Non-metastatic castration-resistant prostate cancer: the decisions you may face
3 treatment settings, 2 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
High-risk nmCRPC (doubling time 10 months or less)
Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.
An AR blocker approved for prostate cancer that has spread and for high-risk disease before it shows on scans.
Enzalutamide is a second-generation androgen-receptor blocker that stops the receptor binding testosterone, entering the nucleus and switching on genes. It is approved at every stage of advanced prostate cancer, from rising PSA after surgery to castration-resistant disease, and fatigue, falls and memory problems are its main drawbacks.
Darolutamide is an AR blocker that barely enters the brain, so it causes fewer falls and cognitive side effects; it is approved with and without chemotherapy.
Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).
- Prolonged disease control
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Seizure risk: caution with drugs that lower the seizure threshold.
- Take with food (exposure roughly doubles).
- Metabolic and bone toxicity; castration resistance inevitable in metastatic disease
- Between Apalutamide, Enzalutamide, Darolutamide and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (high-risk nmcrpc (doubling time 10 months or less)), which of the standard options do you recommend and why?Why: Guideline options include: Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.
- Am I a candidate for Apalutamide, Enzalutamide, Darolutamide, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
Low-risk nmCRPC
Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.
Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).
- Prolonged disease control
The old antiandrogen pill used to block the testosterone flare from GnRH agonists and in combined androgen blockade; superseded by enzalutamide-class drugs.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Metabolic and bone toxicity; castration resistance inevitable in metastatic disease
- Between Androgen deprivation & AR pathway inhibitors and Bicalutamide, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (low-risk nmcrpc), which of the standard options do you recommend and why?Why: Guideline options include: Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.
- Am I a candidate for Bicalutamide, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.
A prostate-cancer-specific PET scan that finds spread far earlier than CT or bone scan, and tells you whether a matched radioactive drug will work.
- Detects recurrence at PSA <0.5 ng/mL
- Theranostic gatekeeper
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- PSMA-negative disease in ~10%
- Uptake in ganglia, salivary glands
- Is PSMA PET the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (staging), which of the standard options do you recommend and why?Why: Guideline options include: PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.
Add these to your appointment list, or take the full question set for this cancer.