9) indicated.
Monitoring (PROS-10) See NCCN Categories of Evidence
Radical Prostatectomy PSA Persistence/Recurrence and Consensus.
(PROS-11)
Radiation Therapy Recurrence (PROS-12) NCCN Categories of Preference:
All recommendations are considered
Systemic Therapy for Castration-Naive Prostate appropriate.
Cancer (PROS-13)
See NCCN Categories of Preference.
Systemic Therapy for M0 Castration-Resistant
Prostate Cancer (CRPC) (PROS-14)
Systemic Therapy for M1 CRPC (PROS-15)
Systemic Therapy for M1 CRPC: Adenocarcinoma
(PROS-16)
The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment.
Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical
circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or
warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN
Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not
be reproduced in any form without the express written permission of NCCN. ©2020.

Table of Contents
Updates in Version 2.2020 of the NCCN Guidelines for Prostate Cancer from Version 1.2020 include:
PROS-16 and PROS-16A
• Systemic therapy for M1 CRPC: Adenocarcinoma
Added olaparib for HRRm to the useful in certain circumstances treatment options under subsequent therapy as a category 1
recommendation with the following footnote: Olaparib is a treatment option for patients with mCRPC and a pathogenic mutation (germline
and/or somatic) in a homologous recombination repair gene (BRCA1, BRCA2, ATM, BARD1, BRIP1, CDK12, CHEK1, CHEK2, FANCL, PALB2,
RAD51B, RAD51C, RAD51D or RAD54L), who have been treated with androgen receptor-directed therapy. Patients with PPP2R2A mutations
in the PROfound trial experienced an unfavorable risk-benefit profile. Therefore, olaparib is not recommended in patients with a PPP2R2A
mutations. (see Discussion).
Changed the Category of Evidence and Consensus for olaparib from a category 2B to a category 1 recommendation as a second-line
treatment option post abiraterone/enzalutamide.
Added rucaparib for BRCAm to the useful in certain circumstances treatment options under second-line treatment and subsequent
therapy as a category 2A recommendation with the following footnote: Rucaparib is a treatment option for patients with mCRPC and a
pathogenic BRCA1 or BRCA2 mutation (germline and/or somatic) who have been treated with androgen receptor-directed therapy and a
taxane-based chemotherapy. If the patient is not fit for chemotherapy, rucaparib can be considered even if taxane-based therapy has not
been given.
PROS-1 intermediate-risk groups with life expectancy ≤5 years, no further workup
• Added a footnote with a link to the new Principles of Genetics, moved imaging or treatment is indicated until the patient becomes symptomatic,
previous footnotes to the new page. at which time ADT should be given (See PROS-G).
• If germline mutation not identified, removed: Genetic counseling to • New footnote: mpMRI is preferred over CT for abdominal/pelvic staging.
review the need for additional testing, if testing based on family history. See PROS-C.
• Changed 'intraductal histology' to intraductal/cribriform histology. • Modified footnote: Men with low or favorable intermediate-risk disease
PROS-2 and life expectancy ≥10 y may consider the use of the following tumor-
• Clarified the clinical pathologic features column by adding qualifiers based molecular assays: Decipher, Oncotype DX Prostate, Prolaris, and
such as: Has all of the following. ProMark. Men with unfavorable intermediate- and high-risk disease and
• Intermediate and high-risk groups, molecular/biomarker analysis of life expectancy ≥10 y may consider the use of Decipher and Prolaris
tumor, changed from "not routinely recommended" to "consider if life tumor-based molecular assays.
expectancy ≥10 y." PROS-3, PROS-4, PROS-5, PROS-6, PROS-7
PROS-2A • Adverse features after radical prostatectomy: EBRT ± ADT (6 mo)
• Modified footnote: For asymptomatic patients in very-low-, low-, and PROS-4, PROS-5
Continued
Version 2.2020, 05/21/20 © 2020 National Comprehensive Cancer Network (NCCN ), All rights reserved. NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
® ® ®
UPDATES

Table of Contents
• Modified: Consider mpMRI and/or prostate biopsy and/or molecular tumor is suggested by modern next-generation imaging but not on conventional
analysis to confirm candidacy for active surveillance. imaging. See Principles of Imaging (PROS-C) and Discussion.
PROS-6 PROS-11
• Changed: EBRT ± ADT (4 mo) to EBRT + ADT (4-6 mo). • Changed: Studies negative for distant metastases or imaging not
• Changed: EBRT + brachytherapy ± ADT (4 mo) to EBRT + brachytherapy ± performed.
ADT (4-6 mo). • Removed definitions from this page:
PROS-7 The term "castration-naive" is used to define patients who are not on
• Expected patient survival, >5 y or symptomatic changed: EBRT + ADT ADT at the time of progression. The NCCN Prostate Cancer Panel uses
(1.5–3 y; category 1 for ADT) ± docetaxel (category 1; for very high-risk the term "castration-naive" even when patients have had neoadjuvant,
only). concurrent, or adjuvant ADT as part of radiation therapy provided they
PROS-7A have recovered testicular function.
• Added the following footnotes: Castration-resistant prostate cancer (CRPC) is prostate cancer that
Decipher molecular assay is recommended to inform adjuvant treatment progresses clinically, radiographically, or biochemically despite
if adverse features are found post-RP. castrate levels of serum testosterone (<50 ng/dL). Scher HI, Halabi S,
Repeat molecular tumor analysis is discouraged. Tannock I, et al. Design and end points of clinical trials for patients
Patients with pN1 disease who chose observation should see PROS-10 with progressive prostate cancer and castrate levels of testosterone:
for monitoring for initial definitive therapy if PSA is undetectable. For recommendations of the Prostate Cancer Clinical Trials Working Group.
patients with pN1 disease and PSA persistence, see workup on PROS- J Clin Oncol 2008;26:1148-1159.
11. PROS-12
If higher grade and/or higher T stage is found, see PROS-2 • Changed: High-intensity focused ultrasound to (category 2B).
For monitoring for N1 on ADT, see PROS-11. • Replaced: "ADT (especially if bone scan positive) or Observation" with a
• Changed footnote: PSA nadir is the lowest value reached after EBRT or link to See Systemic Therapy for Castration-Naive Disease (PROS-13).
brachytherapy. PROS-13
PROS-8 • Listed Preferred regimens:
• Metastatic risk group, changed: Consider Recommend tumor testing for Apalutamide (category 1)
HRRm and consider tumor testing for MSI or dMMR. Abiraterone with prednisone (category 1)
PROS-9, PROS-13, and PROS-16 Docetaxel 75 mg/m2 for 6 cycles (category 1)
• Clarified the different formulations of abiraterone as "Abiraterone with Enzalutamide (category 1)
prednisone" and "Fine-particle abiraterone with methylprednisolone." • Listed Other recommended regimens:
PROS-10 Fine-particle abiraterone with methylprednisolone (category 2B)
• Added a link to the NCCN Guidelines for Survivorship. • Replaced: "Bone imaging for symptoms and as often as every
• Changed: Physical exam + PSA every 3–6 mo 6–12 mo" with Imaging for symptoms or increasing PSA.
• Added: Imaging for symptoms or increasing PSA. • Added footnotes:
• Removed: Bone imaging for symptoms and as often as every 6–12 mo Tumor testing for MSI-H or dMMR and germline tumor testing for
• Modified footnote: Document castrate levels of testosterone if on ADT. homologous recombination gene mutations is recommended. See
Workup for progression should include bone imaging, chest CT, and Principles of Genetics (PROS-B).
abdominal/pelvic CT or abdominal/pelvic MRI with and without contrast. Patients who were under observation for M0 disease should receive an
If there is no evidence of metastases, consider C-11 choline PET/CT or appropriate therapy for castration-naive disease.
PET/MRI or F-18 fluciclovine PET/CT or PET/MRI for further soft tissue PROS-14
and bone evaluation or F-18 sodium fluoride PET/CT or PET/MRI for • PSA > 10 mo, added: Observation (preferred)
further bone evaluation. The Panel remains unsure what to do when M1
Continued
® ® ®
UPDATES

Table of Contents
• PSA ≤ 10 mo, listed Preferred regimens: Listed Useful under certain circumstances regimens:
Apalutamide (category 1) ◊◊Radium-223 for symptomatic bone metastases (category 1)
Darolutamide (category 1) ◊◊Mitoxantrone with prednisone for palliation in symptomatic patients
Enzalutamide (category 1) with visceral metastases who cannot tolerate other therapies.
• Listed Other recommended regimens: Listed Other recommended regimens:
Other secondary hormone therapy ◊◊Fine-particle abiraterone
• Added footnote: ◊◊Other secondary hormone therapy
CRPC is prostate cancer that progresses clinically, radiographically, or • Second-line treatment (first-line abiraterone/enzalutamide):
biochemically despite castrate levels of serum testosterone (<50 ng/dL). Listed Preferred regimens:
Scher HI, Halabi S, Tannock I, et al. Design and end points of clinical ◊◊Docetaxel (category 1)
trials for patients with progressive prostate cancer and castrate levels ◊◊Sipuleucel-T
of testosterone: recommendations of the Prostate Cancer Clinical Trials Listed Useful under certain circumstances regimens:
Working Group. J Clin Oncol 2008;26:1148-1159. ◊◊Olaparib for HRRm (category 2B)
PROS-15 ◊◊Pembrolizumab for MSI-H or dMMRxx (category 2B)
• Changed: Consider Metastatic lesion biopsy. ◊◊Radium-223 for symptomatic bone metastases (category 1).
• Changed: Consider Tumor testing for MSI-H or dMMR if not previously Listed Other recommended regimens:
performed. ◊◊Abiraterone with prednisone
• Changed: Consider genetic counseling and Germline and tumor testing ◊◊Cabazitaxel if visceral metastases present
for homologous recombination gene mutations if not previously ◊◊Enzalutamide
performed. ◊◊Fine-particle abiraterone
• Removed from list of additional treatment options: Immunotherapy with ◊◊Other secondary hormone therapy
sipuleucel-T (category 1) (See PROS-G) Removed: Best supportive care
• Removed: "No visceral metastases" and "Visceral metastases." • Second-line treatment (first-line docetaxel):
• Chemotherapy options, added: Atezolizumab/carboplatin/etoposide Listed Preferred regimens:
(category 3) ◊◊Abiraterone with prednisone (category 1)
• Modified footnote: For additional options for subsequent therapy, see ◊◊Cabazitaxel (category 1)
NCCN Guidelines for Small Cell Lung Cancer. ◊◊Enzalutamide (category 1)
PROS-16 Listed Useful under certain circumstances regimens:
• Previous pages for 'Systemic Therapy For M1 CRPC: Adenocarcinoma ◊◊Mitoxantrone with prednisone for palliation in symptomatic patients
Without Visceral Metastases" and 'Systemic Therapy For M1 CRPC: who cannot tolerate other therapies
Adenocarcinoma With Visceral Metastases' were combined into one ◊◊Olaparib for HRRm (category 2B)
page: Systemic Therapy For M1 CRPC. ◊◊Pembrolizumab for MSI-H or dMMR (category 2B)
• A footnote was added to indicate which category designations apply only ◊◊Radium-223 for symptomatic bone metastases (category 1)
if no visceral metastases. Listed Other recommended regimens:
• First-line treatment: ◊◊Consider docetaxel rechallenge
Listed Preferred regimens: ◊◊Fine-particle abiraterone
◊◊Abiraterone with prednisone (category 1ggg) ◊◊Sipuleucel-T
◊◊Docetaxel (category 1) ◊◊Other secondary hormone therapy
◊◊Enzalutamide (category 1) Removed: Best supportive care
◊◊Sipuleucel-T (category 1) • Subsequent treatment (All systemic therapies are category 2B if visceral
metastases are present):
Continued
UPDATES

Table of Contents
Listed Preferred regimens: • Removed: Imaging studies should be performed based on the best
◊◊Abiraterone with prednisone (category 1ggg) available clinical evidence and not influenced by business or personal
◊◊Cabazitaxel(category 1ggg) interests of the care provider.PROS-C (3 of 3)
◊◊Docetaxel (category 1) • Modified: mpMRI may be used to better risk stratify men who are
◊◊Enzalutamide (category 1) considering active surveillance. Additionally, mpMRI may detect
Listed Useful under certain circumstances regimens: large and poorly differentiated prostate cancer (Grade Group ≥2) and
◊◊Pembrolizumab for MSI-H or dMMR (category 2B) detect extracapsular extension (T staging) and is preferred over CT for
◊◊Mitoxantrone with prednisone for palliation in symptomatic patients abdominal/pelvic staging. mpMRI has been shown to be equivalent to CT
with visceral metastases who cannot tolerate other therapies. scan for pelvic lymph node evaluation.
◊◊Radium-223 for symptomatic bone metastases (category 1) • Modified: The use of PET/CT or PET/MRI imaging using tracers other than
Listed Other recommended regimens: F-18 FDG (next-generation imaging) for staging of small-volume recurrent
◊◊Fine-particle abiraterone with methylprednisolone or metastatic prostate cancer is a rapidly developing field wherein most
◊◊Other secondary hormone therapy of the data are derived from single-institution series or registry studies.
Removed: Best supportive care PROS-D (1 of 2)
PROS-16A • Removed: Observation involves monitoring the course of disease with
• Added footnote: Patients with disease progression on a given therapy the expectation to deliver palliative therapy for the development of
should not repeat that therapy, with the exception of docetaxel, which symptoms or change in exam or PSA levels that suggest symptoms are
can be given as a rechallenge in the second- or subsequent-line imminent.
metastatic CRPC setting if given in the castration-naive setting. PROS-E (1 to 5)
• Changed footnote: Benefit with sipuleucel-T has not been studied • This section was extensively revised.
reported in patients with visceral metastases and is not recommended if PROS-F
visceral metastases are present. Sipuleucel-T also is not recommended • Removed: Laparoscopic and robot-assisted RP are commonly used. In
for patients with small cell/neuroendocrine prostate cancer. experienced hands, the results of these approaches appear comparable
• Changed footnote: Radium-223 is not approved recommended for use in to open surgical approaches.
combination with docetaxel or any other chemotherapy systemic therapy • A heading was added for Salvage Radical Prostatectomy.
except ADT and should not be used in patients with visceral metastases. PROS-G
Concomitant use of denosumab or zoledronic acid is recommended. See • This section was extensively revised.
Principles of Radiation Therapy (PROS-E). PROS-H
• Added footnote: de Wit R, de Bono J, Sternberg C, et al. Cabazitaxel • Systemic Therapy for M1 CRPC added:
versus abiraterone or enzalutamide in metastatic prostate cancer. N Engl Mitoxantrone with prednisone
J Med 2019; 381:2506-2518. Cabazitaxel at 25 mg/m2 with concurrent steroid improved radiographic
PROS-A PFS and reduced the risk of death compared with abiraterone or
• Added: The Memorial Sloan Kettering Male Life Expectancy tool (https:// enzalutamide in patients with prior docetaxel treatment for mCRPC in
webcore.mskcc.org/survey/surveyform.aspx?preview=true&excelsurveyl the CARD study.
istid=4). Consider inclusion of olaparib in men who have an HRRm and have
progressed on prior treatment with enzalutamide and/or abiraterone
PROS-B regardless of prior docetaxel therapy.
• New to the guidelines: Principles of Genetics
PROS-C (1 of 3)
UPDATES

Table of Contents
INITIAL PROSTATE CANCER DIAGNOSISa,b,c

Family history of high-
risk germline mutations
(eg, BRCA1/2, Lynch
Germline
mutation)
testingc
and/or
preferably with
Family history is
pre-test genetic
suspiciousc
counseling
• Perform digital rectal exam and/or
(DRE) to confirm clinical Presence of
stage intraductal/cribriform
• Perform and/or collect histology Germline mutation
not identified See Initial Risk
prostate specific antigen Stratification and
(PSA) and calculate PSA
density and PSA doubling Staging Workup
time (PSADT) for Clinically
• Obtain and review diagnostic Localized Disease
prostate biopsies Germline mutation Genetic
(PROS-2)
• Estimate life expectancy (See identified counseling
Principles of Life Expectancy
Estimation [PROS-A])
• Inquire about known high-risk Family history is
germline mutationsc unknown or not
• Obtain family historyc Consider germline
significant
testing based on
and
clinical featuresc
No intraductal/
cribriform
histology
a See NCCN Guidelines for Older Adult Oncology for tools to aid optimal b See NCCN Guidelines for Prostate Cancer Early Detection.
assessment and management of older adults. c See Principles of Genetics (PROS-B).
Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
PROS-1

Table of Contents
INITIAL RISK STRATIFICATION AND STAGING WORKUP FOR CLINICALLY LOCALIZED DISEASE
Molecular/
f,g Germline Biomarker Initial
Risk Group Clinical/Pathologic Features Imaging
Testingc Analysis of Therapy
Tumorc
Has all of the following:
Recommended
• T1c
if family history
• Grade Group 1 positive or
Very lowd • PSA <10 ng/mL Not indicated Not indicated See PROS-3
• Fewer than 3 prostate biopsy fragments/cores positive, intraductal/cribriform
e histology
≤50% cancer in each fragment/core
See PROS-1
• PSA density <0.15 ng/mL/g
Recommended
Has all of the following but does not qualify for very low risk: if family history
positive or Consider if life
• T1–T2a
Lowd • Grade Group 1
Not indicated expectancy See PROS-4
intraductal/cribriform ≥10 y
j
• PSA <10 ng/mL histology
See PROS-1
Has all of the
Recommended
Has all of the following: following: • Bone imagingh: not recommended for staging
if family history
• No high-risk group • 1 IRF • Pelvic ± abdominal imagingi: recommended if positive or Consider if life
Favorable
features • Grade Group 1 nomogram predicts >10% probability of pelvic lymph expectancy See PROS-5
intermediate intraductal/cribriform j
• No very-high-risk or 2 node involvement ≥10 y
histology
group features • <50% biopsy • If regional or distant metastases are found, see PROS-8 See PROS-1
Intermediated • Has one or more cores positivee
intermediate risk Has one or more of • Bone imagingh: recommended if T2 and PSA >10 ng/ Recommended
factors (IRF): the following: mL if family history Consider if life
i
T2b–T2c Unfavorable • 2 or 3 IRFs • Pelvic ± abdominal imaging : recommended if positive or expectancy
j See PROS-6
Grade Group 2 or 3 intermediate • Grade Group 3 nomogram predicts >10% probability of pelvic lymph intraductal/cribriform ≥10 y
PSA 10–20 ng/mL • >50% biopsy node involvement histology
cores positivee • If regional or distant metastases are found, see PROS-8 See PROS-1
Has no very-high-risk features and has at least one high-risk • Bone imagingh: recommended
i Consider if life
feature: • Pelvic ± abdominal imaging : recommended if
Recommended expectancy
High • T3a OR nomogram predicts >10% probability of pelvic lymph j See PROS-7
≥10 y
• Grade Group 4 or Grade Group 5 OR node involvement
• PSA >20 ng/mL • If regional or distant metastases are found, see PROS-8
Has at least one of the following: • Bone imagingh: recommended

i
• T3b–T4 • Pelvic ± abdominal imaging : recommended if
Recommended Not routinely
Very high • Primary Gleason pattern 5 nomogram predicts >10% probability of pelvic lymph See PROS-7
recommended
• 2 or 3 high-risk features node involvement
• >4 cores with Grade Group 4 or 5 • If regional or distant metastases are found, see PROS-8
See Footnotes for Initial Risk Stratification And Staging Workup For Clinically Localized Disease (PROS-2A).
PROS-2

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INITIAL RISK STRATIFICATION AND STAGING WORKUP FOR CLINICALLY LOCALIZED DISEASE
c See Principles of Genetics (PROS-B).
d For asymptomatic patients in very-low-, low-, and intermediate-risk groups with life expectancy ≤5 years, no imaging or treatment is indicated until the patient becomes
symptomatic, at which time ADT should be given (See PROS-G).
e An ultrasound- or MRI- or DRE-targeted lesion that is biopsied more than once and demonstrates cancer (regardless of percentage core involvement or number of
cores involved) counts as a single positive core.
f See Principles of Imaging (PROS-C).
g Bone imaging should be performed for any patient with symptoms consistent with bone metastases.
h Plain films, CT, MRI, F-18 sodium fluoride PET/CT or PET/MRI, C-11 choline PET/CT or PET/MRI, or F-18 fluciclovine PET/CT or PET/MRI can be considered for
equivocal results on initial bone scan. See PROS-C.
i mpMRI is preferred over CT for abdominal/pelvic staging. See PROS-C.

j Men with low or favorable intermediate-risk disease and life expectancy ≥10 y may consider the use of the following tumor-based molecular assays: Decipher,
Oncotype DX Prostate, Prolaris, and ProMark. Men with unfavorable intermediate- and high-risk disease and life expectancy ≥10 y may consider the use of Decipher
and Prolaris tumor-based molecular assays. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy (RP)
specimens provide prognostic information independent of NCCN or CAPRA risk groups. These include, but are not limited to, likelihood of death with conservative
management, likelihood of biochemical progression after RP or external beam therapy, and likelihood of developing metastasis after RP or salvage radiotherapy. See
Discussion.

PROS-2A

Table of Contents
VERY LOW RISK GROUP

EXPECTED INITIAL THERAPY ADJUVANT THERAPY
PATIENT
SURVIVALk
Active surveillance (preferred)m Progressive diseaseu
• Consider mpMRI and/or prostate biopsy to confirm candidacy for active surveillancen See Initial Risk Stratification
• PSA no more often than every 6 mo unless clinically indicated and Staging Workup for
• DRE no more often than every 12 mo unless clinically indicated Clinically Localized Disease
• Repeat prostate biopsy no more often than every 12 mo unless clinically indicated (PROS-2)
• Repeat mpMRI no more often than every 12 mo unless clinically indicated
≥20 y EBRTo or brachytherapyo

Adverse feature(s):r,s
EBRTo ± ADTt See Monitoring for Initial
or Definitive Therapy (PROS-10)
Radical prostatectomy (RP)p Observationq
No adverse features
Active surveillancem Progressive diseaseu

• Consider mpMRI and/or prostate biopsy to confirm candidacy for active surveillancen See Initial Risk
• PSA no more often than every 6 mo unless clinically indicated
10–20 yl Stratification and Staging
• DRE no more often than every 12 mo unless clinically indicated
• Repeat prostate biopsy no more often than every 12 mo unless clinically indicated Workup for Clinically
• Repeat mpMRI no more often than every 12 mo unless clinically indicated Localized Disease (PROS-2)
<10 yd Observation q See Monitoring (PROS-10)
See Footnotes for Risk Groups (PROS-7A).

PROS-3

Table of Contents
LOW RISK GROUP

PATIENT
SURVIVALk
Active surveillance (preferred)m
• Consider mpMRI and/or prostate biopsy and/or molecular tumor analysisj to confirm Progressive diseaseu
candidacy for active surveillancen See Initial Risk Stratification
• PSA no more often than every 6 mo unless clinically indicated and Staging Workup for
• DRE no more often than every 12 mo unless clinically indicated Clinically Localized Disease
• Repeat prostate biopsy no more often than every 12 mo unless clinically indicatedv (PROS-2)
≥10 y EBRTo or brachytherapyo
Adverse feature(s):r,s
EBRT o ± ADTt See Monitoring for Initial
or Definitive Therapy (PROS-10)
Observation q
RPp
No adverse features
<10 yd Observation q See Monitoring (PROS-10)

PROS-4

Table of Contents
FAVORABLE INTERMEDIATE RISK GROUP

PATIENT
SURVIVALk
Active surveillancem
Progressive diseaseu
• Consider mpMRI and/or prostate biopsy and/or molecular tumor analysisj to confirm
See Initial Risk
candidacy for active surveillancen
Stratification and
• PSA no more often than every 6 mo unless clinically indicated
Staging Workup for
• DRE no more often than every 12 mo unless clinically indicated
Clinically Localized
• Repeat prostate biopsy no more often than every 12 mo unless clinically indicatedv
Disease (PROS-2)
≥10 y EBRTo or brachytherapy aloneo

Adverse feature(s) and no Undetectable PSA See Monitoring for
lymph node metastases:r,s after RP or PSA Initial Definitive
EBRTo ± ADTt nadirw after RT Therapy (PROS-10)
or
Observationq
See Radical
Prostatectomy PSA
RPp ± PLND if predicted No adverse features or Persistence/Recurrence
probability of lymph node lymph node metastases (PROS-11)
metastasis ≥2%
Lymph node metastasis: PSA persistence/
ADTt,z (category 1) ± EBRTo recurrencex,y
(category 2B)
or See Radiation Therapy
Observationq,aa Recurrence (PROS-12)
EBRTo or brachytherapy aloneo
<10 yd
See Monitoring
Observation (preferred)q (PROS-10)

PROS-5

Table of Contents
UNFAVORABLE INTERMEDIATE RISK GROUP

PATIENT
SURVIVALk Adverse feature(s) and no lymph node
metastases:r,s
EBRT o ± ADTt Undetectable PSA See Monitoring for
or after RP or PSA Initial Definitive
Observation q nadirw after RT Therapy (PROS-10)
RPp ± PLND if predicted
probability of lymph No adverse features or lymph node metastases See Radical
node metastasis ≥2% Prostatectomy
PSA Persistence/
Lymph node metastasis: Recurrence
ADTt,z (category 1) ± EBRT o (category 2B) (PROS-11)
≥10 ybb or
Observation q,aa PSA persistence/
recurrencex,y
EBRTo + ADTt (4–6 mo) See Radiation

or Therapy
EBRTo + brachytherapyo ± ADTt (4–6 mo) Recurrence
(PROS-12)
<10 yd
See Monitoring
Observation (preferred)q
(PROS-10)

PROS-6

Table of Contents
HIGH OR VERY HIGH RISK GROUP

PATIENT
SURVIVALk
EBRTo + ADTt (1.5–3 y; category 1) See Monitoring

± docetaxel (category 1; for very high risk only) Undetectable
for Initial
PSA after RP
Definitive
or PSA nadirw
Therapy
after RT
(PROS-10)
EBRTo + brachytherapyo + ADTt (1–3 y; category 1 for ADT)
>5 y or See Radical

symptomaticbb Adverse feature(s) and no lymph node metastases:r,s Prostatectomy
EBRT o ± ADTt PSA
or Persistence/
Observation q Recurrence
(PROS-11)
RPp + PLNDcc No adverse features or lymph node metastases PSA persistence/

recurrencex,y
Lymph node metastasis:
ADTt,z (category 1) ± EBRT o (category 2B) See Radiation
or Therapy
Observation q,aa Recurrence
(PROS-13)
Observationq
or
≤5 y and See Monitoring
ADTt,dd
asymptomatic (PROS-10)
or
EBRTo,dd

PROS-7

Table of Contents
FOOTNOTES
d For asymptomatic patients in very-low-, low-, and intermediate-risk groups with
life expectancy ≤5 years, no imaging or treatment is indicated until the patient t See Principles of Androgen Deprivation Therapy (PROS-G).
becomes symptomatic, at which time ADT should be given (See PROS-G). u Criteria for progression are not well defined and require physician judgment;

j Men with low or favorable intermediate-risk disease and life expectancy ≥10 y however, a change in risk group strongly implies disease progression. See
may consider the use of the following tumor-based molecular assays: Decipher, Discussion.
Oncotype DX Prostate, Prolaris, and ProMark. Men with unfavorable intermediate- v Repeat molecular tumor analysis is discouraged.
and high-risk disease and life expectancy ≥10 y may consider the use of Decipher w PSA nadir is the lowest value reached after EBRT or brachytherapy.
and Prolaris tumor-based molecular assays. Retrospective studies have shown x PSA persistence/recurrence after RP is defined as failure of PSA to fall to
that molecular assays performed on prostate biopsy or RP specimens provide undetectable levels (PSA persistence) or undetectable PSA after RP with a
prognostic information independent of NCCN or CAPRA risk groups. These subsequent detectable PSA that increases on 2 or more determinations (PSA
include, but are not limited to, likelihood of death with conservative management, recurrence).
likelihood of biochemical progression after RP or external beam therapy, and y RTOG-ASTRO (Radiation Therapy Oncology Group - American Society for
likelihood of developing metastasis after RP or salvage radiotherapy. See Therapeutic Radiology and Oncology) Phoenix Consensus: 1) PSA increase by 2
Discussion. ng/mL or more above the nadir PSA is the standard definition for PSA persistence/
k See Principles of Life Expectancy Estimation (PROS-A). recurrence after EBRT with or without HT; and 2) A recurrence evaluation should
l The Panel remains concerned about the problems of overtreatment related be considered when PSA has been confirmed to be increasing after radiation
to the increased diagnosis of early prostate cancer from PSA testing. See even if the increase above nadir is not yet 2 ng/mL, especially in candidates for
NCCN Guidelines for Prostate Cancer Early Detection. Active surveilance is salvage local therapy who are young and healthy. Retaining a strict version of the
recommended for this subset of patients. ASTRO definition allows comparison with a large existing body of literature. Rapid
m Active surveillance involves actively monitoring the course of disease with the increase of PSA may warrant evaluation (prostate biopsy) prior to meeting the
expectation to intervene with potentially curative therapy if the cancer progresses. Phoenix definition, especially in younger or healthier men.
See Principles of Active Surveillance and Observation (PROS-D). z See monitoring for N1 on ADT (PROS-10).
n If higher grade and/or higher T stage is found, see PROS-2. aa Patients with pN1 disease who chose observation should see PROS-10 for
o See Principles of Radiation Therapy (PROS-E). monitoring for initial definitive therapy if PSA is undetectable. For patients with
p See Principles of Surgery (PROS-F). pN1 disease and PSA persistence, see PROS-11.
q Observation involves monitoring the course of disease with the expectation to bb Active surveillance of unfavorable intermediate and high-risk clinically localized
deliver palliative therapy for the development of symptoms or a change in exam or cancers is not recommended in patients with a life expectancy >10 years
PSA that suggests symptoms are imminent. See Principles of Active Surveillance (category 1).
and Observation (PROS-D). cc RP
+ PLND can be considered in younger, healthier patients without tumor
r Adverse laboratory/pathologic features include: positive margin(s); seminal vesicle fixation to the pelvic sidewall.
invasion; extracapsular extension; or detectable PSA. dd ADT or EBRT may be considered in selected patients with high- or very-high-
s Decipher molecular assay is recommended to inform adjuvant treatment if risk disease, where complications, such as hydronephrosis or metastasis, can be
adverse features are found post-RP. expected within 5 y.

PROS-7A

Table of Contents
GENETIC AND MOLECULAR BIOMARKER ANALYSIS FOR ADVANCED PROSTATE CANCERc
Risk Group Clinical/Pathologic Features Germline Testingc Molecular and Biomarker Analysis of Tumorc Initial Therapy
Consider tumor testing for homologous recombination

Regional Any T, N1, M0 Recommended gene mutations (HRRm) and for microsatellite instability See PROS-9
(MSI) or mismatch repair deficiency (dMMR)
Recommend tumor testing for HRRm and consider tumor
Metastaticee Any T, Any N, M1 Recommended testing for MSI or dMMR See PROS-13
ee ADT alone (see PROS-G) or observation is recommended for asymptomatic

c See Principles of Genetics (PROS-B). patients with metastatic disease and life expectancy ≤5 years.

PROS-8

Table of Contents
REGIONAL RISK GROUP

EXPECTED INITIAL THERAPY
PATIENT
SURVIVALk
EBRTo + ADTt (preferred)
EBRTo + ADTt + abirateronet
>5 y EBRTo + ADTt + fine-particle

See Monitoring (PROS-10)
or symptomatic abirateronet (category 2B)
ADTt ± abirateronet
ADTt + fine-particle
abirateronet (category 2B)
Observationq
≤5 y
or
and asymptomatic
ADTt
q Observation involves monitoring the course of disease with the expectation

to deliver palliative therapy for the development of symptoms or a change in
exam or PSA that suggests symptoms are imminent. See Principles of Active
k See Principles of Life Expectancy Estimation (PROS-A). Surveillance and Observation (PROS-D).
o See Principles of Radiation Therapy (PROS-E). t See Principles of Androgen Deprivation Therapy (PROS-G).

PROS-9

Table of Contents
MONITORING RECURRENCE
See Radical
See NCCN Guidelines For Survivorship
PSA persistence/ Prostatectomy PSA
Post-RP
recurrencex Persistence/Recurrence
(PROS-11)
PSA
• PSA every 6–12 mo for 5 y,ff persistence/ See Radiation
Initial definitive then every year Post-RT recurrencey Therapy Recurrence
therapy • DRE every year, but may be or (PROS-12)
omitted if PSA undetectable Positive DRE
Progressiongg to metastatic See Systemic Therapy

disease without PSA persistence/ for Castration-Naive
recurrence Disease (PROS-13)ii
Systemic Therapy for
N1 on ADT N1,M0 M0 CRPC (PROS-14)jj
• Physical exam + PSA every
or
3–6 mo Progressiongg,hh
Localized on
• Imaging for symptoms or See Systemic Therapy for
observation M1
increasing PSAf M1 CRPC (PROS-15)jj
gg Document castrate levels of testosterone if on ADT. Workup for progression should
include bone imaging, chest CT, and abdominal/pelvic CT or abdominal/pelvic MRI with
and without contrast. If there is no evidence of metastases, consider C-11 choline PET/
x PSA persistence/recurrence after RP
CT or PET/MRI or F-18 fluciclovine PET/CT or PET/MRI for further soft tissue and bone
is defined as failure of PSA to fall to undetectable evaluation or F-18 sodium fluoride PET/CT or PET/MRI for further bone evaluation. The
levels (PSA persistence) or undetectable PSA after RP with a subsequent detectable PSA Panel remains unsure of what to do when M1 is suggested by next-generation imaging
that increases on 2 or more determinations (PSA recurrence). but not on conventional imaging. See Principles of Imaging (PROS-C) and Discussion.
y RTOG-ASTRO (Radiation Therapy Oncology Group - American Society for Therapeutic hh Treatment for patients who progressed on observation of localized disease is ADT (See
Radiology and Oncology) Phoenix Consensus: 1) PSA increase by 2 ng/mL or more
Principles of Androgen Deprivation Therapy (PROS-G).
above the nadir PSA is the standard definition for PSA persistence/recurrence after EBRT ii The term "castration-naive" is used to define patients who are not on ADT at the time of
with or without HT; and 2) A recurrence evaluation should be considered when PSA has
progression. The NCCN Prostate Cancer Panel uses the term "castration-naive" even
been confirmed to be increasing after radiation even if the increase above nadir is not yet
when patients have had neoadjuvant, concurrent, or adjuvant ADT as part of radiation
2 ng/mL, especially in candidates for salvage local therapy who are young and healthy.
therapy provided they have recovered testicular function.
Retaining a strict version of the ASTRO definition allows comparison with a large existing jj Castration-resistant prostate cancer (CRPC) is prostate cancer that progresses clinically,
body of literature. Rapid increase of PSA may warrant evaluation (prostate biopsy) prior to radiographically, or biochemically despite castrate levels of serum testosterone (<50 ng/
meeting the Phoenix definition, especially in younger or healthier men. dL). Scher HI, Halabi S, Tannock I, et al. Design and end points of clinical trials for patients
ff PSA
as frequently as every 3 mo may be necessary to clarify disease status, especially in with progressive prostate cancer and castrate levels of testosterone: recommendations of
high-risk men. the Prostate Cancer Clinical Trials Working Group. J Clin Oncol 2008;26:1148-1159.

PROS-10

Table of Contents
RADICAL PROSTATECTOMY PSA PERSISTENCE/RECURRENCE
Studies negative
• Risk stratificationkk for EBRTo ± ADTt See Systemic Therapy
PSADT distant metastases or Progressiongg for Castration-Naive
Consider: or imaging not Observationq Disease (PROS-13)
• Bone imagingf,ll performed
• Chest CTf
• Abdominal/pelvic CT or
PSA persistence/
abdominal/pelvic MRIf
recurrencex
• C-11 choline or F-18
fluciclovine PET/CT or PET/
MRIf,mm
• Prostate bed biopsy See Systemic Therapy for
Studies positive for
(especially if imaging Castration-Naive Disease
distant metastases
suggests local recurrence) (PROS-13)
gg Document castrate levels of testosterone if on ADT. Workup for progression

should include bone imaging, chest CT, and abdominal/pelvic CT or abdominal/
pelvic MRI with and without contrast. If there is no evidence of metastases,
f See Principles of Imaging (PROS-C). consider C-11 choline PET/CT or PET/MRI or F-18 fluciclovine PET/CT or PET/
MRI for further soft tissue and bone evaluation or F-18 sodium fluoride PET/CT
o See Principles of Radiation Therapy (PROS-E).
or PET/MRI for further bone evaluation. The Panel remains unsure of what to
q Observation involves monitoring the course of disease with the expectation do when M1 is suggested by next-generation imaging but not on conventional
to deliver palliative therapy for the development of symptoms or a change in imaging. See Principles of Imaging (PROS-C) and Discussion.
exam or PSA that suggests symptoms are imminent. See Principles of Active kk PSADT
can be calculated to inform nomogram use and counseling and/or
Surveillance and Observation (PROS-D). Decipher molecular assay (category 2B) can be considered to inform counseling.
t See Principles of Androgen Deprivation Therapy (PROS-G). ll F-18 sodium fluoride or C-11 choline or F-18 fluciclovine PET/CT or PET/MRI can
x PSA persistence/recurrence after RP is defined as failure of PSA to fall to be considered after bone scan for further evaluation when clinical suspicion of
undetectable levels (PSA persistence) or undetectable PSA after RP with a bone metastases is high.
subsequent detectable PSA that increases on 2 or more determinations (PSA mm Histologic
confirmation is recommended whenever feasible due to significant
recurrence). rates of false positivity.

PROS-11

Table of Contents
RADIATION THERAPY RECURRENCE

Observationq
or
RP + PLNDp
or
Transrectal Brachytherapyo
ultrasound or
(TRUS) biopsy Cryotherapy
positive, studies or See Systemic
• Risk stratificationnn High-intensity Progressiongg Therapy for
PSADT negative
for distant focused Castration-Naive
• Bone imagingf,ll ultrasound Disease (PROS-13)
Candidate for metastases
• Prostate MRI (HIFU)
local therapy:
• TRUS biopsy (category 2B) or
• Original clinical
• Consider: TRUS biopsy
stage T1–T2,
Chest CTf negative, Observationq See Systemic
NX or N0
• Life expectancy
Abdominal/pelvic studies negative or Therapy for M0
>10 y
CT or abdominal/ for distant ADTt CRPC (PROS-14)
pelvic MRIf metastases
• PSA <10 ng/mL
C-11 choline or F-18 or
fluciclovine PET/CT
or PET/MRIf,mm See Systemic
PSA Studies positive for distant metastases
persistence/ Therapy for M1
recurrencey CRPC (PROS-15)
or
Positive DRE
Not a candidate
Bone imagingf,ll See Systemic Therapy for Castration-Naive Disease (PROS-13)
for local therapy
See footnotes (PROS-12A).

PROS-12

Table of Contents
FOOTNOTES
p See Principles of Surgery (PROS-F).
q Observation involves monitoring the course of disease with the expectation to deliver palliative therapy for the development of symptoms or a change in exam or PSA
that suggests symptoms are imminent. See Principles of Active Surveillance and Observation (PROS-D).
t See Principles of Androgen Deprivation Therapy (PROS-G).
y RTOG-ASTRO (Radiation Therapy Oncology Group - American Society for Therapeutic Radiology and Oncology) Phoenix Consensus: 1) PSA increase by 2 ng/
mL or more above the nadir PSA is the standard definition for PSA persistence/recurrence after EBRT with or without HT; and 2) A recurrence evaluation should be
considered when PSA has been confirmed to be increasing after radiation even if the increase above nadir is not yet 2 ng/mL, especially in candidates for salvage local
therapy who are young and healthy. Retaining a strict version of the ASTRO definition allows comparison with a large existing body of literature. Rapid increase of PSA
may warrant evaluation (prostate biopsy) prior to meeting the Phoenix definition, especially in younger or healthier men.
gg Document castrate levels of testosterone if on ADT. Workup for progression should include bone imaging, chest CT, and abdominal/pelvic CT or abdominal/pelvic MRI
with and without contrast. If there is no evidence of metastases, consider C-11 choline PET/CT or PET/MRI or F-18 fluciclovine PET/CT or PET/MRI for further soft
tissue and bone evaluation or F-18 sodium fluoride PET/CT or PET/MRI for further bone evaluation. The Panel remains unsure of what to do when M1 is suggested by
next-generation imaging but not on conventional imaging. See Principles of Imaging (PROS-C) and Discussion.
ll F-18 sodium fluoride or C-11 choline or F-18 fluciclovine PET/CT or PET/MRI can be considered after bone scan for further evaluation when clinical suspicion of bone
metastases is high.
mm Histologic confirmation is recommended whenever feasible due to significant rates of false positivity.
nn PSADT can be calculated to inform nomogram use and counseling.

PROS-12A

Table of Contents
SYSTEMIC THERAPY FOR CASTRATION-NAIVE PROSTATE CANCERoo
Observation (preferred)q Studies

See
M0 or Systemic
negative
ADTt,ss Therapy for
for distant
M0 CRPC
ADTt with one of the following: metastases
(PROS-14)
• Preferred regimens:
Apalutamide (category 1)t • Physical exam +
Abiraterone (category 1)t PSA every 3–6 mo
Docetaxel 75 mg/m2 for 6 cyclestt (category 1)uu • Imaging for Progression gg,vv
Enzalutamide (category 1)t symptoms or
• Other recommended regimens: increasing PSAf
M1pp,qq,rr Fine-particle abiraterone (category 2B)t See
• EBRTo to the primary tumor for low-volume M1tt Studies
Systemic
or positive
Therapy for
for distant
ADTt,ss metastases
M1 CRPC
(PROS-15)
exam or PSA that suggests symptoms are imminent. See Principles of Active pp EBRT to sites of metastases can be considered if metastases are in weight-
Surveillance and Observation (PROS-D). bearing bones or if the patient is symptomatic.
t See Principles of Androgen Deprivation Therapy (PROS-G). qq ADT alone (see PROS-G) or observation are recommended for asymptomatic
gg Document castrate level of testosterone if on ADT. Workup for progression patients with metastatic disease and life expectancy ≤5 years.
should include bone imaging, chest CT, and abdominal/pelvic CT or abdominal/ rr Tumor testing for MSI-H or dMMR and germline tumor testing for homologous
pelvic MRI with and without contrast. If there is no evidence of metastases, recombination gene mutations is recommended. See Principles of Genetics
consider C-11 choline PET/CT or PET/MRI or F-18 fluciclovine PET/CT or PET/ (PROS-B).
MRI for further soft tissue and bone evaluation or F-18 sodium fluoride PET/CT ss Intermittent
ADT can be considered for men with M0 or M1 disease to reduce
or PET/MRI for further bone evaluation. The Panel remains unsure of what to toxicity. See Principles of Androgen Deprivation Therapy (PROS-G).
do when M1 is suggested by next-generation imaging but not on conventional tt High-volume disease is differentiated from low-volume disease by visceral
imaging. See Principles of Imaging (PROS-C) and Discussion. metastases and/or 4 or more bone metastases, with at least one metastasis
oo The term "castration-naive" is used to define patients who are not on ADT at beyond the pelvis vertebral column. Patients with low-volume disease have less
the time of progression. The NCCN Prostate Cancer Panel uses the term certain benefit from early treatment with docetaxel combined with ADT.
"castration-naive" even when patients have had neoadjuvant, concurrent, uu See Principles of Immunotherapy and Chemotherapy (PROS-H).
or adjuvant ADT as part of radiation therapy provided they have recovered vv Patients who were under observation for M0 disease should receive an
testicular function. appropriate therapy for castration-naive disease.

PROS-13

Table of Contents
SYSTEMIC THERAPY FOR M0 CASTRATION–RESISTANT PROSTATE CANCER (CRPC)jj

Change or
maintain current
No metastases
Observation treatment
(M0)
PSADT (preferred)q and continue
>10 mo or monitoring
Other secondary
hormone therapyt Yes Imaginggg
Continue ADT
Conventional
to maintain
imaging
castrate See Systemic
studies PSA
serum Metastases (M1) Therapy for M1
negative increasing
levels of Preferred regimens: CRPC (PROS-15)
for distant
testosterone • Apalutamidet
metastases
(<50 ng/dL) (category 1)
Darolutamidet Maintain current treatment
No and continue monitoring
(category 1)
PSADT
• Enzalutamidet
≤10 mo
(category 1)
Other recommended
regimens:
• Other secondary
hormone therapyt

exam or PSA that suggests symptoms are imminent. See Principles of Active
Surveillance and Observation (PROS-D).
gg Document castrate level of testosterone if on ADT. Workup for progression
should include bone imaging, chest CT, and abdominal/pelvic CT or abdominal/
pelvic MRI with and without contrast. If there is no evidence of metastases, jj CRPC is prostate cancer that progresses clinically, radiographically, or
consider C-11 choline PET/CT or PET/MRI or F-18 fluciclovine PET/CT or PET/ biochemically despite castrate levels of serum testosterone (<50 ng/dL).
MRI for further soft tissue and bone evaluation or F-18 sodium fluoride PET/CT Scher HI, Halabi S, Tannock I, et al. Design and end points of clinical trials for
or PET/MRI for further bone evaluation. The Panel remains unsure of what to patients with progressive prostate cancer and castrate levels of testosterone:
do when M1 is suggested by next-generation imaging but not on conventional recommendations of the Prostate Cancer Clinical Trials Working Group. J Clin
imaging. See Principles of Imaging (PROS-C) and Discussion. Oncol 2008;26:1148-1159.

PROS-14

Table of Contents
SYSTEMIC THERAPY FOR M1 CRPC
• Metastatic lesion • Continue ADTt to maintain

biopsyww castrate levels of serum
• Tumor testing testosterone (<50 ng/dL) Adenocarcinomaww See PROS-16
for MSI-H or • Additional treatment
CRPC, dMMR if not options:
conventional previously Bone antiresorptive
imaging performedc therapy with denosumab
studies • Germline and (category 1, preferred)
positive tumor testing or zoledronic acid First-line and subsequent treatment
for metastases for homologous if bone metastases optionsxx:
recombination present • Chemotherapyyy,zz
Small cell/
gene mutations Palliative RTo for painful Cisplatin/etoposide
neuroendocrine
if not previously bone metastases Carboplatin/etoposide
prostate
performedc Best supportive care Docetaxel/carboplatin
cancerww
Atezolizumab/carboplatin/etoposide
(category 3)
• Best supportive care
c See Principles of Genetics (PROS-B). xx Workup

for progression should include chest CT, bone imaging, and abdominal/
t See Principles of Androgen Deprivation Therapy (PROS-G). pelvic CT or abdominal/pelvic MRI with and without contrast. See Principles of
o See Principles of Radiation Therapy (PROS-E). Imaging (PROS-C) and Discussion.
ww Histologic evidence of both adenocarcinoma and small cell yy See Principles of Immunotherapy and Chemotherapy (PROS-H).
carcinoma may
zz For additional options for subsequent therapy, see NCCN Guidelines for Small
be present, in which case treatment can follow either pathway. Treat as
adenocarcinoma if biopsy is not feasible or not performed. Cell Lung Cancer.

PROS-15

Table of Contents
SYSTEMIC THERAPY FOR M1 CRPC: ADENOCARCINOMAaaa,bbb,ccc

FIRST-LINE TREATMENT SECOND-LINE TREATMENT SUBSEQUENT TREATMENT
First-line abiraterone/enzalutamidehhh,iii (All systemic therapies
• Preferred regimens: are category 2B if visceral
Docetaxel (category 1)yy,ccc metastases are present)
Sipuleucel-Tyy,fff
• Useful in certain circumstances:
Olaparib for HRRm (category 1)kkk
• Preferred regimens: Pembrolizumab for MSI-H or dMMRyy (category 2B)
Abirateronet (category 1ddd) Radium-223ggg for symptomatic bone metastases
(category 1) • Preferred regimens:
Docetaxelyy,eee (category 1)
Enzalutamidet (category 1) Rucaparib for BRCAmlll Abirateronet (category 1ddd)
Sipuleucel-Tyy,fff (category 1) • Other recommended regimens: Cabazitaxelyy (category 1ddd)
• Useful in certain circumstances: Abirateronet Docetaxel rechallengeyy,ccc
Radium-223ggg for Cabazitaxelyy Enzalutamidet (category 1ddd)
symptomatic bone metastases Enzalutamidet • Useful in certain circumstances:
(category 1) Fine-particle abirateronet Olaparib for HRRm (category 1)kkk
Mitoxantrone for palliation Other secondary hormone therapyt Pembrolizumab for MSI-H or
in symptomatic patients dMMRyy (category 2B)
First-line docetaxeliii Mitoxantrone for palliation in
with visceral metastases • Preferred regimens:
who cannot tolerate other symptomatic patients who cannot
Abirateronet (category 1) tolerate other therapiesyy
therapiesyy
• Other recommended regimens Cabazitaxelyy (category 1)jjj Radium-223ggg for symptomatic
Fine-particle abirateronet Enzalutamidet (category 1) bone metastases (category 1ddd)
Other secondary hormone • Useful in certain circumstances: Rucaparib for BRCAmlll
therapyt Mitoxantrone for palliation in symptomatic patients • Other recommended regimens:
who cannot tolerate other therapiesyy
Fine-particle abirateronet
Olaparib for HRRm (category 2B)kkk
Pembrolizumab for MSI-H or dMMRyy (category 2B) Other secondary hormone therapyt
Radium-223ggg for symptomatic bone metastases
(category 1)
Rucaparib for BRCAmlll
• Other recommended regimens:
Consider docetaxel rechallengeyy,ccc
Fine-particle abirateronet
Sipuleucel-Tyy,fff
See footnotes (PROS-16A). Other secondary hormone therapyt
PROS-16

Table of Contents
FOOTNOTES
yy See Principles of Immunotherapy and Chemotherapy (PROS-H).
aaa Visceral metastases refers to liver, lung, adrenal, peritoneal, and brain metastases. Soft tissue/lymph node sites are not considered visceral metastases.
bbb Patients can continue through all treatment options listed. Best supportive care is always an appropriate option.
ccc Patients with disease progression on a given therapy should not repeat that therapy, with the exception of docetaxel, which can be given as a rechallenge in the
second- or subsequent-line metastatic CRPC setting if given in the castration-naive setting.
ddd The noted category applies only if no visceral metastases.
eee Although most patients without symptoms are not treated with chemotherapy, the survival benefit reported for docetaxel applies to those with or without
symptoms. Docetaxel may be considered for patients with signs of rapid progression or visceral metastases despite lack of symptoms.
fff Benefit with sipuleucel-T has not been reported in patients with visceral metastases and is not recommended if visceral metastases are present. Sipuleucel-T also
is not recommended for patients with small cell/neuroendocrine prostate cancer.
ggg Radium-223 is not recommended for use in combination with docetaxel or any other systemic therapy except ADT and should not be used in patients with
visceral metastases. Concomitant use of denosumab or zoledronic acid is recommended. See Principles of Radiation Therapy (PROS-E).
hhh Consider AR-V7 testing to help guide selection of therapy (See Discussion).
iii Workup for progression should include chest CT, bone imaging, and abdominal/pelvic CT or abdominal/pelvic MRI with and without contrast. Consider metastatic
lesion biopsy. If small cell neuroendocrine is found, see PROS-15. See Principles of Imaging (PROS-C) and Discussion.
jjj de Wit R, de Bono J, Sternberg C, et al. Cabazitaxel versus abiraterone or enzalutamide in metastatic prostate cancer. N Engl J Med 2019; 381:2506-2518.
kkk Olaparib
is a treatment option for patients with mCRPC and a pathogenic mutation (germline and/or somatic) in a homologous recombination repair gene
(BRCA1, BRCA2, ATM, BARD1, BRIP1, CDK12, CHEK1, CHEK2, FANCL, PALB2, RAD51B, RAD51C, RAD51D or RAD54L), who have been treated with
androgen receptor-directed therapy. Patients with PPP2R2A mutations in the PROfound trial experienced an unfavorable risk-benefit profile. Therefore, olaparib
is not recommended in patients with a PPP2R2A mutations. (See Discussion).
lll Rucaparib is a treatment option for patients with mCRPC and a pathogenic BRCA1 or BRCA2 mutation (germline and/or somatic) who have been treated with
androgen receptor-directed therapy and a taxane-based chemotherapy. If the patient is not fit for chemotherapy, rucaparib can be considered even if taxane-
based therapy has not been given.

PROS-16A

Table of Contents
PRINCIPLES OF LIFE EXPECTANCY ESTIMATION

• Life expectancy estimation is critical to informed decision-making in prostate cancer early detection and treatment.
• Estimation of life expectancy is possible for groups of men but challenging for individuals.
• Life expectancy can be estimated using:

The Social Security Administration tables (www.ssa.gov/OACT/STATS/table4c6.html)
The WHO’s Life Tables by country (http://apps.who.int/gho/data/view.main.60000?lang=en)
The Memorial Sloan Kettering Male Life Expectancy tool (https://webcore.mskcc.org/survey/surveyform.aspx?preview=true&excelsurveylis
tid=4).
• Life expectancy can then be adjusted using the clinician’s assessment of overall health as follows:
Best quartile of health - add 50%
Worst quartile of health - subtract 50%
Middle two quartiles of health - no adjustment
• Example of 5-year increments of age are reproduced in the NCCN Guidelines for Older Adult Oncology for life expectancy estimation.

PROS-A

Table of Contents
PRINCIPLES OF GENETICS
Germline Testing does not have clear therapeutic implications in advanced disease,
• The panel recommends inquiring about family and personal history but testing may be valuable for family counseling.
of cancer and family history for known germline variants at time of • Patient should be counseled to inform providers of any update to
initial diagnosis. In cases when a patient says he was tested and family history.
had negative results, the clinician should inquire about the details • Genetic testing in the absence of family history or clinical features
of testing. Direct-to-consumer genetic tests do not test for all known (eg, high- or very-high-risk prostate cancer) may be of low yield.
relevant variants. • The prevalence of inherited (germline) DNA repair gene mutations in
• Germline genetic testing is recommended for patients with prostate men with metastatic prostate cancer, unselected for family history
cancer and any of the following: (n = 692), was found to be 11.8% (BRCA2 5.3%, ATM 1.6%, CHEK2
High-risk, very-high-risk, regional, or metastatic prostate cancer 1.9%, BRCA1 0.9%, RAD51D 0.4%, and PALB2 0.4%). The prevalence
Ashkenazi Jewish ancestry was 6% in the localized high-risk population in the TCGA cohort
Family history of high-risk germline mutations (eg, BRCA1/2, (Cancer Genome Atlas Research Network. The molecular taxonomy
Lynch mutation) of primary prostate cancer. Cell 2015;163:1011-1025; Pritchard CC,
A positive family history of cancer: Mateo J, Walsh MF, et al. Inherited DNA-repair gene mutations in
◊◊A strong family history of prostate cancer consists of: brother men with metastatic prostate cancer. N Engl J Med 2016;375:443-
or father or multiple family members who were diagnosed with 453).
prostate cancer (but not clinically localized Grade Group 1) at • Genetic counseling resources and support is critical and pre-test
<60 years of age or who died from prostate cancer counseling is preferred when feasible, especially if family history is
OR positive.
◊◊≥3 cancers on same side of family, especially diagnoses ≤50 • Post-test genetic counseling is recommended if a germline mutation
years of age: bile duct, breast, colorectal, endometrial, gastric, (pathogenic variant) is identified. Cascade testing for relatives is
kidney, melanoma, ovarian, pancreatic, prostate (but not critical to inform the risk for familial cancers in male and female
clinically localized Grade Group 1), small bowel, or urothelial relatives.
cancer • If no pathogenic variant mutations or only germline variants of
• Limited data suggest that prostate cancers with cribriform (ductal or unknown significance (VUS) are identified but family history is
intraductal) histology have increased genomic instability. positive, genetic counseling is recommended to discuss possible
• Family history for known germline variants and genetic testing for participation in family studies and variant reclassification studies.
germline variants should include MLH1, MSH2, MSH6, and PMS2 (for • Resources are available to check the known pathologic effects of
Lynch syndrome) and homologous recombination genes BRCA1, genomic variants (eg, https://brcaexchange.org/about/app; https://
BRCA2, ATM, PALB2, and CHEK2. www.ncbi.nlm.nih.gov/clinvar/)
Consider cancer predisposition next-generation sequencing • Information regarding germline mutations in patients with metastatic
(NGS) panel testing, which includes BRCA1, BRCA2, ATM, PALB2, disease can be used to inform future treatments or to determine
CHEK2, MLH1, MSH2, MSH6, and PMS2. eligibility for clinical trials.
Additional genes may be appropriate depending on clinical
context. For example, HOXB13 is a prostate cancer risk gene that

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PRINCIPLES OF GENETICS
Somatic Tumor Testing of treatment for CRPC (see PROS-16).
• Recommend evaluating tumor for alterations in homologous
recombination DNA repair genes, such as BRCA1, BRCA2, ATM,
PALB2, FANCA, RAD51D, CHEK2, and CDK12, in patients with
metastatic prostate cancer. This testing can be considered in men
with regional prostate cancer.
At present, this information may be used for genetic counseling,
early use of platinum chemotherapy, olaparib, and/or eligibility
for clinical trials (eg, PARP inhibitors). Clinical trials may include
additional candidate DNA repair genes under investigation as
molecular biomarkers.
If mutations in BRCA1, BRCA2, ATM, PALB2, and CHEK2 are found
and/or there is a strong family history of cancer, refer to genetic
counseling for confirmatory germline testing.
Somatic testing may require repetition when prostate cancer
progresses after treatment.
Patients should be informed that somatic tumor sequencing has
the potential to uncover germline findings. However, virtually
no somatic NGS test is designed or validated for germline
assessment. Therefore, overinterpretation of germline findings
should be avoided. If a germline mutation is suspected, the patient
should be recommended for follow-up with genetic counseling and
dedicated germline testing.
• Tumor testing for MSI-H or dMMR can be considered in patients
with regional or castration-naive metastatic prostate cancer and is
recommended in patients with metastatic CRPC.
DNA analysis for MSI and immunohistochemistry (IHC) for MMR are
different assays measuring the same biological effect. If MSI is
used, testing using an NGS assay validated for prostate cancer
is preferred. Hempelmann JA, Lockwood CM, Konnick EQ, et
al. Microsatellite instability in prostate cancer by PCR or next-
generation sequencing (NGS). J Immunother Cancer 2018;6:29.
If MSI-H or dMMR is found, refer to genetic counseling to assess
for the possibility of Lynch syndrome.
MSI-H or dMMR indicate eligibility for pembrolizumab in later lines

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PRINCIPLES OF IMAGING
Goals of Imaging Ultrasound
• Imaging is performed for the detection and characterization of disease • Ultrasound uses high-frequency sound waves to image small
to select treatment or guide change in management. regions of the body.
• Imaging techniques can evaluate anatomic or functional parameters. Standard ultrasound imaging provides anatomic information.
Anatomic imaging techniques include plain film radiographs, Vascular flow can be assessed using Doppler ultrasound
ultrasound, CT, and MRI. techniques.
Functional imaging techniques include radionuclide bone scan, • Endorectal ultrasound is used to guide transrectal biopsies of the
PET/CT, and advanced MRI techniques, such as spectroscopy and prostate.
diffusion-weighted imaging (DWI). • Endorectal ultrasound can be considered for patients with
Efficacy of Imaging suspected recurrence after RP.
• The utility of imaging for men with early PSA persistence/recurrence • Advanced ultrasound techniques for imaging of the prostate and
after RP depends on risk group prior to operation, pathologic for differentiation between prostate cancer and prostatitis are
Gleason grade and stage, PSA, and PSA doubling time (PSADT) after under evaluation.
recurrence. Low- and intermediate-risk groups with low serum PSAs Bone Imaging
postoperatively have a very low risk of positive bone scans or CT • The use of the term “bone scan” refers to the conventional
scans. technetium-99m-MDP bone scan in which technetium is taken up
• Frequency of imaging should be based on individual risk, age, PSADT, by bone that is turning over and imaged with a gamma camera
Gleason score, and overall health. using planar imaging or 3-D imaging with single-photon emission
• Conventional bone scans are rarely positive in asymptomatic men CT (SPECT).
with PSA <10 ng/mL. The relative risk for bone metastasis or death Sites of increased uptake imply accelerated bone turnover and
increases as PSADT shortens. Bone imaging should be performed may indicate metastatic disease.
more frequently when PSADT ≤8 mo, where there appears to be an Osseous metastatic disease may be diagnosed based on the
inflection point. overall pattern of activity, or in conjunction with anatomic
Plain Radiography imaging.
• Plain radiography can be used to evaluate symptomatic regions in the • Bone scan is indicated in the initial evaluation of patients at high
skeleton. However, conventional plain x-rays will not detect a bone risk for skeletal metastases.
lesion until nearly 50% of the mineral content of the bone is lost or • Bone scan can be considered for the evaluation of the post-
gained. prostatectomy patient when there is failure of PSA to fall to
• CT or MRI may be more useful to assess fracture risk as these undetectable levels, or when there is undetectable PSA after RP
modalities permit more accurate assessment of cortical involvement with a subsequent detectable PSA that increases on 2 or more
than plain films where osteoblastic lesions may obscure cortical subsequent determinations.
involvement. • Bone scan can be considered for the evaluation of patients with
an increasing PSA or positive DRE after RT if the patient is a
candidate for additional local therapy or systemic therapy.
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• Bone scans are helpful to monitor metastatic prostate cancer to Computed Tomography
determine the clinical benefit of systemic therapy. However, new • CT provides a high level of anatomic detail, and may detect gross
lesions seen on an initial post-treatment bone scan, compared to the extracapsular disease, nodal metastatic disease, and/or visceral
pre-treatment baseline scan, may not indicate disease progression. metastatic disease.
• New lesions in the setting of a falling PSA or soft tissue response • CT is generally not sufficient to evaluate the prostate gland.
and in the absence of pain progression at that site may indicate • CT may be performed with and without oral and intravenous
bone scan flare or an osteoblastic healing reaction. For this contrast, and CT technique should be optimized to maximize
reason, a confirmatory bone scan 8–12 weeks later is warranted diagnostic utility while minimizing radiation dose.
to determine true progression from flare reaction. Additional new • CT can be used for examination of the pelvis and/or abdomen for
lesions favor progression. Stable scans make continuation of initial evaluation (see PROS-2) and as part of workup for recurrence
treatment reasonable. Bone scan flare is common, particularly on or progression (see PROS-11 through PROS-16).
initiation of new hormonal therapy, and may be observed in nearly Magnetic Resonance Imaging
half of patients treated with the newer agents, enzalutamide and • The strengths of MRI include high soft tissue contrast and
abiraterone. Similar flare phenomena may exist with other imaging characterization, multiparametric image acquisition, multiplanar
modalities, such as CT or PET/CT imaging. imaging capability, and advanced computational methods to assess
• Bone scans and soft tissue imaging (CT or MRI) in men with function.
metastatic prostate cancer or non-metastatic progressive prostate MRI can be performed with and without the administration of
cancer may be obtained regularly during systemic therapy to assess intravenous contrast material.
clinical benefit. Resolution of MRI images in the pelvis can be augmented using an
• Bone scans should be performed for symptoms and as often as endorectal coil.
every 6–12 mo to monitor ADT. The need for soft tissue images • Standard MRI techniques can be used for examination of the pelvis
remains unclear. In CRPC, 8- to 12-week imaging intervals appear and/or abdomen for initial evaluation (see PROS-2) and as part of
reasonable. workup for recurrence or progression (see PROS-11 through PROS-
• PET/CT for detection of bone metastatic disease in patients with M0 16).
CRPC. • MRI may be considered in patients after RP when PSA fails to fall
F-18 sodium fluoride PET/CT or PET/MRI may be used to detect to undetectable levels or when an undetectable PSA becomes
bone metastatic disease with greater sensitivity but less specificity detectable and increases on 2 or more subsequent determinations,
than standard bone scan imaging. or after RT for increasing PSA or positive DRE if the patient is a
Plain films, CT, MRI, F-18 sodium fluoride PET/CT or PET/MRI, C-11 candidate for additional local therapy. MRI-US fusion biopsy may
choline PET/CT or PET/MRI, or F-18 fluciclovine PET/CT or PET/MRI improve the detection of higher grade (Grade Group ≥2) cancers.
can be considered for equivocal results on initial bone scan. • mpMRI can be used in the staging and characterization of prostate
• Earlier detection of bone metastatic disease may result in earlier cancer. mpMRI images are defined as images acquired with at
use of newer and more expensive therapies, which may not improve least one more sequence in addition to the anatomical T2-weighted
oncologic outcomes or overall survival. images, such as DWI or dynamic contrast-enhanced (DCE) images.
• mpMRI may be used to better risk stratify men who are considering
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active surveillance. Additionally, mpMRI may detect large and When the worst prognosis patients from one risk group move to
poorly differentiated prostate cancer (Grade Group ≥2) and detect the higher risk group, the average outcome of both risk groups
extracapsular extension (T staging) and is preferred over CT for will improve even if treatment has no impact on disease. This
abdominal/pelvic staging. mpMRI has been shown to be equivalent to phenomenon is known as the Will Rogers effect, in which the
CT scan for pelvic lymph node evaluation. improved outcomes of both groups could be falsely attributed
Positron Emission Tomography (PET) to improvement in treatment, but would be due only to improved
• F-18 fluorodeoxyglucose (FDG) PET/CT should not be used routinely risk group assignment. As an example, F-18 sodium fluoride
for staging prostate cancer since data are limited in patients with PET/CT may categorize some patients as M1b who would have
prostate cancer. been categorized previously as M0 using a bone scan (stage
• The use of PET/CT or PET/MRI imaging using tracers other than F-18 migration). Absent any change in the effectiveness of therapy,
FDG (next-generation imaging) for staging of small-volume recurrent the overall survival of both M1b and M0 groups would improve.
or metastatic prostate cancer is a rapidly developing field wherein The definition of M0 and M1 disease for randomized clinical trials
most of the data are derived from single-institution series or registry that added docetaxel or abiraterone to ADT was based on CT
studies. FDA clearance and reimbursement for some tests makes and conventional radionuclide bone scans. Results suggest that
unlikely the conduct of clinical trials to evaluate their utility and overall survival of M1 disease is improved, whereas progression-
impact upon oncologic outcome. free but not overall survival of M0 disease is improved. Therefore,
• PET/CT or PET/MRI for detection of biochemically recurrent disease a subset of patients now diagnosed with M1 disease using F-18
C-11 choline or F-18 fluciclovine PET/CT or PET/MRI may be used to sodium fluoride PET/CT might not benefit from the more intensive
detect small-volume disease in soft tissues and in bone. therapy used in these trials and could achieve equivalent overall
Histologic confirmation is recommended whenever feasible due to survival from less intensive therapy aimed at M0 disease.
significant rates of false positivity. Carefully designed clinical trials using proper staging will be
High variability among PET/CT or PET/MRI equipment, protocols, necessary to prove therapeutic benefit, rather than making
interpretation, and institutions provides challenges for application assumptions compromised by stage migration.
and interpretation of the utility of PET/CT or PET/MRI.
Table 2 (see Discussion) provides a summary of the main PET/CT
or PET/MRI imaging tracers utilized for study in prostate cancer
recurrence after operation or radiation.
PET/CT or PET/MRI results may change treatment but may not
change oncologic outcome.

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PRINCIPLES OF ACTIVE SURVEILLANCE AND OBSERVATION

• The NCCN Prostate Cancer Panel and the NCCN Prostate Cancer in younger men than in older men. Follow-up should include:
Early Detection Panel (See NCCN Guidelines for Prostate Cancer Consider mpMRI and/or prostate biopsy to confirm candidacy for
Early Detection) remain concerned about overdiagnosis and active surveillance.
overtreatment of prostate cancer. The panel recommends that Assess PSA no more often than every 6 mo unless clinically indicated.
patients and their physicians (ie, urologist, radiation oncologist, Perform DRE no more often than every 12 mo unless clinically
medical oncologist, primary care physician) consider active indicated.
surveillance based on careful consideration of the patient’s Repeat prostate biopsy no more often than every 12 mo unless
prostate cancer risk profile, age, and health. clinically indicated.
• The NCCN Guidelines for Prostate Cancer distinguish between Repeat mpMRI no more often than every 12 mo unless clinically
active surveillance and observation. Both involve no more often indicated.
than every-6-month monitoring but active surveillance may Needle biopsy of the prostate should be repeated within 6 mo of
involve surveillance prostate biopsies. Evidence of progression diagnosis if initial biopsy was <10 cores or assessment discordant
will prompt conversion to potentially curative treatment in (eg, palpable tumor contralateral to side of positive biopsy).
active surveillance patients, whereas monitoring continues MRI-US fusion biopsy may improve the detection of higher grade
until symptoms develop or are imminent (ie, PSA >100 ng/mL (Grade Group ≥2) cancers.
or change in exam) in observation patients, who will then begin A repeat prostate biopsy should be considered if prostate exam
palliative ADT. changes, MRI suggests more aggressive disease, or PSA increases,
• Active surveillance is preferred for men with very-low-risk but no parameter is very reliable for detecting prostate cancer
prostate cancer and life expectancy ≥20 y and for men with progression.
low-risk prostate cancer and life expectancy ≥10 y. Observation A repeat prostate biopsy should be considered no more often than
is preferred for men with low-risk prostate cancer with life annually to assess for disease progression, because PSA kinetics
expectancy <10 y. See Risk Group Criteria (PROS-2). may not be as reliable for predicting progression.
• Patients with favorable intermediate-risk prostate cancer (See Repeat prostate biopsies are not indicated when life expectancy is
Risk Group Criteria [PROS-2]) may be considered for active less than 10 y or appropriate when men are on observation.
surveillance. See Discussion. Active surveillance involves actively PSADT appears unreliable for identification of progressive disease
monitoring the course of disease with the expectation to intervene that remains curable.
with curative intent if the cancer progresses.
• Cancer progression may have occurred if:
Gleason Grade 4 or 5 cancer is found upon repeat prostate
biopsy.
Prostate cancer is found in a greater number of prostate
biopsies or occupies a greater extent of prostate biopsy.
• Patients with clinically localized prostate cancers who are
candidates for definitive treatment and choose active surveillance
should have regular follow-up. Follow-up should be more rigorous
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PRINCIPLES OF ACTIVE SURVEILLANCE AND OBSERVATION

• Advantages of active surveillance: • Advantages of observation:
About 2/3 of men eligible for active surveillance will avoid treatment. Men will avoid possible side effects of unnecessary definitive
Men will avoid of possible side effects of definitive therapy that may therapy and early initiation and/or continuous ADT.
be unnecessary. • Disadvantages of observation:
Quality of life/normal activities will potentially be less affected. There will be a risk of urinary retention or pathologic fracture
Risk of unnecessary treatment of small, indolent cancers will be without prior symptoms or concerning PSA levels.
reduced.
• Disadvantages of active surveillance:
Although very low, there will be a chance of missed opportunity for
cure.
About 1/3 of men will require treatment, although treatment delays
do not seem to impact cure rate.
Periodic follow-up mpMRI and prostate biopsies may be necessary.

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PRINCIPLES OF RADIATION THERAPY

Definitive Radiation Therapy General Principles • Biologically effective dose (BED) modeling with the linear-quadratic
• Highly conformal RT techniques should be used to treat localized equation may not be accurate for extremely hypofractionated
prostate cancer. (SBRT/SABR) radiation.
• Photon or proton EBRT are both effective at achieving highly • For brachytherapy:
conformal radiotherapy with acceptable and similar biochemical Patients with a very large prostate or very small prostate,
control and long-term side effect profiles (See Discussion). symptoms of bladder outlet obstruction (high IPSS), or a previous
• Brachytherapy boost, when added to EBRT plus ADT in men TURP are more difficult to implant and may suffer increased
with NCCN intermediate- and high-risk prostate cancer, has risk of side effects. Neoadjuvant ADT may be used to shrink the
demonstrated improved biochemical control over EBRT plus ADT prostate to an acceptable size; however, increased toxicity would
alone in randomized trials, but with higher toxicity. be expected from ADT and prostate size may not decline in some
• Ideally, the accuracy of treatment should be verified by daily men despite neoadjuvant ADT. Potential toxicity of ADT must be
prostate localization, with any of the following: techniques of IGRT balanced against the potential benefit of target reduction.
using CT, ultrasound, implanted fiducials, or electromagnetic Post-implant dosimetry must be performed to document the
targeting/tracking. Endorectal balloons may be used to improve quality of the low dose-rate (LDR) implant.
prostate immobilization. Biocompatible and biodegradable perirectal Definitive Radiation Therapy by Risk Group
spacer materials may be implanted between the prostate and rectum • Very low risk
in patients undergoing external radiotherapy with organ-confined Men with NCCN very-low-risk prostate cancer are encouraged to
prostate cancer in order to displace the rectum from high radiation pursue active surveillance.
dose regions. A randomized phase III trial demonstrated reduced • Low risk
rectal bleeding in patients undergoing the procedure compared to Men with NCCN low-risk prostate cancer are encouraged to pursue
controls. Retrospective data also support its use in similar patients active surveillance.
undergoing brachytherapy. Patients with obvious rectal invasion Prophylactic lymph node radiation should NOT be performed
or visible T3 and posterior extension should not undergo perirectal routinely. ADT or antiandrogen therapy should NOT be used
spacer implantation. routinely.
• Various fractionation and dose regimens can be considered • Favorable intermediate risk
depending on the clinical scenario (See Table 1 on PROS-E 3 of 5). Prophylactic lymph node radiation is not performed routinely, and
Dose escalation has been proven to achieve the best biochemical ADT or antiandrogen therapy is not used routinely. Prophylactic
control in men with intermediate- and high-risk disease. lymph node radiation and/or ADT use is reasonable if additional
• SBRT is acceptable in practices with appropriate technology, risk assessments suggest aggressive tumor behavior.
physics, and clinical expertise.
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• Unfavorable intermediate risk • Low-volume metastatic disease
Prophylactic nodal radiation can be considered if additional risk Radiation therapy to the prostate is an option in patients
assessments suggest aggressive tumor behavior. ADT should with low-volume castration-naive metastatic disease, without
be used unless additional risk assessments suggest less- contraindications to radiotherapy. ADT is required unless
aggressive tumor behavior or if medically contraindicated. The medically contraindicated.
duration of ADT can be reduced when combined with EBRT and This recommendation is based on the STAMPEDE phase 3
brachytherapy. Brachytherapy combined with ADT (without EBRT), randomized trial, which randomized 2,061 men to standard
or SBRT combined with ADT can be considered if delivering systemic therapy with or without radiotherapy to the primary. The
longer courses of EBRT would present medical or social hardship. overall cohort had a significant improvement from the addition of
• High and very high risk radiotherapy to the primary in failure-free survival, but not overall
Prophylactic nodal radiation should be considered. ADT is survival. The prespecified low-volume subset had a significant
required unless medically contraindicated. Brachytherapy improvement in both failure-free survival and overall survival.
combined with ADT (without EBRT), or SBRT combined with ADT, Minimizing toxicity is paramount when delivering radiation therapy
can be considered if delivering longer courses of EBRT would to the primary in patients with metastatic disease.
present a medical or social hardship. It remains uncertain whether treatment of regional nodes in
• Regional disease addition to the primary improves outcomes; nodal treatment
Nodal radiation should be performed. Clinically positive nodes should be performed in the context of a clinical trial.
should be dose-escalated as dose-volume histogram parameters Dose escalation beyond biologically effective dose equivalents
allow. ADT is required unless medically contraindicated, and the of the two dose prescriptions used in STAMPEDE (55 Gy in 20
addition of abiraterone or fine-particle abiraterone (category 2B) to fractions or 6 Gy x 6 fractions) is not recommended given the
ADT can be considered. known increase in toxicity from dose intensification without
overall survival improvement in localized disease.
Brachytherapy is not recommended outside of a clinical trial,
as safety and efficacy have not been established in this patient
population.
• High-volume metastatic disease
Radiation therapy to the prostate should NOT be performed in
men with high-volume metastatic disease outside the context of a
clinical trial unless for palliative intent.
This recommendation is based on two randomized trials, HORRAD
and STAMPEDE, neither of which showed an improvement in
overall survival from the addition of radiotherapy to the primary
when combined with standard systemic therapy.
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Table 1: Below are examples of regimens that have shown acceptable efficacy and toxicity. The optimal regimen for an individual patient warrants evaluation of comorbid conditions, voiding
symptoms and toxicity of therapy. Additional fractionation schemes may be used as long as sound oncologic principles and appropriate estimate of BED are considered.
√ indicates an appropriate regimen option if radiation therapy is given. See PROS-3, PROS-4, PROS-5, PROS-6, PROS-7, PROS-9, PROS-13, and PROS-G for other recommendations, including
recommendations for neoadjuvant/concomitant/adjuvant ADT.
NCCN Risk Group
( indicates an appropriate regimen option if radiation therapy is given)
Regimen Preferred Dose/Fractionation
Very Low Favorable Unfavorable High and Low Volume
Regional N1
and Low Intermediate Intermediate Very Highc M1a
EBRT
3 Gy x 20 fx
Moderate Hypofractionation 2.7 Gy x 26 fx     
(Preferred) 2.5 Gy x 28 fx
2.75 Gy x 20 fx 
Conventional Fractionation 1.8–2 Gy x 37–45 fx     
7.25–8 Gy x 5 fx  
6.1 Gy x 7 fx  
Ultra-Hypofractionation
6 Gy x 6 fx 
Brachytherapy Monotherapy
LDR
Iodine 125 145 Gy
Palladium 103 125 Gy  
Cesium 115 Gy
HDR
13.5 Gy x 2 implants  
Iridium-192
9.5 Gy BID x 2 implants
EBRT and Brachytherapy (combined with 45–50.4 Gy x 25–28 fx or 37.5 Gy x 15 fx)
LDR
Iodine 125 110–115 Gy  
Palladium 103 90–100 Gy
Cesium 85 Gy
HDR 15 Gy x1 fx  
Iridium-192 10.75 Gy x 2 fx
a High-volume disease is differentiated from low-volume disease by visceral metastases and/or 4 or more bone metastases, with at least one metastasis beyond the
pelvis vertebral column. Patients with low-volume disease have less certain benefit from early treatment with docetaxel combined with ADT.

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Salvage Brachytherapy • EBRT with 2 years of anti-androgen therapy with 150 mg/day of
• Permanent LDR or temporary high dose-rate (HDR) brachytherapy bicalutamide demonstrated improved overall and metastasis-free
is a treatment option for pathologically confirmed local recurrence survival on a prospective randomized trial (RTOG 9601) versus
after EBRT or brachytherapy. Subjects should have restaging radiation alone in the salvage setting. EBRT with 6 months of
imaging according to the NCCN high-risk stratification group to ADT improved biochemical or clinical progression at 5 years on a
rule out regional nodal or metastatic disease. Patients should be prospective randomized trial (GETUG-16) versus radiation alone.
counseled that salvage brachytherapy significantly increases the • Nuclear medicine advanced imaging techniques can be useful
probability of urologic, sexual, and bowel toxicity compared to for localizing disease with PSA levels as low as 0.5 ng/mL (see
primary brachytherapy. Discussion).
Post-Prostatectomy Radiation Therapy • Nomograms, and tumor-based molecular assays, can be used
• The panel recommends use of nomograms and consideration of to prognosticate risk of metastasis and prostate cancer-specific
age and comorbidities, clinical and pathologic information, PSA mortality in men with adverse risk features after RP.
levels, and PSADT to individualize treatment discussion. Decipher • Target volumes include the prostate bed and may include the whole
molecular assay is recommended to inform adjuvant treatment, pelvis according to physician discretion.
if adverse features are found after RP. The panel recommends
consultation with the American Society for Radiation Oncology
(ASTRO)/American Urological Association (AUA) Guidelines.
Evidence supports offering adjuvant/salvage RT in most men with
adverse pathologic features or detectable PSA and no evidence of
disseminated disease.
• Indications for adjuvant RT include pT3 disease, positive margin(s),
or seminal vesicle involvement. Adjuvant RT is usually given within
1 year after RP and after operative side effects have improved/
stabilized. Patients with positive surgical margins may benefit the
most.
• Indications for salvage RT include an undetectable PSA
that becomes subsequently detectable and increases on 2
measurements or a PSA that remains persistently detectable after
RP. Treatment is more effective when pre-treatment PSA is low and
PSADT is long.
• The recommended prescribed doses for adjuvant/salvage post-
prostatectomy RT are 64–72 Gy in standard fractionation. Biopsy-
proven gross recurrence may require higher doses.
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Radiopharmaceutical Therapy Palliative Radiotherapy
• Radium-223 is an alpha-emitting radiopharmaceutical that has been • 8 Gy as a single dose is as effective for pain palliation at any bony
shown to extend survival in men who have CRPC with symptomatic site as longer courses of radiation, but re-treatment rates are higher.
bone metastases, but no visceral metastases. Radium-223 alone has • Widespread bone metastases can be palliated using strontium-89 or
not been shown to extend survival in men with visceral metastases samarium-153 with or without focal external beam radiation.
or bulky nodal disease (>3–4 cm). Radium-223 differs from beta- • 30 Gy in 10 fractions or 37.5 Gy in 15 fractions may be used as
emitting agents, such as samarium 153 and strontium-89, which alternative palliative dosing depending on clinical scenario (both
are palliative and have no survival advantage. Radium-223 causes category 2B).
double-strand DNA breaks and has a short radius of activity. Grade
3–4 hematologic toxicity (2% neutropenia, 3% thrombocytopenia, 6%
anemia) occurs at low frequency.
• Radium-223 is administered intravenously once a month for 6
months by an appropriately licensed facility, usually in nuclear
medicine or RT departments.
• Prior to the initial dose, patients must have absolute neutrophil count
(ANC) ≥1.5 x 10⁹/L, platelet count ≥100 x 10⁹/L, and hemoglobin ≥10 g/
dL.
• Prior to subsequent doses, patients must have ANC ≥1 x 10⁹/L
and platelet count ≥50 x 10⁹/L (per label). Radium-223 should be
discontinued if a delay of 6–8 weeks does not result in the return of
blood counts to these levels.
• Non-hematologic side effects are generally mild, and include nausea,
diarrhea, and vomiting. These symptoms may occur because
radium-223 is eliminated predominantly by fecal excretion.
• Radium-223 is not intended to be used in combination with
chemotherapy due to the potential for additive myelosuppression,
except in a clinical trial.
• Radium-223 may increase fracture risk when given concomitantly
with abiraterone.
• Radium-223 is not recommended for use in combination with
docetaxel or any other systemic therapy except ADT.
• Concomitant use of denosumab or zoledronic acid is recommended;
it does not interfere with the beneficial effects of radium-223 on
survival.

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PRINCIPLES OF SURGERY
Pelvic Lymph Node Dissection Radical Prostatectomy
• An extended PLND will discover metastases approximately twice as • RP is an appropriate therapy for any patient with clinically localized
often as a limited PLND. Extended PLND provides more complete prostate cancer that can be completely excised surgically, who has
staging and may cure some men with microscopic metastases; a life expectancy of ≥10 years, and who has no serious comorbid
therefore, an extended PLND is preferred when PLND is performed. conditions that would contraindicate an elective operation.
• An extended PLND includes removal of all node-bearing tissue • High-volume surgeons in high-volume centers generally provide
from an area bound by the external iliac vein anteriorly, the pelvic better outcomes.
sidewall laterally, the bladder wall medially, the floor of the pelvis • Blood loss can be substantial with RP, but can be reduced by
posteriorly, Cooper's ligament distally, and the internal iliac artery using laparoscopic or robotic assistance or by careful control of
proximally. the dorsal vein complex and periprostatic vessels when performed
• A PLND can be excluded in patients with <2% predicated probability open.
of nodal metastases by nomograms, although some patients with • Urinary incontinence can be reduced by preservation of urethral
lymph node metastases will be missed. length beyond the apex of the prostate and avoiding damage to
• PLND can be performed using an open, laparoscopic, or robotic the distal sphincter mechanism. Bladder neck preservation may
technique. decrease the risk of incontinence. Anastomotic strictures increase
the risk of long-term incontinence.
• Recovery of erectile function is directly related to age at RP,
preoperative erectile function, and the degree of preservation of the
cavernous nerves. Replacement of resected nerves with nerve grafts
has not been shown to be beneficial. Early restoration of erections
may improve late recovery.
Salvage Radical Prostatectomy

• Salvage RP is an option for highly selected patients with local
recurrence after EBRT, brachytherapy, or cryotherapy in the
absence of metastases, but the morbidity (ie, incontinence, loss of
erection, anastomotic stricture) is high and the operation should be
performed by surgeons who are experienced with salvage RP.

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PRINCIPLES OF ANDROGEN DEPRIVATION THERAPY

ADT for Clinically Localized (N0,M0) Disease ADT for Regional (N1,M0) Disease
• Neoadjuvant ADT for RP is strongly discouraged outside of a clinical trial. • Patients with N1,M0 prostate cancer and a life expectancy >5 y can be
• ADT should not be used as monotherapy in clinically localized prostate treated with EBRT and neoadjuvant, concurrent, and/or adjuvant ADT as
cancer unless there is a contraindication to definitive local therapy such for patients with N0,M0 disease (see above) without abiraterone or LHRH
as life expectancy ≤5 years and comorbidities. Under those circumstances, agonist or LHRH antagonist with abiraterone or they can be treated with
ADT (luteinizing hormone-releasing hormone [LHRH] agonist, LHRH ADT alone or with abiraterone (see below).
antagonist [category 2B], or orchiectomy) may be an acceptable alternative • Abiraterone should be given with concurrent steroid:
if the disease is high or very high risk. Prednisone 5 mg orally once daily for the standard formulation
• Giving ADT before, during, and/or after radiation (neoadjuvant, concurrent, Methylprednisolone 4 mg orally twice daily for the fine-particle
and/or adjuvant ADT) prolongs survival in selected radiation-managed formulation (category 2B).
patients. Options are: Neither formulation of abiraterone should be given following progression
LHRH agonist alone on the other formulation.
◊◊Goserelin, histrelin, leuprolide, or triptorelin • Options for ADT alone or with abiraterone are:
LHRH agonist (as above) plus first-generation antiandrogen Orchiectomy
◊◊Nilutamide, flutamide, or bicalutamide LHRH agonist alone
LHRH antagonist ◊◊Goserelin, histrelin, leuprolide, or triptorelin
◊◊Degarelix LHRH agonist (as above) plus first-generation antiandrogen
• Studies of short-term (4–6 mo) and long-term (2–3 y) neoadjuvant, ◊◊Nilutamide, flutamide, or bicalutamide
concurrent, and/or adjuvant ADT all have used combined androgen LHRH antagonist
blockade. Whether the addition of an antiandrogen is necessary requires ◊◊Degarelix (category 2B)
further study. Orchiectomy plus abiraterone
• The largest randomized trial to date using the antiandrogen bicalutamide LHRH agonist (as above) plus abiraterone
alone at high dose (150 mg) showed a delay in recurrence of disease but LHRH antagonist (as above) plus abiraterone
no improvement in survival; however, longer follow-up is needed. Patients with regional disease and life expectancy <5 y who chose ADT
can receive LHRH agonist, LHRH antagonist, or orchiectomy.
ADT for pN1 Disease
• In one randomized trial, immediate and continuous use of ADT in men
with positive nodes following RP resulted in significantly improved
overall survival compared to men who received delayed ADT. Therefore,
such patients should be considered for immediate LHRH agonist, LHRH
antagonist (category 2B for LHRH antagonist), or orchiectomy. EBRT
may be added (category 2B), in which case the ADT options are as for
neoadjuvant, concurrent, and/or adjuvant ADT for clinically localized
disease (see above). Many of the side effects of continuous ADT are
cumulative over time on ADT.
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ADT for M0 PSA Persistence/Recurrence After RP or EBRT (ADT for ◊◊LHRH agonist (as above) plus first-generation antiandrogen
M0 Castration-Naive Disease) –– Nilutamide, flutamide, or bicalutamide
• The timing of ADT for patients whose only evidence of cancer after ◊◊ LHRH antagonist
definitive treatment is an increasing PSA is influenced by PSA velocity, –– Degarelix
patient anxiety, the short- and long-term side effects of ADT, and the ADT for Metastatic Castration-Naive Disease
underlying comorbidities of the patient. • ADT is the gold standard for men with metastatic prostate cancer.
• Most patients will have a good 15-year prognosis, but their prognosis is • A phase 3 trial compared continuous ADT to intermittent ADT, but the
best approximated by the absolute level of PSA, the rate of change in the study could not demonstrate non-inferiority for survival. However, quality-
PSA level (PSADT), and the initial stage, grade, and PSA level at the time of of-life measures for erectile function and mental health were better in the
definitive therapy. intermittent ADT arm after 3 months of ADT compared to the continuous
• Earlier ADT may be better than delayed ADT, although the definitions of ADT arm.
early and late (what level of PSA) are controversial. Since the benefit of • In addition, three meta-analyses of randomized controlled trials failed to
early ADT is not clear, treatment should be individualized until definitive show a difference in survival between intermittent and continuous ADT.
studies are done. Patients with a shorter PSADT (or a rapid PSA velocity) • Close monitoring of PSA and testosterone levels and possibly imaging
and an otherwise long life expectancy should be encouraged to consider is required when using intermittent ADT, especially during off-treatment
ADT earlier. periods, and patients may need to switch to continuous ADT upon signs of
• Some patients are candidates for salvage therapy after PSA persistence/ disease progression.
recurrence. See PROS-11 and PROS-12. • Treatment options for men with M1 castration-naive disease are:
• Men with prolonged PSADTs (>12 mo) and who are older are candidates for Orchiectomy ± docetaxel
observation. LHRH agonist alone ± docetaxel (a first-generation antiandrogen must be
• Men who choose ADT should consider intermittent ADT. A phase 3 trial that given for ≥7 days to prevent testosterone flare if metastases are present
compared intermittent to continuous ADT showed that intermittent ADT in weight-bearing bone)
was not inferior to continuous ADT with respect to survival, and quality of ◊◊Goserelin, histrelin, leuprolide, or triptorelin
life was better for the intermittent ADT arm. The 7% increase in prostate LHRH agonist (as above) plus first-generation antiandrogen ± docetaxel
cancer deaths in the intermittent ADT arm was balanced by more non- ◊◊Nilutamide, flutamide, or bicalutamide
prostate cancer deaths in the continuous ADT arm. An unplanned subset LHRH antagonist ± docetaxel
analysis showed that men with Grade Group 4 or 5 prostate cancer in the ◊◊Degarelix
continuous arm had a median overall survival that was 14 mo longer (8 y) Orchiectomy plus abiraterone, enzalutamide, or apalutamide
than those in the intermittent arm (6.8 y). LHRH agonist (as above) plus abiraterone, enzalutamide, or apalutamide
• ADT options are: LHRH antagonist (as above) plus abiraterone, enzalutamide, or
M0 RP PSA Persistence/Recurrence: apalutamide
◊◊ EBRT +/- neoadjuvant, concurrent, and/or adjuvant ADT [See ADT for • Abiraterone should be given with concurrent steroid (see ADT for Regional
Clinically Localized (N0,M0) Disease] (N1,M0) Disease). Neither formulation of abiraterone should be given
M0 EBRT PSA Persistence/Recurrence, TRUS-biopsy negative or M0 PSA following progression on the other formulation.
Persistence/Recurrence after progression on salvage EBRT:
• When EBRT to primary is given with ADT in low-volume M1, the options are
◊◊ Orchiectomy
LHRH agonist, LHRH antagonist, and orchiectomy.
◊◊ LHRH agonist alone
• Two randomized phase 3 clinical trials of abiraterone with prednisone plus
–– Goserelin, histrelin, leuprolide, or triptorelin
ADT in men with castration-naïve metastatic prostate cancer demonstrated
Note: All recommendations are category 2A unless otherwise indicated. Continued

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improved overall survival over ADT alone. Adverse events were higher with ◊◊Ketoconazole
abiraterone and prednisone but were generally mild in nature and were ◊◊Ketoconazole plus hydrocortisone
largely related to mineralocorticoid excess (ie, hypertension, hypokalemia, ◊◊First-generation antiandrogen (nilutamide, flutamide, or bicalutamide)
edema), hormonal effects (ie, fatigue, hot flushes), and liver toxicity. ◊◊Corticosteroids (hydrocortisone, prednisone, or dexamethasone)
Cardiac events, severe hypertension, and liver toxicity were increased with ◊◊Estrogens including diethylstilbestrol (DES)
abiraterone. ◊◊Antiandrogen withdrawal
• A double-blind randomized phase 3 clinical trial of apalutamide plus ADT • Abiraterone should be given with concurrent steroid, either prednisone 5
in men with castration-naïve metastatic prostate cancer demonstrated mg orally twice daily for the standard formulation or methylprednisolone 4
improved overall survival over ADT alone. Adverse events that were mg orally twice daily for the fine-particle formulation. Neither formulation
more common with apalutamide than with placebo included rash, of abiraterone should be given following progression on the other
hypothyroidism, and ischemic heart disease. formulation.
• An open-label randomized phase 3 clinical trial of enzalutamide plus ADT • Ketoconazole ± hydrocortisone should not be used if the disease
in men with castration-naïve metastatic prostate cancer demonstrated progressed on abiraterone.
improved overall survival over ADT alone. In a separate double-blind • DES has cardiovascular and thromboembolic side effects at any dose,
randomized phase 3 clinical, enzalutamide reduced the risk of metastatic but frequency is dose and agent dependent. DES should be initiated
progression or death compared with placebo. Adverse events associated at 1 mg/day and increased, if necessary, to achieve castrate levels of
with enzalutamide included fatigue, seizures, and hypertension. serum testosterone (<50 ng/dL). Other estrogens delivered topically or
parenterally may have less frequent side effects but data are limited.
Secondary Hormone Therapy for M0 or M1 CRPC
• A phase 3 study of patients with M0 CRPC and a PSADT ≤10 mo showed
• Androgen receptor activation and autocrine/paracrine androgen synthesis
apalutamide (240 mg/day) improved the primary endpoint of metastasis-
are potential mechanisms of recurrence of prostate cancer during ADT
free survival over placebo (40.5 mo vs. 16.2 mo). No significant difference
(CRPC). Thus, castrate levels of testosterone (<50 ng/dL) should be
was seen in overall survival at the first interim analysis. Adverse events
maintained by continuing LHRH agonist or antagonist while additional
included rash (24% vs. 5.5%), fracture (11% vs. 6.5%), and hypothyroidism
therapies are applied.
(8% vs. 2%). Bone support should be used in patients receiving
• Once the tumor becomes resistant to initial ADT, there are a variety of
apalutamide.
options that may afford clinical benefit. The available options are based on
whether the patient has evidence of metastases by conventional imaging,
enzalutamide (160 mg/day) improved the primary endpoint of metastasis-
M0 CRPC vs. M1 CRPC, and whether or not the patient is symptomatic.
free survival over placebo (36.6 mo vs. 14.7 mo). No significant difference
• Administration of secondary hormonal therapy can include:
was seen in overall survival at the first interim analysis. Adverse events
Second-generation antiandrogen
included falls and nonpathologic fractures (17% vs. 8%), hypertension
◊◊Apalutamide (for M0 and PSADT ≤10 mo)
(12% vs. 5%), major adverse cardiovascular events (5% vs. 3%), and
◊◊Darolutamide (for M0 and PSADT ≤10 mo)
mental impairment disorders (5% vs. 2%). Bone support should be used in
◊◊Enzalutamide (for M0 and PSADT ≤10 mo or M1)
patients receiving enzalutamide.
Androgen metabolism inhibitor
◊◊Abiraterone + prednisone (for M1 only)
darolutamide (600 mg twice daily) improved the primary endpoint
◊◊Fine-particle abiraterone + methylprednisolone (for M1 only)
of metastasis-free survival over placebo (40.4 mo vs. 18.4 mo). An
Other secondary hormone therapy (for M0 or M1)
improvement in overall survival was seen at the first interim analysis

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(HR for death, 0.71; 95% CI, 0.50–0.99; P = .045), although these data are mg/day enzalutamide improved PFS compared to 50 mg/day bicalutamide
immature (median survival was not reached in either arm). Adverse events in men with treatment-naive M1 CRPC and, therefore, enzalutamide may
that occurred more frequently in the treatment arm included fatigue (12.1% be the preferred option in this setting. However, bicalutamide can still be
vs. 8.7%), pain in an extremity (5.8% vs. 3.2%), and rash (2.9% vs. 0.9%). considered in some patients, given the different side effect profiles of the
The incidence of fractures was similar between darolutamide and placebo agents and the increased cost of enzalutamide.
(4.2% vs. 3.6%). • Evidence-based guidance on the sequencing of agents in either pre- or
• In a randomized controlled trial in the setting of M1 CRPC prior to post-docetaxel remains unavailable.
docetaxel chemotherapy, abiraterone, and low-dose prednisone (5 mg ADT for Patients on Observation Who Require Treatment and Those with
BID) compared to prednisone alone improved radiographic progression-
Life Expectancy ≤5 Years
free survival (rPFS), time to initiation of chemotherapy, time to onset or
• Treatment for patients who progressed on observation of localized disease
worsening of pain, and time to deterioration of performance status. An
is LHRH agonist or antagonist (category 2B for LHRH antagonist) or
improvement in overall survival was demonstrated. Use of abiraterone
orchiectomy.
and prednisone in this setting is a category 1 recommendation. The
side effects of abiraterone that require ongoing monitoring include Optimal ADT
hypertension, hypokalemia, peripheral edema, atrial fibrillation, congestive • LHRH agonist or antagonist (medical castration) and bilateral orchiectomy
heart failure, liver injury, and fatigue, as well as the known side effects of (surgical castration) are equally effective.
ADT and long-term corticosteroid use. • Combined androgen blockade (medical or surgical castration combined
• A phase 3 study of docetaxel-naive men with M1 CRPC showed that with an antiandrogen) provides modest to no benefit over castration alone
enzalutamide (160 mg daily) resulted in significant improvement in rPFS in patients with metastatic disease.
and overall survival. The use of enzalutamide in this setting is category 1. • Antiandrogen therapy should precede or be coadministered with LHRH
The side effects of enzalutamide that require long-term monitoring include agonist and be continued in combination for at least 7 days for patients
fatigue, diarrhea, hot flashes, headache, and seizures (reported in 0.9% of with overt metastases who are at risk of developing symptoms associated
men on enzalutamide). with the flare in testosterone with initial LHRH agonist alone.
• For symptomatic patients with M1 CRPC, all secondary hormone • Antiandrogen monotherapy appears to be less effective than medical or
options listed above are allowed, but initial use of docetaxel may be surgical castration and is not recommended.
preferred. Both randomized trials of abiraterone and enzalutamide in the • No clinical data support the use of finasteride or dutasteride with combined
pre-docetaxel setting were conducted in men who had no or minimal androgen blockade.
symptoms due to M1 CRPC. How these agents compare to docetaxel • Patients who do not achieve adequate suppression of serum testosterone
for pain palliation in this population of patients is not clear. Both drugs (less than 50 ng/dL) with medical or surgical castration can be considered
have palliative effects in the post-docetaxel setting. Both abiraterone and for additional hormonal manipulations (with estrogen, antiandrogens,
enzalutamide are approved in this pre-docetaxel setting and have category LHRH antagonists, or steroids), although the clinical benefit remains
1 recommendations. Both drugs are suitable options for men who are not uncertain. Consider monitoring testosterone levels 12 weeks after first
good candidates to receive docetaxel. dose of LHRH therapy, then upon increase in PSA. The optimal level of
• In the post-docetaxel M1 CRPC population, enzalutamide and abiraterone serum testosterone to effect “castration” has yet to be determined.
plus prednisone have been shown to extend survival in randomized Monitor/Surveillance
controlled trials. Therefore, each agent has a category 1 recommendation. • ADT has a variety of adverse effects, including hot flashes, loss of libido,
• Two randomized clinical trials (STRIVE and TERRAIN) showed that 160 erectile dysfunction, shrinkage of penis and testicles, loss of muscle

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mass and strength, fatigue, anemia, breast enlargement and tenderness/ alendronate (70 mg PO weekly) increase bone mineral density, a surrogate
soreness, depression and mood swings, hair loss, osteoporosis, greater for fracture risk, during ADT for prostate cancer. Treatment with either
incidence of clinical fractures, obesity, insulin resistance, alterations denosumab, zoledronic acid, or alendronate sodium is recommended when
in lipids, and greater risk for diabetes and cardiovascular disease. The the absolute fracture risk warrants drug therapy.
intensity and spectrum of these side effects vary greatly, and many are • Screening for and intervention to prevent/treat diabetes and cardiovascular
reversible or can be avoided or mitigated. For example, physical activity disease are recommended in men receiving ADT. These medical conditions
can counter many of these symptoms and should be recommended are common in older men and it remains uncertain whether strategies
(see NCCN Guidelines for Survivorship). Use of statins also should be for screening, prevention, and treatment of diabetes and cardiovascular
considered. Patients and their medical providers should be advised about disease in men receiving ADT should differ from the general population.
these risks prior to treatment.
• Screening and treatment for osteoporosis are advised according to
guidelines for the general population from the National Osteoporosis
Foundation (www.nof.org). The National Osteoporosis Foundation guidelines
include recommendations for: 1) calcium (1000–1200 mg daily from food
and supplements) and vitamin D3 (400–1000 IU daily); and 2) additional
treatment for men aged ≥50 y with low bone mass (T-score between -1.0
and -2.5, osteopenia) at the femoral neck, total hip, or lumbar spine by
DEXA and a 10-year probability of hip fracture ≥3% or a 10-year probability
of a major osteoporosis-related fracture ≥20%. Fracture risk can be
assessed using FRAX®, the algorithm released by WHO. ADT should be
considered “secondary osteoporosis” when using the FRAX® algorithm.
Treatment options to increase bone density, a surrogate for fracture risk
in men without metastases, include denosumab (60 mg SQ every 6 mo),
zoledronic acid (5 mg IV annually), and alendronate (70 mg PO weekly).
• A baseline DEXA scan should be obtained before starting therapy in men
at increased risk for fracture based on FRAX® screening. A follow-up
DEXA scan after 1 year of therapy is recommended by the International
Society for Clinical Densitometry, although there is no consensus on the
optimal approach to monitoring the effectiveness of drug therapy. Use of
biochemical markers of bone turnover to monitor response to therapy is
not recommended. The serum level of 25-hydroxy vitamin D and average
daily dietary intake of vitamin D will assist the nutritionist in making a
patient-specific recommendation for vitamin D supplementation. There are
currently no guidelines on how often to monitor vitamin D levels. However,
for those who require monitoring with DEXA scans, it makes sense to
check the serum vitamin D level at the same time.
• Denosumab (60 mg SQ every 6 mo), zoledronic acid (5 mg IV annually), and

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PRINCIPLES OF IMMUNOTHERAPY AND CHEMOTHERAPY

Systemic Therapy for M1 Castration-Naive Prostate Cancer be based on the assessment of benefit and toxicities. In the pivotal trials
• Men with high-volume, ADT-naive, metastatic disease should be considered establishing survival advantage of docetaxel-based chemotherapy, patients
for ADT (See PROS-G) and docetaxel based on the results of the ECOG received up to 10 cycles of treatment if no progression and no prohibitive
3805 (CHAARTED) trial. In this study, 790 men were randomized to 6 toxicities were noted.
cycles of docetaxel at 75 mg/m every 3 weeks with dexamethasone with
2 • Patients who are not candidates for docetaxel or who are intolerant of
ADT vs. ADT alone. In the majority subset of patients with high-volume docetaxel should be considered for cabazitaxel with concurrent steroid,
based on recent results that suggest clinical activity of cabazitaxel
disease, defined as 4 or more bone metastases including one extra-axial
in mCRPC. Cabazitaxel was associated with lower rates of peripheral
bone lesion or visceral metastases, a 17-month improvement in overall neuropathy than docetaxel, particularly at 20 mg/m2 (12% vs. 25%) and may
survival was observed (HR, 0.60; P = .0006). Improvements in PSA response, be appropriate in patients with pre-existing mild peripheral neuropathy.
time to clinical progression, and time to recurrence were observed with Current data do not support greater efficacy of cabazitaxel over docetaxel.
use of docetaxel. Toxicities of 6 cycles of docetaxel included fatigue, • Increasing PSA should not be used as the sole criteria for progression.
neuropathy, stomatitis, diarrhea, and neutropenia with or without fever. Assessment of response should incorporate clinical and radiographic
The use of myeloid growth factors should follow the NCCN Guidelines criteria.
for Hematopoietic Growth Factors, based on risk of neutropenic fever. • Cabazitaxel at 25 mg/m² with concurrent steroid has been shown in a
Docetaxel should not be offered to men with low-volume metastatic prostate randomized phase 3 study (TROPIC) to prolong overall survival, PFS, and
cancer, since this subgroup was not shown to have improved survival in PSA and radiologic responses when compared with mitoxantrone with
prednisone and is FDA approved in the post-docetaxel second-line setting.
either the ECOG study or a similar European (GETUG-AFU 15) trial.
Toxicity at this dose was significant and included febrile neutropenia,
severe diarrhea, fatigue, nausea/vomiting, anemia, thrombocytopenia,
Systemic Therapy for M1 CRPC
sepsis, and renal failure. A recent trial, PROSELICA, compared cabazitaxel
• Chemotherapy 25 mg/m² every 3 weeks to 20 mg/m² every 3 weeks. Cabazitaxel 20 mg/
Docetaxel with concurrent steroid m² had less toxicity; febrile neutropenia, diarrhea, and fatigue were less
◊◊Concurrent steroids may include: dexamethasone on the day of frequent. Cabazitaxel at 20 mg/m² had a significantly lower PSA response
chemotherapy or daily prednisone. rate but nonsignificantly lower radiographic response rate and non-
Cabazitaxel with concurrent steroid significantly shorter PFS and overall survival (13.4 vs. 14.5 mo) compared
◊◊Concurrent steroids may include: dexamethasone on the day of to 25 mg/m². Cabazitaxel starting dose can be either 20 mg/m² or 25 mg/
chemotherapy or daily prednisone. m² for men with mCRPC who have progressed despite prior docetaxel
Mitoxantrone with prednisone chemotherapy. Cabazitaxel 25 mg/m² with concurrent steroid may be
• Every-3-week docetaxel with concurrent steroid is the preferred first- considered for healthy men who wish to be more aggressive. Growth factor
line chemotherapy treatment based on phase 3 clinical trial data for men support may be needed with either dose.
with symptomatic mCRPC. Radium-223 has been studied in symptomatic
• Cabazitaxel at 25 mg/m2 with concurrent steroid improved radiographic
patients who are not candidates for docetaxel-based regimens and resulted
PFS and reduced the risk of death compared with abiraterone or
in improved overall survival. Abiraterone and enzalutamide have been
shown to extend survival in patients who progressed on docetaxel. (See enzalutamide in patients with prior docetaxel treatment for mCRPC in the
PROS-G). Mitoxantrone with prednisone may provide palliation but have not CARD study.
been shown to extend survival. • Consider inclusion of olaparib in men who have an HRRm and have
• Only regimens utilizing docetaxel on an every-3-week schedule progressed on prior treatment with enzalutamide and/or abiraterone
demonstrated beneficial impact on survival. The duration of therapy should regardless of prior docetaxel therapy.
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PRINCIPLES OF IMMUNOTHERAPY AND CHEMOTHERAPY

• Docetaxel retreatment can be attempted in second or subsequent lines of • A phase 3 clinical trial that assessed a role for zoledronic acid in men
therapy for mCRPC in men who have not demonstrated definitive evidence beginning ADT for bone metastases was negative.
of progression on prior docetaxel therapy. • Choice of agent may depend on underlying comorbidities, whether the
• No chemotherapy regimen to date has demonstrated improved survival or patient has been treated with zoledronic acid previously, logistics, and/or
quality of life after cabazitaxel, and trial participation should be encouraged. cost considerations.
• Treatment decisions around off-label chemotherapy use in the treatment- Denosumab (preferred) is given subcutaneously every 4 weeks.
refractory CRPC should be individualized based on comorbidities and Although renal monitoring is not required, denosumab is not
functional status and after informed consent. recommended in patients with creatinine clearance <30 mL/min. When
• No benefits of combination approaches over sequential single-agent creatinine clearance is <60 mL/min, the risk for severe hypocalcemia
therapies have been demonstrated, and toxicity is higher with combination increases. Even in patients with normal renal function, hypocalcemia
regimens.
is seen twice as often with denosumab than zoledronic acid and all
See NCCN Guidelines for Hematopoietic Growth Factors for recommendations
patients on denosumab should be treated with vitamin D and calcium
on growth factor support.
with periodic monitoring of serum calcium levels.
• Immunotherapy
Zoledronic acid is given intravenously every 3 to 4 weeks or every 12
Men with asymptomatic or minimally symptomatic mCRPC may consider
immunotherapy. weeks. The dose is based on the serum creatinine obtained just prior to
each dose and must be adjusted for impaired renal function. Zoledronic
Sipuleucel-T
◊◊Sipuleucel-T is only for asymptomatic or minimally symptomatic, no acid is not recommended for creatinine clearance <30 mL/min.
liver metastases, life expectancy >6 mo, ECOG performance status 0–1. • Osteonecrosis of the jaw (ONJ) is seen with both agents; risk is
◊◊Sipuleucel-T is not recommended for patients with small cell/ increased in patients who have tooth extractions, poor dental hygiene,
neuroendocrine prostate cancer. or a dental appliance. Patients should be referred for dental evaluation
◊◊Sipuleucel-T has been shown in a phase 3 clinical trial to extend mean before starting either zoledronic acid or denosumab. If invasive dental
survival from 21.7 mo in the control arm to 25.8 mo in the treatment arm, procedures are required, bone-targeted therapy should be withheld until
which constitutes a 22% reduction in mortality risk. the dentist indicates that the patient has healed completely from all
◊◊Sipuleucel-T is well tolerated; common complications include chills, dental procedure(s).
pyrexia, and headache. • The optimal duration of therapy for either denosumab or zoledronic acid
Pembrolizumab (for MSI-H or dMMR) remains uncertain.
◊◊Only as subsequent systemic therapy for patients who have progressed • The toxicity profile of denosumab when denosumab is used in patients
through at least one line of systemic therapy for M1 CRPC who have been treated with zoledronic acid remains uncertain.
Prevention of Skeletal-Related Events

• In men with CRPC who have bone metastases, denosumab and zoledronic
acid have been shown to prevent disease-related skeletal complications,
which include fracture, spinal cord compression, or the need for surgery or
RT to bone.
• When compared to zoledronic acid, denosumab was shown to be superior in
prevention of skeletal-related events.

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American Joint Committee on Cancer (AJCC)

TNM Staging System For Prostate Cancer (8th ed., 2017)
Pathological T (pT)
Table 1. Definitions for T, N, M
Clinical T (cT) T Primary Tumor
T Primary Tumor T2 Organ confined
TX Primary tumor cannot be assessed T3 Extraprostatic extension
T0 No evidence of primary tumor T3a Extraprostatic extension (unilateral or bilateral) or microscopic
T1 Clinically inapparent tumor that is not palpable invasion of bladder neck
T1a Tumor incidental histologic finding in 5% or less of T3b Tumor invades seminal vesicle(s)
tissue resected T4 Tumor is fixed or invades adjacent structures other than seminal
T1b Tumor incidental histologic finding in more than 5% vesicles such as external sphincter, rectum, bladder, levator
of tissue resected muscles, and/or pelvic wall
Note: There is no pathological T1 classification.
T1c Tumor identified by needle biopsy found in one or both sides, Note: Positive surgical margin should be indicated by an R1 descriptor, indicating
but not palpable residual microscopic disease.
T2 Tumor is palpable and confined within prostate
T2a Tumor involves one-half of one side or less N Regional Lymph Nodes
T2b Tumor involves more than one-half of one side but NX Regional lymph nodes cannot be assessed
not both sides N0 No positive regional nodes
T2c Tumor involves both sides N1 Metastases in regional node(s)
T3 Extraprostatic tumor that is not fixed or does not invade
adjacent structures M Distant Metastasis
T3a Extraprostatic extension (unilateral or bilateral) M0 No distant metastasis
T3b Tumor invades seminal vesicle(s) M1 Distant metastasis
T4 Tumor is fixed or invades adjacent structures other M1a Nonregional lymph node(s)
than seminal vesicles such as external sphincter, rectum, M1b Bone(s)
bladder, levator muscles, and/or pelvic wall.
M1c Other site(s) with or without bone disease
Note: When more than one site of metastasis is present, the most advanced category
is used. M1c is most advanced.
Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging Manual, Eighth Edition
(2017) published by Springer International Publishing.
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Table 2. AJCC Prognostic Groups

Group T N M PSA (ng/mL) Grade Group Histopathologic Type
Stage I cT1a-c N0 M0 PSA <10 1 This classification applies to adenocarcinomas and squamous carcinomas,
cT2a N0 M0 PSA <10 1 but not to sarcoma or transitional cell (urothelial) carcinoma of the prostate.
Adjectives used to describe histologic variants of adenocarcinomas of
pT2 N0 M0 PSA <10 1 prostate include mucinous, signet ring cell, ductal, and neuroendocrine,
Stage IIA cT1a-c N0 M0 PSA ≥10 <20 1 including small cell carcinoma. There should be histologic confirmation of the
cT2a N0 M0 PSA ≥10 <20 1 disease.
pT2 N0 M0 PSA ≥10 <20 1 Definition of Histologic Grade Group (G)
cT2b N0 M0 PSA <20 1 Recently, the Gleason system has been compressed into so-called Grade
cT2c N0 M0 PSA <20 1 Groups.
Stage IIB T1-2 N0 M0 PSA <20 2
Grade Group Gleason Score Gleason Pattern
Stage IIC T1-2 N0 M0 PSA <20 3
1 ≤6 ≤3+3
T1-2 N0 M0 PSA <20 4
2 7 3+4
Stage IIIA T1-2 N0 M0 PSA ≥20 1-4
3 7 4+3
Stage IIIB T3-4 N0 M0 Any PSA 1-4
4 8 4+4, 3+5, 5+3
Stage IIIC Any T N0 M0 Any PSA 5
5 9 or 10 4+5, 5+4, 5+5
Stage IVA Any T N1 M0 Any PSA Any
Stage IVB Any T Any N M1 Any PSA Any
Note: W
hen either PSA or Grade Group is not available, grouping should be
determined by T category and/or either PSA or Grade Group as available.
Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging Manual, Eighth Edition
(2017) published by Springer International Publishing.
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NCCN Categories of Evidence and Consensus

Category 1 Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.
Category 3 Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.
All recommendations are category 2A unless otherwise indicated.
NCCN Categories of Preference

Interventions that are based on superior efficacy, safety, and evidence; and, when appropriate,
Preferred intervention affordability.
Other recommended Other interventions that may be somewhat less efficacious, more toxic, or based on less mature data;
intervention or significantly less affordable for similar outcomes.
Useful in certain
Other interventions that may be used for selected patient populations (defined with recommendation).
circumstances
All recommendations are considered appropriate.
CAT-1
NCCN Guidelines Version 2.2020

Prostate Cancer
Discussion This discussion corresponds to the NCCN Guidelines for Prostate Cancer. Last updated on 08/19/2019.
Table of Contents
Overview ......................................................................................... MS-2 ADT for Regional Disease ......................................................... MS-31
Literature Search Criteria and Guidelines Update Methodology ........ MS-2 Palliative ADT ........................................................................... MS-32
Estimates of Life Expectancy ........................................................... MS-3 ADT for Castration-Naive Disease ............................................. MS-32
Prostate Cancer Genetics ................................................................ MS-3 Intermittent Versus Continuous ADT (Non-Metastatic) ............... MS-36
Homologous DNA Repair Genes .................................................. MS-3 Intermittent Versus Continuous ADT (Metastatic) ....................... MS-36
DNA Mismatch Repair Genes ....................................................... MS-4 Adverse Effects of Traditional ADT ............................................ MS-37
Effect of Intraductal or Ductal Histology ........................................ MS-4 Secondary Hormone Therapy for CRPC ....................................... MS-39
Genetic Testing Recommendations .............................................. MS-5 Abiraterone Acetate in M1 CRPC .............................................. MS-40
Risk Stratification for Clinically Localized Disease ............................ MS-6 Enzalutamide in M0 and M1 CRPC............................................ MS-41
Nomograms ................................................................................. MS-7 Apalutamide in M0 CRPC .......................................................... MS-42
Tumor Multigene Molecular Testing .............................................. MS-8 Darolutamide in M0 CRPC ........................................................ MS-42
Imaging ........................................................................................... MS-9 Chemotherapy and Immunotherapy .............................................. MS-43
Multiparametric MRI ................................................................... MS-10 Docetaxel .................................................................................. MS-43
Nuclear Imaging ......................................................................... MS-10 Cabazitaxel ............................................................................... MS-44
Risks of Imaging ........................................................................ MS-11 Sipuleucel-T .............................................................................. MS-45
Observation ................................................................................... MS-12 Pembrolizumab ......................................................................... MS-45
Active Surveillance ........................................................................ MS-13 Treatment Implications for Patients with DNA Repair Gene Mutations
Rationale ................................................................................... MS-13 ................................................................................................. MS-46
Patient Selection ........................................................................ MS-14 Agents Related to Bone Health in CRPC ................................... MS-47
Surveillance Program and Reclassification Criteria ..................... MS-15 NCCN Recommendations ............................................................. MS-47
Radical Prostatectomy ................................................................... MS-17 Summary ...................................................................................... MS-61
Operative Techniques and Adverse Effects ................................ MS-18 Table 1. Available Tissue-Based Tests for Prostate Cancer Risk
Pelvic Lymph Node Dissection ................................................... MS-19 Stratification/Prognosis ................................................................. MS-62
Radiation Therapy ......................................................................... MS-19 Table 2. Summary of Main PET Imaging Tracers Studied in Prostate
External Beam Radiation Therapy .............................................. MS-20 Cancer*......................................................................................... MS-63
Stereotactic Body Radiation Therapy ......................................... MS-22 Table 3. Selected Active Surveillance Experiences in North America..
Brachytherapy............................................................................ MS-23 ..................................................................................................... MS-64
Proton Therapy .......................................................................... MS-25 References ................................................................................... MS-65
Radiation for Distant Metastases ................................................ MS-27
Comparison of Treatment Options for Localized Disease ............... MS-28
Other Local Therapies ................................................................... MS-28
Androgen Deprivation Therapy ...................................................... MS-29
ADT for Clinically Localized (N0M0) Disease .............................. MS-29
MS-1
Version 2.2020 © 2020 National Comprehensive Cancer Network© (NCCN©), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.

Prostate Cancer
Prostate Cancer Early Detection, available at www.NCCN.org) should

Overview decrease the risk of overdetection and overtreatment AND preserve the
An estimated 174,650 new cases of prostate cancer will be diagnosed in decrease in prostate cancer mortality.
2019, accounting for 20% of new cancer cases in men.1 The age-adjusted
death rates from prostate cancer have declined 51% from 1993 to 2016.1 Literature Search Criteria and Guidelines Update
Researchers have estimated that prostate cancer will account for 9.8% of
Methodology
male cancer deaths in 2018.1 Over the past several years, the incidence of An electronic search of the PubMed database was performed to obtain
prostate cancer has declined, likely in part as a result of decreased key literature in prostate cancer published since the previous Guidelines
detection attributed to decreased rates of prostate-specific antigen (PSA) update, using the search term “prostate cancer,” prior to the update of this
screening.2-4 The decreasing and comparatively low death rate suggests version of the NCCN Guidelines® for Prostate Cancer. The PubMed
that increased public awareness with earlier detection and treatment has database was chosen because it remains the most widely used resource
affected mortality from this prevalent cancer. for medical literature and indexes peer-reviewed biomedical literature.20
Early detection can lead to overtreatment of prostate cancers that do not The search results were narrowed by selecting studies in humans
threaten life expectancy, which results in unnecessary side effects that published in English. Results were confined to the following article types:
impair quality of life (QOL) and increase health care expenditures. The Clinical Trial, Phase III; Clinical Trial, Phase IV; Guideline; Randomized
U.S. Preventive Services Task Force (USPSTF) recommended against Controlled Trial; Meta-Analysis; Systematic Reviews; and Validation
PSA testing in 2012.5 The incidence of metastatic disease has Studies.
increased.4,6 The rate of prostate cancer mortality, which had been in
The PubMed search resulted in 383 citations and their potential relevance
decline for 2 decades, has stabilized.4 Prostate cancer incidence and
was examined. The data from key PubMed articles selected by the panel
deaths have increased in the past few years for the first time in recent
for review during the Guidelines update as well as articles from additional
history, with prostate cancer deaths increasing from an estimated 26,730
sources deemed as relevant to these Guidelines and discussed by the
in 2017 to 31,620 in 2019.1,7 Increases in the incidence of metastases at
panel have been included in this version of the Discussion section (eg, e-
presentation and prostate cancer deaths may be influenced by declines in
publications ahead of print, meeting abstracts). Recommendations for
the rates of prostate cancer early detection, biopsies, diagnosis of
which high-level evidence is lacking are based on the panel’s review of
localized prostate cancers, and radical prostatectomy that followed the
lower-level evidence and expert opinion.
2012 USPSTF recommendations.8-18 The USPSTF released updated
recommendations in 2018 that include individualized, informed decision- The complete details of the Development and Update of the NCCN
making regarding prostate cancer screening in men aged 55 to 69 years.19 Guidelines are available at www.NCCN.org.
These updated recommendations may allow for a more balanced
approach to prostate cancer early detection. Better use of PSA for early
detection of potentially fatal prostate cancer (see the NCCN Guidelines for
MS-2

Prostate Cancer
Estimates of Life Expectancy risk for second cancers. Some patients with prostate cancer and their
Estimates of life expectancy have emerged as a key determinant of families may be at increased risk for breast and ovarian cancer,
primary treatment, particularly when considering active surveillance or melanoma, and pancreatic cancer (HBOC); colorectal cancers (Lynch
observation. Life expectancy can be estimated for groups of men, but it is syndrome); and other cancer types. Data also suggest that patients with
difficult to extrapolate these estimates to an individual patient. Life prostate cancer who have BRCA1/2 germline mutations have increased
expectancy can be estimated using the Minnesota Metropolitan Life risk of progression on local therapy and decreased overall survival (OS).33-
35
Insurance Tables, the Social Security Administration Life Insurance This information should be discussed with such men if they are
Tables,21 or the WHO’s Life Tables by Country,22 and adjusted for considering active surveillance. Finally, there are possible treatment
individual patients by adding or subtracting 50% based on whether one implications for patients with DNA repair defects (see Treatment
believes the patient is in the healthiest quartile or the unhealthiest quartile, Implications for Patients with DNA Repair Gene Mutations, below).
respectively.23 As an example, the Social Security Administration Life
Prostate cancer is often associated with somatic mutations that occur in
Expectancy for a 65-year-old American man is 17.7 years. If judged to be
the tumor but not in the germline. An estimated 89% of metastatic
in the upper quartile of health, a life expectancy of 26.5 years is assigned.
castration-resistant prostate cancer (CRPC) tumors contain a potentially
If judged to be in the lower quartile of health, a life expectancy of 8.8 years
actionable mutation, with only about 9% of these occurring in the
is assigned. Thus, treatment recommendations could change dramatically
germline.36 Both germline and tumor mutations are discussed herein.
using the NCCN Guidelines if a 65-year-old man was judged to be in
either poor or excellent health. Homologous DNA Repair Genes
Somatic mutations in DNA repair pathway genes occur in a reported 19%
Prostate Cancer Genetics
of localized prostate tumors and 23% of metastatic CRPC tumors, with
Family history of prostate cancer raises the risk of prostate cancer.24-26 In most mutations found in BRCA2 and ATM.36,37 These tumor mutations are
addition, prostate cancer has been associated with hereditary breast and often associated with germline mutations. For example, 42% of patients
ovarian cancer (HBOC) syndrome (due to germline mutations in with metastatic CRPC and somatic mutations in BRCA2 were found to
homologous DNA repair genes) and Lynch syndrome (resulting from carry the mutation in their germlines.36 In localized prostate cancer, that
germline mutations in DNA mismatch repair genes).27-31 In fact, number was 60%.37 In fact, recent data indicate that 11.8% of men with
approximately 11% of patients with prostate cancer and at least 1 metastatic prostate cancer have germline mutations in 1 of 16 DNA repair
additional primary cancer carry germline mutations associated with genes: BRCA2 (5.3%), ATM (1.6%), CHEK2 (1.9%), BRCA1 (0.9%),
increased cancer risk.32 Therefore, the panel recommends a thorough RAD51D (0.4%), PALB2 (0.4%), ATR (0.3%), and NBN, PMS2, GEN1,
review of personal and family history for all patients with prostate cancer. MSH2, MSH6, RAD51C, MRE11A, BRIP1, or FAM175A.38 In patients with
localized prostate cancer in the TCGA cohort,37 the rates of germline DNA
The newfound appreciation of the frequency of germline DNA repair gene
repair mutations were 6% in those with high-risk prostate cancer and 2%
mutations (discussed in more detail below) has implications for family
in low/intermediate risk.38 In another study, 16% of unselected patients
genetic counseling, cancer risk syndromes, and assessment of personal
MS-3

Prostate Cancer
with metastatic CRPC harbored germline mutations in BRCA2, ATM, and mutations appears to occur earlier, has a more aggressive phenotype, and
BRCA1.39 is associated with significantly reduced survival times than in non-carrier
patients.34,35,59-62
An additional study showed that 9 of 125 men with high-risk, very-high-
risk, or metastatic prostate cancer (7.2%) had pathogenic germline DNA Mismatch Repair Genes
mutations in MUTYH (4), ATM (2), BRCA1 (1), BRCA2 (1), and BRIP1 Tumor mutations in MLH1, MSH2, MSH6, and PMS2 may result in tumor
(1).40 In this study, the rate of mutation identification in men with metastatic microsatellite instability (MSI) and deficient mismatch repair (dMMR;
disease was 28.6% (2 of 7 men). Although having a relative with breast detected by immunohistochemistry) and are sometimes associated with
cancer was associated with germline mutation identification (P = .035), germline mutations and Lynch syndrome. In a study of >15,000 patients
only 45.5% of the mutation carriers in the study had mutations that were with cancer treated at Memorial Sloan Kettering Cancer Center who had
concordant with their personal and family history. Another study also found their tumor and matched normal DNA sequenced and tumor MSI status
that a family history of breast cancer increased the chances of identifying assessed, approximately 5% of 1048 patients with prostate cancer had
a germline DNA repair gene mutation in men with prostate cancer (OR, MSI-high (MSI-H) or MSI-indeterminate tumors, 5.6% of whom were found
1.89; 95% CI, 1.33–2.68; P = .003).41 In a study of an unselected cohort of to have Lynch syndrome (0.29% of patients with prostate cancer).27 In
3607 patients with a personal history of prostate cancer who had germline another prospective case series, the tumors of 3.1% of 1033 patients with
genetic testing based on clinician referral, 11.5% had germline mutations prostate cancer demonstrated MSI-H/dMMR status, and 21.9% of these
in BRCA2, CHEK2, ATM, BRCA1, or PALB2.42 patients had Lynch syndrome (0.68% of the total population).63 In a study
of an unselected cohort of 3607 patients with a personal history of prostate
More than 2% of Ashkenazi Jews carry germline mutations in BRCA1 or
cancer who had germline genetic testing based on clinician referral, 1.7%
BRCA2, and these carriers have a 16% chance (95% CI, 4%–30%) of
had germline mutations in PMS2, MLH1, MSH2, or MSH6.42
developing prostate cancer by the age of 70.43 In a study of 251
unselected Ashkenazi Jewish patients with prostate cancer, 5.2% had Effect of Intraductal or Ductal Histology
germline mutations in BRCA1 and BRCA2, compared with 1.9% of control
Ductal prostate carcinomas are rare, accounting for approximately 1.3% of
Ashkenazi Jewish men.44
prostate carcinomas.64 Intraductal prostate cancer may be more common,
Germline BRCA1 or BRCA2 mutations have been associated with an especially in higher risk groups.65 It is important to note that there is
increased risk for prostate cancer in numerous reports.30,31,44-54 In significant overlap in diagnostic criteria and that intraductal, ductal, and
particular, BRCA2 mutations have been associated with a 2- to 6-fold invasive cribriform features may coexist in the same biopsy. By definition,
increase in the risk for prostate cancer, whereas the association of BRCA1 intraductal carcinoma includes cribriform proliferation of malignant cells as
mutations and increased risks for prostate cancer are less long as they remain confined to a preexisting gland that is surrounded by
consistent.30,31,44,46,48,53 In addition, limited data suggest that germline basal cells. These features are seen frequently with an adjacent invasive
mutations in ATM, PALB2, and CHEK2 increase the risk of prostate cribriform component and would be missed without the use of basal cell
cancer.55-58 Furthermore, prostate cancer in men with germline BRCA markers.
MS-4

Prostate Cancer
Limited data suggest that prostate tumors with ductal or intraductal clinical context. For example, HOXB13 is a prostate cancer risk gene and,
histology have increased genomic instability.66-68 In particular, tumors with whereas there are not currently clear therapeutic implications in the
these histologies may be more likely to harbor somatic and/or germline advanced disease setting, testing may be valuable for family
MMR gene alterations than those with adenocarcinoma histology.69,70 In counseling.74,75
addition, limited data suggest that germline homologous DNA repair gene
Somatic Tumor Testing Based on Risk Groups
mutations may be more common in prostate tumors of ductal or intraductal
origin71,72 and that intraductal histology is common in germline BRCA2 Tumor testing recommendations are as follows:
mutation carriers with prostate cancer.73 Overall, the panel believes that 1. Tumor testing for somatic homologous recombination gene
the data connecting histology and the presence of genomic alterations are mutations (eg, BRCA1, BRCA2, ATM, PALB2, FANCA, RAD51D,
stronger for intraductal than ductal histology at this time. Therefore, CHEK2) can be considered in patients with regional or metastatic
patients with presence of intraductal carcinoma on biopsy should have prostate cancer.
germline testing as described below. 2. Tumor testing for MSI or dMMR can be considered in patients with
regional or metastatic prostate cancer.
Genetic Testing Recommendations 3. Multigene molecular testing can be considered for patients with low
Germline Testing Based on Family History, Histology, and Risk Groups and favorable-intermediate-risk prostate cancer and life
The panel recommends inquiring about family and personal history of expectancy ≥10 years (see Tumor Multigene Molecular Testing,
cancer at time of initial diagnosis. Based on the data discussed above, the below).
panel recommends germline genetic testing, with or without pre-test 4. The Decipher molecular assay can be considered as part of
genetic counseling, for patients with prostate cancer and any of the counseling for risk stratification in patients with PSA
following: resistance/recurrence after radical prostatectomy (category 2B;
 A positive family history (see definition in the guidelines above) see Tumor Multigene Molecular Testing, below).
 High-risk, very-high-risk, regional, or metastatic prostate cancer,
regardless of family history If mutations in BRCA2, BRCA1, ATM, CHEK2, or PALB2 are found, the
patient should be referred for genetic counseling to assess for the
 Ashkenazi Jewish ancestry
possibility of HBOC.
 Intraductal histology
If MSI testing is performed, testing using an NGS assay validated for
Germline testing, when performed, should include MLH1, MSH2, MSH6,
prostate cancer is preferred.76-78 If MSI-H or dMMR is found, the patient
and PMS2 (for Lynch syndrome) and the homologous recombination
should be referred for genetic counseling to assess for the possibility of
genes BRCA2, BRCA1, ATM, PALB2, and CHEK2. Cancer predisposition
Lynch syndrome. MSI-H or dMMR indicate eligibility for pembrolizumab in
next-generation sequencing (NGS) panel testing, at a minimum including
second and subsequent lines of treatment for CRPC (see Pembrolizumab,
BRCA2, BRCA1, ATM, CHEK2, PALB2, MLH1, MSH2, MSH6, and PMS2,
below).
can be considered. Additional genes may be appropriate depending on
MS-5

Prostate Cancer
Patients should be informed that somatic tumor sequencing has the group stratification has been published widely and validated, and provides
potential to uncover germline findings. However, virtually none of the NGS a better basis for treatment recommendations than clinical stage alone.80,81
tests is designed or validated for germline assessment. Therefore, over-
interpretation of germline findings should be avoided. If a germline A new prostate cancer grading system was developed during the 2014
mutation is suspected, the patient should be recommended for genetic International Society of Urological Pathology (ISUP) Consensus
counseling and follow-up dedicated germline testing. Conference.82 Several changes were made to the assignment of Gleason
pattern based on pathology. The new system assigns Grade Groups from
Additional Testing 1 to 5, derived from the Gleason score.
Tumors from a majority of patients with metastatic CRPC harbor mutations  Grade Group 1: Gleason score ≤6; only individual discrete well-
in genes involved in the androgen receptor signaling pathway.36 AR-V7 formed glands
testing in circulating tumor cells (CTCs) can be considered to help guide  Grade Group 2: Gleason score 3+4=7; predominantly well-formed
selection of therapy in the post-abiraterone/enzalutamide metastatic glands with lesser component of poorly formed/fused/cribriform
CRPC setting (discussed in more detail below, under Progression After glands
Enzalutamide or Abiraterone).  Grade Group 3: Gleason score 4+3=7; predominantly poorly
formed/fused/cribriform glands with lesser component of well-
Risk Stratification for Clinically Localized Disease formed glands
Optimal treatment of prostate cancer requires assessment of risk: How o For cases with >95% poorly formed/fused/cribriform glands
likely is a given cancer to be confined to the prostate or spread to the or lack of glands on a core or at radical prostatectomy, the
regional lymph nodes? How likely is the cancer to progress or metastasize component of <5% well-formed glands is not factored into
after treatment? How likely is adjuvant or salvage radiation to control the grade.
cancer after an unsuccessful radical prostatectomy? Prostate cancers are  Grade Group 4: Gleason score 4+4=8; 3+5=8; 5+3=8
best characterized by a digital rectal exam (DRE) and radiographically o Only poorly formed/fused/cribriform glands; or
determined clinical T stage, Gleason score and extent of cancer in the o Predominantly well-formed glands and lesser component
biopsy specimen, and serum PSA level. Imaging studies (ie, ultrasound, lacking glands (poorly formed/fused/cribriform glands can
MRI) have been investigated intensively but have yet to be accepted as be a more minor component); or
essential adjuncts to staging. o Predominantly lacking glands and lesser component of
well-formed glands (poorly formed/fused/cribriform glands
The NCCN Guidelines have, for many years, incorporated a risk
can be a more minor component)
stratification scheme that uses a minimum of stage, Gleason grade, and
 Grade Group 5: Gleason score 9-10; lack gland formation (or with
PSA to assign patients to risk groups. These risk groups are used to select
necrosis) with or without poorly formed/fused/cribriform glands
the appropriate options that should be considered and to predict the
o For cases with >95% poorly formed/fused/cribriform glands
probability of biochemical recurrence after definitive local therapy.79 Risk
or lack of glands on a core or at radical prostatectomy, the
MS-6

Prostate Cancer
component of <5% well-formed glands is not factored into score (8–10) or PSA level (>20 ng/mL), although it did not reach statistical
the grade. significance. Other studies have reported differences in outcomes in the
high-risk group depending on risk factors or primary Gleason pattern.92,93
Many experts believe that ISUP Grade Groups will enable patients to Evidence also shows heterogeneity in the low-risk group, with PSA levels
better understand their true risk level and thereby limit overtreatment. The and percent positive cores affecting pathologic findings after radical
new Grade Group system was validated in 2 separate cohorts, one of prostatectomy.94,95
>26,000 men and one of 5880 men, treated for prostate cancer with either
radical prostatectomy or radiation.83,84 Both studies found that Grade In a retrospective study, 1024 patients with intermediate-risk prostate
Groups predicted the risk of recurrence after primary treatment. For cancer were treated with radiation with or without neoadjuvant and
instance, in the larger study, the 5-year biochemical recurrence-free concurrent ADT.96 Multivariate analysis revealed that primary Gleason
progression probabilities after radical prostatectomy for Grade Groups 1 pattern 4, number of positive biopsy cores ≥50%, and presence of >1
through 5 were 96% (95% CI, 95–96), 88% (95% CI, 85–89), 63% (95% intermediate-risk factors (IRFs; ie, T2b-c, PSA 10–20 ng/mL, Gleason
CI, 61–65), 48% (95% CI, 44–52), and 26% (95% CI, 23–30), respectively. score 7) were significant predictors of increased incidence of distant
The separation between Grade Groups was less pronounced in the metastasis. The authors used these factors to separate the patients into
radiation therapy (RT) cohort, likely because of increased use of unfavorable and favorable intermediate-risk groups and determined that
neoadjuvant/concurrent/adjuvant androgen deprivation therapy (ADT) in the unfavorable intermediate-risk group had worse PSA recurrence-free
the higher risk groups. In another study of the new ISUP Grade Group survival and higher rates of distant metastasis and prostate cancer-
system, all-cause mortality and prostate cancer-specific mortality were specific mortality than the favorable intermediate-risk group. The use of
higher in men in Grade Group 5 than in those in Grade Group 4.85 active surveillance in men with favorable intermediate-risk prostate cancer
Additional studies have supported the validity of this new system.86-90 The is discussed below (see Favorable Intermediate Risk).
NCCN Panel has accepted the new Grade Group system to inform better
Nomograms
treatment discussions compared to those using Gleason score. Patients
remain divided into very-low-, low-, intermediate-, high-, and very-high-risk The more clinically relevant information that is used in the calculation of
groups. time to PSA recurrence, the more accurate the result. A nomogram is a
predictive instrument that takes a set of input data (variables) and makes
The NCCN Guidelines Panel recognized that heterogeneity exists within predictions about an outcome. Nomograms predict more accurately for the
each risk group. For example, an analysis of 12,821 patients showed that individual patient than risk groups, because they combine the relevant
men assigned to the intermediate-risk group by clinical stage (T2b–T2c) prognostic variables. The Partin tables were the first to achieve
had a lower risk of recurrence than men categorized according to Gleason widespread use for counseling men with clinically localized prostate
score (7) or PSA level (10–20 ng/mL).91 A similar trend of superior cancer.97-100 The tables give the probability (95% CIs) that a patient with a
recurrence-free survival was observed in men placed in the high-risk certain clinical stage, Gleason score, and PSA will have a cancer of each
group by clinical stage (T3a) compared to those assigned by Gleason pathologic stage. Nomograms can be used to inform treatment decision-
MS-7

Prostate Cancer
making for men contemplating active surveillance,101-103 radical than 10 years or very-low-risk prostate cancer and life expectancy less
prostatectomy,104-107 neurovascular bundle preservation108-110 or omission than 20 years. Although risk groups, life expectancy estimates, and
of pelvic lymph node dissection (PLND) during radical prostatectomy,111-114 nomograms help inform decisions, uncertainty about the risk of disease
brachytherapy,104,115-117 or external beam RT (EBRT).104,118 Biochemical progression persists. American men continue to under-select active
progression-free survival can be reassessed postoperatively using age, surveillance and their physicians may under-recommend it, likely as a
diagnostic serum PSA, and pathologic grade and stage.104,119-121 Potential result of this uncertainty.132 In 2013, <20% of men with low-risk prostate
success of adjuvant or salvage RT after unsuccessful radical cancer were managed with active surveillance.16 However, active
prostatectomy can be assessed using a nomogram.104,122 surveillance has become more common in some areas, such as Michigan,
where its frequency has been measured and educational efforts have
None of the current models predicts with perfect accuracy, and only some begun.133,134
of these models predict metastasis103,104,119,123,124 and cancer-specific
death.105,107,125-127 Given the competing causes of mortality, many men who Several tissue-based molecular assays have been developed in an effort
sustain PSA recurrence will not live long enough to develop clinical to improve decision-making in newly diagnosed men considering active
evidence of distant metastases or to die from prostate cancer. Those with surveillance and in treated men considering adjuvant therapy or treatment
a short PSA doubling time (PSADT) are at greatest risk of death. Not all for recurrence. Uncertainty about the risk of disease progression can be
PSA recurrences are clinically relevant; thus, PSADT may be a more reduced if such molecular assays can provide accurate and reproducible
useful measure of risk of death.128 The NCCN Guidelines Panel prognostic or predictive information beyond NCCN risk group assignment
recommends that NCCN risk groups be used to begin the discussion of and currently available life expectancy tables and nomograms.
options for the treatment of clinically localized prostate cancer and that Retrospective case cohort studies have shown that these assays provide
nomograms be used to provide additional and more individualized prognostic information independent of NCCN or CAPRA risk groups,
information. which include likelihood of death with conservative management,
likelihood of biochemical recurrence after radical prostatectomy or EBRT,
Tumor Multigene Molecular Testing likelihood of adverse pathologic features after radical prostatectomy, and
Personalized or precision medicine is a goal for many translational and likelihood of developing metastasis after operation or salvage EBRT.135-144
clinical investigators. The National Academy of Medicine has described A prospective, clinical utility study of 3966 patients newly diagnosed with
several lessons that should accelerate the development of useful localized prostate cancer found that the rates of active surveillance
biomarkers129 to inform men and their physicians about proper choices for increased with use of a tissue-based gene expression classifier.145 Active
treatment of clinically localized prostate cancer. Dr. Hayes has warned surveillance rates were 46.2%, 75.9%, and 57.9% for those whose
that a “bad tumor marker is as bad as a bad drug.”130,131 The NCCN classifier results were above the specified threshold, below the threshold,
Prostate Cancer Guidelines Panel strongly advocates for use of life and those who did not undergo genomic testing, respectively (P < .001).
expectancy estimation, use of nomograms, and active surveillance as the The authors estimate that 1 additional patient may chose active
only option for men with low-risk prostate cancer and life expectancy less
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Prostate Cancer
surveillance for every 9 men with favorable risk prostate cancer who details on each technique are outlined in the algorithm under Principles of
undergo genomic testing. Imaging.
No randomized controlled trials have studied the utility of these tests. The guidelines recommend pelvic +/- abdominal CT or MRI imaging as
Several of these assays are available, and 4 have received positive part of staging workup for men with longer life expectancies and favorable
reviews by the Molecular Diagnostic Services Program (MolDX) and are intermediate or higher risk disease if nomogram-predicted probability of
likely to be covered by CMS (Centers for Medicare & Medicaid Services). lymph node involvement >10%. Multivariate analysis of retrospective data
Several other tests are under development, and the use of these assays is on 643 men with newly diagnosed prostate cancer who underwent staging
likely to increase in the coming years. CT found that PSA, Gleason score, and clinical T stage were associated
independently with a positive finding (P < .05 for all).146 A validation of
Table 1 lists these tests in alphabetical order and provides an overview of NCCN’s pelvic imaging recommendations using the SEER database found
each test, populations where each test independently predicts outcome, that only 0.3% to 0.4% of patients with positive lymph nodes are missed,
and supporting references. These molecular biomarker tests have been depending on which nomogram is used, whereas the negative predictive
developed with extensive industry support, guidance, and involvement, value (NPV) was 99.5%.147
and have been marketed under the less rigorous FDA regulatory pathway
for biomarkers. Although full assessment of their clinical utility requires Bone imaging is recommended as part of staging for patients with longer
prospective randomized clinical trials, which are unlikely to be done, the life expectancies and higher Gleason grade, higher T stage, or higher PSA
panel believes that men with low or favorable intermediate disease may values as delineated in the algorithm. Conventional bone scan is
consider the use of Decipher, Oncotype DX Prostate, Prolaris, or ProMark recommended first, with subsequent plain films, CT, MRI, or F-18 sodium
during initial risk stratification. In addition, Decipher may be considered fluoride PET/CT or PET/MRI, C-11 choline PET/CT or PET/MRI, or F-18
during workup for radical prostatectomy PSA persistence or recurrence fluciclovine PET/CT or PET/MRI (see Nuclear Imaging, below) to address
(category 2B). Future comparative effectiveness research may allow these equivocal findings. Retrospective evidence suggests that Gleason score
tests and others like them to gain additional evidence regarding their utility and PSA levels are associated with positive bone scan findings.148 The
for better risk stratification of men with prostate cancer. SEER database validation of NCCN’s imaging recommendations found
that only 0.14% of patients with bone metastases would have been
Imaging missed, whereas the NPV was 99.8%.147
Imaging techniques are useful for staging and for detecting metastases
and tumor recurrence. Anatomic imaging techniques include radiographs, Transrectal ultrasonography (TRUS) is the most common technique for
ultrasound, CT, and MRI. Functional techniques include radionuclide bone anatomic visualization of the prostate. TRUS is used to guide transrectal
scan (conventional Tc EDTMP scan), PET/CT, PET/MRI, and advanced biopsies, and can be considered for patients with biochemical recurrence
MRI, such as spectroscopy and diffusion-weighted imaging (DWI). More after operation or radiation.
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Prostate Cancer
The utility of imaging for men with an early biochemical recurrence after been shown to be equivalent to CT scan for staging of pelvic lymph
radical prostatectomy depends on disease risk before operation and nodes.160,161 Finally, mpMRI out-performs bone scan and targeted x-rays
pathologic stage, Gleason grade, PSA, and PSADT after recurrence. for detection of bone metastases, with a sensitivity of 98% to 100% and
Patients with low- and intermediate-risk disease and low postoperative specificity of 98% to 100% (vs. sensitivity of 86% and specificity of 98%–
serum PSA levels have a very low risk of positive bone scans or CT 100% for bone scan plus targeted x-rays).162
scans.149,150 In a series of 414 bone scans performed in 230 men with
biochemical recurrence after radical prostatectomy, the rate of a positive Nuclear Imaging
bone scan for men with PSA >10 ng/mL was only 4%.151 Serial PSA The use of PET/CT or PET/MRI imaging using tracers other than F-18
measurements can be helpful for stratifying men at highest risk of fluorodeoxyglucose (FDG) for staging of small-volume recurrent or
progression and metastases. Some men have detectable PSA after metastatic prostate cancer is a rapidly developing field wherein most of the
radical prostatectomy due to benign prostate tissue in the prostate fossa. data are derived from single-institution series or registry studies. High
They have low stable PSAs and a very low risk of prostate cancer variability among equipment, protocols, interpretation, and institutions
progression.152,153 provides challenges for application and interpretation of the utility of
PET/CT or PET/MRI. Furthermore, FDA clearance and reimbursement for
Multiparametric MRI some tests makes unlikely the conduct of clinical trials to evaluate their
The use of multiparametric MRI (mpMRI) in the staging and utility and impact upon oncologic outcome. Three PET tracers are FDA
characterization of prostate cancer has increased in the last few years. To cleared for use in men with prostate cancer: C-11 choline, F-18 sodium
be considered “multiparametric,” MRI images must be acquired with at fluoride, and F-18 fluciclovine.
least one more sequence apart from the anatomical T2-weighted one,
such as DWIs or dynamic contrast-enhanced (DCE) images. Furthermore, C-11 choline PET/CT or PET/MRI and F-18 fluciclovine PET/CT or
a high-quality mpMRI requires a 3.0 T magnet; the need for an endorectal PET/MRI detect small-volume disease in bone and soft tissues.163,164 The
coil remains controversial. reported sensitivity and specificity of C-11 choline PET/CT in restaging
patients with biochemical recurrence ranges from 32% to 93% and from
Evidence supports the implementation of mpMRI in several aspects of 40% to 93%, respectively.165-174 The reported sensitivity and specificity of
prostate cancer management. First, mpMRI helps detect large and poorly F-18 fluciclovine PET/CT ranges from 37% to 90% and from 40% to
differentiated cancers (ie, Grade Group ≥2).154 mpMRI has been 100%, respectively.171,175,176 A prospective study compared F-18
incorporated into MRI-TRUS fusion-targeted biopsy protocols, which has fluciclovine and C-11 choline PET/CT scans in 89 patients, and agreement
led to an increase in the diagnosis of high-grade cancers with fewer biopsy was 85%.171 The panel believes that F-18 fluciclovine PET/CT or PET/MRI
cores, while reducing detection of low-grade and insignificant cancers.155- or C-11 choline PET/CT or PET/MRI may be used in men with biochemical
157
Second, mpMRI aids in the detection of extracapsular extension (T recurrence after primary treatment for further soft tissue and/or bone
staging), with high NPVs in low-risk men.158 mpMRI results may inform evaluation after bone scan, chest CT, and abdominal/pelvic CT or
decision-making regarding nerve-sparing operation.159 Third, mpMRI has abdominal/pelvic MRI.
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Prostate Cancer
F-18 sodium fluoride PET/CT detects bone metastases with greater detection of bone metastatic disease, for instance, may result in earlier
sensitivity, but less specificity, than standard bone scan imaging, use of newer and more expensive therapies, which may not improve
reportedly in the range of 87% to 100% and 62% to 89%, respectively.177- oncologic outcome or OS. The Panel remains unsure of how to treat
180
F-18 sodium fluoride PET/CT was evaluated in men with biochemical patients when M1 is suggested by PET-based imaging but not by
relapse after prior local therapy.181 The positive detection rate of bone conventional imaging.
metastases not seen on CT and bone scan was 16.2%.
Table 2 summarizes the main PET imaging tracers studied in prostate
The panel believes that F-18 sodium fluoride, C-11 choline, and F-18 cancer. F-18 FDG PET should not be used routinely, because data are
fluciclovine PET/CT or PET/MRI may be considered after bone scan for limited in patients with prostate cancer and suggest that its sensitivity is
further evaluation of the bones when bone scan results are equivocal. A significantly lower than that seen with other tracers.181,190,191
typical application is to resolve uncertainty when bone scan reveals a
single lesion and suspicion for diffuse metastases is high. The panel Risks of Imaging
cautions, however, that earlier detection of bone metastatic disease may As with any medical procedure, imaging is not without risk. Some of these
result in earlier use of newer and more expensive therapies, which may risks are concrete and tangible, while others are less clear. Risks
not improve oncologic outcome or OS. associated with imaging include exposure to ionizing radiation, adverse
reaction to contrast media, false-positive scans, and overdetection.
Newer tracers are under development, but they are neither FDA cleared
nor readily available and are considered investigational at this time. For Deterministic and stochastic are two types of effects from exposure to
instance, gallium-68 prostate-specific membrane antigen (PSMA) may ionizing radiation by x-ray, CT, or PET/CT. Deterministic effects are those
provide better detection of recurrences at lower PSA levels than reported that occur at a certain dose level, and include events such as cataracts
for FDA-approved imaging agents, and has comparable sensitivity (76%– and radiation burns. No effect is seen below the dose threshold. Medical
86%) and specificity (86%–100%).182-185 Another investigational agent, F- imaging is always performed almost below the threshold for deterministic
18 fluorodihydrotestosterone (FDHT), targets the androgen receptor and is effects. Stochastic effects tend to occur late, increase in likelihood as dose
not effective in the castration-naïve setting, but shows promise in CRPC, increases, and have no known lower “safe” limit. The major stochastic
with sensitivity in the range of 63% to 97%.186,187 C-11 acetate relies upon effect of concern in medical imaging is radiation-induced malignancy.
increased levels of fatty acid synthetase reported in prostate cancer. C-11 Unfortunately, no direct measurements are available to determine risk of
acetate performs similarly to C-11 choline but may have better specificity, cancer arising from one or more medical imaging events, so risks are
except high-quality data remain unavailable.188 calculated using other models (such as from atomic bomb survivors). The
literature is conflicting with regard to the precise risk of secondary
The panel notes that false-positive rates are high; therefore, histologic malignancies in patients undergoing medical imaging procedures. There is
confirmation is strongly recommended whenever feasible. Moreover, these a small but finite risk of developing secondary malignancies as a result of
PET/CT and PET/MRI tests are expensive, and, whereas results may medical imaging procedures, and the risk is greatest in young patients.
change treatment,189 they may not change oncologic outcome. Earlier
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Prostate Cancer
However, the absolute risk of fatal malignancy arising from a medical Accurate and medically relevant interpretation of imaging studies requires
imaging procedure is very low, and is difficult to detect given the familiarity and expertise in the imaging modality, attention to detail in
prevalence of cancer in the population and the multiple factors that image review, knowledge of tumor biology, and familiarity with treatment
contribute to oncogenesis.192 Efforts should be made to minimize dose options and algorithms. Challenging cases are best addressed through
from these procedures, which begin with judicious use of imaging only direct communication, either physician-to-physician or in a multidisciplinary
when justified by the clinical situation. Harm may arise from not imaging a tumor board setting.
patient, through disease non-detection, or from erroneous staging.
Medical imaging is a critical tool in the evaluation and management of
Many imaging studies make use of contrast material delivered by oral, patients with malignancy. However, as with any medical procedure,
intravenous, or rectal routes. The use of contrast material may improve imaging is not without risks to patients. Inappropriate use of imaging also
study performance, but reactions to contrast material may occur and they has been identified as a significant contributor to health care costs in the
should be used only when warranted. Some patients develop adverse United States and worldwide. Therefore, imaging should be performed
reactions to iodinated intravenous contrast material. Most reactions are only when medically appropriate, and in a manner that reduces risk (eg,
mild cutaneous reactions (eg, hives, itching) but occasionally severe minimizing radiation dose). An algorithmic approach to the use of imaging,
reactions can be life-threatening (bronchospasm or anaphylactoid). The such as by NCCN and the Appropriateness Criteria developed by the
risk of severe reaction is low with non-ionic contrast materials and may be American College of Radiology,194 can assist in medical decision-making.
about 1:170,000 injections.193 Both iodinated CT contrast material and
gadolinium-based MR contrast materials can affect renal function, Observation
particularly when renal function is impaired. MR contrast materials also Observation involves monitoring the course of prostate cancer with the
have been associated with systemic nephrogenic sclerosis in patients with expectation to deliver palliative therapy for development of symptoms or
impaired renal function. Centers performing imaging studies with contrast change in exam or PSA that suggests symptoms are imminent.
materials should have policies in place to address the use of contrast in Observation thus differs from active surveillance. The goal of observation
these patients. is to maintain QOL by avoiding noncurative treatment when prostate
cancer is unlikely to cause mortality or significant morbidity. The main
Every imaging test has limitations for sensitivity, specificity, and accuracy, advantage of observation is avoidance of possible side effects of
which are modulated further by the expertise of the interpreting physician. unnecessary definitive therapy or ADT. However, patients may develop
Harm can arise from failure to detect a tumor or tumor recurrence (ie, false urinary retention or pathologic fracture without prior symptoms or
negative), but harm to the patient and added expense to the medical increasing PSA level.
system also can result from false-positive scans. Improper interpretation of
a benign finding as malignant can lead to significant patient anxiety, Observation is applicable to elderly or frail men with comorbidity that will
additional and unnecessary imaging, and invasive procedures that carry likely out-compete prostate cancer for cause of death. Johansson and
their own risks for adverse outcomes. colleagues195 observed that only 13% of men developed metastases 15
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Prostate Cancer
years after diagnosis of T0-T2 disease and only 11% had died from participants), 8 were in the active surveillance group, 5 were in the
prostate cancer. Because prostate cancer will not be treated for cure for operation group, and 4 were in the radiation group (P = .48 for the overall
patients with shorter life expectancies, observation for as long as possible comparison). However, higher rates of disease progression and
is a reasonable option based on physician discretion. Monitoring should metastases were seen in the active surveillance group. Approximately
include PSA and physical exam no more often than every 6 months, but 23% of participants had Gleason scores 7–10, and 5 of 8 deaths in the
will not involve surveillance biopsies or radiographic imaging. When active surveillance group were in this subset. Patient-reported outcomes
symptoms develop or are imminent, patients can begin palliative ADT. were compared among the 3 groups.203 The operation group experienced
the greatest negative effect on sexual function and urinary continence,
Active Surveillance whereas bowel function was worst in the radiation group.
Active surveillance (formerly referred to as watchful waiting, expectant
management, or deferred treatment) involves actively monitoring the In addition, studies have shown that active surveillance does not adversely
course of the disease with the expectation to deliver curative therapy if the impact psychological wellbeing or QOL.203-208 Possible disadvantages of
cancer progresses. Unlike observation, active surveillance is mainly active surveillance are listed in the Principles section of the algorithm and
applicable to younger men with seemingly indolent cancer with the goal to include the possible necessity of follow-up prostate biopsies.
defer treatment and its potential side effects. Because these patients have
Rationale
a longer life expectancy, they should be followed closely and treatment
should start promptly should the cancer progress so as not to miss the The NCCN Guidelines Panel remains concerned about the problems of
chance for cure. overtreatment related to the increased frequency of diagnosis of prostate
cancer from widespread use of PSA for early detection or screening (see
In one study, approximately two thirds of eligible men avoided treatment, the NCCN Guidelines for Prostate Cancer Early Detection, available at
and thus the possible associated side effects of treatment, after 5 years of www.NCCN.org).
active surveillance.196 In another study, 55% of the population remained
untreated at 15 years.197 Although a proportion of men on active The debate about the need to diagnose and treat every man who has
surveillance will eventually undergo treatment, the delay does not appear prostate cancer is fueled by the high prevalence of prostate cancer upon
to impact cure rates, and several studies have shown that active autopsy of the prostate209; the high frequency of positive prostate biopsies
surveillance is safe.196-200 In fact, a 2015 meta-analysis of 26 active in men with normal DREs and serum PSA values210; the contrast between
surveillance cohort studies that included 7627 men identified only 8 the incidence and mortality rates of prostate cancer; and the need to treat
prostate cancer deaths and 5 cases of metastasis.201 Further, the ProtecT an estimated 37 men with screen-detected prostate cancer211,212 or 100
study, which randomized 1643 men with localized prostate cancer to men with low-risk prostate cancer213 to prevent one death from the
active surveillance, radical prostatectomy, or RT, found no significant disease. The controversy regarding overtreatment of prostate cancer and
difference in the primary outcome of prostate cancer mortality at a median the value of prostate cancer early detection211-217 has been further
of 10 years follow-up.202 Of 17 prostate cancer deaths (1% of study informed by publication of the Goteborg study, a subset of the European
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Prostate Cancer
Randomized Study of Screening for Prostate Cancer (ERSPC).218,219 Many compromising chance of cure; and the chance and consequences of
believe that this study best approximates proper use of PSA for early treatment side effects.
detection because it was population-based and involved a 1:1
randomization of 20,000 men who received PSA every 2 years and used Patient Selection
thresholds for prostate biopsy of PSA >3 and >2.5 since 2005. The 14- Epstein and colleagues224 introduced clinical criteria to predict
year follow-up reported in 2010 was longer than the European study as a pathologically “insignificant” prostate cancer. Insignificant prostate cancer
whole (9 years) and the Prostate, Lung, Colorectal, and Ovarian (PLCO) is identified by: clinical stage T1c, biopsy Grade Group I, the presence of
trial (11.5 years). Prostate cancer was diagnosed in 12.7% of the disease in fewer than 3 biopsy cores, ≤50% prostate cancer involvement
screened group compared to 8.2% of the control group. Prostate cancer in any core, and PSA density <0.15 ng/mL/g. Despite the usefulness of
mortality was 0.5% in the screened group and 0.9% in the control group, these criteria, physicians are cautioned against using these as the sole
which gave a 40% absolute cumulative risk reduction of prostate cancer decision maker. Studies have shown that as many as 8% of cancers that
death (compared to ERSPC 20% and PLCO 0%).218 Most impressively, qualified as insignificant using the Epstein criteria were not organ-confined
40% of the patients were initially managed using active surveillance and based on postoperative findings.225,226 A new nomogram may be better.227
28% were still on active surveillance at the time these results were Although many variations upon this definition have been proposed
analyzed. To prevent a prostate cancer death, 12 men would need to be (reviewed by Bastian and colleagues228), a consensus of the NCCN
diagnosed and treated as opposed to the ERSPC as a whole where 37 Guidelines Panel was reached that insignificant prostate cancer,
men needed to be treated. Analysis of 18-year follow-up data from the especially when detected early using serum PSA, poses little threat to
Goteborg study reduced the number needed to be diagnosed to prevent 1 men with a life expectancy of <20 years. The confidence that Americans
prostate cancer death to 10.220 Thus, early detection, when applied with very-low-risk prostate cancer have a very small risk of prostate cancer
properly, should reduce prostate cancer mortality. However, that reduction death is enhanced by lead time bias introduced by PSA early detection
comes at the expense of overtreatment that may occur in as many as 50% that ranges from an estimated 12.3 years in a 55-year-old man to 6 years
of men treated for PSA-detected prostate cancer.221 in a 75-year-old man.223 At this time, the NCCN Panel recommends active
surveillance for all men with very-low-risk prostate cancer and life
The best models of prostate cancer detection and progression estimate expectancy <20 years and believes that it should be considered for men
that 23% to 42% of all U.S. screen-detected cancers were overtreated222 with very-low-risk prostate cancer and life expectancy ≥20 years. The
and that PSA detection was responsible for up to 12.3 years of lead-time panel recommends active surveillance for all men with low- and favorable
bias.223 The NCCN Guidelines Panel responded to these evolving data intermediate-risk prostate cancer and life expectancy <10 years and
with careful consideration of which men should be recommended active believes that it should be considered for men with low and favorable
surveillance. However, the NCCN Guidelines Panel recognizes the intermediate risk and life expectancy ≥10 years. The use of active
uncertainty associated with the estimation of chance of competing causes surveillance in favorable intermediate-risk prostate cancer is discussed in
of death; the definition of very-low-, low-, and favorable intermediate-risk detail in Favorable Intermediate Risk, below.
prostate cancer; the ability to detect disease progression without
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Prostate Cancer
Race is emerging as an important factor to consider when contemplating with targeted image-guided biopsies, which have been reported to improve
active surveillance, particularly for African-American men. From 2010 to detection of clinically significant tumors in some men.246
2012, African-American men had a higher lifetime risk of developing
(18.2% vs. 13.3%) and dying from (4.4% vs. 2.4%) prostate cancer The proportion of men with low-risk prostate cancer choosing active
compared to Caucasian-American men.229 In one study, the increase in surveillance in the Veterans Affairs Integrated Health Care System
prostate-cancer-specific mortality in African-American men was limited to increased from 2005 to 2015: from 4% to 39% of men <65 years and from
those with grade group 1.230 Multiple studies have shown that African 3% to 41% of men ≥65 years.247 An analysis of the SEER database found
Americans with very-low-risk prostate cancer may harbor high-grade a similar trend, with the use of active surveillance in men with low-risk
(Grade Group ≥2) cancer that is not detected by pre-treatment biopsies. prostate cancer increasing from 14.5% in 2010 to 42.1% in 2015.248 An
Compared to Caucasian Americans matched on clinical parameters, international, hospital-based, retrospective analysis of >115,000 men with
African Americans have been reported to have a 1.7- to 2.3-fold higher low-risk prostate cancer reported that active surveillance utilization
change of pathologic upgrading.231,232 However, other studies have not increased, but the proportions were lower at 7% in 2010 and 20% in
seen different rates of upstaging or upgrading.233,234 For example, in a 2014.249 Ultimately, a recommendation for active surveillance must be
retrospective study of 895 men in the SEARCH database, no significant based on careful individualized weighing of a number of factors: life
differences were seen in the rates of pathologic upgrading, upstaging, or expectancy, general health condition, disease characteristics, potential
biochemical recurrence between African American and Caucasian side effects of treatment, and patient preference.
Americans.233 Several studies have reported that, among men with low-
Surveillance Program and Reclassification Criteria
risk prostate cancer who are enrolled in active surveillance programs,
African Americans have higher risk of disease progression to higher Before starting on an active surveillance program, mpMRI and/or prostate
Gleason grade or volume cancer than Caucasian Americans.235-237 African biopsy should be considered to confirm candidacy for active surveillance.
Americans in the low- to intermediate-risk categories also appear to suffer Men with PI-RADS 4 or 5 on mpMRI have an increased risk of biopsy
from an increased risk of biochemical recurrence after treatment.238 In progression during active surveillance.250
addition, African American men with low-risk or favorable intermediate-risk
The current NCCN recommendations for the active surveillance program
prostate cancer have an increase in all-cause mortality after treatment,
include PSA no more often than every 6 months unless clinically indicated;
mainly due to cardiovascular complications after ADT.239 Reasons for
DRE no more often than every 12 months unless clinically indicated;
these clinical disparities are under investigation and may include
repeat prostate biopsy no more often than every 12 months unless
difference in tumor location within the prostate that may reflect different
clinically indicated; and repeat mpMRI no more often than every 12
prostate cancer subtypes related to differences in gene expression.240-243
months unless clinically indicated.
In addition, treatment disparities and access to health care may play a
significant role.244,245 Strategies to improve risk-stratification for African Results of a study of 211 patients with Grade Group 1 prostate cancer
Americans considering active surveillance may include mpMRI in concert who had initial and repeat mpMRIs and PSA monitoring suggest that a
negative initial mpMRI predicts a low risk of Gleason upgrading by
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Prostate Cancer
systematic biopsy.251 In addition, PSA velocity was significantly associated demonstrated that a PSA trigger point of PSADT <3 years could not be
with subsequent progression in those with an initial negative mpMRI. In improved upon by using a PSA threshold of 10 or 20, PSADT calculated in
contrast, those with high-risk visible lesions on mpMRI before initiation of various ways, or PSA velocity >2 ng/mL/y.265 The Johns Hopkins group
active surveillance had an increased risk of progression. A meta-analysis used biopsy-demonstrated reclassification to Gleason pattern 4 or 5 or
of 43 studies found the sensitivity and NPV for mpMRI to be 0.81 and increased tumor volume on biopsy as their criteria for reclassification. Of
0.78, respectively.252 290 men on an annual prostate biopsy program, 35% demonstrated
reclassification at a median follow-up of 2.9 years.266 Neither PSADT (area
Early experience supports the utilization of mpMRI in biopsy protocols to under the curve [AUC], 0.59) nor PSA velocity (AUC, 0.61) was associated
better risk-stratify men under active surveillance.253-255 However, more with prostate biopsy reclassification. Both groups have concluded that
recent studies have shown that a significant proportion of high-grade PSA kinetics cannot replace regular prostate biopsy, although treatment of
cancers are detected with systematic biopsy and not targeted biopsy in most men who demonstrate reclassification on prostate biopsy prevents
men on active surveillance.256-258 evaluation of biopsy reclassification as a criterion for treatment or
reduction of survival. Treatment of all men who developed Gleason pattern
A repeat prostate biopsy should be considered if the prostate exam
4 on annual prostate biopsies has thus far resulted in only 2 prostate
changes, if mpMRI (if done) suggests more aggressive disease, or if PSA
cancer deaths among 1298 men (0.15%) in the Johns Hopkins study.199
increases, but no parameter is very reliable for detecting prostate cancer
However, it remains uncertain whether treatment of all who progressed to
progression. Furthermore, a repeat prostate biopsy should be considered
Gleason pattern 4 was necessary. Studies remain in progress to identify
to assess for disease progression regardless of these changes, but no
the best trigger points when interventions with curative intent may still be
more often than every 12 months, because PSA kinetics may not be
successful.
reliable for predicting progression. Repeat biopsy is useful to determine
whether higher Gleason grade elements, which may influence prognosis The Toronto group published findings on 3 patients who died of prostate
and hence the decision to continue active surveillance or proceed to cancer in their experience with 450 men on active surveillance.262 These 3
definitive local therapy, are evolving although the risk appears small.259 deaths led them to revise their criteria for offering men active surveillance,
because each of these 3 men probably had metastatic disease at the time
Each of the major active surveillance series has used different criteria for
of entry on active surveillance. The 450 men were followed for a median of
reclassification.197,199,260-264 Reclassification criteria were met by 23% of
6.8 years; OS was 78.6% and prostate cancer-specific survival was
men with a median follow-up of 7 years in the Toronto experience,262 36%
97.2%.262 Of the 30% (n = 145) of men who progressed, 8% had an
of men with a median follow-up of 5 years in the Johns Hopkins
increase in Gleason grade, 14% had a PSADT <3 years, 1% developed a
experience,199 and 16% of men with a median follow-up of 3.5 years in the
prostate nodule, and 3% were treated because of anxiety. One hundred
University of California, San Francisco (UCSF) experience261 (Table 3).
thirty-five of these 145 men were treated: 35 by radical prostatectomy, 90
Uncertainty regarding reclassification criteria and the desire to avoid
by EBRT with or without ADT, and 10 with ADT alone. Follow-up is
missing an opportunity for cure drove several reports that dealt with the
available for 110 of these men, and 5-year biochemical progression-free
validity of commonly used reclassification criteria. The Toronto group
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Prostate Cancer
survival is 62% for those undergoing radical prostatectomy and 43% for The panel believes there is an urgent need for further clinical research
those undergoing radiation. Longer-term follow-up of this cohort was regarding the criteria for recommending active surveillance, the criteria for
reported in 2015.197 The 10- and 15-year actuarial cause-specific survival reclassification on active surveillance, and the schedule for active
rates for the entire cohort were 98.1% and 94.3 %, respectively. Only 15 of surveillance especially as it pertains to prostate biopsies, which pose an
993 (1.5%) patients had died of prostate cancer, an additional 13 men increasing burden. One such study is a prospective multi-institutional
(1.3%) had developed metastatic disease, and only 36.5% of the cohort cohort study, which has been funded by the NCI.271 Nine hundred and five
had received treatment by 10 years. In an analysis of 592 patients enrolled men, median age 63 years and median follow-up 28 months,
in this cohort who had ≥1 repeat prostate biopsy, 31.3% of cases were demonstrated 19% conversion to therapy. Much should be learned about
upgraded. Fifteen percent of upgraded cases were upgraded to Gleason the criteria for selection of and progression on active surveillance as this
≥8, and 62% of total upgraded cases proceeded to active treatment.267 cohort and research effort mature. Literature suggests that as many as 7%
Another analysis of this cohort revealed that metastatic disease developed of men undergoing prostate biopsy will suffer an adverse event,215 and
in 13 of 133 men with Gleason 7 disease (9.8%) and 17 of 847 men with those who develop urinary tract infection are often fluoroquinolone-
Gleason ≤6 disease (2.0%).268 PSADT and the number of positive scores resistant.273 Radical prostatectomy may become technically challenging
were also predictors of increased risk for the development of metastatic after multiple sets of biopsies, especially as it pertains to potency
disease. preservation.274
In comparison, among 192 men on active surveillance who underwent Radical Prostatectomy
delayed treatment at a median of 2 years after diagnosis in the Johns Radical prostatectomy is appropriate for any patient whose cancer
Hopkins experience, 5-year biochemical progression-free survival was appears clinically localized to the prostate. However, because of potential
96% for those who underwent radical prostatectomy and 75% for those perioperative morbidity, radical prostatectomy should be reserved for
who underwent radiation.264 The two groups were similar by pathologic patients whose life expectancy is 10 years or more. Stephenson and
Gleason grade, pathologic stage, and margin positivity. All men treated by colleagues107 reported a low 15-year prostate cancer-specific mortality of
radical prostatectomy after progression on active surveillance had freedom 12% in patients who underwent radical prostatectomy (5% for patients with
from biochemical progression at a median follow-up of 37.5 months, low-risk disease), although it is unclear whether the favorable prognosis is
compared to 97% of men in the primary radical prostatectomy group at a due to the effectiveness of the procedure or the low lethality of cancers
median follow-up of 35.5 months. A later publication from this group detected in the PSA era.
showed that 23 of 287 men who were treated after active surveillance
(8%) experienced biochemical recurrence, and the rate was independent Radical prostatectomy was compared to watchful waiting in a randomized
of the type of treatment.199 Several studies have shown that delayed trial of 695 patients with early-stage prostate cancer (mostly T2).275,276 With
radical prostatectomy does not increase the rates of adverse pathology.269- a median follow-up of 12.8 years, those assigned to the radical
272
prostatectomy group had significant improvements in disease-specific
survival, OS, and risk of metastasis and local progression.275 The
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Prostate Cancer
reduction in mortality was confirmed at 18 years of follow-up, with an Operative Techniques and Adverse Effects
absolute difference of 11%.276 Overall, 8 men needed to be treated to Long-term cancer control has been achieved in most patients with both the
avert one death; that number fell to 4 for men younger than 65 years of retropubic and the perineal approaches to radical prostatectomy; high-
age. Longer follow-up results were also reported, in which the cumulative volume surgeons in high-volume centers generally achieve superior
incidence of death from prostate cancer was 19.6% and 31.3% in the outcomes.281,282 Laparoscopic and robot-assisted radical prostatectomy
radical prostatectomy and watchful waiting groups, respectively, at 23 are commonly used and are considered comparable to conventional
years, with a mean increase of 2.9 years of life in the radical approaches in experienced hands.283-285 In a cohort study using SEER
prostatectomy group.277 The results of this trial offer high-quality evidence Medicare-linked data on 8837 patients, minimally invasive compared to
to support radical prostatectomy as a treatment option for clinically open radical prostatectomy was associated with shorter length of hospital
localized prostate cancer. stay, less need for blood transfusions, and fewer surgical complications,
but rates of incontinence and erectile dysfunction were higher.286 A second
Some patients at high or very high risk may benefit from radical
large study reported no difference in overall complications, readmission,
prostatectomy. In an analysis of 842 men with Gleason scores 8 to 10 at
and additional cancer therapies between open and robot-assisted radical
biopsy who underwent radical prostatectomy, predictors of unfavorable
prostatectomy, although the robotic approach was associated with higher
outcome included PSA level over 10 ng/mL, clinical stage T2b or higher,
rates of genitourinary complications and lower rates of blood
Gleason score 9 or 10, higher number of biopsy cores with high-grade
transfusion.287 Oncologic outcome of a robotic versus open approach was
cancer, and over 50% core involvement.278 Patients without these
similar when assessed by use of additional therapies286 or rate of positive
characteristics showed higher 10-year biochemical-free and disease-
surgical margins,288 although longer follow-up is necessary. A meta-
specific survival after radical prostatectomy compared to those with
analysis on 19 observational studies (n = 3893) reported less blood loss
unfavorable findings (31% vs. 4% and 75% vs. 52%, respectively). Radical
and lower transfusion rates with minimally invasive techniques than with
prostatectomy is an option for men with high-risk disease and in select
open operation.288 Risk of positive surgical margins was the same. Two
patients with very-high-risk disease.
more recent meta-analyses showed a statistically significant advantage in
Radical prostatectomy is a salvage option for patients experiencing favor of a robotic approach compared to an open approach in 12-month
biochemical recurrence after primary EBRT, but morbidity (incontinence, urinary continence289 and potency recovery.290 Early results from a
erectile dysfunction, and bladder neck contracture) remains significantly randomized controlled phase 3 study comparing robot-assisted
higher than when radical prostatectomy is used as initial therapy.279,280 laparoscopic radical prostatectomy and open radical retropubic
Overall and cancer-specific 10-year survival ranged from 54% to 89% and prostatectomy in 326 men were published in 2016.291,292 Urinary function
70% to 83%, respectively.279 Patient selection is important, and salvage and sexual function scores and rates of postoperative complications did
prostatectomy should only be performed by highly experienced surgeons. not differ significantly between the groups at 6, 12, and 24 months after
surgery. Rates of positive surgical margins were similar, based on a
superiority test (10% in the open group vs. 15% in the robotic group).
Assessment of oncologic outcomes from this trial will be limited because
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Prostate Cancer
postoperative management and additional cancer therapies were not PLND because this avoids 47.7% of PLNDs at a cost of missing 12.1% of
standardized between the groups.291 positive pelvic lymph nodes.112 A more recent analysis of 26,713 patients
in the SEER database treated with radical prostatectomy and PLND
An analysis of the Prostate Cancer Outcomes Study on 1655 men with between 2010 and 2013 found that the 2% nomogram threshold would
localized prostate cancer compared long-term functional outcomes after avoid 22.3% of PLNDs at a cost of missing 3.0% of positive pelvic lymph
radical prostatectomy or EBRT.293 At 2 and 5 years, patients who nodes.299 The panel recommends use of a nomogram developed at
underwent radical prostatectomy reported higher rates of urinary Memorial Sloan Kettering Cancer Center that uses pretreatment PSA,
incontinence and erectile dysfunction but lower rates of bowel urgency. clinical stage, and Gleason sum to predict the risk of pelvic lymph node
However, no significant difference was observed at 15 years. In a large metastases.112
retrospective cohort study involving 32,465 patients, those who received
EBRT had a lower 5-year incidence of urological procedures than those PLND should be performed using an extended technique.300,301 An
who underwent radical prostatectomy, but higher incidence for hospital extended PLND includes removal of all node-bearing tissue from an area
admissions, rectal or anal procedures, open surgical procedures, and bounded by the external iliac vein anteriorly, the pelvic side wall laterally,
secondary malignancies.294 the bladder wall medially, the floor of the pelvis posteriorly, Cooper’s
ligament distally, and the internal iliac artery proximally. Removal of more
Return of urinary continence after radical prostatectomy may be improved lymph nodes using the extended technique has been associated with
by preserving the urethra beyond the prostatic apex and by avoiding increased likelihood of finding lymph node metastases, thereby providing
damage to the distal sphincter mechanism. Bladder neck preservation more complete staging.302-304 A survival advantage with more extensive
may allow more rapid recovery of urinary control.295 Anastomotic strictures lymphadenectomy has been suggested by several studies, possibly due to
that increase the risk of long-term incontinence are less frequent with elimination of microscopic metastases,303,305-307 although definitive proof of
modern surgical techniques. Recovery of erectile function is related oncologic benefit is lacking.308 PLND can be performed safely
directly to the degree of preservation of the cavernous nerves, age at laparoscopically, robotically, or as an open procedure, and complication
surgery, and preoperative erectile function. Improvement in urinary and rates should be similar among the three approaches.
sexual function has been reported with nerve-sparing techniques.296,297
Replacement of resected nerves with nerve grafts does not appear to be Radiation Therapy
effective for patients undergoing wide resection of the neurovascular RT techniques used in prostate cancer include EBRT, proton radiation,
bundles.298 The ability of mpMRI to detect extracapsular extension can aid and brachytherapy. EBRT techniques include IMRT and hypofractionated,
in decision-making in nerve-sparing surgery.159 image-guided SBRT. An analysis that included propensity-score matching
of patients showed that, among younger men with prostate cancer, SBRT
Pelvic Lymph Node Dissection
and IMRT had similar toxicity profiles whereas proton radiation was
The decision to perform PLND should be guided by the probability of nodal associated with reduced urinary toxicity and increased bowel toxicity. The
metastases. The NCCN Guidelines Panel chose 2% as the cutoff for
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Prostate Cancer
cost of proton therapy was almost double that of IMRT, and SBRT was patients, can be considered as an alternative to conventionally
slightly less expensive.309 fractionated regimens when clinically indicated. The panel lists
fractionation schemes that have shown acceptable efficacy and toxicity on
The panel believes that highly conformal RT (CRT) techniques should be PROS-D page 3 of 5 in the algorithm above. An ASTRO/ASCO/AUA
used to treat localized prostate cancer. Photon and proton beam radiation evidence-based guideline regarding the use of hypofractionated radiation
are both effective at achieving highly CRT with acceptable and similar in men with localized prostate cancer concluded that moderately
biochemical control and long-term side effect profiles. Radiation fractionated regimens are justified for routine use in this setting and
techniques are discussed in more detail below. provides more detail on the topic.329
External Beam Radiation Therapy Daily prostate localization using image-guided RT (IGRT) is essential with
Over the past several decades, EBRT techniques have evolved to allow either 3D-CRT or IMRT for target margin reduction and treatment
higher doses of radiation to be administered safely. Three-dimensional accuracy. Imaging techniques, such as ultrasound, implanted fiducials,
(3D) CRT (3D-CRT) uses computer software to integrate CT images of the electromagnetic targeting and tracking, or endorectal balloon, can improve
patients’ internal anatomy in the treatment position, which allows higher cure rates and decrease complications.
cumulative doses to be delivered with lower risk of late effects.123,310-312
The second-generation 3D technique, intensity-modulated RT (IMRT), has These techniques have permitted safer dose escalation, and results of
been used increasingly in practice.313 IMRT reduced the risk of randomized trials have suggested that dose escalation is associated with
gastrointestinal toxicities and rates of salvage therapy compared to 3D- improved biochemical outcomes.330-335 Kuban and colleagues333 published
CRT in some but not all older retrospective and population-based studies, an analysis of their dose-escalation trial of 301 patients with stage T1b to
although treatment cost is increased.314-317 More recently, moderately T3 prostate cancer. Freedom from biochemical or clinical recurrence was
hypofractionated image-guided IMRT regimens (2.4–4 Gy per fraction over higher in the group randomized to 78 Gy compared to 70 Gy (78% vs.
4–6 weeks) have been tested in randomized trials, and their efficacy has 59%, P = .004) at a median follow-up of 8.7 years. The difference was
been similar or non-inferior to conventionally fractionated IMRT, with one even greater among patients with diagnostic PSA >10 ng/mL (78% vs.
trial showing fewer treatment failures with a moderately fractionated 39%, P = .001). An analysis of the National Cancer Database found that
regimen.318-327 Toxicity was similar between moderately hypofractionated dose escalation (75.6–90 Gy) resulted in a dose-dependent improvement
and conventional regimens in some318,322,325,326 but not all of the in OS for men with intermediate- or high-risk prostate cancer.336 In light of
trials.320,323,324 In addition, efficacy results varied among the trials, with these findings, the conventional 70 Gy dose is no longer considered
some showing noninferiority or similar efficacy and others showing that adequate. A dose of 75.6 to 79.2 Gy in conventional fractions to the
hypofractionation may be less effective than conventional fractionation prostate (with or without seminal vesicles) is appropriate for patients with
schemes. These safety and efficacy differences are likely a result of low-risk cancers. Intermediate-risk and high-risk patients should receive
differences in fractionation schedules.328 Overall, the panel believes that doses of up to 81.0 Gy.314,337,338
hypofractionated IMRT techniques, which are more convenient for
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Prostate Cancer
Data suggested that EBRT and radical prostatectomy were effective for Contraindications to EBRT include prior pelvic irradiation, active
the treatment of localized prostate cancer.339 EBRT of the primary prostate inflammatory disease of the rectum, or a permanent indwelling Foley
cancer shows several distinct advantages over radical prostatectomy. catheter. Relative contraindications include very low bladder capacity,
EBRT avoids complications associated with operation, such as bleeding chronic moderate or severe diarrhea, bladder outlet obstruction requiring a
and transfusion-related effects, and risks associated with anesthesia, such suprapubic catheter, and inactive ulcerative colitis.
as myocardial infarction and pulmonary embolus. 3D-CRT and IMRT
EBRT for Early Disease
techniques are widely available and are possible for patients over a wide
range of ages. EBRT has a low risk of urinary incontinence and stricture EBRT is one of the principal treatment options for clinically localized
and a good chance of short-term preservation of erectile function.340 prostate cancer. The NCCN Guidelines Panel consensus was that modern
EBRT and surgical series show similar progression-free survival in
The disadvantages of EBRT include a treatment course of 8 to 9 weeks. patients with low-risk disease treated with radical prostatectomy or EBRT.
Up to 50% of patients have some temporary bladder or bowel symptoms In a study of 3546 patients treated with brachytherapy plus EBRT,
during treatment. There is a low but definite risk of protracted rectal disease-free survival (DFS) remained steady at 73% between 15 and 25
symptoms from radiation proctitis, and the risk of erectile dysfunction years of follow-up.346 The panel lists several acceptable dosing schemas
increases over time.340,341 The risk of late rectal complications following RT in the guidelines. The NRG Oncology/RTOG 0126 randomized clinical trial
is related to the volume of the rectum receiving doses of radiation close to compared 79.2 Gy (44 fractions) and 70.2 Gy (39 fractions), both in 1.8 Gy
or exceeding the radiation dose required to control the primary fractions, in 1499 men with intermediate-risk prostate cancer.347 After a
tumor. Biomaterials have been developed, tested, and FDA approved to median follow-up of 8.4 years, the escalated dose reduced biochemical
serve as spacer materials when inserted between the rectum and recurrences, but increased late toxicity and had no effect on OS.
prostate.342 In a randomized phase 3 multicenter clinical trial of patients
EBRT for Patients with High-Risk or Very-High-Risk Disease
undergoing image-guided intensity-modulated RT (IG-IMRT), with the risk
of late (3-year) common terminology criteria for adverse events (CTCAE) EBRT has demonstrated efficacy in patients at high risk and very high risk.
grade 2 or higher, physician-recorded rectal complications declined from One study randomized 415 patients to EBRT alone or EBRT plus 3-year
5.7% to 0% in the control versus hydrogel spacer group.343 The hydrogel ADT.348 In another study (RTOG 8531), 977 patients with T3 disease
spacer group had a significant reduction in bowel QOL decline. No treated with EBRT were randomized to adjuvant ADT or ADT at relapse.349
significant differences in adverse events were noted in those receiving Two other randomized phase 3 trials evaluated long-term ADT with or
hydrogel placement versus controls. Results of a secondary analysis of without radiation in a population of patients who mostly had T3 disease.350-
353
this trial suggest that use of a spacer may decrease the sexual side effects In all four studies, the combination group showed improved disease-
of radiation.344 specific survival and OS compared to single-modality treatment. Patients
with a PSA nadir >0.5 ng/mL after radiation and 6 months of ADT have an
If the cancer recurs, salvage radical prostatectomy is associated with a adjusted hazard ratio (HR) for all-cause mortality of 1.72 (95% CI, 1.17–
higher risk of complications than primary radical prostatectomy.345 2.52; P = .01) compared with patients who received radiation only.354
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Prostate Cancer
EBRT for Node-Positive Disease Stereotactic Body Radiation Therapy

See Adjuvant or Salvage Therapy After Radical Prostatectomy under The relatively slow proliferation rate of prostate cancer is reflected in a low
NCCN Recommendations. α/β ratio,362 most commonly reported between 1 and 4. These values are
similar to that for the rectal mucosa. Because the α/β ratio for prostate
EBRT to the Primary Tumor in Low-Volume M1 Disease
cancer is similar to or lower than the surrounding tissues responsible for
Patients with newly diagnosed, low-volume metastatic prostate cancer can
most of the toxicity reported with radiation, appropriately designed
be considered for ADT with EBRT to the primary tumor based on results
radiation treatment fields and schedules using extremely hypofractionated
from the randomized controlled phase 3 STAMPEDE trial.355 In this
regimens should result in similar cancer control rates without increased
multicenter, international study, 2061 patients were randomized to lifelong
risk of late toxicity.
ADT with or without EBRT to the primary tumor (either 55 Gy in 20 daily
fractions over 4 weeks or 36 Gy in 6 weekly fractions over 6 weeks). The Stereotactic body RT (SBRT) is a technique that delivers highly conformal,
primary outcome of OS by intention-to-treat analysis was not met (HR, high-dose radiation in 5 or fewer treatment fractions, which are safe to
0.92; 95% CI, 0.80–1.06; P = .266), but EBRT improved the secondary administer only with precise, image-guided delivery.363 Single-institution
outcome of failure-free survival (FFS; HR, 0.76; 95% CI, 0.68–0.84; P < series with median follow-up as long as 6 years report excellent
.0001). In a pre-planned subset analysis, outcomes of patients with high biochemical progression-free survival and similar early toxicity (bladder,
metastatic burden (defined as visceral metastases; ≥4 bone metastases rectal, and QOL) compared to standard radiation techniques.362-368
with ≥1 outside the vertebral bodies or pelvis; or both) and those with low According to a pooled analysis of phase 2 trials, the 5-year biochemical
metastatic burden (all others) were determined. EBRT improved OS relapse-free survival is 95%, 84%, and 81% for patients with low-,
(adjusted HR, 0.68; 95% CI, 0.52–0.90), prostate cancer-specific survival intermediate-, and high-risk disease, respectively.369 A study of individual
(adjusted HR, 0.65; 95% CI, 0.47–0.90), FFS (adjusted HR, 0.59; 95% CI, patient data from a cohort of 2142 patients with low or intermediate-risk
0.49–0.72), and progression-free survival (adjusted HR, 0.78; 95% CI, prostate cancer from 10 single institution phase 2 trials and 2 multi-
0.63–0.98) in patients with low metastatic burden, but not in patients with institutional phase 2 trials found that the 7-year cumulative rates of
high metastatic burden. Randomized clinical trials are ongoing to better biochemical recurrence were 4.5%, 8.6%, and 14.9% for low-risk disease,
test the value of removal or radiation of the primary tumor in patients with favorable intermediate risk disease, and unfavorable intermediate risk
low metastatic burden who are beginning ADT.356-360 disease, respectively.370 Severe acute toxicity was rare, at 0.6% for grade
3 or higher genitourinary toxic events and 0.09% for grade 3 or higher
The panel recommends against EBRT to the primary tumor in the case of
gastrointestinal toxic events. Late (7-year cumulative incidence) toxicity
high-volume M1 disease based on the HORRAD and STAMPEDE
rates were 2.4% and 0.4% for grade 3 or higher genitourinary toxic events
trials.355,361 No improvement in OS was seen from the addition of EBRT to
and gastrointestinal toxic events, respectively.
the primary when combined with standard systemic therapy in patients
with high-volume M1 disease in either trial. SBRT may be associated with more toxicity than moderately fractionated
IMRT. One retrospective study of 4005 patients reported higher
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Prostate Cancer
genitourinary toxicity at 24 months after SBRT than IMRT (44% vs. 36%; P addition, the risk of incontinence is minimal in patients without a previous
= .001).371 Another phase 2 trial found increased toxicity with doses >47.5 transurethral resection of the prostate (TURP), and erectile function is
Gy delivered in 5 fractions.372 An analysis using the SEER database also preserved in the short term.341 Disadvantages of brachytherapy include the
reported that SBRT was more toxic than IMRT.373 requirement for general anesthesia and the risk of acute urinary retention.
Irritative voiding symptoms may persist for as long as 1 year after
A phase 3 trial has been initiated that is comparing 38 Gy in 5 fractions implantation. The risk of incontinence is greater after TURP because of
with 79.2 Gy in 44 fractions.374 Preliminary results show that the acute retention and bladder neck contractures, and many patients develop
cumulative incidence of grade 2 or higher genitourinary and bowel toxicity progressive erectile dysfunction over several years. IMRT causes less
was similar between the arms after median follow-up of 36 months in 75 acute and late genitourinary toxicity and similar freedom from biochemical
patients. recurrence compared with iodine-125 or palladium-103 permanent seed
implants.379,380 Current brachytherapy techniques attempt to improve the
SBRT/extremely hypofractionated image-guided IMRT regimens (6.5 Gy
radioactive seed placement and radiation dose distribution.
per fraction or greater) can be considered as an alternative to
conventionally fractionated regimens at clinics with appropriate There are currently two methods for prostate brachytherapy: low dose-rate
technology, physics, and clinical expertise. Longer follow-up and (LDR) and high dose-rate (HDR). LDR brachytherapy consists of
prospective multi-institutional data are required to evaluate longer-term placement of permanent seed implants in the prostate. The short range of
results, especially because late toxicity theoretically could be worse in the radiation emitted from these low-energy sources allows delivery of
hypofractionated regimens compared to conventional fractionation (1.8– adequate dose levels to the cancer within the prostate, with excessive
2.0 Gy per fraction). irradiation of the bladder and rectum avoided. Post-implant dosimetry
should be performed to document the quality of an LDR implant.381 HDR
Brachytherapy
brachytherapy, which involves temporary insertion of a radiation source, is
Brachytherapy involves placing radioactive sources into the prostate a newer approach.
tissue. Brachytherapy has been used traditionally for low-risk cases
because earlier studies found it less effective than EBRT for high-risk Two groups have observed a lower risk of urinary frequency, urgency, and
disease.81,375 However, increasing evidence suggests that technical rectal pain with HDR brachytherapy compared with LDR brachytherapy
advancements in brachytherapy may provide a role for contemporary (permanent seed implant).382,383 Vargas and colleagues384 reported that
brachytherapy in high-risk localized and locally advanced prostate HDR brachytherapy results in a lower risk of erectile dysfunction than LDR
cancer.376,377 brachytherapy. Commonly prescribed doses for LDR and HDR
brachytherapy are listed in the guidelines.
The advantage of brachytherapy is that the treatment is completed in 1
day with little time lost from normal activities. In appropriate patients, the For patients with very large or very small prostates, symptoms of bladder
cancer-control rates appear comparable to radical prostatectomy (over outlet obstruction (high International Prostate Symptom Score), or a
90%) for low-risk prostate cancer with medium-term follow-up.378 In previous TURP, seed implantation may be more difficult. These patients
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Prostate Cancer
also have an increased risk of side effects. Neoadjuvant ADT may be used rates were similar between the groups at 96.1% after brachytherapy and
to shrink the prostate to an acceptable size; however, increased toxicity is 97.4% after radical prostatectomy (P = .35).390 At 6 months follow-up,
expected from ADT, and prostate size may not decline in some men. The continence was better in the brachytherapy group whereas potency was
potential toxicity of ADT must be weighed against the possible benefit of better in the radical prostatectomy group.
target reduction.
Brachytherapy Boost
Ideally, the accuracy of brachytherapy treatment should be verified by LDR or HDR brachytherapy can be added as a boost to EBRT plus ADT in
daily prostate localization with techniques of IGRT: CT, ultrasound, men with unfavorable intermediate-, high-, or very-high-risk prostate
implanted fiducials, or electromagnetic targeting/tracking. Endorectal cancer being treated with curative intent. Combining EBRT and
balloons may be used to improve prostate immobilization. Perirectal brachytherapy allows dose escalation while minimizing acute or late
spacer materials (discussed under External Beam Radiation Therapy, toxicity in patients with high-risk localized or locally advanced cancer.391-394
above) may be employed when the previously mentioned techniques are This combination has demonstrated improved biochemical control over
insufficient to improve oncologic cure rates and/or reduce side effects due EBRT plus ADT alone in randomized trials, but with higher toxicity.395-397
to anatomic geometry or other patient-related factors (eg, medication An analysis of a cohort of 12,745 patients with high-risk disease found that
usage, comorbid conditions). Patients with obvious rectal invasion or treatment with brachytherapy (HR, 0.66; 95% CI, 0.49–0.86) or
visible T3 and posterior extension should not undergo perirectal spacer brachytherapy plus EBRT (HR, 0.77; 95% CI, 0.66–0.90) lowered disease-
implantation. specific mortality compared to EBRT alone.398
Brachytherapy Alone for Localized Disease The randomized ASCENDE-RT trial compared 2 methods of dose
Brachytherapy alone is an option for patients with very low, low, or escalation in 398 men with intermediate- or high-risk prostate cancer:
favorable intermediate-risk prostate cancer, depending on life expectancy. dose-escalated EBRT boost to 78 Gy or LDR brachytherapy boost.399 All
Patients with high-risk cancers are generally considered poor candidates men were initially treated with 12 months of ADT and pelvic EBRT to 46
for brachytherapy alone. Either LDR or HDR brachytherapy can be used in Gy. An intention-to-treat analysis found that the primary endpoint of
this setting. biochemical progression-free survival was 89% versus 84% at 5 years;
86% versus 75% at 7 years; and 83% versus 62% at 9 years for the LDR
Retrospective analyses show that LDR or HDR brachytherapy alone can versus EBRT boost arms (log-rank P < .001). Toxicity was higher in the
be effective and well tolerated in this population.385-388 A phase 2 trial in brachytherapy arm, with the cumulative incidence of grade 3 genitourinary
300 patients with intermediate-risk prostate cancer also found LDR events at 5 years of 18.4% for brachytherapy boost and 5.2% for EBRT
brachytherapy alone to be safe and effective.389 However, randomized boost (P < .001).400 A trend for increased gastrointestinal toxicity with
controlled trials comparing brachytherapy to radical prostatectomy or brachytherapy boost was also seen (cumulative incidence of grade 3
EBRT in this population are limited. In a single-center trial, 165 patients events at 5 years, 8.1% vs. 3.2%; P = .12). However, at 6-year follow-up,
with low-risk prostate cancer were randomized to LDR brachytherapy with health-related QOL was similar between the groups in most domains,
iodine-125 seeds or radical prostatectomy. The 2-year biochemical FFS
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Prostate Cancer
except that physical and urinary function scales were significantly lower in therapy and permanent brachytherapy after biochemical recurrence, the
the LDR arm.401 Whereas the toxicity is increased with the use of cancer-free and biochemical relapse-free survival rates were 96% and
brachytherapy boost, this and other randomized controlled trials have 88%, respectively, after a median follow-up of 30 months.410 Results of a
failed to show an improvement in overall or cancer-specific survival.402 phase 2 study of salvage HDR brachytherapy after EBRT included
relapse-free survival, distant metastases-free survival, and cause-specific
Addition of ADT (2 or 3 years) to brachytherapy and EBRT is common for survival rates of 68.5%, 81.5%, and 90.3%, respectively, at 5 years.411
patients at high risk of recurrence. The outcome of trimodality treatment is Toxicities were mostly grade 1 and 2 and included gastrointestinal toxicity
excellent, with 9-year progression-free survival and disease-specific and urethral strictures, and one case of Grade 3 urinary incontinence. In
survival reaching 87% and 91%, respectively.403,404 However, it remains another prospective phase 2 trial, the primary endpoint of grade ≥3 late
unclear whether the ADT component contributes to outcome improvement. treatment-related gastrointestinal and genitourinary adverse events at 9 to
D’Amico and colleagues studied a cohort of 1342 patients with PSA over 24 months post salvage brachytherapy was below the unacceptable
20 ng/mL and clinical T3/T4 and/or Gleason score 8 to 10 disease.405 threshold, at 14%.412
Addition of either EBRT or ADT to brachytherapy did not confer an
advantage over brachytherapy alone. The use of all three modalities Data on the use of brachytherapy after permanent brachytherapy are
reduced prostate cancer-specific mortality compared to brachytherapy limited, but the panel agrees that it can be considered for carefully
alone (adjusted HR, 0.32; 95% CI, 0.14–0.73). Other analyses did not find selected patients. Decisions regarding the use of brachytherapy in the
an improvement in recurrence rate when ADT was added to recurrent-disease setting should consider comorbidities, extent of disease,
brachytherapy and EBRT.406,407 and potential complications. Brachytherapy in this setting is best
performed at high-volume centers.
A large, multicenter, retrospective cohort analysis that included 1809 men
with Gleason score 9–10 prostate cancer found that multimodality therapy Proton Therapy
with EBRT, brachytherapy, and ADT was associated with improved Proton beam RT has been used to treat patients with cancer since the
prostate cancer-specific mortality and longer time to distant metastasis 1950s. Proponents of proton therapy argue that this form of RT could have
than either radical prostatectomy or EBRT with ADT.408 In addition, an advantages over x-ray (photon)-based radiation in certain clinical
analysis of outcomes of almost 43,000 men with high-risk prostate cancer circumstances. Proton therapy and x-ray–based therapies like IMRT can
in the National Cancer Database found that mortality was similar in men deliver highly conformal doses to the prostate. Proton-based therapies will
treated with EBRT, brachytherapy, and ADT versus those treated with deliver less radiation dose to some of the surrounding normal tissues like
radical prostatectomy, but was worse in those treated with EBRT and muscle, bone, vessels, and fat not immediately adjacent to the prostate.
ADT.409 These tissues do not routinely contribute to the morbidity of prostate
radiation and are relatively resilient to radiation injury; therefore, the
Salvage Brachytherapy
benefit of decreased dose to these types of normal, non-critical tissues
Brachytherapy can be considered in men with biochemical recurrence
has not been apparent. The critical normal structures adjacent to the
after EBRT. In a retrospective study of 24 men who had EBRT as primary
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Prostate Cancer
prostate that can create prostate cancer treatment morbidity include the revealed significant problems with incontinence, bowel dysfunction, and
bladder, rectum, neurovascular bundles, and occasionally small bowel. impotence at 3 months, 12 months, and >2 years after treatment with
proton therapy.414 In that report, only 28% of men with normal erectile
The weight of the current evidence about prostate cancer treatment function maintained it after therapy. The largest retrospective comparative
morbidity supports the notion that the volume of the rectum and bladder effectiveness analysis to date comparing IMRT to proton therapy was
that receives radiobiologically high doses of radiation near the prescription performed using SEER-Medicare claims data for the following long-term
radiation dose accounts for the likelihood of long-term treatment morbidity, endpoints: gastrointestinal morbidity, urinary incontinence, non-
as opposed to higher volume, lower dose exposures. Numerous incontinence urinary morbidity, sexual dysfunction, and hip fractures.417
dosimetric studies have been performed trying to compare x-ray–based With follow-up as mature as 80 months and using both propensity scoring
IMRT plans to proton therapy plans to illustrate how one or the other type and instrumental variable analysis, the authors concluded that men
of treatment can be used to spare the bladder or rectum from higher dose receiving IMRT therapy had statistically significantly lower gastrointestinal
parts of the exposure. These studies suffer from the biases and talents of morbidity than patients receiving proton therapy, whereas rates of urinary
the investigators who plan and create computer models of dose deposition incontinence, non-incontinence urinary morbidity, sexual dysfunction, hip
for one therapy or the other.413 Although dosimetric studies in-silico can fractures, and additional cancer therapies were statistically
suggest that the right treatment planning can make an IMRT plan beat a indistinguishable between the cohorts. However, firm conclusions
proton therapy plan and vice-versa, they do not accurately predict clinically regarding differences in toxicity or effectiveness of proton and photon
meaningful endpoints. therapy cannot be drawn because of the limitations inherent in
retrospective/observational studies.
Comparative effectiveness studies have been published in an attempt to
compare toxicity and oncologic outcomes between proton and photon The costs associated with proton beam facility construction and proton
therapies. Two comparisons between men treated with proton therapy or beam treatment are high compared to the expense of building and using
EBRT report similar early toxicity rates.414,415 A prospective QOL the more common photon linear accelerator-based practice.415 The
comparison of patient-reported outcomes using the EPIC instrument American Society for Radiation Oncology (ASTRO) evaluated proton
between IMRT (204 patients) and proton therapy (1234 patients) therapy and created a model policy to support the society’s position on
concluded that “No differences were observed in summary score changes payment coverage for proton beam therapy in 2014.418 This model policy
for bowel, urinary incontinence, urinary irritative/obstructive, and sexual was updated in 2017 and recommends coverage of proton therapy for the
domains between the 2 cohorts” after up to 2 years of follow-up.416 A treatment of non-metastatic prostate cancer if the patient is enrolled in
Medicare analysis of 421 men treated with proton therapy and a matched either an institutional review board (IRB)-approved study or a multi-
cohort of 842 men treated with IMRT showed less genitourinary toxicity at institutional registry that adheres to Medicare requirements for Coverage
6 months for protons, although the difference disappeared after 1 year.415 with Evidence Development (CED).419 The policy states: “In the treatment
No other significant differences were seen between the groups. In of prostate cancer, the use of [proton beam therapy] is evolving as the
contrast, a single-center report of prospectively collected QOL data comparative efficacy evidence is still being developed. In order for an
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Prostate Cancer
informed consensus on the role of [proton beam therapy] for prostate metastases based on therapeutic guidelines from the American College of
cancer to be reached, it is essential to collect further data, especially to Radiology.423
understand how the effectiveness of proton therapy compares to other RT
Radium-223 and Other Radiopharmaceuticals
modalities such as IMRT and brachytherapy. There is a need for more
well-designed registries and studies with sizable comparator cohorts to In May 2013, the U.S. Food and Drug Administration (FDA) approved
help accelerate data collection. Proton beam therapy for primary treatment radium-223 dichloride, an alpha particle-emitting radioactive agent. This
of prostate cancer should only be performed within the context of a first-in-class radiopharmaceutical was approved for treatment of metastatic
prospective clinical trial or registry.” CRPC in patients with symptomatic bone metastases and no known
visceral metastatic disease. Approval was based on clinical data from a
An ongoing prospective randomized trial is accruing patients to compare multicenter, phase 3, randomized trial (ALSYMPCA) that included 921
prostate proton therapy and prostate IMRT. The NCCN Panel believes no men with symptomatic CRPC, 2 or more bone metastases, and no known
clear evidence supports a benefit or decrement to proton therapy over visceral disease.424 Fifty-seven percent of the patients received prior
IMRT for either treatment efficacy or long-term toxicity. Conventionally docetaxel and all patients received best supportive care. Patients were
fractionated prostate proton therapy can be considered a reasonable randomized in a 2:1 ratio to 6 monthly radium-223 intravenous injections
alternative to x-ray–based regimens at clinics with appropriate technology, or placebo. Compared to placebo, radium-223 significantly improved OS
physics, and clinical expertise. (median 14.9 months vs. 11.3 months; HR, 0.70; 95% CI, 0.058–0.83; P <
.001) and prolonged time to first skeletal-related event (SRE) (median 15.6
Radiation for Distant Metastases months vs. 9.8 months). Preplanned subset analyses showed that the
Radiation is an effective means of palliating bone metastases from survival benefit of radium-223 was maintained regardless of prior
prostate cancer. Isolated symptomatic bone metastases can be managed docetaxel use.425 Intention-to-treat analyses from ALSYMPCA showed that
with EBRT. Recent studies have confirmed the common practice in radium-223 also may reduce the risk of symptomatic SREs.426 Grade 3/4
Canada and Europe of managing prostate cancer with bone metastases hematologic toxicity was low (3% neutropenia, 6% thrombocytopenia, and
with a short course of radiation. A short course of 8 Gy x 1 is as effective 13% anemia), likely due to the short range of radioactivity.424 Fecal
as, and less costly than, 30 Gy in 10 fractions.420 In a randomized trial of elimination of the agent led to generally mild non-hematologic side effects,
898 patients with bone metastases, grade 2–4 acute toxicity was observed which included nausea, diarrhea, and vomiting. Radium-223 was
less often in the 8-Gy arm (10%) than the 30-Gy arm (17%) (P = .002); associated with improved or slower decline of QOL in ALSYMPCA.427
however, the retreatment rate was higher in the 8-Gy group (18%) than in
the 30-Gy group (9%) (P < .001).421 In another study of 425 patients with Beta-emitting radiopharmaceuticals are an effective and appropriate
painful bone metastases, a single dose of 8 Gy was non-inferior to 20 Gy option for patients with widespread metastatic disease, particularly if they
in multiple fractions in terms of overall pain response to treatment.422 Most are no longer candidates for effective chemotherapy.423 Because many
patients should be managed with a single fraction of 8 Gy for non-vertebral patients have multifocal bone pain, systemic targeted treatment of skeletal
metastases offers the potential of pain relief with minimal side effects.
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Unlike the alpha-emitting agent radium-223, beta emitters confer no therapies. At this time, the panel recommends only cryosurgery and high-
survival advantage and are palliative. Beta-emitting radiopharmaceuticals intensity focused ultrasound (HIFU) as options for RT recurrence in the
developed for the treatment of painful bone metastases most commonly absence of metastatic disease.
used for prostate cancer include strontium-89 (89Sr) or samarium-153
(153Sm).428,429 Cryosurgery, also known as cryotherapy or cryoablation, is an evolving
minimally invasive therapy that damages tumor tissue through local
Comparison of Treatment Options for Localized Disease freezing. In the initial disease setting, the reported 5-year biochemical
Several large prospective, population/cohort-based studies have disease-free rate after cryotherapy ranged from 65% to 92% in patients
compared the outcomes of patients with localized prostate cancer treated with low-risk disease using different definitions of biochemical
with EBRT, brachytherapy, radical prostatectomy, observation, and/or recurrence.433 A report suggests that cryotherapy and radical
active surveillance. Barocas et al compared radical prostatectomy, EBRT, prostatectomy give similar oncologic results for unilateral prostate
and active surveillance in 2550 men and found that, after 3 years, radical cancer.434 A study by Donnelly and colleagues435 randomly assigned 244
prostatectomy was associated with a greater decrease in urinary and men with T2 or T3 disease to either cryotherapy or EBRT. All patients
sexual function than either EBRT or active surveillance.430 Active received neoadjuvant ADT. There was no difference in 3-year OS or DFS.
surveillance, however, was associated with an increase in urinary irritative Patients who received cryotherapy reported poorer sexual function.436 For
symptoms. Health-related QOL measures including bowel and hormonal patients with locally advanced cancer, cryoablation was associated with
function were similar among the groups, as was disease-specific survival. lower 8-year biochemical progression-free rate compared to EBRT in a
small trial of 62 patients, although disease-specific survival and OS were
Chen et al compared radical prostatectomy, EBRT, and brachytherapy similar.437
against active surveillance in 1141 men.431 As in the Barocas study,
radical prostatectomy was associated with greater declines in sexual and Cryosurgery has been assessed in patients with recurrent disease after
urinary function than other treatments at 3 months. In this study, EBRT RT.438-440 In one registry-based study of 91 patients, the biochemical DFS
was associated with worse short-term bowel function, and both EBRT and rates at 1, 3, and 5 years were 95.3%, 72.4%, and 46.5%, respectively.
brachytherapy were associated with worsened urinary obstructive and Adverse events included urinary retention (6.6%), incontinence (5.5%),
irritative symptoms. By 2 years, however, differences among the groups and rectourethral fistula (3.3%).440
compared with active surveillance were insignificant. Results of a
HIFU has been studied for treatment of initial disease.441,442 A prospective
systematic review showed similar findings to these studies.432
multi-institutional study used HIFU in 111 patients with localized prostate
cancer.441 The radical treatment-free survival rate was 89% at 2 years, and
Other Local Therapies
continence and erectile functions were preserved in 97% and 78% of
Many therapies have been investigated for the treatment of localized
patients, respectively, at 12 months. Morbidity was acceptable, with a
prostate cancer in the initial disease and recurrent settings, with the goals
grade III complication rate of 13%. In another prospective multi-
of reducing side effects and matching the cancer control of other
institutional study, 625 men with localized prostate cancer were treated
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Prostate Cancer
with HIFU.443 Eighty-four percent of the cohort had intermediate- or high- In the community, ADT has been commonly used as primary therapy for
risk disease. The primary endpoint of FFS was 88% at 5 years (95% CI, early-stage, low-risk disease, especially in the elderly. This practice has
85%–91%). Pad-free urinary continence was reported by 98% of been challenged by a large cohort study of 66,717 elderly men with T1-T2
participants. tumors.455 No 15-year survival benefit was found in patients receiving ADT
compared to observation alone. Similarly, another cohort study of 15,170
HIFU also has been studied for treatment of radiation recurrence.444-450 men diagnosed with clinically localized prostate cancer who were not
Analysis of a prospective registry of men treated with HIFU for radiation treated with curative intent therapy reported no survival benefit from
recurrence revealed median biochemical recurrence-free survival at 63 primary ADT after adjusting for demographic and clinical variables.456
months, 5-year OS of 88%, and cancer-specific survival of 94%.451 Placing patients with early prostate cancer on ADT should not be routine
Morbidity was acceptable, with grade III/IV complication rate 3.6%. practice.
Analysis of a separate prospective registry showed that 48% of men who
received HIFU following radiotherapy failure were able to avoid ADT at a Antiandrogen monotherapy (bicalutamide) after completion of primary
median follow-up of 64 months.452 treatment was investigated as an adjuvant therapy in patients with
localized or locally advanced prostate cancer, but results did not support
Other emerging local therapies, such as vascular-targeted photodynamic its use in this setting.457,458
(VTP) therapy, warrant further study.453 The multicenter, open-label, phase
3, randomized controlled CLIN1001 PCM301 trial compared VTP therapy Castrate levels of serum testosterone (<50 ng/dL; <1.7 nmol/L) should be
(IV padeliporfin, optical fibers inserted into the prostate, and subsequent achieved with ADT, because low nadir serum testosterone levels were
laser activation) to active surveillance in 413 men with low-risk prostate shown to be associated with improved cause-specific survival in the PR-7
cancer.454 After a median follow-up of 24 months, 28% of participants in study.459
the VTP arm had disease progression compared with 58% in the active
surveillance arm (adjusted HR, 0.34; 95% CI, 0.24–0.46; P < .0001). ADT for Clinically Localized (N0M0) Disease
Negative prostate biopsy results were more prevalent in the VTP group In the clinically localized setting, ADT using an LHRH agonist—alone or
(49% vs. 14%; adjusted RR, 3.67; 95% CI, 2.53–5.33; P < .0001). The with a first-generation antiandrogen—or an LHRH antagonist is used as a
most common serious adverse event in the VTP group was urinary neoadjuvant, concurrent, and/or adjuvant to EBRT, as described in more
retention (3 of 206 patients), which resolved within 2 months in all cases. detail below.
Androgen Deprivation Therapy ADT used as neoadjuvant treatment before radical prostatectomy is
ADT is administered as primary systemic therapy for regional or advanced strongly discouraged outside of a clinical trial. Furthermore, ADT should
disease and as neoadjuvant/concomitant/adjuvant therapy in combination not be used as monotherapy in clinically localized prostate cancer unless
with radiation in localized or locally advanced prostate cancers. there is a contraindication to definitive local therapy, such as life
expectancy <5 years and comorbidities. Under those circumstances, ADT
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Prostate Cancer
may be an acceptable alternative if the disease is high or very high risk metastases (16% vs. 14%; P = .42), or DFS (22% vs. 26%; P = .61), but a
(see Palliative ADT, below). substantial increase in toxicity (3.9% vs. 0% treatment-related deaths),
which resulted in early closure of the trial.468 Thus, the fact that 6 months
Neoadjuvant, Concurrent, and/or Adjuvant ADT with EBRT for
of ADT improved survival compared to EBRT alone does not mean it is
Intermediate-Risk Disease
better than 4 months of ADT, and the fact that systemic chemotherapy is
The addition of short-term ADT to radiation improved overall and cancer-
effective in one setting (high-volume metastatic disease or CRPC) should
specific survival in three randomized trials containing 20% to 60% of men
not lead to the assumption that it will be beneficial in other settings (eg,
with intermediate-risk prostate cancer (Trans Tasman Radiation Oncology
high-risk localized disease).469,470
Group [TROG] 9601, Dana Farber Cancer Institute [DFCI] 95096, and
Radiation Therapy Oncology Group [RTOG] 9408).460-463 Only a cancer- Neoadjuvant, Concurrent, and/or Adjuvant ADT with EBRT for High-Risk or
specific survival benefit was noted in a fourth trial that recruited mostly Very-High-Risk Disease
high-risk men (RTOG 8610).464 Results of the EORTC 22991 trial showed ADT combined with EBRT is an effective primary treatment for patients at
that the addition of 6 months of ADT significantly improved biochemical high risk or very high risk, as discussed in the Radiation Therapy section,
DFS compared with radiation alone in intermediate-risk (75% of study above. Combination therapy was consistently associated with improved
population) and high-risk men.465 disease-specific survival and OS compared to single-modality treatment in
randomized phase 3 studies.348,349,351,352
RTOG 9910 and RTOG 9902 reinforced two important principles
concerning the optimal duration of ADT and use of systemic Increasing evidence favors long-term over short-term
chemotherapy in conjunction with EBRT.466,467 RTOG 9910 is a phase 3 neoadjuvant/concurrent/adjuvant ADT for patients with high- and very-
randomized trial targeting men with intermediate-risk prostate cancer that high-risk disease. The RTOG 9202 trial included 1521 patients with T2c-
compared 4 months to 9 months of ADT. RTOG 9408 had previously T4 prostate cancer who received 4 months of ADT before and during
shown that 4 months of ADT combined with EBRT improved survival in EBRT.471 They were randomized to no further treatment or an additional 2
men with intermediate-risk disease compared to EBRT alone.462 years of ADT. At 10 years, the long-term group was superior for all
Consistent with earlier studies, RTOG 9910 demonstrated that there is no endpoints except OS. A subgroup analysis of patients with a Gleason
reason to extend ADT beyond 4 months when given in conjunction with score of 8 to 10 found an advantage in OS for long-term ADT at 10 years
EBRT in men with intermediate-risk disease. (32% vs. 45%, P = .0061). At a median follow-up of 19.6 years, long-term
ADT was superior for all endpoints including OS in the entire cohort (12%
RTOG 9902 compared long-term ADT and EBRT with and without relative reduction; P = .03).472
paclitaxel, estramustine, and etoposide (TEE) chemotherapy in men with
locally advanced, high-risk prostate cancer.468 In the randomized cohort of The EORTC 22961 trial also showed superior survival when 2.5 years of
397 patients with a median follow-up of 9.2 years, results demonstrated no ADT were added to EBRT given with 6 months of ADT in 970 patients,
significant difference in ADT+EBRT versus ADT+EBRT+TEE in OS (65% most of whom had T2c-T3, N0 disease.473 The DART01/05 GICOR trial
vs. 63%; P = .81), biochemical recurrence (58% vs. 54%; P = .82), distant also reported similar results in men with high-risk disease.474 In a
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Prostate Cancer
secondary analysis of RTOG 8531, which mandated lifelong ADT for The EORTC 30846 trial randomized 234 treatment-naïve patients with
patients with locally advanced prostate cancer treated with EBRT, those node-positive prostate cancer to immediate versus delayed ADT.479 At 13
who adhered to the protocol had better survival than those who years median follow-up, the authors reported similar survival between the
discontinued ADT within 5 years.475 Two randomized, phase 3 trials two arms, although the study was not powered to show non-inferiority.
showed 1.5 years of ADT was not inferior to 3 years of ADT.476,477
Neoadjuvant, Concurrent, and/or Adjuvant ADT with EBRT for Regional
A meta-analysis of data from 992 patients enrolled in 6 randomized Disease
controlled trials showed that a longer duration of ADT with EBRT benefited Men initially diagnosed with pelvic lymph node-positive disease who have
men with Grade Group 4 or 5 prostate cancer.478 a life expectancy >5 years can be treated with EBRT with 2 to 3 years of
neoadjuvant/concurrent/adjuvant ADT (category 1) with or without
Neoadjuvant, Concurrent, and/or Adjuvant ADT with EBRT for Recurrent abiraterone. Alternatively, they can receive primary ADT without EBRT
Disease with or without abiraterone (see Primary ADT for Lymph Node Metastases,
Men who develop PSA recurrence after radical prostatectomy without above and Abiraterone Acetate in Castration-Naïve Prostate Cancer,
evidence of metastases can receive pelvic EBRT with below).
neoadjuvant/concurrent/adjuvant ADT (see Adjuvant or Salvage Therapy
After Radical Prostatectomy, below). Neoadjuvant/concurrent/adjuvant ADT options are an LHRH agonist, an
LHRH agonist with a first-generation antiandrogen, or an LHRH
ADT for Regional Disease antagonist. Abiraterone should not be coadministered with an
Primary ADT for Lymph Node Metastases antiandrogen.
Men initially diagnosed with node-positive disease who have a life
expectancy >5 years can be treated with primary ADT. Primary ADT Adjuvant ADT for Lymph Node Metastases after RP
options are orchiectomy, an LHRH agonist, an LHRH agonist with a first- The role of adjuvant ADT after radical prostatectomy is restricted to cases
generation antiandrogen, or an LHRH antagonist (category 2B); or where positive pelvic lymph nodes are found, although reports in this area
orchiectomy, LHRH agonist, or LHRH antagonist with abiraterone. Another reveal mixed findings. Messing and colleagues randomly assigned 98
option for these men is EBRT with 2 to 3 years of patients who were found to have positive lymph nodes at the time of
neoadjuvant/concurrent/adjuvant ADT (category 1, see Neoadjuvant, radical prostatectomy to immediate continuous ADT or observation.480 In
Concurrent, and/or Adjuvant ADT with EBRT for Regional Disease, the immediate ADT arm of 47 patients, 30 remained alive, 29 of whom
below). Abiraterone acetate (abiraterone) can be added to either were prostate cancer recurrence-free and 26 of whom were PSA
treatment, although abiraterone should not be coadministered with an recurrence-free after a median follow-up of 11.9 years (range, 9.7–14.5
antiandrogen (see Abiraterone Acetate in Castration-Naïve Prostate years for survivors).480,481 Those receiving immediate ADT also had a
Cancer, below). significant improvement in OS (HR, 1.84; 95% CI, 1.01–3.35).
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Prostate Cancer
However, these results differ from a SEER Medicare, population-based concurrent, and/or adjuvant ADT as part of RT provided they have
test of ADT published subsequently.482 The SEER Medicare-based study recovered testicular function.
of men who underwent radical prostatectomy and had positive lymph
nodes used propensity matching to compare men who received ADT ADT for castration-naïve prostate cancer can be accomplished using
within 120 days to those who were observed. The groups had similar bilateral orchiectomy, an LHRH agonist or antagonist, or an LHRH agonist
median and range of follow-up for survivors, but OS and prostate cancer- plus a first-generation antiandrogen. As discussed below, abiraterone or
specific survival were similar. The Messing study occurred prior to the docetaxel can be added to orchiectomy, LHRH agonist, or LHRH
PSA era, but the studies are similar in almost all other respects. The antagonist for M1 disease. For patients with M0 disease, observation is
Messing study showed almost unbelievable benefit, and the population- preferred over ADT.
based study of 731 men showed no benefit. Furthermore, a meta-analysis
LHRH agonists and LHRH antagonists appear equally effective in patients
resulted in a recommendation against ADT for pathologic lymph node
with advanced prostate cancer.484 Medical or surgical castration combined
metastatic prostate cancer in the ASCO guidelines.483 In addition, a cohort
with an antiandrogen is known as combined androgen blockade. No
analysis of 731 men with positive nodes failed to demonstrate a survival
prospective randomized studies have demonstrated a survival advantage
benefit of ADT initiated within 4 months of radical prostatectomy compared
with combined androgen blockade over the serial use of an LHRH agonist
to observation.482 At this time, the panel recommends that patients with
and an antiandrogen.483 Meta-analysis data suggest that bicalutamide may
lymph node metastases found at radical prostatectomy should be
provide an incremental relative improvement in OS by 5% to 20% over
considered for immediate ADT (category 1) with or without EBRT
LHRH agonist monotherapy.485,486 However, others have concluded that
(category 2B; see Adjuvant or Salvage Therapy After Radical
more complete disruption of the androgen axis (with finasteride,
Prostatectomy, above), but that observation is also an option for these
dutasteride, or antiandrogen added to medical or surgical castration)
patients.
provides little if any benefit over castration alone.487
Palliative ADT
Antiandrogen monotherapy appears to be less effective than medical or
Palliative ADT can be given to men with a life expectancy of ≤5 years who surgical castration and is not recommended for primary ADT. Furthermore,
have high-risk, very-high-risk, regional, or metastatic prostate cancer. dutasteride plus bicalutamide showed no benefit over bicalutamide alone
Palliative ADT also can be given to patients with disease progression in patients with locally advanced or metastatic prostate cancer.488
during observation, usually when symptoms develop or when changes in
PSA levels suggest that symptoms are imminent. Recent evidence suggests that orchiectomy may be safer than an LHRH
agonist. Four hundred twenty-nine men with metastatic prostate cancer
ADT for Castration-Naive Disease who underwent orchiectomy were compared to 2866 men who received
The term “castration-naive" is used to define patients who are not on ADT LHRH agonist between 1995 and 2009. Orchiectomy was associated with
at the time of progression. The NCCN Prostate Cancer Panel uses the lower risk of fracture, peripheral arterial disease, and cardiac-related
term "castration-naive" even when patients have had neoadjuvant, complications, although risk was similar for diabetes, deep vein
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Prostate Cancer
thrombosis, pulmonary embolism, and cognitive disorders.489 Post-hoc there were no differences over 5 years in global QOL, physical functioning,
analysis of a randomized trial of LHRH antagonist versus LHRH agonist role or emotional functioning, insomnia, fatigue, dyspnea, or feeling less
found lower risk of cardiac events in patients with existing cardiac disease masculine. However, sexual activity was lower and the hormone-
treated with LHRH antagonist.490 The heart and T lymphocytes have treatment-related symptoms score was higher in the immediate ADT group
receptors for LHRH. Therefore, LHRH agonists may affect cardiac compared with the delayed ADT group. Most clinical trials in this patient
contractility, vascular plaque stability, and inflammation.491 population require PSA level ≥0.5 mg/dL (after radical prostatectomy) or
“nadir + 2” (after radiation) for enrollment.
ADT for M0 Biochemical Recurrence
Controversy remains about the timing and duration of ADT when local The panel believes that the benefit of early ADT is uncertain and must be
therapy has failed. Many believe that early ADT is best, but cancer control balanced against the risk of ADT side effects. Patients with an elevated
must be balanced against side effects. Early ADT is associated with PSA and/or a shorter PSADT (rapid PSA velocity) and an otherwise long
increased side effects and the potential development of the metabolic life expectancy should be encouraged to consider ADT earlier.
syndrome.
Primary ADT for M1 Castration-Naïve Prostate Cancer
Patients with an increasing PSA level and with no symptomatic or clinical ADT is the gold standard for initial treatment of patients with metastatic
evidence of cancer after definitive treatment present a therapeutic disease at presentation.483 A PSA value ≤4 ng/mL after 7 months of ADT
dilemma regarding the role of ADT. Some of these patients will ultimately is associated with improved survival of patients newly diagnosed with
die of their cancer. Timing of ADT for patients whose only evidence of metastatic prostate cancer.494
cancer is increasing PSA is influenced by PSA velocity (PSADT), patient
and physician anxiety, the short-term and long-term side effects of ADT, ADT options for M1 castration-naïve disease are:
and underlying comorbidities of the patient. Early ADT is acceptable, but  Orchiectomy ± docetaxel
an alternative is close observation until progression of cancer, at which  LHRH agonist alone ± docetaxel
time appropriate therapeutic options may be considered. Earlier ADT may  LHRH agonist plus first-generation antiandrogen ± docetaxel
be better than delayed therapy, although the definitions of early and late  LHRH antagonist ± docetaxel
(ie, what level of PSA) remain controversial. The multicenter phase 3  Orchiectomy plus abiraterone
TROG 03.06/VCOG PR 01-03 [TOAD] trial randomized 293 men with PSA  LHRH agonist plus abiraterone
relapse after operation or radiation (n = 261) or who were not considered  LHRH antagonist plus abiraterone
for curative treatment (n = 32) to immediate ADT or ADT delayed by a
recommended interval of ≥2 years.492 Five-year OS was improved in the In patients with overt metastases in weight-bearing bone who are at risk of
immediate therapy arm compared with the delayed therapy arm (91.2% developing symptoms associated with the flare in testosterone with initial
vs. 86.4%; log-rank P = .047). No significant differences were seen in the LHRH agonist alone, antiandrogen therapy should precede or be
secondary endpoint of global health-related QOL at 2 years.493 In addition, coadministered with LHRH agonist for at least 7 days to diminish ligand
binding to the androgen receptor.495,496 LHRH antagonists rapidly and
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Prostate Cancer
directly inhibit the release of androgens, unlike LHRH agonists that initially flushes), and liver toxicity.498 Cardiac events, such as atrial fibrillation,
stimulate LHRH receptors prior to hypogonadism. Therefore, no initial flare were rare but slightly increased with abiraterone. The overall
is associated with these agents and coadministration of antiandrogen is discontinuation rate due to side effects was 12%. Patient-reported
unnecessary. outcomes were improved with the addition of abiraterone, with
improvements in pain intensity progression, fatigue, functional decline,
The data supporting the addition of abiraterone or docetaxel to ADT in this prostate cancer-related symptoms, and overall health-related QOL.499 A
setting are discussed below. ADT with addition of EBRT to the primary limitation of this trial is that only 27% of placebo-treated men received
tumor for low-volume metastatic disease is discussed in EBRT to the abiraterone or enzalutamide at progression, and only 52% of these men
Primary Tumor in Low-Volume M1 Disease, above. received any life-prolonging therapy.498
Abiraterone Acetate in Castration-Naïve Prostate Cancer
A second randomized trial (STAMPEDE) of 1917 men with castration-
In February 2018, the FDA approved abiraterone in combination with naïve prostate cancer demonstrated similar OS benefits.500 However,
prednisone for metastatic castration-naïve prostate cancer.497 This unlike LATITUDE, STAMPEDE eligibility permitted men with high-risk N0
approval was based on 2 randomized phase 3 clinical trials of abiraterone M0 disease (2 of 3 high-risk factors: stage T3/4, PSA >40, or Gleason
and low-dose prednisone plus ADT that were reported in men with newly score 8–10; n = 509), or N1 M0 disease (pelvic nodal metastases; n =
diagnosed metastatic prostate cancer or high-risk or node-positive disease 369) in addition to M1 patients, who made up the majority of patients (n =
(STAMPEDE and LATITUDE) that demonstrated improved OS over ADT 941). The majority of men were newly diagnosed, while a minority of men
alone.498 In LATITUDE, 1199 men with high-risk, metastatic, castration- had recurrent, high-risk, or metastatic disease after local therapy (n = 98).
naïve prostate cancer were randomized to abiraterone with prednisone 5 Thus, STAMPEDE was a heterogeneous mix of patients with high-risk,
mg once daily or matching placebos. High-risk disease was defined as at non-metastatic, node-positive, or M1 disease. In M1 patients, treatment
least 2 of the following: Gleason score 8–10, ≥3 bone metastases, and with abiraterone plus prednisone was continued until progression. In
visceral metastases.498 Efficacy was demonstrated at the first interim patients with N1 or M0 disease, 2 years of abiraterone plus prednisolone
analysis, and the trial was unblinded. The primary endpoint of OS was was used if curative-intent EBRT was utilized. OS was improved in the
met, and favored abiraterone (HR, 0.62; 95% CI, 0.51–0.76; P < .0001). overall population (HR, 0.63; 95% CI, 0.5–0.76; P < .0001) and in the M1
Estimated 3-year OS rates improved from 49% to 66% at 30 months and N1 subsets, without any heterogeneity of treatment effect by
follow-up. Secondary endpoints were improved and included delayed metastatic status. The survival benefit of abiraterone was larger in men
castration-resistant radiographic progression (from median 14.8–33.2 <70 years of age than in older men (HR, 0.94 vs. HR, 0.51). Older men
months), PSA progression (7.4–33.2 months), time to pain progression, also suffered increased toxicities, which suggests heterogeneity in clinical
and initiation of chemotherapy. benefits by age and comorbidity. The secondary endpoint of FFS, which
included PSA recurrence, was improved overall (HR, 0.29; P < .0001) and
Adverse events were higher with abiraterone and prednisone but were
in all subgroups regardless of M1 (HR, 0.31), N1 (HR, 0.29), or M0 (HR,
generally mild in nature and largely related to mineralocorticoid excess (ie,
0.21) status. No heterogeneity for FFS was observed based on subgroups
hypertension, hypokalemia, edema), hormonal effects (ie, fatigue, hot
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Prostate Cancer
or by age. In this trial, subsequent life-prolonging therapy was received by Apalutamide in Castration-Naïve Prostate Cancer
58% of men in the control group, which included 22% who received The double-blind phase 3 TITAN clinical trial randomized 1052 patients
abiraterone and 26% who received enzalutamide. Thus, these data reflect with metastatic, castration-naïve prostate cancer to ADT with apalutamide
a survival advantage of initial abiraterone in newly diagnosed men (240 mg/day) or placebo.502 Participants were stratified by Gleason score
compared with deferring therapy to the CRPC setting. at diagnosis, geographic region, and previous docetaxel treatment. The
median follow-up was 22.7 mo. Both primary endpoints were met:
Adverse events in STAMPEDE were similar to that reported in LATITUDE, radiographic PFS (68.2% vs. 47.5% at 24 mo; HR for radiographic
but were increased in older men, with higher incidences of grade 3–5 progression or death, 0.48; 95% CI, 0.39-0.60; P < .001) and OS (82.4%
adverse events with abiraterone (47% vs. 33%) and 9 versus 3 treatment- vs. 73.5% at 24 mo; HR for death, 0.67; 95% CI, 0.51-0.89; P = .005).
related deaths. Severe hypertension or cardiac disorders were noted in Adverse events that were more common with apalutamide than with
10% of men and grade 3–5 liver toxicity in 7%, which illustrates the need placebo included rash, hypothyroidism, and ischemic heart disease.
for blood pressure and renal and hepatic function monitoring.
Apalutamide is a category 1 option for patients with M1 castration-naïve
Taken together, these data led the NCCN Panel to recommend prostate cancer.
abiraterone with 5-mg once-daily prednisone as a treatment option with
ADT for men with newly diagnosed, M1, castration-naïve prostate cancer Enzalutamide in Castration-Naïve Prostate Cancer
(category 1). Alternatively, the fine-particle formulation of abiraterone can The open-label randomized phase 3 ENZAMET clinical trial compared
be used (category 2B; see Abiraterone Acetate in M1 CRPC, below). For enzalutamide (160 mg/day) plus ADT with ADT alone in 1125 men with
men undergoing curative-intent treatment for N1 disease, abiraterone can metastatic castration-naïve prostate cancer.503 Stratification was by
be added to EBRT with 2 to 3 years of neoadjuvant/concurrent/adjuvant volume of disease, planned use of early docetaxel, planned use of bone
ADT or can be given with ADT for castration-naïve disease (without anti-resorptive therapy, comorbidity score, and trial site. The primary
EBRT). The fine-particle formulation of abiraterone is an option (category endpoint of OS was met at the first interim analysis with median follow-up
2B; see Abiraterone Acetate in M1 CRPC, below). However, there was 34 months (HR for death, 0.67; 95% CI, 0.52-0.86; P = .002).
insufficient survival, FFS data, and follow-up available to recommend Enzalutamide also improved secondary endpoints, such as PFS using
abiraterone for men with high-risk or very-high-risk N0 M0 prostate cancer. PSA levels and clinical PFS.
Further follow-up and dedicated ongoing clinical trials are needed in this
In the double-blind randomized phase 3 ARCHES clinical, 1150 men with
curative-intent RT population.
metastatic castration-naïve prostate cancer were randomized to receive
Abiraterone with prednisone can be given at 250 mg/d and administered ADT with either enzalutamide (160 mg/day) or placebo. Participants were
following a low-fat breakfast, as an alternative to the dose of 1000 mg/d stratified by disease volume and prior docetaxel use. The primary endpoint
after an overnight fast (see Abiraterone Acetate in M1 CRPC, below).501 was radiographic PFS, which was improved in the enzalutamide group
The cost savings may reduce financial toxicity and improve compliance. after median follow-up 14.4 mo (19.0 mo vs. not reached; HR, 0.39; 95%
CI, 0.30-0.50; P < .001).504
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The safety of enzalutamide in these trials was similar to that seen in Follow-up longer than 6.9 years may be required for disease-specific
previous trials in the castration-resistant setting. Adverse events deaths to out-balance deaths by other causes.
associated with enzalutamide in these trials included fatigue, seizures, and
hypertension.503,504 An unplanned Cox regression analysis of the trial showed that men with
Gleason sum >7 in the continuous ADT arm had a median survival (8
Enzalutamide is a category 1 option for patients with M1 castration-naïve years) that was 14 months longer than those with the same Gleason sum
prostate cancer. in the intermittent ADT arm (6.8 years).507 In this situation, patients should
be given the option to weigh the effects of ADT on QOL against a possible
Intermittent Versus Continuous ADT (Non-Metastatic) impact on survival, although pathology was not centrally reviewed and the
ADT is associated with substantial side effects, which generally increase study was not powered to detect small differences in survival based on
with the duration of treatment. Intermittent ADT is an approach based on Gleason sum.508
the premise that cycles of androgen deprivation followed by re-exposure
may delay “androgen independence,” reduce treatment morbidity, and The multinational European ICELAND trial randomized 702 participants
improve QOL.505,506 with locally advanced or biochemically recurrent prostate cancer to
continuous or intermittent ADT.509 Clinical outcomes, which included time
The Canadian-led PR.7 trial was a phase 3 trial of intermittent versus to PSA progression, PSA progression-free survival, OS, mean PSA levels
continuous ADT in patients with non-metastatic prostate cancer who over time, QOL, and adverse events, were similar between the arms.
experienced biochemical recurrence after primary or salvage EBRT.507
One thousand three hundred eighty-six patients with PSA >3 ng/mL were A 2015 meta-analysis identified 6 randomized controlled trials comparing
randomly assigned to intermittent ADT or continuous ADT. At a median continuous with intermittent ADT in men with locally advanced prostate
follow-up of 6.9 years, the intermittent approach was non-inferior to cancer and found no difference in mortality and progression and an
continuous ADT with respect to OS (8.8 vs. 9.1 years, respectively; HR, advantage of the intermittent approach in terms of QOL and adverse
1.02; 95% CI, 0.86–1.21). More patients died from prostate cancer in the effects.510
intermittent ADT arm (120 of 690 patients) than in the continuous ADT arm
Intermittent Versus Continuous ADT (Metastatic)
(94 of 696 patients), but this was balanced by more non-prostate cancer
deaths in the continuous ADT arm. Physical function, fatigue, urinary Hussain and colleagues511 conducted the SWOG (Southwest Oncology
problems, hot flashes, libido, and erectile dysfunction showed modest Group) 9346 trial to compare intermittent and continuous ADT in patients
improvement in the intermittent ADT group. The test population was with metastatic disease. After 7 months of induction ADT, 1535 patients
heterogenous, so it remains unclear which of these asymptomatic patients whose PSA dropped to 4 ng/mL or below (thereby demonstrating
benefitted from treatment. It is possible that many of these patients could androgen sensitivity) were randomized to intermittent or continuous ADT.
have delayed ADT without harm. The test population had a low disease At a median follow-up of 9.8 years, median survival was 5.1 years for the
burden and 59% of deaths in the trial were not related to prostate cancer. intermittent ADT arm and 5.8 years for the continuous ADT arm. The HR
for death with intermittent ADT was 1.10 with a 90% CI between 0.99 and
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1.23, which exceeded the pre-specified upper boundary of 1.20 for non- A more personalized approach could be to treat all patients with metastatic
inferiority. The authors stated that the survival results were inconclusive, disease with ADT. After 7 months of ADT, patients can be assigned a risk
and that a 20% greater mortality risk with the intermittent approach cannot category based on the PSA value at that time point494: low risk is defined
be ruled out. The study demonstrated better erectile function and mental by a PSA less than 0.2 ng/mL (median survival of 75 months);
health in patients receiving intermittent ADT at 3 months, but the intermediate risk is defined by a PSA between 0.2 and 4.0 ng/mL (median
difference became insignificant thereafter, most likely due to survival of 44 months), and high risk is defined by a PSA higher than 4.0
contamination of assessments of those on the intermittent arm who may ng/mL (median survival of 13 months). Those patients who have few or no
have returned to ADT at the pre-specified time points. A secondary symptoms related to ADT after 7 months of therapy will not benefit from
analysis of SWOG 9346 showed that intermittent ADT did not reduce intermittent ADT in terms of QOL, and therefore continuous is reasonable
endocrine, bone, or cognitive events, whereas it increased the incidence because it is easier to administer.508 However, for those patients with
of ischemic and thrombotic events.512 significant side effects impacting QOL, intermittent ADT should be
considered for those with low or intermediate risk after a discussion about
In a post-hoc stratification analysis of the trial, patients with minimal the impact on survival. A final consideration is based on a subgroup
disease had a median survival of 5.4 years when receiving intermittent analysis of S9346 that suggested that those who initially present with pain
ADT versus 6.9 years when receiving continuous ADT (HR, 1.19; 95% CI, have better survival on continuous therapy than intermittent therapy.
0.98–1.43).511 The median survival was 4.9 years in the intermittent ADT
arm compared to 4.4 years in the continuous ADT arm for patients with Adverse Effects of Traditional ADT
extensive disease (HR, 1.02; 95% CI, 0.85–1.22). These subgroup ADT has a variety of adverse effects including hot flashes, vasomotor
analyses are hypothesis-generating. instability, osteoporosis, greater incidence of clinical fractures, obesity,
insulin resistance, alterations in lipids, and greater risk for diabetes, acute
A population-based analysis that included 9772 patients with advanced
kidney injury, and cardiovascular disease.518-520 Recent evidence suggests
prostate cancer aged ≥66 years showed that intermittent ADT reduced the
that a link between ADT and cognitive decline or future Alzheimer’s
risks of total serious cardiovascular events by 36%, heart failure by 38%,
disease may exist, although data are inconsistent, the risk is low, and the
and pathologic fracture by 48%, compared with continuous ADT.513
link remains to be proven.521-525 In general, the side effects of continuous
Furthermore, several meta-analyses of randomized controlled trials
ADT increase with the duration of treatment. Patients and their medical
reported no difference in survival between intermittent ADT and
providers should be advised about these risks prior to treatment.
continuous ADT.514-516 Another recent analysis concluded that the non-
inferiority of intermittent to continuous ADT in terms of survival has not Bone Health During ADT
been clearly demonstrated.517 Still, the intermittent approach leads to ADT is associated with greater risk for clinical fractures. In large
marked improvement in QOL compared to the continuous approach in population-based studies, for example, ADT was associated with a 21% to
most studies, and the panel believes that intermittent ADT should be 54% relative increase in fracture risk.526-528 Longer treatment duration
strongly considered. conferred greater fracture risk. Age and comorbidity also were associated
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with higher fracture incidence. In a population-based cohort of 3295 with non-metastatic prostate cancer undergoing ADT to either biannual
patients, surgical castration was associated with a significantly lower risk denosumab or placebo. At 24 months, denosumab increased bone
of fractures than medical castration using a GnRH agonist (HR, 0.77; 95% mineral density by 6.7% and reduced fractures (1.5% vs. 3.9%) compared
CI, 0.62–0.94; P = .01).491 ADT increases bone turnover and decreases to placebo.539 Denosumab also was approved for prevention of SREs in
bone mineral density,529-532 a surrogate for fracture risk in patients with patients with bone metastasis (see Chemotherapy and Immunotherapy).
non-metastatic disease. Bone mineral density of the hip and spine
decreases by approximately 2% to 3% per year during initial therapy. Most Currently, treatment with denosumab (60 mg every 6 months), zoledronic
studies have reported that bone mineral density continues to decline acid (5 mg IV annually), or alendronate (70 mg PO weekly) is
steadily during long-term therapy. ADT significantly decreases muscle recommended when the absolute fracture risk warrants drug therapy. A
mass,533 and treatment-related sarcopenia appears to contribute to frailty baseline DEXA scan before start of therapy and a follow-up DEXA scan
and increased risk of falls in older men. after one year of therapy is recommended by the International Society for
Clinical Densitometry to monitor response. Use of biochemical markers of
The NCCN Guidelines Panel recommends screening and treatment for bone turnover is not recommended. There are no existing guidelines on
osteoporosis according to guidelines for the general population from the the optimal frequency of vitamin D testing, but vitamin D levels can be
National Osteoporosis Foundation.534 The National Osteoporosis measured when DEXA scans are obtained.
Foundation guidelines include: 1) calcium (1000–1200 mg daily from food
Diabetes and Cardiovascular Disease
and supplements) and vitamin D3 (400–1000 IU daily); and 2) additional
treatment for men aged ≥50 years with low bone mass (T-score between - In a landmark population-based study, ADT was associated with higher
1.0 and -2.5, osteopenia) at the femoral neck, total hip, or lumbar spine by incidence of diabetes and cardiovascular disease.540 After controlling for
dual-energy x-ray absorptiometry (DEXA) scan and a 10-year probability other variables, which included age and comorbidity, ADT with a GnRH
of hip fracture ≥3% or a 10-year probability of a major osteoporosis-related agonist was associated with increased risk for new diabetes (HR, 1.44; P
fracture ≥20%. Fracture risk can be assessed using the algorithm FRAX®, < .001), coronary artery disease (HR, 1.16; P < .001), and myocardial
recently released by WHO.535 ADT should be considered “secondary infarction (HR, 1.11; P = .03). Studies that evaluated the potential
osteoporosis” using the FRAX® algorithm. relationship between ADT and cardiovascular mortality have produced
mixed results.464,540-547 In a Danish cohort of 31,571 patients with prostate
Earlier randomized controlled trials demonstrated that bisphosphonates cancer, medical castration was associated with an increased risk for
increase bone mineral density, a surrogate for fracture risk, during ADT.536- myocardial infarction (HR, 1.31; 95% CI, 1.16–1.49) and stroke (HR, 1.19;
538
In 2011, the FDA approved denosumab as a treatment to prevent bone 95% CI, 1.06–1.35) whereas surgical castration was not.548 Other
loss and fractures during ADT. Denosumab binds to and inhibits the population-based studies resulted in similar findings.491,549 However, a
receptor activator of NF-B ligand (RANKL) to blunt osteoclast function Taiwan National Health Insurance Research Database analysis found no
and delay generalized bone resorption and local bone destruction. difference in ischemic events with LHRH agonist therapy or
Approval was based on a phase 3 study that randomized 1468 patients orchiectomy.550 A French database study showed the cardiovascular risk
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Prostate Cancer
to be similar in men taking LHRH agonists and antagonists.551 However, sources of androgen in CRPC refutes earlier beliefs that CRPC was
some data suggest that LHRH antagonists might be associated with a resistant to further hormone therapies. The development of novel
lower risk of cardiac events within 1 year in men with preexisting hormonal agents demonstrating efficacy in the metastatic CRPC setting
cardiovascular disease (history of myocardial ischemia, coronary artery dramatically changed the paradigm of CRPC treatment.
disease, myocardial infarction, cerebrovascular accident, angina pectoris,
or coronary artery bypass) compared with agonists.490 Men with a recent For men who develop CRPC, ADT with an LHRH agonist or antagonist
history of cardiovascular disease appear to have higher risk,552 and should be continued to maintain castrate serum levels of testosterone
increased physical activity may decrease the symptoms and (<50 ng/dL). Options for secondary hormone therapy include a first-
cardiovascular side effects of men treated with ADT.553 generation antiandrogen, antiandrogen withdrawal, ketoconazole (adrenal
enzyme inhibitor) with or without hydrocortisone, corticosteroid,
Several mechanisms may contribute to greater risk for diabetes and diethylstilbestrol (DES), or other estrogen.562,563 However, none of these
cardiovascular disease during ADT. ADT increases fat mass and strategies has yet been shown to prolong survival in randomized clinical
decreases lean body mass.533,554,555 ADT with a GnRH agonist increases trials. New secondary hormone options include abiraterone (M1 only),
fasting plasma insulin levels556,557 and decreases insulin sensitivity.558 ADT enzalutamide (M0 or M1), and apalutamide (M0 only), as discussed below.
also increases serum levels of cholesterol and triglycerides.556,559
DES can produce safe chemical castration in many men. Gynecomastia
Cardiovascular disease and diabetes are leading causes of morbidity and and cardiovascular side effects occur with increasing frequency with
mortality in the general population. Based on the observed adverse increasing dose. Side effects are rare, and survival appears equivalent to
metabolic effects of ADT and the association between ADT and higher that of other means of ADT at a 1-mg daily dose. The mechanism of action
incidence of diabetes and cardiovascular disease, screening for and of DES remains uncertain because a 1-mg dose does not render some
intervention to prevent/treat diabetes and cardiovascular disease are men castrate, and DES produces responses when used in CRPC.564
recommended for men receiving ADT. Whether strategies for screening,
prevention, and treatment of diabetes and cardiovascular disease in men Transdermal estradiol may provide similar cancer control with fewer side
receiving ADT should differ from those of the general population remains effects.565 The ongoing PATCH clinical trial demonstrated similar rates of
uncertain. castrate levels of testosterone, PSA response, and side effects in 85 men
treated with LHRH agonist and 168 men treated with 100 mcg/24 hours
Secondary Hormone Therapy for CRPC estrogen patches twice weekly.566 QOL outcomes and the experience of
Most men with advanced disease eventually stop responding to traditional vasomotor symptoms were better at 6 months in the transdermal group
ADT and are categorized as castration-resistant (also known as compared with the agonist group, but rates of significant gynecomastia
castration-recurrent). Research has shown enhancement of autocrine were higher in the transdermal group (37% vs. 5%).567 The PATCH trial
and/or paracrine androgen synthesis in the tumor microenvironment of continues enrollment in order to assess survival (NCT00303784).
men receiving ADT.560,561 Androgen signaling consequent to non-gonadal
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Prostate Cancer
Abiraterone Acetate in M1 CRPC The most common adverse reactions with abiraterone/prednisone (>5%)
In April 2011, the FDA approved the androgen synthesis inhibitor, were fatigue (39%); back or joint discomfort (28%–32%); peripheral
abiraterone, in combination with low-dose prednisone, for the treatment of edema (28%); diarrhea, nausea, or constipation (22%); hypokalemia
men with metastatic CRPC who have received prior chemotherapy (17%); hypophosphatemia (24%); atrial fibrillation (4%); muscle discomfort
containing docetaxel. (14%); hot flushes (22%); urinary tract infection; cough; hypertension
(22%, severe hypertension in 4%); urinary frequency and nocturia;
FDA approval in the post-docetaxel setting was based on the results of a dyspepsia; or upper respiratory tract infection. The most common adverse
phase 3, randomized, placebo-controlled trial (COU-AA-301) in men with drug reactions that resulted in drug discontinuation were increased
metastatic CRPC previously treated with docetaxel-containing aspartate aminotransferase and/or alanine aminotransferase (11%–12%),
regimens.568,569 Patients were randomized to receive either abiraterone or cardiac disorders (19%, serious in 6%).
1000 mg orally once daily (n = 797) or placebo once daily (n = 398), and
both arms received daily prednisone. In the final analysis, median survival In May 2018, the FDA approved a novel, fine-particle formulation of
was 15.8 vs. 11.2 months in the abiraterone and placebo arm, respectively abiraterone, in combination with methylprednisolone, for the treatment of
(HR, 0.74; 95% CI, 0.64–0.86; P < .0001).569 Time to radiographic patients with metastatic CRPC.573 In studies of healthy men, this
progression, PSA decline, and pain palliation also were improved by formulation at 500 mg was shown to be bioequivalent to 1000 mg of the
abiraterone.569,570 originator formulation.574,575 In a phase 2 therapeutic equivalence study, 53
men with metastatic CRPC who were not treated previously with
FDA approval in the pre-docetaxel setting occurred on December 10, abiraterone, enzalutamide, radium-223, or chemotherapy (docetaxel for
2012, and was based on the randomized phase 3 COU-AA-302 trial of metastatic CRPC completed ≥1 year prior to enrollment was allowed) were
abiraterone and prednisone (n = 546) versus prednisone alone (n = 542) randomized to 500 mg daily of the new formulation plus 4 mg
in men with asymptomatic or minimally symptomatic, metastatic CRPC.571 methylprednisolone orally twice daily or to 1000 mg of the originator
Most men in this trial were not taking narcotics for cancer pain and none formulation daily plus 5 mg prednisone orally twice daily.576
had visceral metastatic disease or prior ketoconazole exposure. The Bioequivalence of these doses was confirmed based on serum
coprimary endpoint of radiographic progression-free survival was testosterone levels, PSA response, and abiraterone pharmacokinetics.
improved by treatment from 8.3 to 16.5 months (HR, 0.53; P < .001). OS The rates of total and grade 3/4 adverse events were similar between the
was improved at final analysis with a median follow-up of 49.2 months arms, with musculoskeletal and connective tissue disorders occurring
(34.7 months vs. 30.3 months; HR, 0.81; 95% CI, 0.70–0.93; P = .003).572 more frequently in the originator-treated patients (37.9% vs. 12.5%). The
Key secondary endpoints of time to symptomatic deterioration, time to panel believes that the fine-particle formulation of abiraterone can be used
chemotherapy initiation, time to pain progression, and PSA progression- instead of the original formulation of abiraterone in the treatment of men
free survival improved significantly with abiraterone treatment, and PSA with metastatic CRPC (category 2A), but switching from one formulation to
declines (62% vs. 24% with >50% decline) and radiographic responses the other upon disease progression should not be undertaken. Abiraterone
(36% vs. 16% RECIST responses) were more common.
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Prostate Cancer
with either steroid should not be given following progression on received prior docetaxel chemotherapy. Approval was based on the
abiraterone with the other steroid. results of the randomized, phase 3, placebo-controlled trial
(AFFIRM).577,578 AFFIRM randomized 1199 men to enzalutamide or
Abiraterone should be given with concurrent steroid (either oral placebo in a 2:1 ratio and the primary endpoint was OS. Median survival
prednisone 5 mg twice daily or oral methylprednisolone 4 mg twice daily, was improved with enzalutamide from 13.6 to 18.4 months (HR, 0.63; P <
depending on which formulation is given) to abrogate signs of .001). Survival was improved in all subgroups analyzed. Secondary
mineralocorticoid excess that can result from treatment. These signs endpoints also were improved significantly, which included the proportion
include hypertension, hypokalemia, and peripheral edema. Thus, of men with >50% PSA decline (54% vs. 2%), radiographic response (29%
monitoring of liver function, potassium and phosphate levels, and blood vs. 4%), radiographic progression-free survival (8.3 vs. 2.9 months), and
pressure readings on a monthly basis is warranted during abiraterone time to first SRE (16.7 vs. 13.3 months). QOL measured using validated
therapy. Symptom-directed assessment for cardiac disease also is surveys was improved with enzalutamide compared to placebo. Adverse
warranted, particularly in patients with pre-existing cardiovascular disease. events were mild, and included fatigue (34% vs. 29%), diarrhea (21% vs.
18%), hot flushes (20% vs. 10%), headache (12% vs. 6%), and seizures
A randomized phase 2 non-inferiority study of 75 patients with M1 CRPC
(0.6% vs. 0%). The incidence of cardiac disorders did not differ between
compared 1000 mg/d abiraterone with prednisone after an overnight fast
the arms. Enzalutamide is dosed at 160 mg daily. Patients in the AFFIRM
with 250 mg/d after a low-fat breakfast.501 The primary endpoint was log
study were maintained on GnRH agonist/antagonist therapy and could
change in PSA, with secondary endpoints of PSA response (≥ 50%) and
receive bone supportive care medications. The seizure risk in the
progression-free survival. The primary endpoint favored the low-dose arm
enzalutamide FDA label was 0.9% versus 0.6% in the manuscript.577,579
(log change in PSA, -1.59 vs. -1.19), as did the PSA response rate (58%
vs. 50%), with an equal progression-free survival of 9 months in both Another phase 3 trial studied enzalutamide in the pre-chemotherapy
arms. Noninferiority of the low dose was established according to the setting. The PREVAIL study randomly assigned 1717 patients with
predefined criteria. Therefore, abiraterone with prednisone can be given at chemotherapy-naïve metastatic prostate cancer to daily enzalutamide or
250 mg/d administered following a low-fat breakfast, as an alternative to placebo.580,581 The study was stopped early due to benefits shown in the
the dose of 1000 mg/d after an overnight fast. The cost savings may treatment arm. Compared to the placebo group, the enzalutamide group
reduce financial toxicity and improve compliance. Food impacts absorption showed improved median progression-free survival (20.0 months vs. 5.4
unpredictably; side effects should be monitored and standard dosing months) and median OS (35.3 months vs. 31.3 months). Improvements in
(1000 mg on empty stomach) utilized if excess toxicity is observed on all secondary endpoints were also observed (eg, the time until
modified dosing (250 mg with food). chemotherapy initiation or first SRE).
Enzalutamide in M0 and M1 CRPC Two randomized clinical trials have reported that enzalutamide may be
On August 31, 2012, the FDA approved enzalutamide, a next-generation superior to bicalutamide for cancer control in metastatic CRPC. The
antiandrogen, for treatment of men with metastatic CRPC who had TERRAIN study randomized 375 men with treatment-naïve, metastatic
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Prostate Cancer
CRPC to 160 mg/d enzalutamide or 50 mg/d bicalutamide in a 1:1 seen in OS, although OS data were not mature at the time of final analysis
manner.582 The enzalutamide group had significantly better progression- for metastasis-free survival. Adverse events included fatigue (33% vs.
free survival (defined as PSA progression, soft tissue progression, or 14%), hypertension (12% vs. 5%), major adverse cardiovascular events
development of additional bony metastases) compared to the bicalutamide (5% vs. 3%), and mental impairment disorders (5% vs. 2%). Patient-
group (median time to progression, 15.7 vs. 5.8 months; HR, 0.44; 95% reported outcomes from PROSPER indicate that enzalutamide delayed
CI, 0.34–0.57). pain progression, symptom worsening, and decrease in functional status,
compared with placebo.585 The FDA expanded approval for enzalutamide
The STRIVE trial randomized 396 men with M0 or M1 treatment-naïve to include men with non-metastatic CRPC on July 13, 2018,579 and the
CRPC to 160 mg/d enzalutamide or 50 mg/d bicalutamide in a 1:1 panel believes that patients with M0 CRPC can be offered enzalutamide, if
manner.583 The primary endpoint in this study was progression-free PSADT is ≤10 months (category 1).
survival, defined as either PSA progression, radiographic progression of
disease, or death from any cause. Enzalutamide reduced the risk of Apalutamide in M0 CRPC
progression or death by 76% compared to bicalutamide (HR, 0.24; 95% The FDA approved apalutamide for treatment of patients with non-
CI, 0.18–0.32). These studies demonstrated that enzalutamide extended metastatic CRPC on February 14, 2018.586 This approval was based on
progression-free survival better than bicalutamide in men choosing an the phase 3 SPARTAN trial of 1207 patients with M0 CRPC and PSADT
antiandrogen for secondary hormonal therapy treatment of CRPC. ≤10 months.587 Participants were stratified according to PSADT (>6
Bicalutamide can still be considered in some patients, given the different months vs. ≤6 months), use of bone-sparing agents, and the presence of
side-effect profiles of the agents and the increased cost of enzalutamide. metastatic pelvic lymph nodes (N0 vs. N1). After median follow-up of 20.3
months, apalutamide at 240 mg/d with ADT improved the primary endpoint
Thus, enzalutamide represents a treatment option for men in both the pre-
of metastasis-free survival over placebo with ADT (40.5 months vs. 16.2
docetaxel and post-docetaxel metastatic CRPC setting and is a
months; HR for metastasis or death, 0.28; 95% CI, 0.23–0.35; P < .001).
reasonable choice for men who are not candidates for chemotherapy.
No significant difference was seen in OS, although OS data were not
Patients receiving enzalutamide have no restrictions for food intake and
mature at the time of final analysis for metastasis-free survival. Adverse
concurrent prednisone is permitted but not required.577
events included rash (24% vs. 5.5%), fracture (11% vs. 6.5%), and
The randomized, double-blind, placebo-controlled phase 3 PROSPER trial hypothyroidism (8% vs. 2%). Patients with M0 CRPC can be offered
assessed the use of enzalutamide in 1401 men with non-metastatic apalutamide, if PSADT is ≤10 months (category 1). In a prespecified
CRPC.584 Men with PSADT ≤10 months were stratified according to exploratory analysis of SPARTAN, health-related QOL was maintained in
PSADT (<6 months vs. ≥6 months) and use of bone-sparing agents and both the apalutamide and placebo groups.588
randomized 2:1 to enzalutamide (160 mg/d) plus ADT or placebo plus
Darolutamide in M0 CRPC
ADT. Enzalutamide improved the primary endpoint of metastasis-free
survival over placebo (36.6 months vs. 14.7 months; HR for metastasis or The FDA approved darolutamide for treatment of patients with non-
death, 0.29; 95% CI, 0.24–0.35; P < .0001). No significant difference was metastatic CRPC on July 30, 2019.589 The phase 3 ARAMIS study
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Prostate Cancer
randomized 1509 patients with M0 CRPC and PSADT ≤10 mo 2:1 to docetaxel is a biweekly regimen of 50 mg/m2. This regimen is based on a
darolutamide (600 mg twice daily) or placebo.590 Participants were large randomized phase 2 trial of 346 men with metastatic CRPC
stratified according to PSADT (>6 months vs. ≤6 months) and the use of randomized to either every-2-week docetaxel or every-3-week docetaxel,
osteoclast-targeted agents. The median follow-up time was 17.9 mo. each with maintenance of ADT and prednisone.593 Men treated with the
Darolutamide improved the primary endpoint of metastasis-free survival every-2-week regimen survived an average of 19.5 months compared to
compared to placebo (40.4 mo vs. 18.4 mo; HR for metastasis or death, 17.0 months with the every-3-week regimen (P = .015). Time-to-
0.41; 95% CI, 0.34–0.50; P < .001). An improvement in overall survival progression and PSA decline rate favored every-2-week therapy.
was observed at the first interim analysis (HR for death, 0.71; 95% CI, Tolerability was improved with every-2-week docetaxel; febrile neutropenia
0.50-0.99; P = .045), although these data are immature (median survival rate was 4% versus 14% and other toxicities and overall QOL were
was not reached in either arm). Adverse events that occurred more similar.
frequently in the treatment arm included fatigue (12.1% vs. 8.7%), pain in
an extremity (5.8% vs. 3.2%), and rash (2.9% vs. 0.9%). The incidence of Docetaxel is included as an upfront option for men with castration-naïve
fractures was similar between darolutamide and placebo (4.2% vs. 3.6%). prostate cancer and distant metastases based on results from two phase 3
trials (ECOG 3805/CHAARTED and STAMPEDE).594,595 CHAARTED
Darolutamide is a category 1 option for patients with M0 CRPC if PSADT randomized 790 men with metastatic, castration-naïve prostate cancer to
is ≤10 months. docetaxel (75 mg/m2 IV q3 weeks x 6 doses) plus ADT or ADT alone.595
After a median follow-up of 53.7 months, the patients in the combination
Chemotherapy and Immunotherapy arm experienced a longer OS than those in the ADT arm (57.6 months vs.
Recent research has expanded the therapeutic options for patients with 47.2 months; HR, 0.72; 95% CI, 0.59–0.89; P = .002).596 Subgroup
metastatic CRPC depending on the presence or absence of symptoms. analysis showed that the survival benefit was more pronounced in the
65% of participants with high-volume disease (HR, 0.63; 95% CI, 0.50–
Docetaxel 0.79; P < .001). Men with low-volume disease in CHAARTED did not
Two randomized phase 3 studies evaluated docetaxel-based regimens in derive a survival benefit from the inclusion of docetaxel (HR, 1.04; 95% CI,
symptomatic or rapidly progressive disease (TAX 327 and SWOG 0.70–1.55; P = .86).
9916).470,591,592 TAX 327 compared docetaxel (every 3 weeks or weekly)
plus prednisone to mitoxantrone plus prednisone in 1006 men.591 Every-3- The STAMPEDE trial, a multi-arm, multi-stage phase 3 trial, included
week docetaxel resulted in higher median OS than mitoxantrone (18.9 vs. patients with both M0 and M1 castration-naïve prostate cancer.594 The
16.5 months; P = .009). This survival benefit was maintained at extended results in the M1 population essentially confirmed the survival advantage
follow-up.592 The SWOG 9916 study also showed improved survival with of adding docetaxel (75 mg/m2 IV q3 weeks x 6 doses) to ADT seen in the
docetaxel when combined with estramustine compared to mitoxantrone CHAARTED trial. In STAMPEDE, extent of disease was not evaluated in
plus prednisone.470 Docetaxel is FDA-approved for metastatic CRPC. The the 1087 men with metastatic disease, but the median OS for all patients
standard regimen is every 3 weeks. An alternative to every-3-week with M1 disease was 5.4 years in the ADT-plus-docetaxel arm versus 3.6
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Prostate Cancer
years in the ADT-only arm (a difference of 1.8 years between groups cabazitaxel compared to mitoxantrone (HR, 0.72; P < .0001). The
compared with a 1.1-year difference in CHAARTED). The results of the improvement in survival was balanced against a higher toxic death rate
STAMPEDE trial seem to confirm the results of the CHAARTED trial. with cabazitaxel (4.9% vs. 1.9%), which was due, in large part, to
differences in rates of sepsis and renal failure. Febrile neutropenia was
Some data suggest that the use of docetaxel in combination with ADT and observed in 7.5% of cabazitaxel-treated men versus 1.3% of
EBRT may benefit fit men with high- and very-high-risk localized disease. mitoxantrone-treated men. The incidences of severe diarrhea (6%), fatigue
The GETUG 12 trial, which randomized 413 men with high- or very-high (5%), nausea/vomiting (2%), anemia (11%), and thrombocytopenia (4%)
risk prostate cancer to IMRT and ADT or ADT, docetaxel, and also were higher in cabazitaxel-treated men, which indicated the need for
estramustine.597 After a median follow-up of 8.8 years, 8-year relapse-free vigilance and treatment or prophylaxis in this setting to prevent febrile
survival was 62% in the combination therapy arm and 50% in the ADT- neutropenia. The survival benefit was sustained at an updated analysis
only arm (adjusted HR, 0.71; 95% CI, 0.54–0.94; P = .017). The with a median follow-up of 25.5 months.600 Furthermore, results of a post-
multicenter, phase 3 NRG Oncology RTOG 0521 trial randomized 563 hoc analysis of this trial suggested that the occurrence of grade ≥3
patients with high- or very-high-risk prostate cancer ADT plus EBRT with neutropenia after cabazitaxel treatment was associated with
or without docetaxel.598 After median follow-up of 5.7 years, 4-year OS improvements in both progression-free survival and OS.601
was 89% (95% CI, 84%–92%) for ADT/EBRT and 93% (95% CI, 90%–
96%) for ADT/EBRT/docetaxel (HR, 0.69; 90% CI, 0.49–0.97; one-sided P The phase 3 open-label, multinational, non-inferiority PROSELICA study
= .03). Improvements were also seen in DFS and the rate of distant compared 20 mg/m2 cabazitaxel with 25 mg/m2 cabazitaxel in 1,200
metastasis. The panel does not recommended the addition of docetaxel to patients with metastatic CRPC who progressed on docetaxel.602 The lower
ADT plus EBRT in patients with high and very-high-risk prostate cancer, dose was found to be noninferior to the higher dose for median OS (13.4
however, at this time. Longer follow-up is needed to determine the effects months [95% CI, 12.19–14.88] vs. 14.5 months [95% CI, 13.47–15.28]),
of early docetaxel on response to subsequent treatment. In addition, and grade 3/4 adverse events were decreased (39.7% vs. 54.5%). In
longer follow-up will show whether the long-term side effects of EBRT, particular, grade ≥3 neutropenia rates were 41.8% and 73.3% for the
which generally begin 4 to 5 years after EBRT, are increased with lower and higher dose groups, respectively. Cabazitaxel at 20 mg/m2
docetaxel. every 3 weeks, with or without growth factor support, is now standard of
care for fit patients. Cabazitaxel at 25 mg/m2 may be considered for
Cabazitaxel healthy men who wish to be more aggressive.
In June 2010, the FDA approved cabazitaxel, a semi-synthetic taxane
derivative, for men with metastatic CRPC previously treated with a Recent results from the phase 3 FIRSTANA study suggested that
docetaxel-containing regimen. An international randomized phase 3 trial cabazitaxel has clinical activity in patients with chemotherapy-naïve
(TROPIC) randomized 755 men with progressive metastatic CRPC to mCRPC.603 Median OS, the primary endpoint, was similar between 20
receive cabazitaxel 25 mg/m2 or mitoxantrone 12 mg/m2, each with daily mg/m2 cabazitaxel, 25 mg/m2 cabazitaxel, and 75 mg/m2 docetaxel (24.5
prednisone.599 A 2.4-month improvement in OS was demonstrated with months, 25.2 months, and 24.3 months, respectively). Cabazitaxel was
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Prostate Cancer
associated with lower rates of peripheral sensory neuropathy than mortality risk (HR, 0.78; 95% CI, 0.61–0.98; P = .03). Common
docetaxel, particularly at 20 mg/m2 (12% vs. 25%). Therefore, patients complications included mild to moderate chills (54.1%), pyrexia (29.3%),
who are not candidates for docetaxel, who are intolerant of docetaxel, or and headache (16.0%), which usually were transient.
who have pre-existing mild peripheral neuropathy should be considered
for cabazitaxel.603 The panel prefers that sipuleucel-T be used as initial therapy for
asymptomatic or minimally symptomatic patients with metastatic CRPC,
Cabazitaxel should be given with concurrent steroids (daily prednisone or so that disease burden is lower and immune function is potentially more
dexamethasone on the day of chemotherapy). Physicians should follow intact. Clinicians and patients should be aware that the usual markers of
current guidelines for prophylactic white blood cell growth factor use, benefit (decline in PSA and improvement in bone or CT scans) are not
particularly in this heavily pre-treated, high-risk population. In addition, seen. Therefore, benefit to the individual patient cannot be ascertained
supportive care should include antiemetics (prophylactic antihistamines, using currently available testing.
H2 antagonists, and corticosteroids prophylaxis) and symptom-directed
antidiarrheal agents. Cabazitaxel was tested in patients with hepatic Pembrolizumab
dysfunction in a small, phase I, dose-escalation study.604 Cabazitaxel was The FDA approved the use of pembrolizumab, an anti-PD1 antibody, for
tolerated in patients with mild to moderate hepatic impairment. However, treatment of patients with “unresectable or metastatic microsatellite
cabazitaxel should not be used in patients with severe hepatic dysfunction. instability-high (MSI-H) or mismatch repair (MMR)-deficient solid tumors
Cabazitaxel should be stopped upon clinical disease progression or who have progressed on prior treatment and who have no satisfactory
intolerance. alternative treatment options” on May 23, 2017.606 The indication has since
been expanded to include several cancer types, but not prostate cancer
Sipuleucel-T specifically.607 The recommended adult dose of pembrolizumab for this
In April 2010, sipuleucel-T became the first in a new class of cancer indication is 200 mg intravenously once every 3 weeks.
immunotherapeutic agents to be approved by the FDA. This autologous
cancer “vaccine” involves collection of the white blood cell fraction- FDA-accelerated approval was based on the treatment of 149 patients
containing, antigen-presenting cells from each patient; exposure of the across 5 clinical studies involving MSI-H or MMR-deficient (dMMR)
cells to the prostatic acid phosphatase-granulocyte macrophage colony- colorectal (n = 90) or non-colorectal (n = 59) cancer for an objective
stimulating factor (PAP-GM-CSF recombinant fusion protein); and response rate of 40% (59/149).606 All patients received ≥1 prior regimen.
subsequent reinfusion of the cells. The pivotal study was a phase 3, Among the non-colorectal cohorts, 2 patients had metastatic CRPC: one
multicenter, randomized, double-blind trial (D9902B).605 Five hundred achieved a partial objective response, and the other achieved stable
twelve patients with minimally symptomatic or asymptomatic metastatic disease for >9 months.
CRPC were randomized 2:1 to receive sipuleucel-T or placebo. Median
A limited number of additional patients with metastatic CRPC treated with
survival in the vaccine arm was 25.8 months compared to 21.7 months in
pembrolizumab have been reported.63,608-610 In one study, only 1 patient
the control arm. Sipuleucel-T treatment resulted in a 22% reduction in
had prostate cancer.609 He had treatment-refractory, progressive,
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Prostate Cancer
metastatic, dMMR disease and experienced a complete response; his progressed through at least one line of systemic therapy for M1 CRPC
prior therapy was not reported. In the other study, 10 patients with CRPC (category 2B). The prevalence of MMR deficiency in metastatic CPRC is
and non-visceral metastases (bone = 7; lymph nodes = 2; bone and liver = estimated at 2% to 5%,36,609 and testing for MSI-H or dMMR can be
1) who had disease progression on enzalutamide were treated with performed using DNA testing or immunohistochemistry. If tumor MSI-H or
pembrolizumab and enzalutamide.608 Some of the patients also had dMMR is identified, the panel recommends referral to genetic counseling
experienced disease progression on additional therapies (docetaxel for for consideration of germline testing for Lynch syndrome.
castration-naïve disease, abiraterone, and/or sipuleucel-T). Three of the
10 patients showed a near complete PSA response. Two of these 3 Treatment Implications for Patients with DNA Repair Gene
Mutations
patients had radiographically measurable disease and achieved a partial
radiographic response (including a response in liver metastases). Of the Early studies suggest germline and somatic mutations in homologous
remaining patients, 3 showed stable disease, and 4 displayed no evidence recombination repair genes (eg, BRCA1, BRCA2, ATM, PALB2, FANCA,
of clinical benefit. Genetic analysis of biopsy tissue from 2 PSA RAD51D, CHEK2) may be predictive of the clinical benefit of poly-ADP
responders and 2 PSA non-responders revealed that one responder had ribose polymerase (PARP) inhibitors.611-613 In particular, phase 2 data
an MSI-H tumor, whereas the other responder and the non-responders did suggest that one PARP inhibitor, olaparib, has clinical activity in such
not. The nonrandomized phase Ib KEYNOTE-028 trial included 23 patients, and trials of this agent and other PARP inhibitors are ongoing to
patients with advanced, progressive prostate cancer, of whom 74% had assess the overall net clinical benefit of such therapy in men with CRPC,
received ≥2 previous therapies for metastatic disease.610 The objective particularly in those men with either germline or somatically acquired DNA
response rate by investigator review was 17.4% (95% CI, 5.0%–38.8%), repair enzyme mutations.612,613 One of these trials was randomized,
with 4 confirmed partial responses. Eight patients (34.8%) had stable double-blind, and placebo-controlled, and the primary endpoint of median
disease. Treatment-related adverse events occurred in 61% of patients radiographic progression-free survival was met (13.8 months in the
after a median follow-up of 7.9 months; 17% of the cohort experienced olaparib/abiraterone arm vs. 8.2 months in the placebo/abiraterone arm;
grade 3/4 events (ie, grade 4 lipase increase, grade 3 peripheral HR, 0.65; 95% CI, 0.44–0.97; P = .034).613 The 142 patients in this trial
neuropathy, grade 3 asthenia, grade 3 fatigue). were not selected based on mutational status. At present, no PARP
inhibitor is approved for use in prostate cancer.
The most common adverse events from pembrolizumab are fatigue,
pruritus, diarrhea, anorexia, constipation, nausea, rash, fever, cough, DNA repair defects have been reported to be predictive for sensitivity to
dyspnea, and musculoskeletal pain. Pembrolizumab also may be platinum agents in CRPC and other cancers.614-616 Platinum agents have
associated with immune-mediated side effects, which include colitis, shown some activity in patients with CRPC without molecular selection.617
hepatitis, endocrinopathies, pneumonitis, or nephritis. Studies of platinum agents in patients with CRPC that have DNA repair
gene mutations are needed.
Based on the available data, the panel supports the use of pembrolizumab
in patients with MSI-H or dMMR metastatic CRPC whose disease has In addition, a recent study suggested that patients with metastatic CRPC
and germline mutations in DNA repair genes may have better outcomes if
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Prostate Cancer
treated with abiraterone or enzalutamide than with taxanes.39 However, it P = .01) and decreased the total SREs (424 vs. 605) compared with
should be noted that the response of patients with metastatic CRPC and docetaxel alone.
homologous recombination repair gene mutations to standard therapies is
similar to the response of patients without mutations.618,619 Denosumab was compared to zoledronic acid in a randomized, double-
blind, placebo-controlled study in men with CRPC.624 The absolute
The panel recommends clinical trial enrollment for men with prostate incidence of SREs was similar in the 2 groups; however, the median time
cancer and DNA repair gene mutations. to first SRE was delayed by 3.6 months by denosumab compared to
zoledronic acid (20.7 vs. 17.1 months; P = .0002 for non-inferiority, P =
Agents Related to Bone Health in CRPC .008 for superiority). The rates of important SREs with denosumab were
In a multicenter study, 643 men with CRPC and asymptomatic or similar to zoledronic acid and included spinal cord compression (3% vs.
minimally symptomatic bone metastases were randomized to intravenous 4%), need for radiation (19% vs. 21%), and pathologic fracture (14% vs.
zoledronic acid every 3 weeks or placebo.620 At 15 months, fewer men in 15%).
the zoledronic acid 4-mg group than men in the placebo group had SREs
(33% vs. 44%; P = .02). An update at 24 months also revealed an Treatment-related toxicities reported for zoledronic acid and denosumab
increase in the median time to first SRE (488 days vs. 321 days; P = were similar and included hypocalcemia (more common with denosumab
.01).621 No significant differences were found in OS. Other 13% vs. 6%), arthralgias, and osteonecrosis of the jaw (ONJ, 1%–2%
bisphosphonates have not been shown to be effective for prevention of incidence). Most, but not all, patients who develop ONJ have preexisting
disease-related skeletal complications. Earlier use of zoledronic acid in dental problems.625
men with castration-sensitive prostate cancer and bone metastases is not
NCCN Recommendations
associated with lower risk for SREs, and in general should not be used for
SRE prevention until the development of metastatic CRPC.622 Initial Prostate Cancer Diagnosis
Initial suspicion of prostate cancer is based on an abnormal DRE or an
The randomized TRAPEZE trial used a 2 X 2 factorial design to compare elevated PSA level. A separate NCCN Guidelines Panel has written
clinical progression-free survival (pain progression, SREs, or death) as the guidelines for prostate cancer early detection (see the NCCN Guidelines
primary outcome in 757 men with bone metastatic CRPC treated with for Prostate Early Detection, available at www.NCCN.org). Definitive
docetaxel alone or with zoledronic acid, 89Sr, or both.623 The bone- diagnosis requires biopsies of the prostate, usually performed by a
directed therapies had no statistically significant effect on the primary urologist using a needle under TRUS guidance. A pathologist assigns a
outcome or on OS in unadjusted analysis. However, adjusted analysis Gleason primary and secondary grade to the biopsy specimen. Clinical
revealed a small effect for 89Sr on clinical progression-free survival (HR, staging is based on the TNM classification from the AJCC Staging Manual,
0.85; 95% CI, 0.73-0.99; P = .03). For secondary outcomes, zoledronic 8th edition.626 NCCN treatment recommendations are based on risk
acid improved the SRE-free interval (HR, 0.78; 95% CI, 0.65–0.95; stratification that includes TNM staging rather than on AJCC prognostic
grouping.
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Prostate Cancer
Pathology synoptic reports (protocols) are useful for reporting results from group alone have been proposed based on data from a quality
examinations of surgical specimens; these reports assist pathologists in improvement collaborative in the state of Michigan.146 For pelvic CT, the
providing clinically useful and relevant information. The NCCN Guidelines following criteria would identify almost all men with a positive study and
Panel favors pathology synoptic reports from the College of American reduce the number of negative studies: 1) PSA level >20 ng/mL; 2) Grade
Pathologists (CAP) that comply with the Commission on Cancer Group 4–5; or 3) clinical stage ≥T3. Use of these criteria may reduce the
requirements.627 number of negative study results without missing a significant number of
positive studies. Biopsy should be considered for further evaluation of
Initial Clinical Assessment and Staging Evaluation suspicious nodal findings. For all other patients, no additional imaging is
For patients with very-low-, low-, and intermediate-risk prostate cancer required for staging. NCCN panelists voiced concern about inappropriate
and a life expectancy of 5 years or less and without clinical symptoms, use of PET imaging. F-18 PET/CT or PET/MRI is not recommended for
further workup and treatment should be delayed until symptoms develop. initial assessment. However, F-18 sodium fluoride PET/CT or PET/MRI
Those with a life expectancy ≤5 years who fall into the high- or very-high- may be used after bone scan for further evaluation of equivocal findings.
risk categories should undergo bone imaging and, if indicated by
nomogram prediction of lymph node involvement, pelvic +/- abdominal Risk stratification and treatment options are described below. ADT as a
imaging. If regional or metastatic disease is found, then patients can be primary treatment for localized prostate cancer does not improve survival
started on ADT. If the patient remains as N0M0, ADT or EBRT may be and is not recommended by the NCCN Guidelines Panel. Cryotherapy or
considered for selected patients with high- or very-high-risk disease, other local therapies are not recommended as routine primary therapy for
where complications, such as hydronephrosis or metastases, are likely localized prostate cancer due to lack of long-term data comparing these
within 5 years. Patients with life expectancies ≤5 years with high-risk, very- treatments to radiation or radical prostatectomy.
high-risk, regional, and metastatic disease are also candidates for
Very Low Risk
observation if the risks and complications of therapy are judged to be
greater than the benefit in terms of prolonged life or improved QOL. Men with all of the following tumor characteristics are categorized in the
very-low-risk group: clinical stage T1c, biopsy Grade Group 1, PSA <10
For symptomatic patients and/or those with a life expectancy of greater ng/mL, presence of disease in fewer than 3 biopsy cores, ≤50% prostate
than 5 years, bone imaging is appropriate for patients with unfavorable cancer involvement in any core, and PSA density <0.15 ng/mL/g. The use
intermediate-risk prostate cancer and T2 disease with PSA over 10 of targeted biopsy increases the chance that patients will have a higher
ng/mL628; high- or very-high-risk disease;148 or symptomatic disease. number of positive cores or >50% involvement in some cores. Men with
Pelvic +/- abdominal imaging is recommended for intermediate or higher targeted biopsies who otherwise qualify for very-low-risk prostate cancer
risk disease when a nomogram indicates a >10% chance of lymph node should still be considered as very low risk regardless of percent core
involvement, although staging studies may not be cost-effective until the involvement or number of positive cores in the targeted biopsies. A
chance of lymph node positivity reaches 45%.629 Alternative approaches to targeted lesion counts as one core.
imaging based on the likelihood of a positive study rather than by risk
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Prostate Cancer
Given the potential side effects of definitive therapy, men in this group who Observation is indicated for patients in this risk group with a life
have an estimated life expectancy of less than 10 years should undergo expectancy ≤5 years. Options for patients with favorable intermediate-risk
observation (monitoring no more often than every 6 months). Unlike active prostate cancer and a life expectancy of 5 to 10 years include: 1)
surveillance, observation schedules do not involve biopsies. Men with very observation (preferred); 2) EBRT; and 3) brachytherapy.
low risk and a life expectancy of 10 to 20 years should undergo active
surveillance. For patients who meet the very-low-risk criteria but who have Men in this group with a life expectancy ≥10 years can consider molecular
a life expectancy of 20 years or above, the NCCN Panel agreed that active tumor testing for additional prognostic information independent of their
surveillance (preferred), EBRT or brachytherapy, or radical prostatectomy NCCN risk group (see Tumor Multigene Molecular Testing, above). Initial
are all viable options and should be discussed thoroughly. treatment options for these patients include: 1) radical prostatectomy, with
PLND if the predicted probability of lymph node metastasis is ≥2%; 2)
Low Risk EBRT; 3) brachytherapy; and 4) active surveillance. A multicenter cohort
The NCCN Guidelines define the low-risk group as patients with clinical of 2550 men showed that the addition of ADT to the treatment options is
stage T1 to T2a, Grade Group 1, and serum PSA level <10 ng/mL. unlikely to benefit men in the favorable intermediate-risk group.630
Observation is recommended for men with low-risk prostate cancer and a
The literature on outcomes of active surveillance in men with intermediate-
life expectancy of less than 10 years. If the patient’s life expectancy is 10
risk prostate cancer is limited.631 In the PIVOT trial, men with clinically
years or more, initial treatment options include: 1) active surveillance
localized prostate cancer and a life expectancy ≥10 years were
(preferred); 2) EBRT or brachytherapy; or 3) radical prostatectomy.
randomized to radical prostatectomy or observation.632 Of the 120
Molecular tumor testing can be considered for these men for prognostic
participants with intermediate-risk disease who were randomized to
information independent of NCCN risk groups (see Tumor Multigene
observation, 13 died from prostate cancer, a non-significant difference
Molecular Testing, above).
compared with 6 prostate cancer deaths in 129 participants with
Favorable Intermediate Risk intermediate-risk disease in the radical prostatectomy arm (HR, 0.50; 95%
CI, 0.21–1.21; P = .12). After longer follow-up (median 12.7 years), a small
The NCCN Guidelines define the intermediate-risk group as patients with
difference was seen in all-cause mortality in those with intermediate-risk
no high- or very-high-risk features and ≥1 IRF (T2b-T2c, Grade Group 2 or
disease (absolute difference, 14.5 percentage points; 95% CI, 2.8–25.6),
3, PSA 10–20 ng/mL). Patients with intermediate risk fall into the favorable
but not in those with low-risk disease (absolute difference, 0.7 percentage
intermediate-risk group if they have no more than 1 IRF, Grade Group ≤2,
points; 95% CI, -10.5–11.8).633 Urinary incontinence and erectile and
and <50% of biopsy cores positive. Patients with multiple IRFs, Grade
sexual dysfunction, however, were worse through 10 years in the radical
Group 3, or ≥50% positive cores should be shifted to the unfavorable
prostatectomy group. These results and the less-than-average health of
intermediate-risk group.96 The panel notes that an ultrasound-, MRI-, or
men in the PIVOT study634 suggest that men with competing risks may
DRE-targeted lesion that is biopsied more than once and demonstrates
safely be offered active surveillance. Other prospective studies of active
cancer counts as a single positive core for purposes of risk stratification.
surveillance that included men with intermediate-risk prostate cancer
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Prostate Cancer
resulted in prostate cancer-specific survival rates of 94% to 100% for the High and Very High Risk
full cohorts.197,198,200 Men with prostate cancer that is clinical stage T3a, Grade Group 4–5, or
PSA level greater than 20 ng/mL are categorized by the panel as high risk.
The panel interpreted these data to show that a subset of men with
Patients at very high risk (locally advanced) are defined by the NCCN
intermediate-risk prostate cancer may be considered for active
Guidelines as men with clinical stage T3b to T4, primary Gleason pattern
surveillance, although longer-term follow-up is needed in these and others
5, or more than 4 biopsy cores with Grade Group 4–5.639 Men in these risk
studies to increase confidence about the risks and benefits of active
groups can be considered for germline testing for mutations in
surveillance in this population. Men must understand that a significant
homologous recombination genes (see Homologous DNA Repair Genes,
proportion of men clinically staged as having favorable intermediate-risk
above). Treatment options are the same for these 2 risk groups.
prostate cancer may have higher risk disease.635-638
Selected asymptomatic patients with a life expectancy ≤5 years in these
The panel believes that active surveillance may be considered for men
risk groups can be considered for ADT or EBRT if complications, such as
with favorable intermediate-risk prostate cancer, but should be
hydronephrosis or metastasis, can be expected within 5 years. Otherwise,
approached with caution, include informed decision-making, and use close
observation is indicated for most patients.
monitoring for progression.
If life expectancy is >5 years or the patient is symptomatic, treatment
Unfavorable Intermediate Risk
options include EBRT in conjunction with 1.5 to 3 years of
NCCN defines unfavorable intermediate risk as T2b-T2c, Grade Group 2- neoadjuvant/concurrent/adjuvant ADT (category 1 for the ADT
3, and/or PSA 10 to 20 ng/mL. Patients with only one of these risk factors, component); ADT alone is insufficient. In particular, patients with low-
Grade Group 1 or 2, and fewer than 50% of biopsy cores positive for volume, high-grade tumor warrant aggressive local radiation combined
cancer fall into the favorable intermediate risk group. with 1.5 to 3 years of neoadjuvant/concurrent/adjuvant ADT. The shorter
duration of ADT is supported by data from two randomized, phase 3
Observation is indicated for patients in this risk group with a life
trials.476,477 The combination of EBRT and brachytherapy, with 1 to 3 years
expectancy ≤5 years and is the preferred option for men with a life
of neoadjuvant/concurrent/adjuvant ADT, is another primary treatment
expectancy of 5 to 10 years. Options for treatment for men with
option (category 1 for the ADT component).399 Finally, radical
unfavorable intermediate risk include: 1) EBRT with or without 4 months of
prostatectomy with PLND remains an option. In particular, younger and
ADT; and 2) EBRT + brachytherapy with or without 4 months of ADT for
healthier men may benefit from operation. Aggressive treatment is
life expectancy >5 years. Additionally, for men with a life expectancy ≥10
warranted in men with high- and very-high-risk prostate cancer, because
years, radical prostatectomy, with PLND if the predicted probability of
5-year prostate cancer-specific survival rates have been reported in the
lymph node metastasis is ≥2%, is an option for treatment.
range of 75% to 98%.640,641
Active surveillance is not recommended for patients with unfavorable
intermediate-risk prostate cancer (category 1).
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Prostate Cancer
Nodal Disease Disease Monitoring

The average time from lymph node metastasis to bone metastasis is 3 Patients treated with either medical or surgical ADT have increased risk
years, and survival is approximately 3 more years with ADT and perhaps 5 for osteoporosis. A baseline bone mineral density study should be
more years with ADT and new agents. EBRT to the primary tumor plus considered for these patients. Supplementation is recommended using
neoadjuvant/concurrent/adjuvant ADT (preferred) or ADT for castration- calcium (500 mg) and vitamin D (400 IU). Men who are
naïve disease are options for patients diagnosed with N1 disease on osteopenic/osteoporotic should be considered for denosumab, zoledronic
presentation and life expectancy >5 years. In addition, abiraterone may be acid, or alendronate.
added to either treatment (category 2B for abiraterone with
Patients on Active Surveillance
methylprednisolone). Analysis of data from the control arm of STAMPEDE
supports the use of EBRT with ADT in men with node-positive, non- For patients who choose active surveillance, an appropriate active
metastatic disease.642 Two-year FFS was improved with the planned use surveillance schedule includes PSA measurement no more often than
of radiation in this subset of trial participants (53% vs. 81%; HR, 0.48; 95% every 6 months unless clinically indicated, DRE no more often than every
CI, 0.29–0.79). Data for the use of abiraterone for regional disease comes 12 months unless clinically indicated, and repeat prostate biopsy no more
from the STAMPEDE trial, discussed in Abiraterone Acetate in Castration- often than every 12 months unless clinically indicated. A repeat prostate
Naïve Prostate Cancer, above.500 biopsy within 6 months of diagnosis is indicated if the initial biopsy was
less than 10 cores or if assessment results show discordance. Many
Observation and ADT are the recommended options for asymptomatic clinicians choose to wait 2 years for a biopsy if there are no signs of
patients presenting with regional disease and life expectancy ≤5 years. progression. Repeat biopsies are not indicated when life expectancy is
<10 years or when men are on observation.
Positive nodal disease identified during radical prostatectomy is addressed
under Adjuvant or Salvage Therapy After Radical Prostatectomy. Reliable parameters of prostate cancer progression await the results of
ongoing clinical trials. Change in prostate exam or increase in PSA level
Metastatic Disease may prompt consideration for repeat biopsy at the discretion of the
ADT is recommended for patients diagnosed with metastatic disease. physician. mpMRI may be considered to exclude the presence of anterior
Options are described in ADT for Castration-Naïve Disease, above. cancer if the PSA level increases and systematic prostate biopsy remains
Abiraterone, docetaxel, or EBRT to the primary tumor is sometimes added negative.643 PSADT is not considered reliable enough to be used alone to
to ADT as discussed in Abiraterone Acetate in Castration-Naïve Prostate detect disease progression.644
Cancer; Docetaxel; and EBRT to the Primary Tumor in Low-Volume M1
Disease, above, respectively. Observation also is appropriate for If repeat biopsy shows Grade Group ≥3 disease, or if tumor is found in a
asymptomatic patients with metastatic disease and life expectancy ≤5 greater number of biopsy cores or in a higher percentage of a given biopsy
years. core, cancer progression may have occurred.
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Prostate Cancer
Patients After Initial Definitive Therapy Workup for Progression

For patients initially treated with intent to cure, serum PSA levels should Patients with advanced disease who show signs of progression should
be measured every 6 to 12 months for the first 5 years and then annually. undergo disease workup with bone imaging, chest CT, and an
PSA testing every 3 months may be better for men at high risk of abdominal/pelvic CT or abdominal/pelvic MRI with and without contrast. C-
recurrence. When prostate cancer recurred after radical prostatectomy, 11 choline PET/CT or PET/MRI or F-18 fluciclovine PET/CT or PET/MRI
Pound and colleagues found that 45% of patients experienced recurrence can be considered for further soft tissue and bone evaluation, and F-18
within the first 2 years, 77% within the first 5 years, and 96% by 10 sodium fluoride PET/CT or PET/MRI can be considered for further bone
years.645 Local recurrence may result in substantial morbidity and can, in evaluation for patients without known metastatic disease (see Nuclear
rare cases, occur in the absence of a PSA elevation. Therefore, annual Imaging, above). The panel remains unsure what to do when M1 is
DRE is appropriate to monitor for prostate cancer recurrence and to detect suggested by PET-based imaging but not on conventional imaging.
colorectal cancer. Similarly, after EBRT, the monitoring of serum PSA
levels is recommended every 6 months for the first 5 years and then Adjuvant or Salvage Therapy After Radical Prostatectomy
annually and a DRE is recommended annually. The clinician may opt to Most patients who have undergone radical prostatectomy are cured of
omit the DRE if PSA levels remain undetectable. prostate cancer. However, some men will have adverse pathologic
features, positive lymph nodes, or biochemical persistence or recurrence.
Patients with Castration-Naïve Disease on ADT Selecting men appropriately for adjuvant or salvage radiation is difficult. A
The intensity of clinical monitoring for patients on ADT for castration-naïve multi-institutional, propensity score-matched cohort study compared post-
disease is determined by the response to initial ADT, EBRT, or both. radiation biochemical failure, freedom from distant metastases, and OS in
Follow-up evaluation of these patients should include history and physical 1,566 men with adverse pathologic features after radical prostatectomy
examination and PSA measurement every 3 to 6 months based on clinical who had received either adjuvant radiation or early salvage radiation for
judgment. Bone imaging should be performed for symptoms and as often biochemical recurrence.647 All 3 outcomes were improved with the use of
as every 6 to 12 months. The relative risk for bone metastasis or death adjuvant radiation. Prospective validation of these findings is needed, and
increases as PSADT falls; a major inflection point appears at PSADT of 8 at this time adjuvant radiation or observation may be considered in men
months. Bone imaging should be performed more frequently in these with adverse pathologic features after radical prostatectomy.
men.646
Adjuvant Therapy
Patients with Localized Disease Under Observation Adjuvant radiation with or without 6 months of ADT can be given to men
Patients with localized disease on observation follow the same monitoring with PSA persistence (failure of PSA to fall to undetectable levels) or
recommendations as patients with castration-naïve disease who are on adverse pathologic features (ie, positive margins, seminal vesicle invasion,
ADT, except that the physical exam and PSA measurement should only extracapsular extension) who do not have lymph node metastases.
be done every 6 months. Although observation after radical prostatectomy is appropriate, adjuvant
EBRT after recuperation from operation is likely beneficial in men with one
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Prostate Cancer
or more adverse laboratory or pathologic features, which include positive results suggest that continued follow-up of these series of patients may
surgical margin, seminal vesicle invasion, and/or extracapsular extension show a survival advantage.
as recommended in the guideline by the American Urological Association
(AUA) and ASTRO.648 Positive surgical margins are unfavorable, The value of whole pelvic irradiation is unclear due to a lack of benefit in
especially if diffuse (>10-mm margin involvement or ≥3 sites of positivity) progression-free survival in 2 trials (RTOG 9413 and GETUG 01)655-658;
or associated with persistent serum levels of PSA. The defined target whole pelvic radiation may be appropriate for selected patients.
volumes include the prostate bed.649
Adjuvant therapy can also be given to men with positive lymph nodes
Published trials provide high-level evidence that can be used to counsel found during or after radical prostatectomy. Several management options
patients more appropriately regarding the use of adjuvant therapy. should be considered. ADT is a category 1 option, as discussed above
Thompson and colleagues reported the results of SWOG 8794, which (see Adjuvant ADT for Lymph Node Metastases after RP).480 Another
enrolled 425 men with extraprostatic cancer found at radical option is observation. Retrospective data show that initial observation may
prostatectomy. Patients were randomized to receive either adjuvant EBRT be safe in some men with N1 disease at radical prostatectomy, because
or usual care, and follow-up has reached a median of 12.6 years.650 The 28% of a cohort of 369 patients remained free from biochemical
initial study report revealed that adjuvant EBRT reduced the risk of PSA recurrence at 10 years.659 A third option is the addition of pelvic EBRT to
relapse and disease recurrence.651 An update reported improved 10-year ADT (category 2B). This last recommendation is based on retrospective
biochemical FFS for patients with high-risk disease (seminal vesicle studies and a National Cancer Database analysis that demonstrated
positive) receiving post-prostatectomy adjuvant radiation compared to improved biochemical recurrence-free survival, cancer-specific survival,
observation (36% vs. 12%; P = .001).652 and all-cause survival with post-prostatectomy EBRT and ADT compared
to adjuvant ADT alone in patients with lymph node metastases.660-663
Another randomized trial conducted by EORTC compared post-
Biochemical Recurrence After Radical Prostatectomy
prostatectomy observation and adjuvant EBRT in 1005 patients.653 All
patients had extraprostatic disease and/or positive surgical margins. The Men who suffer biochemical recurrence after radical prostatectomy fall into
5-year biochemical progression-free survival significantly improved with 3 groups: 1) those whose PSA level fails to fall to undetectable levels after
EBRT compared to observation for patients with positive surgical margins radical prostatectomy (persistent disease); 2) those who achieve an
(78% vs. 49%), but benefit was not seen for patients with negative surgical undetectable PSA after radical prostatectomy with a subsequent
margins. detectable PSA level that increases on 2 or more subsequent laboratory
determinations (PSA recurrence); or 3) the occasional case with persistent
A German study by Wiegel and colleagues reported results on 268 but low PSA levels attributed to slow PSA metabolism or residual benign
patients.654 All participants had extraprostatic disease and undetectable tissue. Consensus has not defined a threshold level of PSA below which
PSA levels after radical prostatectomy. Postoperative EBRT improved 5- PSA is truly “undetectable.”152 Group 3 does not require further evaluation
year biochemical progression-free survival compared to observation alone until PSA increases, but the workup for 1 and 2 must include an evaluation
(72% vs. 54%; HR, 0.53; 95% CI, 0.37–0.79). Collectively, these trial for distant metastases.
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Several retrospective studies have assessed the prognostic value of Patients with PSA recurrence (undetectable PSA that increases on two or
various combinations of pretreatment PSA levels, Gleason scores, more measurements) after radical prostatectomy may be observed or
PSADT, and the presence or absence of positive surgical margins.664-668 A undergo primary salvage EBRT with or without ADT if distant metastases
large retrospective review of 501 patients who received salvage radiation are not detected.648
for detectable and increasing PSA after radical prostatectomy667 showed
that the predictors of progression were Gleason score 8 to 10, pre-EBRT Large retrospective cohort studies support the use of EBRT in the setting
PSA level >2 ng/mL, seminal vesicle invasion, negative surgical margins, of biochemical recurrence, because it is associated with decreased all-
and PSADT ≤10 months. However, prediction of systemic disease versus cause and prostate cancer-specific survival.669,673 The recommended post-
local recurrence and hence responsiveness to postoperative radiation has radical prostatectomy EBRT dose is 64 to 72 Gy and may be increased for
proven unfeasible for individual patients using clinical and pathologic gross recurrence that has been proven by biopsy. The target volume
criteria.669 Delivery of adjuvant or salvage EBRT becomes both therapeutic includes the prostate bed and may include the whole pelvis in selected
and diagnostic—PSA response indicates local persistence/recurrence. patients.649 Treatment is most effective when pre-treatment PSA level is
Delayed biochemical recurrence requires restaging, and a nomogram104,670 below 0.5 ng/mL.670 Paradoxically, salvage EBRT was shown to be most
may prove useful to predict response, but it has not been validated. beneficial when the PSADT time was <6 months in a cohort analysis of
635 men,669 although another study of 519 men reported mortality
The specific staging tests depend on the clinical history, but should include reduction for both men with PSADT <6 months and those with PSADT ≥6
a calculation of PSADT to inform nomogram use and counseling. In months.673 Most men with prolonged PSADT may be observed safely.674
addition, bone imaging; chest CT; abdominal/pelvic CT or
abdominal/pelvic MRI; C-11 choline PET/CT or PET/MRI or F-18 Six months of concurrent/adjuvant ADT can be coadministered with
fluciclovine PET/CT or PET/MRI; and prostate bed biopsy may be useful. salvage radiation based on the results of GETUG-16.675 An LHRH agonist
The Decipher molecular assay can be considered for prognostication after should be used. Two years instead of 6 months of ADT can be considered
radical prostatectomy (category 2B). A meta-analysis of 5 studies with 855 in addition to radiation for men with persistent PSA after radical
patients and median follow-up of 8 years found that the 10-year prostatectomy or for PSA levels that exceed 1.0 ng/mL at the time of
cumulative incidence metastases rates for men classified as low, initiation of salvage therapy, based on results of RTOG 9601.463 For 2
intermediate, and high risk by Decipher after radical prostatectomy were years of ADT, level 1 evidence supports 150 mg bicalutamide daily but an
5.5%, 15.0%, and 26.7%, respectively (P < .001).671 LHRH agonist could be considered as an alternative.463
Bone imaging is appropriate when patients develop symptoms or when ADT alone becomes the salvage treatment when there is proven or high
PSA levels are increasing rapidly. In one study, the probability of a positive suspicion for distant metastases. Pelvic radiation is not recommended but
bone scan for a patient not on ADT after radical prostatectomy was less may be given to the site of metastasis if in weight-bearing bones or if the
than 5% unless the PSA increased to 40 to 45 ng/mL.672 A TRUS biopsy patient is symptomatic. Observation remains acceptable for selected
may be helpful when imaging suggests local recurrence. patients, with ADT delayed until symptoms develop or PSA levels suggest
that symptoms are imminent. In all cases, the form of primary or
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Prostate Cancer
secondary systemic therapy should be based on the hormonal status of Options for primary salvage therapy for those with positive biopsy but low
the patient. suspicion of metastases to distant organs include observation or radical
prostatectomy with PLND in selected cases by highly experienced
Post-Irradiation Recurrence surgeons. Salvage radical prostatectomy can result in long-term disease
The 2006 Phoenix definition was revised by ASTRO and the RTOG in control, but is often associated with impotence and urinary incontinence.678
Phoenix: 1) PSA rise by 2 ng/mL or more above the nadir PSA is the Other options for localized interventions include cryotherapy,679 HIFU,444-
standard definition for biochemical recurrence after EBRT with or without 447,451,452
and brachytherapy (reviewed by Allen and colleagues680 and
hormonal therapy; and 2) A recurrence evaluation should be considered discussed in Salvage Brachytherapy). Treatment, however, needs to be
when PSA has been confirmed to be increasing after radiation even if the individualized based on the patient's risk of progression, the likelihood of
rise above nadir is not yet 2 ng/mL, especially in candidates for salvage success, and the risks involved with salvage therapy.
local therapy who are young and healthy.676 Retaining a strict version of
the ASTRO definition allows comparison with a large existing body of Negative TRUS biopsy after post-radiation biochemical recurrence poses
literature. Rapid increase of PSA may warrant evaluation (prostate biopsy) clinical uncertainties. Observation, ADT, and enrolling in clinical trials are
prior to meeting the Phoenix definition, especially in younger or healthier viable options.
men.
Patients with radiographic evidence of distant metastases should proceed
Further workup is indicated in patients who are considered candidates for to ADT for castration-naïve disease. Patients who were not initially
local therapy. These patients include those with original clinical stage candidates for local therapy should be treated with ADT or observed.
T1-2, life expectancy >10 years, and current PSA <10 ng/mL.677 Workup
typically includes PSADT calculation, bone imaging, TRUS biopsy, and Castration-Naïve Disease
prostate MRI; in addition, a chest CT, an abdominal/pelvic CT or The term "castration-naïve" is used to define patients who are not on ADT
abdominal/pelvic MRI, C-11 choline PET/CT or PET/MRI, or F-18 at the time of progression. The NCCN Prostate Cancer Panel uses the
fluciclovine PET/CT or PET/MRI can be considered. term "castration-naïve" even when patients have had neoadjuvant,
concurrent, or adjuvant ADT as part of RT provided they have recovered
Local radiation recurrences are most responsive to salvage therapy when testicular function. Options for patients with castration-naïve disease who
PSA levels at the time of treatment are low (<5 ng/mL). Biopsy should be require ADT depend on the presence of distant metastases. Men with M0
encouraged at the time of radiation biochemical recurrence if staging disease can undergo orchiectomy or ADT with LHRH agonist with or
workup does not reveal metastatic disease. Prostate biopsy in the setting without an antiandrogen or LHRH antagonist or they can be observed until
of suspected local recurrence after radiation should be considered, symptoms develop or are imminent. Options for men with M1 disease and
including biopsy at the junction of the seminal vesicle and prostate, life expectancy >5 years include: 1) ADT and docetaxel (category 1); 2)
because this is a common site of recurrence. ADT and abiraterone with prednisone (category 1); 3) ADT and EBRT to
the primary tumor for low-volume M1; 4) ADT alone; and 5) ADT and
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Prostate Cancer
abiraterone with methylprednisolone (category 2B). ADT alone or with prolonged PSADTs who are older are excellent candidates for
observation are recommended for asymptomatic patients with M1 disease observation.
and life expectancy ≤5 years.
Patients with metastatic disease should be queried about adverse effects
The option of upfront docetaxel and ADT is based on results from the related to ADT. Intermittent ADT should be used for those who experience
phase 3 CHAARTED and STAMPEDE trials (as discussed under significant side effects of ADT. Some men who have no ADT-related
Docetaxel).594,595 Abiraterone use in the metastatic castration-naïve setting morbidity may find the uncertainty of intermittent ADT not worthwhile.
is based on results of STAMPEDE (see Abiraterone Acetate in Castration- Intermittent ADT requires close monitoring of PSA and testosterone levels,
Naïve Prostate Cancer, above).500 The direct randomized comparison of especially during off-treatment periods, and patients may need to switch to
docetaxel with ADT and abiraterone with ADT in STAMPEDE showed that continuous therapy upon signs of disease progression.
the two treatment options resulted in similar efficacy and safety
outcomes.681 Combined androgen blockade therapy adds to cost and side effects, and
prospective randomized evidence that combined androgen blockade is
Docetaxel should not be offered to men with M0 castration-naïve prostate more efficacious than ADT is lacking.
cancer based on results of a pre-planned subgroup analysis of the
STAMPEDE trial that showed no OS benefit for participants with M0 Progression to CRPC
disease.594 Men with low-volume metastatic disease can be offered early CRPC is prostate cancer that progresses clinically, radiographically, or
treatment with docetaxel combined with ADT; however, they have less biochemically despite castrate levels of serum testosterone (<50 ng/dL).687
certain benefit from treatment than men with higher-volume disease, as Patients whose disease progresses to CRPC during primary ADT should
this subgroup did not have definitively improved survival outcomes in the receive a laboratory assessment to assure a castrate level of testosterone
ECOG CHAARTED study or a similar European trial (GETUG-AFU (<50 ng/dL; <1.7 nmol/L). Imaging tests may be indicated to monitor for
15).595,682,683 Meta-analyses of randomized controlled trials also concluded signs of distant metastases. Factors affecting the frequency of imaging
that docetaxel provides a significant OS benefit in this setting, with no include individual risk, age, overall patient health, PSA velocity, and
evidence that the benefit was dependent on the volume of disease.684-686 Gleason grade.
In the setting of non-metastatic, biochemical relapse after local therapy, A number of options for systemic therapy should be considered based on
observation is preferred over ADT based on results of the TOAD trial (see metastasis status, as discussed in the following sections.
ADT for M0 Biochemical Recurrence, above).492 Men who opt for ADT
should consider the intermittent approach. The timing of ADT initiation CRPC Without Signs of Metastasis
should be individualized according to PSA velocity, patient anxiety, and Patients with CRPC and no signs of distant metastasis on conventional
potential side effects. Patients with shorter PSADT or rapid PSA velocity imaging studies (M0) can consider observation if PSADT is >10 months,
and long life expectancy may be encouraged to consider early ADT. Men because these patients will have a relatively indolent disease history.688
Secondary hormone therapy is an option mainly for patients with shorter
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Prostate Cancer
PSADT (≤10 months), because the androgen receptor may remain active. 95% CI, 1.07–3.82). Genomic analysis showed that DNA repair mutations
Specifically, apalutamide or enzalutamide may be considered if PSADT is and small cell/neuroendocrine histology were almost mutually exclusive.
≤10 months (see Secondary Hormone Therapy for CRPC, above).587
Patients whose disease progresses on combined androgen blockade can Small cell/neuroendocrine carcinoma of the prostate should be considered
have the antiandrogen discontinued to exclude an “antiandrogen in patients who no longer respond to ADT and test positive for metastases.
withdrawal response.”689,690 These relatively rare tumors are associated with low PSA levels despite
large metastatic burden and visceral disease.694 Those with initial Grade
Metastatic CRPC Group 5 are especially at risk. Biopsy of accessible metastatic lesions
All patients with metastatic CRPC should maintain castrate levels of serum should be considered to identify patients with small cell/neuroendocrine
testosterone (<50 ng/dL; <1.7 nmol/L) through continuation of LHRH histomorphologic features in patients with visceral metastases.695
agonist or antagonist and should receive best supportive care. Metastatic
These cases may be managed by cytotoxic chemotherapy (ie,
lesion biopsy can be considered. These patients also can be considered
cisplatin/etoposide, carboplatin/etoposide, docetaxel/carboplatin).696,697
for MSI/MMR testing. If MSI-H or dMMR is found, referral to genetic
Participation in a clinical trial is another option. Physicians should consult
counseling should be made to assess for the possibility of Lynch
the NCCN Guidelines for Small Cell Lung Cancer (available at
syndrome. These patients can be considered for germline and tumor
www.NCCN.org), because the behavior of small cell/neuroendocrine
testing to check for mutations in homologous recombination genes (ie,
carcinoma of the prostate is similar to that of small cell carcinoma of the
BRCA1, BRCA2, ATM, PALB2, FANCA).691 This information may be used
lung.
for genetic counseling, early use of platinum chemotherapy, or eligibility
for clinical trials (eg, PARP inhibitors). Bone Metastases
Denosumab every 4 weeks (category 1) or zoledronic acid every 3 to 4
Treatment options for specific settings are discussed below.
weeks is recommended for men with CRPC and bone metastases to
Small Cell/Neuroendocrine Prostate Cancer prevent or delay disease-associated SREs. SREs include pathologic
De novo small cell carcinoma in untreated prostate cancers occurs rarely fractures, spinal cord compression, operation, or EBRT to bone. The
and is very aggressive.692 Treatment-associated small cell/neuroendocrine optimal duration of zoledronic acid or denosumab in men with CRPC and
prostate cancer that occurs in men with metastatic CRPC is more bone metastases remains unclear. A multi-institutional, open-label,
common.693 In a multi-institution prospective series of 202 consecutive randomized trial in 1822 patients with bone-metastatic prostate cancer,
patients with metastatic CRPC, all of whom underwent metastatic breast cancer, or multiple myeloma found that zoledronic acid every 12
biopsies, small cell/neuroendocrine histology was present in 17%.693 weeks was non-inferior to zoledronic acid every 4 weeks.698 In the every-
Patients with small cell/neuroendocrine tumors and prior abiraterone 12-weeks and every-4-weeks arms, 28.6% and 29.5% experienced at
and/or enzalutamide had a shorter OS when compared with those with least 1 SRE within 2 years of randomization, respectively.
adenocarcinoma and prior abiraterone and/or enzalutamide (HR, 2.02;
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Prostate Cancer
Oral hygiene, baseline dental evaluation for high-risk individuals, and myelosuppression.703 Radium-223 can be used with denosumab or
avoidance of invasive dental surgery during therapy are recommended to zoledronic acid.
reduce the risk of ONJ.699 If invasive dental surgery is necessary, therapy
should be deferred until the dentist confirms that the patient has healed The use of systemic radiation with either 89Sr or 153Sm occasionally
completely from the dental procedure. Supplemental calcium and vitamin benefits patients with widely metastatic, painful, skeletal involvement that
D are recommended to prevent hypocalcemia in patients receiving either is not responding to palliative chemotherapy or systemic analgesia and
denosumab or zoledronic acid. who are not candidates for localized EBRT.428 The risk of bone marrow
suppression, which might influence the ability to provide additional
Monitoring of creatinine clearance is required to guide dosing of zoledronic systemic chemotherapy, should be considered before this therapy is
acid. Zoledronic acid should be dose reduced in men with impaired renal initiated.
function (estimated creatinine clearance 30–60 mL/min), and held for
M1 CRPC without Visceral Metastases
creatinine clearance <30 mL/min.700 Denosumab may be administered to
men with impaired renal function or even men on hemodialysis; however, Based on phase 3 randomized trial evidence, sipuleucel-T is a category 1
the risk for severe hypocalcemia and hypophosphatemia is greater, and recommended option for patients with metastatic CRPC who are
the dose, schedule, and safety of denosumab have not yet been defined. asymptomatic or minimally symptomatic, and have good performance
A single study of 55 patients with creatinine clearance <30 mL/min or on level (ECOG 0-1), estimated life expectancy >6 months, and no liver
hemodialysis evaluated the use of 60-mg-dose denosumab.701 metastases (see Sipuleucel-T, above).605 Sipuleucel-T has not been
Hypocalcemia should be corrected before starting denosumab, and serum studied in patients with visceral metastases. The panel prefers that
calcium monitoring is required for denosumab and recommended for sipuleucel-T only be used as initial therapy for metastatic CRPC.
zoledronic acid, with repletion as needed. Treatment subsequent to sipuleucel-T treatment should proceed as
clinically indicated, particularly if symptoms develop. Enzalutamide and
Clinical research continues on the prevention or delay of disease spread abiraterone with prednisone also are category 1 options for first-line
to bone. A phase 3 randomized trial of 1432 patients with non-metastatic therapy of patients with asymptomatic, chemotherapy-naïve, metastatic
CRPC at high risk of bone involvement showed that denosumab delayed CRPC. Abiraterone with methylprednisolone is another option.
bone metastasis by 4 months compared to placebo.702 OS was not
improved, and the FDA did not approve this indication for denosumab. Docetaxel with concurrent steroid is the traditional mainstay of treatment
for symptomatic metastases (category 1). Docetaxel is not commonly used
Radium-223 is a category 1 option to treat symptomatic bone metastases for asymptomatic patients, but may be considered when the patient shows
without visceral metastases. Hematologic evaluation should be performed signs of rapid progression or visceral metastases despite lack of
according to the FDA label before treatment initiation and before each symptoms. Treatment with ≥8 cycles docetaxel may be associated with
subsequent dose.703 Radium-223 given in combination with chemotherapy better OS than fewer cycles in the metastatic CRPC setting, but
(such as docetaxel) outside of a clinical trial has the potential for additive prospective trials are necessary to test 6 versus 10 cycles of docetaxel in
the metastatic castration-naïve and CRPC settings.704 Retrospective
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Prostate Cancer
analysis from the GETUG-AFU 15 trial suggests that docetaxel only Radium-223 alone has not been shown to extend survival in men with
benefits some patients with CRPC who received docetaxel in the visceral metastases or bulky lymph node metastases (>3–4 cm) and is not
castration-naïve setting.705 recommended in this setting.
Radium-223 is a category 1 option to treat symptomatic bone metastases Additional treatment options can be continued beyond second-line therapy
without visceral metastases. Other options for patients with M1 CRPC in patients with visceral metastases (category 2B), as delineated in the
without visceral metastases include clinical trial participation and other guidelines. Clinical trial and best supportive care are additional options.
secondary hormone therapy (first-generation antiandrogen, antiandrogen
Progression After Enzalutamide or Abiraterone
withdrawal, ketoconazole with or without hydrocortisone, corticosteroid,
DES, or other estrogens). Ketoconazole should not be used if the disease Patients with disease progression after enzalutamide or abiraterone have
progressed on abiraterone; both drugs inhibit CYP17A1. the following options: docetaxel (category 1), abiraterone if previously
given enzalutamide therapy, enzalutamide if previously given abiraterone,
CRPC with Visceral Metastases radium-223 for bone-predominant disease without visceral metastases
The panel defines visceral metastases as those occurring in the liver, lung, (category 1), sipuleucel-T if asymptomatic or minimally symptomatic and
adrenal gland, peritoneum, or brain. Soft tissue/lymph node sites are not without visceral metastases, life expectancy >6 months, and ECOG score
considered visceral metastases. Every-3-week docetaxel and prednisone 0–1, pembrolizumab if MSI-H/dMMR (category 2B), clinical trial, or
is the preferred first-line chemotherapy treatment for symptomatic CRPC secondary hormone therapy. All patients can continue through all
with visceral metastases (category 1). PSA increase alone does not define treatment options and should receive best supportive care.
progression on docetaxel; the patient may benefit from continued
chemotherapy if clinical progression is not apparent. The addition of No randomized trials that compare taxane chemotherapies versus novel
estramustine to docetaxel has been shown to increase side effects without hormonal therapies in this setting have been reported, and some data
enhancing efficiency and is not recommended.706 suggest cross-resistance between abiraterone and enzalutamide.709-712
One molecular biomarker that may aid appropriate selection of therapy
Enzalutamide is another category 1 recommended option in this setting. after progression on abiraterone or enzalutamide is the presence of
Abiraterone has not been assessed formally in symptomatic men with androgen receptor splice variant 7 (AR-V7) in CTCs.713 Lack of response
CRPC prior to docetaxel. Therefore, its use in these patients is a category of men with metastatic CRPC to abiraterone and enzalutamide was
2A recommendation. Use of abiraterone is reasonable for men who are associated with detection of AR-V7 mRNA in CTCs using an RNA-based
not candidates for docetaxel or who decline chemotherapy. polymerase chain reaction (PCR) assay.714 AR-V7 presence did not
preclude clinical benefit from taxane chemotherapies (docetaxel and
Mitoxantrone may provide palliative benefit for symptomatic patients who cabazitaxel).715 Men with AR-V7–positive CTCs exhibited superior
cannot tolerate docetaxel.707,708 Clinical trials and other secondary progression-free survival with taxanes compared to novel hormonal
hormone therapies are additional options. therapies (abiraterone and enzalutamide); the two classes of agents
resulted in comparable progression-free survival in men with AR-V7–
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Prostate Cancer
negative CTCs. A confirmatory study used a different CTC assay that provided these agents were not used before docetaxel. Other options
detected nuclear-localized AR-V7 protein using immunofluorescence. Men include radium-223 for symptomatic bone metastases without visceral
with AR-V7–positive CTCs had superior OS with taxanes versus metastases (category 1), cabazitaxel (category 1), sipuleucel-T if not
abiraterone or enzalutamide, whereas OS was not different between the previously given and if asymptomatic or minimally symptomatic and
two classes of agents among patients with AR-V7–negative CTCs.716 A without visceral or liver metastases (life expectancy >6 months and ECOG
blinded, correlative study at 3 cancer centers assessed the correlation score 0–1), abiraterone with methylprednisolone, pembrolizumab if MSI-
between AR-V7 results before second-line treatment and OS in men with H/dMMR (category 2B), clinical trial, docetaxel rechallenge, mitoxantrone
metastatic CRPC.717 Approximately half of the validation cohort received with prednisone, and other secondary hormone therapy. Patients can
taxane therapy in first line, whereas half received an androgen receptor continue through all treatment options and should receive best supportive
signaling inhibitor. In a high-risk subset of this cohort, patients negative for care.
AR-V7 had superior OS if they were treated with an androgen receptor
signaling inhibitor than if they were treated with a taxane (median OS, 19.8 The decision to initiate therapy in the post-docetaxel CRPC setting should
vs. 12.8 months; HR, 1.67; 95% CI, 1.00–2.81; P = .05). Thus AR-V7 may be based on the available high-level evidence of safety, efficacy, and
be a useful predictive biomarker in men with metastatic CRPC after tolerability of these agents and the application of this evidence to an
progression on abiraterone or enzalutamide. individual patient. Prior exposures to these agents should be considered.
No data inform the proper sequence for delivery of these agents in men
These clinical experiences suggest that AR-V7 assays are promising with metastatic CRPC. No randomized trials have been reported that
predictors of abiraterone and enzalutamide resistance. Furthermore, the compared these agents, and no predictive models or biomarkers help to
prevalence of AR-V7 positivity is only 3% in patients prior to treatment with identify patients who are likely to benefit from any of these agents. Choice
enzalutamide, abiraterone, and taxanes,716 so the panel believes AR-V7 of therapy is based largely on clinical considerations, which include patient
detection would not be useful to inform treatment decisions in the naïve preferences, prior treatment, presence or absence of visceral disease,
setting. On the other hand, the prevalence of AR-V7 positivity is higher symptoms, and potential side effects. NCCN recommends that patients be
after progression on abiraterone or enzalutamide (19%–39%714), but data closely monitored with radiologic imaging (ie, CT, bone imaging), PSA
have already shown that abiraterone/enzalutamide crossover therapy is tests, and clinical exams for evidence of progression. Therapy should be
rarely effective and taxanes are more effective in this setting. The panel continued until clinical progression or intolerability in cases where PSA or
recommends that use of AR-V7 tests can be considered to help guide bone imaging changes may indicate flare rather than true clinical
selection of therapy in the post-abiraterone/enzalutamide metastatic progression.718,719 The sequential use of these agents is reasonable in a
CRPC setting. patient who remains a candidate for further systemic therapy.
Progression After Docetaxel The NCCN Guidelines Panel included cabazitaxel as an option for second-
Both abiraterone with prednisone and enzalutamide represent standard of line therapy after progression on docetaxel for patients with symptomatic
care after progression on docetaxel for metastatic CRPC (category 1), metastatic CRPC. This recommendation is category 1 based on
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Prostate Cancer
randomized phase 3 study data (see Cabazitaxel, above).599,603 NCCN symptomatic. In a subset analysis, both those who did and those who did
panelists agreed that docetaxel rechallenge may be useful in some not receive prior chemotherapy benefited from sipuleucel-T treatment.
patients (category 2A instead of category 1 in this setting), especially in
those who have not shown definitive evidence of progression on prior Summary
docetaxel therapy. Docetaxel rechallenge can be considered in patients The intention of these guidelines is to provide a framework on which to
who received docetaxel with ADT in the metastatic castration-naïve base treatment decisions. Prostate cancer is a complex disease, with
setting. many controversial aspects of management and with a dearth of sound
data to support many treatment recommendations. Several variables
Some patients with metastatic CRPC may be deemed unsuitable for (including adjusted life expectancy, disease characteristics, predicted
taxane chemotherapy; such patients could be considered for radium-223 outcomes, and patient preferences) must be considered by the patient and
or a second-line hormonal agent. In addition, mitoxantrone remains a physician to tailor prostate cancer therapy for the individual patient.
palliative treatment option for men who are not candidates for taxane-
based therapy based on older randomized studies that showed palliative
benefit.707,708 No chemotherapy regimen has demonstrated improved
survival or QOL after cabazitaxel, although several systemic agents other
than mitoxantrone have shown palliative and radiographic response
benefits in clinical trials (ie, carboplatin, cyclophosphamide, doxorubicin,
vinorelbine, carboplatin/etoposide, docetaxel/carboplatin,
gemcitabine/oxaliplatin, paclitaxel/carboplatin720-729). Prednisone or
dexamethasone at low doses may provide palliative benefits in the
chemotherapy-refractory setting.730 No survival benefit for combination
regimens over sequential single-agent regimens has been demonstrated,
and toxicity is higher with combination regimens. Treatment with these
agents could be considered after an informed discussion between the
physician and an individual patient about treatment goals and risks/side
effects and alternatives, which must include best supportive care.
Participation in a clinical trial is encouraged.
In the phase 3 sipuleucel-T trial, 18.2% of patients had received prior

chemotherapy, which included docetaxel, because eligibility requirements
included no chemotherapy for 3 months and no steroids for 1 month prior
to enrollment.605 These men were asymptomatic or minimally
MS-61

Prostate Cancer
Table 1. Available Tissue-Based Tests for Prostate Cancer Risk Stratification/Prognosis

Populations Outcome(s) Reported Selected Molecular Diagnostic Services Program (MolDX)
Test Platform
Studied (Test independently predicts) References Recommendations
Decipher Whole-transcriptome 1.4M Post radical prostatectomy (RP),  Metastasis 140,143,144,243 Cover post-biopsy for NCCN very-low- and low-risk
RNA expression (44,000 adverse pathology/high-risk  Prostate cancer-specific mortality ,671,731-743 prostate cancer in patients with at least 10 years life
genes) oligonucleotide features expectancy who have not received treatment for
 Postoperative radiation sensitivity
microarray optimized for prostate cancer and are candidates for active
FFPE tissue (PORTOS) surveillance or definitive therapy
Post RP, biochemical recurrence  Metastasis
 Prostate cancer-specific mortality Cover post-RP for 1) pT2 with positive margins; 2)
 PORTOS any pT3 disease; 3) rising PSA (above nadir)
Post RP, adjuvant, or salvage  Metastasis
radiation  Prostate cancer-specific mortality
 PORTOS
Biopsy, localized prostate  Metastasis
cancer post RP or EBRT  Prostate cancer-specific mortality
 Gleason grade ≥4 disease at RP
 Adverse pathologic features at RP
Ki-67 IHC Biopsy, intermediate- to high-  Metastasis 744-747 Not recommended
risk treated with EBRT
Biopsy, conservatively managed  Prostate cancer-specific mortality
(active surveillance)
Oncotype Quantitative RT-PCR for 12 Biopsy, low- to intermediate-risk  Non-organ-confined pT3 or Gleason 139,748-751 Cover post-biopsy for NCCN very-low-, low-risk, and
DX prostate cancer-related treated with RP grade 4 disease on RP favorable intermediate-risk prostate cancer in patients
Prostate genes and 5 housekeeping with at least 10 years life expectancy who have not
controls received treatment for prostate cancer and are
candidates for active surveillance or definitive therapy
Prolaris Quantitative RT-PCR for 31 Transurethral resection of the  Prostate cancer-specific mortality 135-138,752-754 Cover post-biopsy for NCCN very-low-, low-risk, and
cell cycle-related genes prostate (TURP), conservatively favorable intermediate-risk prostate cancer in patients
and 15 housekeeping managed (active surveillance) with at least 10 years life expectancy who have not
controls Biopsy, conservatively managed  Prostate cancer-specific mortality received treatment for prostate cancer and are
(active surveillance) candidates for active surveillance or definitive therapy
Biopsy, localized prostate  Biochemical recurrence
cancer  Metastasis
Biopsy, intermediate-risk treated  Biochemical recurrence
with EBRT
RP, node-negative localized  Biochemical recurrence
prostate cancer
ProMark Multiplex Biopsy, Gleason grade 3+3 or  Non–organ-confined pT3 or Gleason 755 Cover post-biopsy for NCCN very-low- and low-risk
immunofluorescent staining 3+4 pattern 4 disease on RP prostate cancer in patients with at least 10 years life
of 8 proteins expectancy who have not received treatment for
prostate cancer and are candidates for active
surveillance or definitive therapy.
PTEN Fluorescence in situ TURP, conservatively managed  Prostate cancer-specific mortality 756-760 Not recommended
hybridization or IHC (active surveillance)
Biopsy, Gleason grade 3+3  Upgrading to Gleason pattern 4 on RP
RP, high-risk localized disease  Biochemical recurrence
MS-62

Prostate Cancer
Table 2. Summary of Main PET Imaging Tracers Studied in Prostate Cancer *

Tracer Half- Cyclotron Mechanism Excretion Sensitivity Specificity FDA Status Panel Recommendation
life of Action (%)* (%)*
(min)
C-11 choline 20 Onsite Cell Hepatic 32–93 40–93  Cleared  May be used for detection
membrane of biochemically recurrent
synthesis small-volume disease in
soft tissues
 May be used after bone
scan for further evaluation
of equivocal findings
F-18 110 Regional Amino acid Renal 37–90 40–100  Cleared  May be used for detection
fluciclovine transport of biochemically recurrent
small-volume disease in
soft tissues
 May be used after bone
scan for further evaluation
of equivocal findings
F-18 NaF 110 Regional Adsorption Hepatic 87–100 62–89  Cleared  May be used after bone
within bone scan for further evaluation
matrix of equivocal findings
C-11 20 Onsite Lipid Lung 59–69 83–98  Not cleared  May be used in clinical
acetate synthesis trial or registry
Ga-68 68 Generator PSMA Renal 76–86 86–100  Not cleared  May be used in clinical
PSMA (no analog trial or registry
cyclotron)
* Interpret with caution; few studies used biopsy/surgery as gold standard; see Nuclear Imaging, above, for references.
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Prostate Cancer
Table 3. Selected Active Surveillance Experiences in North America

Center Toronto197,262,268 Johns UCSF261 UCSF (newer Canary PASS271
Hopkins199,260,263,26 cohort)761
4
No. patients 993 1298 321 810 905

Median age (y) 68 66 63 62 63
Median follow-up (months) 77 60 43 60 28
Overall survival 80% (10-y) 93% (10-y) 98% (10-y) 98% (5-y) -
Cancer-specific survival 98% (10-y) 99.9% (10-y) 100% (5-y) - -
Conversion to treatment 36.5% (10-y) 50% (10-y) 24% (3-y) 40% (5-y) 19% (28-mo)
Reason for treatment (% of entire cohort)
Gleason grade change 9.5% 15.1% 38% - -
PSA increase 11.7%* - 26%† - -
Positive lymph node - 0.4% - - -
Personal choice -1.6% 8% 8% - -
* PSA doubling time <3 years
† PSA velocity >0.75 ng/mL/year
MS-64

Prostate Cancer
prostate cancer diagnoses in the United States. J Urol 2015;194:1587-

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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)

NCCN Guidelines for Patients®

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

Edward Schaeffer, MD, PhD/Chair ω Xin Gao, MD † Þ Julio M. Pow-Sang, MD ω

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

INITIAL PROSTATE CANCER DIAGNOSISa,b,c

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

Has at least one of the following: • Bone imagingh: recommended

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

VERY LOW RISK GROUP

≥20 y EBRTo or brachytherapyo

Active surveillancem Progressive diseaseu

<10 yd Observation q See Monitoring (PROS-10)

See Footnotes for Risk Groups (PROS-7A).

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

LOW RISK GROUP

≥10 y EBRTo or brachytherapyo

<10 yd Observation q See Monitoring (PROS-10)

See Footnotes for Risk Groups (PROS-7A).

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

FAVORABLE INTERMEDIATE RISK GROUP

≥10 y EBRTo or brachytherapy aloneo

See Footnotes for Risk Groups (PROS-7A).

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

UNFAVORABLE INTERMEDIATE RISK GROUP

EBRTo + ADTt (4–6 mo) See Radiation

See Footnotes for Risk Groups (PROS-7A).

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

HIGH OR VERY HIGH RISK GROUP

EBRTo + ADTt (1.5–3 y; category 1) See Monitoring

>5 y or See Radical

RPp + PLNDcc No adverse features or lymph node metastases PSA persistence/

See Footnotes for Risk Groups (PROS-7A).

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

GENETIC AND MOLECULAR BIOMARKER ANALYSIS FOR ADVANCED PROSTATE CANCERc

Consider tumor testing for homologous recombination

ee ADT alone (see PROS-G) or observation is recommended for asymptomatic

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2020 NCCN Guidelines Index

REGIONAL RISK GROUP

gg Document castrate levels of testosterone if on ADT. Workup for progression

q Observation involves monitoring the course of disease with the expectation