The first 60 days: Non-metastatic castration-resistant prostate cancer
Non-metastatic castration-resistant prostate cancer is a PSA that keeps rising on hormone therapy while scans still show nothing. Three androgen receptor blockers, apalutamide, enzalutamide and darolutamide, each delay metastasis by about two years and lengthen life, and darolutamide is the gentlest. Below, week by week, is what OnCo's record of Non-metastatic castration-resistant 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.
PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.
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.
- RadiologistNamed in the standard of care for: Low-risk nmCRPC, Staging.
- Medical oncologistNamed in the standard of care for: High-risk nmCRPC (doubling time 10 months or less), Low-risk nmCRPC.
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.
Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.
Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.
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 Castrate testosterone, PSA doubling time, Conventional imaging negative, PSMA PET, AR alterations and AR-V7), 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 High-risk nmCRPC, Low-risk nmCRPC, PSMA PET-positive, conventional imaging-negative castration-resistant disease.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
High-risk nmCRPC (doubling time 10 months or less)
- For my situation (high-risk nmcrpc (doubling time 10 months or less)), which of the standard options do you recommend and 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?Knowing the expected toxicities helps you plan work, family, and supportive care.
Low-risk nmCRPC
- For my situation (low-risk nmcrpc), which of the standard options do you recommend and 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?Knowing the expected toxicities helps you plan work, family, and supportive care.
Staging
- For my situation (staging), which of the standard options do you recommend and why?Guideline options include: PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.
Any stage
- Are there clinical trials I could join, for example of Darolutamide, PSMA PET, AR-V7 splice variant?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 “Whether PSMA PET-detected metastases should be treated locally or the man treated as metastatic”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Cost and side effects of years of androgen receptor inhibition in men without symptoms”. 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.
- Non-metastatic castration-resistant prostate cancer: the full pageNon-metastatic castration-resistant prostate cancer is a PSA that keeps rising on hormone therapy while scans still show nothing. Three androgen receptor blockers, apalutamide, enzalutamide and darolutamide, each delay metastasis by about two years and lengthen life, and darolutamide is the gentlest.
- 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.
- mCRPC and mHSPC (castration-resistant vs hormone-sensitive prostate cancer): Prostate cancer starts out fed by testosterone (hormone-sensitive) and shrinks when it is removed.
- AR-V7 splice variant: A truncated form of the androgen receptor that is permanently switched on and ignores hormone-blocking pills.
- Castration-resistant prostate cancer (CRPC): Prostate cancer that keeps growing even though testosterone has been reduced to castrate levels.
- PSA (prostate-specific antigen): A blood protein made by the prostate; raised levels prompt further tests, and falling levels show treatment is working.
Every term links to the glossary.