The first 60 days: Neuroendocrine and small-cell prostate cancer
Neuroendocrine prostate cancer is a form that has stopped depending on the androgen receptor, either from the start or after years of hormone therapy. It no longer shows up on PSA, spreads to the liver and brain, and is treated with the platinum chemotherapy used for small-cell lung cancer. Below, week by week, is what OnCo's record of Neuroendocrine and small-cell prostate cancer says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Recognition and biopsy.
- RadiologistNamed in the standard of care for: Small-cell or predominantly neuroendocrine, Recognition and biopsy.
- Medical oncologistNamed in the standard of care for: Small-cell or predominantly neuroendocrine, Mixed adenocarcinoma and neuroendocrine, or aggressive variant, Recognition and biopsy, Trials.
- Transplant and cell therapy teamNamed in the standard of care for: Small-cell or predominantly neuroendocrine.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Cisplatin or carboplatin with etoposide, as for small-cell lung cancer; continue androgen deprivation; brain imaging.
Carboplatin plus docetaxel or cabazitaxel, then platinum with etoposide; clinical trial enrolment preferred.
Biopsy any progression with low PSA, visceral metastases or PSMA-negative FDG-avid lesions; test for mismatch repair deficiency (pembrolizumab) and HRR genes.
- 4.Trials
DLL3 T-cell engagers (tarlatamab), EZH2 inhibitors and aurora kinase inhibitors against the lineage switch; lurbinectedin borrowed from small-cell lung cancer.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Synaptophysin, chromogranin and INSM1 staining, Loss of androgen receptor and PSA expression, Combined RB1 and TP53 loss, MYCN and AURKA amplification, DLL3 expression), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include De novo small-cell carcinoma of the prostate, Treatment-emergent neuroendocrine prostate cancer, Mixed adenocarcinoma and neuroendocrine carcinoma.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Small-cell or predominantly neuroendocrine
- For my situation (small-cell or predominantly neuroendocrine), which of the standard options do you recommend and why?Guideline options include: Cisplatin or carboplatin with etoposide, as for small-cell lung cancer; continue androgen deprivation; brain imaging.
- Am I a candidate for Platinum + etoposide (EP / CE), Cisplatin, Carboplatin or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Mixed adenocarcinoma and neuroendocrine, or aggressive variant
- For my situation (mixed adenocarcinoma and neuroendocrine, or aggressive variant), which of the standard options do you recommend and why?Guideline options include: Carboplatin plus docetaxel or cabazitaxel, then platinum with etoposide; clinical trial enrolment preferred.
- Am I a candidate for Carboplatin, Docetaxel, Cabazitaxel, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Recognition and biopsy
- For my situation (recognition and biopsy), which of the standard options do you recommend and why?Guideline options include: Biopsy any progression with low PSA, visceral metastases or PSMA-negative FDG-avid lesions; test for mismatch repair deficiency (pembrolizumab) and HRR genes.
- Am I a candidate for Pembrolizumab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Trials
- For my situation (trials), which of the standard options do you recommend and why?Guideline options include: DLL3 T-cell engagers (tarlatamab), EZH2 inhibitors and aurora kinase inhibitors against the lineage switch; lurbinectedin borrowed from small-cell lung cancer.
- Am I a candidate for Tarlatamab, Mevrometostat, Lurbinectedin, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Tarlatamab, Mevrometostat, Lurbinectedin, Ifinatamab deruxtecan?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “No approved therapy specific to the disease; every regimen is borrowed from lung cancer”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “No blood test reliably detects the lineage switch before it shows on scans”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Neuroendocrine and small-cell prostate cancer: the full pageNeuroendocrine prostate cancer is a form that has stopped depending on the androgen receptor, either from the start or after years of hormone therapy. It no longer shows up on PSA, spreads to the liver and brain, and is treated with the platinum chemotherapy used for small-cell lung cancer.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Castration-resistant prostate cancer (CRPC): Prostate cancer that keeps growing even though testosterone has been reduced to castrate levels.
Every term links to the glossary.