What are the treatment protocols for very high risk advanced prostate cancer?

Updated: Dec 29, 2020
  • Author: Winston W Tan, MD, FACP; Chief Editor: E Jason Abel, MD  more...
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Very high risk:

  • Clinical stage T3b-T4 treatment options include radiation therapy (doses of 78-80+ Gy) with 3D-CRT/IMRT plus  long-term neoadjuvant/concomitant/adjuvant ADT for 2-3 y or

  • Radiation therapy (doses of 78-80+ Gy) with 3D-CRT/IMRT with daily IGRT plus brachytherapy with or without short-term neoadjuvant/concomitant/ADT for 4-6 mo or

  • RP plus PLND for selected patients (those with clinically localized prostate cancer that can be completely excised surgically, life expectancy of at least 10 years, and no serious comorbid conditions that would contraindicate elective surgery) [7] or

  • ADT alone, in patients with T3 disease and/or node-positive disease and PSA doubling time less than 10 months

For biochemical recurrence of nonmetastatic castration-resistant prostate cancer with doubling time of less than 10 months, improvement in metastasis-free survival has been reported with use of the following androgen receptor inhibitors:

  • Apalutamide 240 mg (ie, four 60-mg tablets) PO daily [28] or
  • Enzalutamide 160 mg PO once daily [29]   or 
  • Darolutamide 600 mg PO BID [30] plus
  • A gonadotropin-releasing hormone analog, unless the patient has had bilateral orchiectomy

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