Prostate_Cancer_Resource_Guide_Complete (1) (1) by BethWrightCancerCenter

PROSTATE CANCER RESOURCE GUIDE Information, support, and practical resources for patients, survivors, and families

Prepared for the Downeast Maine Community Beth C. Wright Cancer Resource Center | Downeast Group

MAINELY PELVIC PHYSICAL THERAPY

Cadie Saucier, DPT 97 Beechland Rd. Ellsworth, ME 04605

207-949-0290

UPDATED SEPTEMBER 2026

TABLE OF CONTENTS

UNDERSTANDING PROSTATE CANCER 1

About Prostate Cancer: One-Page Overview

3-4

NEWLY DIAGNOSED 2

Newly Diagnosed Prostate Cancer Guide

5-40

EARLY-STAGE PROSTATE CANCER 3

NCCN Guidelines for Patients: Early-Stage Prostate Cancer

41-132

ADVANCED PROSTATE CANCER 4

Advanced Prostate Cancer: Patient Education Flyer

133-134

ADVANCED-STAGE TREATMENT 5

NCCN Guidelines for Patients: Advanced-Stage Prostate Cancer

135-218

NEWS AND EMERGING INFORMATION 6

ZERO Advanced Prostate Cancer News - Winter 2023/2024

219-226

PLANNING AHEAD 7

Maine Health Care Advance Directive Form

227-243

SUPPORT AND LOCAL RESOURCES 8

Downeast Group Prostate Cancer Resources

244

Educational materials do not replace medical advice. Please discuss questions and treatment decisions with your care team.

Beth C. Wright Cancer Resource Center | bethwrightcancercenter.org

ABOUT PROSTATE CANCER Other than skin cancer, prostate cancer is the most commonly diagnosed cancer in U.S. men. Fortunately, when diagnosed early, prostate cancer has a better chance of being treated effectively. If caught early, more than 99% of people diagnosed today with prostate cancer will be alive in five years. The prostate is a small, walnut-shaped gland in the male reproductive system. It sits just below the bladder and surrounds the upper part of the urethra, which is the tube that carries urine from the bladder. The prostate is necessary for reproduction and helps make some of the fluid in semen. It also produces prostate-specific antigen (PSA), a substance that may increase if a man has prostate cancer. Elevated PSA levels don’t always mean cancer. PSA levels can also increase due to age, recent sexual or physical activity, or an enlarged or inflamed prostate gland. WHAT IS PROSTATE CANCER? Prostate cancer occurs when prostate cells stop behaving normally. Normal cells grow, divide, and die on a regular basis. Sometimes something goes wrong with this process and the cells don’t die as they should. Instead, they grow and divide and cause a tumor. Tumors can be benign, meaning non-cancerous, or malignant, meaning cancerous.

PENIS URETHRA

Most prostate cancer grows very slowly with many men never knowing they have the disease. However, some prostate cancers are aggressive and will spread beyond the prostate to other parts of the body such as the bones, lymph nodes, and lungs.

ANUS

TESTIS SCROTUM

SYMPTOMS AND THE IMPORTANCE OF EARLY DETECTION Most men do not have symptoms when prostate cancer is at an early stage. Some symptoms, such as frequent or painful urination, difficulty urinating, blood in the urine, or painful ejaculation, can be mistaken for other disorders. Common symptoms of advanced prostate cancer may include pelvic or back pain, leg weakness, anemia, and weight loss. Prostate cancer is most frequently detected with a PSA blood test and a digital rectal exam (DRE). Both tests can easily be done in a doctor’s office. If there is concern with the results of the PSA test or DRE, the doctor might request a biopsy, which is how prostate cancer is diagnosed. It is important to understand your personal risk and talk with your doctor about routine testing. Early detection saves lives. RISK FACTORS All men are at risk of developing prostate cancer at some time in their lives, but certain factors may increase a man’s chances of a diagnosis: • Age – almost all prostate cancer occurs in men 50 and over • Race – Black men are 1.7 times more likely to be diagnosed with and 2.1 times more likely to die from prostate cancer than white men • Family history – father, brother, or a son with prostate cancer, as well as close relatives with breast, ovarian, or pancreatic cancer • Diet – eating large amounts of animal fat can increase risk • Chemical exposure – those exposed to Agent Orange and other chemicals • Genes – certain genetic mutations such as BRCA1 and BRCA2 A PATIENT EDUCATION SERIES

RISK FACTORS RACE

FAMILY HISTORY

AGING

DIET

GENE CHANGES

CHEMICALS

ABOUT PROSTATE CANCER TREATMENT If prostate cancer is diagnosed, your doctor will determine the extent (Stage) and grade (Gleason score) of the cancer. This information helps identify the best treatment options for your situation. Learning all you can about treatment options and finding the right prostate cancer care team will help you make the most informed decisions. Many treatments for prostate cancer can cause side effects that are disruptive, such as urinary incontinence and erectile dysfunction. Consider all of your options before deciding on a plan, especially if diagnosed with slow-growing cancer that is not aggressive. Treatment options include: • Active Surveillance • Local Therapies – Surgery – Radiation – High Intensity Focused Ultrasound (HIFU) – Cryotherapy

• Systemic Therapies – Hormone Therapy – Immunotherapy – Targeted Therapy – Radiopharmaceuticals – Chemotherapy • Clinical Trials

QUESTIONS FOR THE DOC

• What is the stage of my cancer? • Has my cancer spread and, if so, how far? • How aggressive is the cancer? • What are all of my treatment options? • What are the possible side effects of each treatment? • Should I get a second opinion?

Your doctor and care team should be open to any questions you have regarding your diagnosis, and they should be fully supportive of any second opinions you might wish to seek. SURVIVORSHIP Once you have completed your treatment, talk with your doctor about your follow-up plan. Find out what tests are recommended and how often you need to return for screening. It is important to stay on top of your screenings. Ask about a treatment summary. This is a convenient way to record your diagnosis and any treatment decisions you and your care team have made to fight the disease. A treatment summary is a helpful tool for any doctors who care for you during your lifetime. Life after treatment for prostate cancer may be different from before you were diagnosed. Remember, you are not alone. More than 3.1 million men are living with prostate cancer in the U.S. Continue talking to your healthcare providers about nutrition, physical therapy, ongoing side effects, and how you can not only survive, but thrive.

3.1+ 3.1 +

MILLION MEN

LIVING WITH PROSTATE CANCER

LEARN MORE We encourage you to use this information in conversations with your healthcare team about prostate cancer and related topics. For more information about prostate cancer and ZERO Prostate Cancer, visit our website www.zerocancer.org/learn. ZERO Prostate Cancer provides this information as a service. It is not intended to take the place of medical professionals or the recommendations of your healthcare team. We strongly suggest consulting your healthcare team if you have questions about your specific care. A PATIENT EDUCATION SERIES

NEWLY DIAGNOSED PROSTATE CANCER GUIDE NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Newly diagnosed with prostate cancer?

You are not alone.

A A PATIENT PATIENT EDUCATION EDUCATION SERIES SERIES || ZEROCANCER.ORG ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

ZERO Prostate Cancer is the leading national nonprofit with the mission to end prostate cancer and help all who are impacted. ZERO advances research, provides support, and creates solutions to achieve health equity to meet the most critical needs of our community.

A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Table of Contents

Page

Prostate Cancer Basics....................................................................4 Diagnosing Prostate Cancer...........................................................7 Prostate Cancer Imaging.................................................................8 Understanding Your Diagnosis and Stage.......................................9 Genetic Testing.............................................................................12 Biomarker Testing.........................................................................13 Prostate Cancer Progression and Treatment.................................14 Prostate-Specific Membrane Antigen (PSMA)...............................18 Clinical Trials.................................................................................19 Managing Treatment Side Effects.................................................20 Your Healthcare Team...................................................................21 Getting a Second Opinion............................................................23 Living with Prostate Cancer..........................................................25 Prostate Cancer Terms to Know....................................................27 Newly Diagnosed Worksheet........................................................29 Questions for Your Doctor: Newly Diagnosed..............................30 Questions for Your Doctor: Advanced Prostate Cancer................31 ZERO Support Programs...............................................................32 Prostate Cancer Family Tree.........................................................33 Notes Pages..................................................................................34

A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Basics Now What? Hearing the words “you have prostate cancer” can be scary and overwhelming. Once you recover from the shock of hearing those words, it’s important to arm yourself with information about prostate cancer diagnosis, treatment, side effect management, and survivorship. This guide provides easy-to-understand information on prostate cancer and a variety of support resources for you and your family, so you can make the best possible decisions. After reviewing this guide, please visit our website – zerocancer.org – for more in-depth information on prostate cancer treatment, imaging, side effects, and more. It’s important to know that you are not alone. More than 3.3 million American men are living with prostate cancer today. Diagnosis and treatment advances happen regularly and staying informed and connected will help you in this fight.

“Keep educating yourself and do research. If you don’t understand, ask questions. And find support, whether it’s from a support group, your church, your loved ones, or your friends. You don’t have to face prostate cancer alone.” Rob Alexander, prostate cancer survivor

A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Facts and Stats Knowing how many men are affected by prostate cancer, as well as basic facts and figures, will help you better understand this disease, and may help you feel comfortable spreading awareness to those around you. One in eight American men will have prostate cancer during their lifetime. Prostate cancer is the second leading cause of cancer death among American men and is the most commonly diagnosed after skin cancers. The American Cancer Society estimates that 299,010 men will be diagnosed with prostate cancer and 35,250 will die from the disease this year. The five-year survival rate for all prostate cancer diagnoses is 97%. More than 3.3 million Americans are living with prostate cancer. Learn more prostate cancer facts at zerocancer.org/facts-statistics.

Prostate Cancer Risk Factors The most common risk factor for prostate cancer is age, but other risk factors include family history, African ancestry, and exposure to chemicals that are thought to, or known to, cause cancer. Learn more at zerocancer.org/risk-factors. Family History Understanding your genetics and family history of cancer is important. A man with at least one close relative, such as a father, brother, or son, who has had prostate cancer has twice the risk of the disease as the general population. In addition, it is important to know about a family history of breast, ovarian, or pancreatic cancers. Some gene mutations found in those cancers have also been identified in prostate cancer and have been linked to more aggressive disease and increased lifetime risk of developing one or more cancers. Learn more about genetic testing on page 12 of this guide.

RISK FACTORS RACE

FAMILY HISTORY

AGING

GENE CHANGES

DIET

CHEMICALS

Racial Disparities & Health Equity in Prostate Cancer Prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer death in Black/African American men in the United States. Not only are Black men more likely to get prostate cancer, but they are also more likely to be diagnosed with advanced disease than white men. In fact, Black men are 1.7 times more likely to be diagnosed with prostate cancer and 2.1 times more likely to die from the disease.

A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE Recent research suggests that these differences in health outcomes are likely caused by several factors within the U.S. healthcare system, including: access to care, insurance status, racial biases, and distrust in the medical system – it cannot be solely explained by genetic differences. ZERO is committed to bridging the gap between racial and health disparities in prostate cancer among Black men. Learn more at zerocancer.org/health-equity. Veterans and Prostate Cancer One in eight men will be diagnosed with prostate cancer in their lifetime. However, the prostate cancer incidence rate for Veterans is 1 in 5, making prostate cancer the most commonly diagnosed cancer among U.S. Veterans. Studies have shown Vietnam and Korean War Veterans with exposure to defoliants like Agent Orange have a higher occurrence of prostate cancer. ZERO is committed to bringing the Veteran community the education, resources, and tools needed to fight prostate cancer. Learn more at zerocancer.org/veterans.

Prostate Cancer Screening Routine prostate cancer screening starts with a PSA blood test and may include a rectal exam. Both are quick and simple. Learn more at zerocancer.org/early-detection. PSA Test – The PSA test is a blood test that measures the amount of prostate-specific antigen (PSA) in your blood. PSA is a protein produced by normal cells in your prostate and also by prostate cancer cells. It is normal to have a small amount of PSA in your blood, and the amount rises as you get older. Digital Rectal Examination (DRE) – During a digital rectal examination, a doctor or nurse feels your prostate through the wall of the rectum to check for any lumps or hard areas and to get an idea of its size. The DRE only lasts a few seconds and your healthcare provider will wear a glove and use lubricant to reduce discomfort. DREs are also used to determine the T (Tumor) stage.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Diagnosing Prostate Cancer After a PSA test or a digital rectal exam show abnormal results, further testing is needed to determine if prostate cancer is present. You may have already had some of these described below. Additional tests could help you find out if the cancer has spread or how aggressive the cancer is. Learn more at zerocancer.org/diagnosis. MRI – Magnetic resonance imaging (MRI) is a scan that provides more detailed images than an ultrasound. It can help determine if a biopsy is needed, guide needles for a biopsy, and help determine the stage of cancer. Prostate Biopsy – If the results of the PSA test and/or DRE indicate any abnormalities, the doctor will recommend a biopsy as the next step. A biopsy involves using a thin needle to take small pieces of tissue from the prostate. The tissue is then looked at under a microscope to check for cancer. Cancer can only be diagnosed with a biopsy. Biopsy results will determine your Gleason score. Different types of prostate biopsies are available, including transrectal, transperineal, and transurethral. Talk to your doctor about which one is right for you. If prostate cancer is confirmed by the biopsy, your doctor may want to test nearby lymph nodes for signs of cancer as well. Several other tests and procedures can be used to determine more about the location and/or severity of your cancer. Ultrasound – A scan that uses sound waves to look for suspicious areas in the prostate. It is often used to help guide a biopsy.

“If your doctor suggests you may need a future biopsy based on PSA and/or DRE results, you should also ask your doctor whether or not you qualify for an MRI as an additional part of your screening process. This technology provides additional helpful information in many situations of what could be happening within specific areas of the prostate and near the prostate. It also estimates the size of the prostate with good accuracy, and the MRI has already helped many men and their doctors make more informed decisions.” Dr. Mark Moyad, University of Michigan Medical Center, Department of Urology, and Public Health Educator/Clinical Researcher

A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Imaging A variety of imaging scans may be used to help your doctor biopsy, diagnose, and stage prostate cancer. Imaging scans can also help determine if and where the cancer has spread, help plan treatment, or determine if treatment is working.

IMAGING TYPE

Conventional Imaging

Advanced Imaging

ABOUT THE IMAGING SCAN

Ultrasound

• Used to look for suspicious areas in the prostate

Bone Scan

• Shows prostate cancer that may have spread to bones • Requires other tests to confirm cancer in the bones

MRI Scan

• Used to determine if a biopsy is needed • Guides a needle for a biopsy • Can help determine the stage of prostate cancer

CT Scan

• Detects prostate cancer in lymph nodes • After a recurrence, can help determine organ involvement

PET/CT Scan

• Shows images of prostate cancer that may have spread • Are often less detailed than MRI or CT images • Uses new and advanced imaging agents to detect cancer

Advanced Imaging and New Imaging Agents All imaging tests have limitations. Some are better at detecting cancer in lymph nodes, some work best if the PSA levels are rising, and others may miss small areas of prostate cancer that have come back or spread. With the discovery of new imaging agents, these pictures of the inside of the body make it easier to see prostate cancer cells, even in small amounts, that have traveled outside the prostate to other places in the body. These advances are improving how a patient’s prognosis (forecasted outcome) is determined, how treatment decisions are made, and if the treatment is working. Learn more at zerocancer.org/diagnosis/imaging. Be sure to talk to your doctor about which scans might be best for you. Here are some questions to get you started: What are the differences between a CT scan, MRI scan, and PET/CT scan? Will I need more than one imaging scan? How long do these scans take and how do I prepare? How often will I need to have scans? What kind of imaging agent will be used? Should I be concerned about side effects from any of the imaging agents? Does my PSA level have to be rising to qualify for any of these imaging scans? What will the results tell me? CT=Computed Tomography; DRE=Digital Rectal Exam; MRI=Magnetic Resonance Imaging; PET=Positron Emission Tomography; PSA=Prostate-Specific Antigen

A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Understanding Your Diagnosis and Stage Stages The stage of the prostate cancer tells you if, and how far, the prostate cancer has spread beyond the prostate. There are different ways to describe the prostate cancer stage, shown in the table below. Information used to determine your stage of cancer may include results from your DRE, biopsy (Gleason score), PSA, and imaging scans. Together, these results should help you and your doctor decide which treatments might be suitable for you. Learn more at zerocancer.org/stages-and-grading.

PROSTATE CANCER STAGES Localized or Early

Stage I

The cancer is small and only in the prostate.

Localized or Early

Stage II

The cancer is larger and may be in both lobes of the prostate, but is still confined to the prostate.

Locally Advanced or Regional

Stage III

The cancer has spread beyond the prostate to nearby lymph glands or seminal vesicles.

Stage IV

The cancer has spread to other parts of the body, such as to the bones, liver, or lungs. This is referred to as metastatic or advanced prostate cancer. If prostate cancer spreads, or metastasizes, to the bone, you have prostate cancer cells in the bone, not bone cancer.

Advanced or Metastatic

Gleason’s Pattern Scale

Gleason Score The Gleason score indicates what the prostate cancer cells look like under a microscope. The Gleason score is determined by assigning a grade to the most common type of cells in the biopsy, and a second grade to the second most common type of cells in the biopsy. Those grades are then added together for the score. For example, 3 + 4 = 7. The five historical Gleason grades of prostate cancer (Humpath.com – Human pathology, Paris, France).

1. Small, uniform glands.

2. More space (stroma) between glands.

Well differentiated

Moderately differentiated

3. Distinctly infiltrations of cells from glands at margins. Poorly differentiated Anaplastic 4. Irregular masses of neoplastic cells with few glands. 5. Lack of or occasional glands, sheets of cells.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Grade Group The Gleason score can be misleading for some prostate cancer patients. The Grade Groups may replace the Gleason score over time but, for now, you might see one or both on a pathology report. RISK GROUP

GRADE GROUP

GLEASON SCORE

DESCRIPTION

Gleason X

Gleason score cannot be determined

Low/Very Low

Grade Group 1

Gleason 6 (or less)

The tumor tissue is well differentiated, less aggressive and likely to grow more slowly

Intermediate (Favorable or Unfavorable)

Grade Group 2 Grade Group 3

Gleason 3 + 4 = 7 Gleason 4 + 3 = 7

The tumor tissue is moderately differentiated, moderately aggressive and likely to grow but may not spread quickly

High/Very High

Grade Group 4 Grade Group 5

Gleason 8 Gleason 9–10

The tumor tissue is poorly differentiated or undifferentiated, highly aggressive and likely to grow faster and spread

Tumor Categories The standardized Tumor, Node, and Metastasis (TNM) system is used to stage prostate cancer. The T category is based on the extent of the tumor itself. The N category is based on whether the cancer has spread to nearby lymph nodes. The M category is based on whether the cancer has spread beyond nearby lymph nodes. T1: The tumor cannot be felt with a DRE or seen with imaging. T1a: The tumor is found accidentally during a surgery for benign prostatic hyperplasia or another prostate condition. The tumor takes up less than 5% of the removed tissue. T1b: The tumor is found accidentally during a surgery, and the tumor takes up more than 5% of the removed tissue. T1c: The tumor is diagnosed with a needle biopsy, usually because of an elevated PSA. T2: The tumor is confined to the prostate and can be either felt with a DRE or seen with imaging. T2a: The tumor is confined to half of one lobe of the prostate. T2b: The tumor is present in more than half of one lobe, but is not in both lobes. T2c: The tumor is present in both lobes of the prostate. T3: The tumor has grown outside of the prostate and may be present in the seminal vesicles. T3a: The tumor is outside of the prostate, but is not in the seminal vesicles. T3b: The tumor is outside of the prostate and has spread to the seminal vesicles. T4: The tumor has grown into tissues beyond the seminal vesicles. For more on TNM staging, please visit zerocancer.org/stages-and-grading. 10

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Risk Group For those patients with localized (stages I-II) or locally advanced prostate cancer (stage III), the cancer can be further divided into risk groups. Knowing your risk group is important for understanding your prognosis, including how aggressive your prostate cancer might be. Low-risk prostate cancer must have all of the following features to be classified as low risk: cT1-cT2a Grade Group 1 PSA less than 10 ng/mL Intermediate-risk prostate cancer has one or more of the following features: cT2b-cT2c Grade Group 2 or 3 PSA 10-20 ng/mL Intermediate-risk prostate cancer can be further subdivided into favorable and unfavorable: Favorable intermediate risk has one of the above features with a Grade Group of 1 or 2 and less than 50% of biopsy cores positive Unfavorable intermediate risk has 2-3 of the above features with Grade Group 3 or greater than or equal to 50% biopsy cores positive High-risk prostate cancer has any of the following features: cT3a Grade Group 4 or 5 PSA greater than 20 ng/mL Talk to your doctor about your risk group, and how it might affect your treatment options.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Genetic Testing Genetic testing identifies gene mutations that can impact patients and their families. Two different types of genetic tests in prostate cancer are germline and somatic. These are clinical tests that are used by doctors to learn more about a patient’s prostate cancer and to help develop treatment plans. Understanding the differences between these tests is important to decide which one may be right for you.

GENETIC OR GERMLINE TESTING

BIOMARKER OR SOMATIC TESTING

Inherited, or hereditary, mutations

Acquired mutations

Inherited - passed from parent to child

Not passed from parent to child

Inherited gene mutations exist in every cell of the body

Acquired gene mutations exist only in the tumor itself

10% of prostate cancer is thought to be caused by inherited, germline mutations

90% of prostate cancer is thought to be due to non-inherited, acquired mutations

Provides eligibility for targeted cancer therapies

May provide information on family member’s risk of developing certain cancers

Does not provide information on cancer risk in other family members

Identified through a blood or saliva sample

Identified by testing the tumor itself or tumor cells that are circulating in the blood

Approximately 10% of prostate cancers are thought to be caused by an inherited gene mutation. Inherited genetic mutations can be found in the BRCA1, BRCA2, and HOBX13 genes, among others. Genetic or germline testing is done with a simple blood or saliva test. A genetic counselor can help you better understand the pros and cons of genetic testing. It is important to know that, while prostate cancer can run in some families, most prostate cancers occur in men without a family history of it. Targeted therapies are available for men with a genetic mutation and metastatic castrate-resistant prostate cancer (mHRPC). Genetic testing also provides family members with valuable information regarding their cancer risks. Family members of men with hereditary cancer have a 50% chance of having the same genetic mutation. Genetic testing can help family members know if they should also be tested or take measures to reduce their risk of developing cancer. All men with prostate cancer should consider genetic testing. Learn more at zerocancer.org/genetic-testing.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Biomarker Testing Biomarker Testing and Precision Medicine Biomarker testing and precision medicine are somewhat newer terms in the cancer space. Biomarker testing looks for genes, proteins, and tumor markers that tell us more about your specific cancer. Biomarkers can help doctors diagnose cancer and monitor cancer, and can also affect how some treatments will work for you.

What is Biomarker Testing in Prostate Cancer? Biomarker or somatic testing is done on cancerous tissue taken from the prostate to provide information about how your prostate cancer might behave. Biomarker testing may also be called somatic testing, tumor testing, or genomic testing. It can be performed on both biopsy tissue and on tissue from an entire prostate following a prostatectomy. These tests look for mutations in genes that are relevant in cancer and that may drive cancer growth. Some of these biomarkers tell your doctors how aggressive your prostate cancer might be. Biomarker testing may help you and your doctor better understand your particular cancer and choose the best treatment option for you. There are many different tumor biomarker tests available. Talk to your doctor about testing and which biomarker test might be right for you. Learn more at zerocancer.org/biomarker-testing.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Progression and Treatment Prostate cancer can be diagnosed at various stages, depending on when the prostate cancer is detected and how far the disease has progressed. Many patients respond immediately to treatment and don’t require any further treatment. Others may already have metastatic disease by the time the cancer is first diagnosed or later develop metastatic disease after treatment completion for early-stage disease. Treatment to lower testosterone is a mainstay of therapy for patients with metastatic disease. When prostate cancer becomes resistant to this type of therapy it is called hormone or castrate resistant. The definitions and ways prostate cancer can progress may be confusing, but here is a chart to help you:

Prostate Cancer and Treatment Progression Radiation, Surgery

Novel Antiandrogens, Chemotherapy

Hormone Therapy

Targeted Therapy, Chemotherapy, Immunotherapy

Clinical Trials

Non-Metastatic Prostate Cancer

Metastatic Prostate Cancer

Hormone-Sensitive Prostate Cancer (HSPC)

Hormone-Resistant Prostate Cancer (HRPC)

Hormone-Sensitive Prostate Cancer (HSPC, also called Castration-Sensitive Prostate Cancer or CSPC) This is a form of prostate cancer that still responds to testosterone suppression therapy. HSPC can be referred to as non-metastatic, or nmHSPC, when there is no detectable metastases - spread of cancer - upon imaging. It can be referred to as mHSPC when it has advanced to metastatic stage. Hormone-Resistant Prostate Cancer (HRPC, also called Castration-Resistant Prostate Cancer or CRPC) This is a form of prostate cancer that keeps growing even when the amount of testosterone in the body is reduced to very low levels. HRPC can be referred to as non-metastatic, or nmHRPC, when there is no detectable metastases upon imaging, and as mHRPC when it has advanced to metastatic stage. Before deciding on a treatment with your doctor, learning about all treatment options, as well as clinical trials, is important. Treatment decisions should be based on many factors, including your age, overall health, family history, stage at diagnosis, aggressiveness of the disease, and results of genetic testing, among others. In addition, understanding possible side effects of each treatment, how side effects can be managed, weighing quality of life issues, and deciding what is most important to you and your family should all be considered. Learn more at zerocancer.org/treatment-options. 14

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Types of Prostate Cancer Treatment Active Surveillance

Active surveillance is a disease management strategy for low-risk, early stage prostate cancer. This strategy monitors the disease for signs of progression (with regular PSA testing and DREs) but avoids immediate treatment with surgery or radiation. If test results change, treatment may be warranted.

Local Therapies

Local therapy is treatment that is directed to a specific organ or limited area of the body, such as the prostate. Local therapies for prostate cancer include surgery, radiation, HIFU, and cryotherapy. Surgery Surgically removing all or part of the prostate, also known as a prostatectomy, aims to remove all of the prostate cancer. The full removal of the prostate is called a radical prostatectomy. Robotic-assisted surgical removal of the prostate is the most widely used form of localized prostate cancer surgery. Like other surgical methods, this procedure still requires an experienced surgeon, but robotic surgery may lead to a faster recovery time, reduced blood loss, and a lower risk of infection. Whichever type of surgery is performed, it usually requires an overnight hospital stay and patients typically will need a catheter to help drain urine for up to 14 days post-surgery. Many physical activities will be limited for up to two months after the surgery. Radiation Therapy Radiation therapy, or radiotherapy, uses various forms of radiation to safely and effectively treat prostate cancer. It works by damaging the genetic material within the prostate cancer cells and limiting their ability to successfully reproduce. When these damaged cancer cells die, the body naturally eliminates them. The goal of radiation is to kill the tumor while sparing as much healthy tissue as possible. Radiation therapy can be given externally (directed from outside the body) or internally (placed inside the body) when treating localized prostate cancer. These two categories are further broken into several types of treatment that vary by method, dose, frequency, and intended use. External beam radiation therapy (EBRT) is non-invasive, so patients can be active during and after treatment with no down time. Brachytherapy, while less common, is a type of internal radiation therapy that involves the placement of radioactive seeds or temporary catheters into the prostate. This is a minimally invasive procedure, and most patients can expect to return to normal activity in less than a week. In patients with advanced prostate cancer, EBRT can be used to relieve pain from bone metastases and may also be used in combination with hormone therapy.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE High Intensity Focused Ultrasound (HIFU) HIFU is an FDA-approved, minimally invasive procedure for the ablation (destruction) of prostate tissue. It destroys prostate cancer cells through precise and focused ultrasound energy, or sound waves. Ultrasound may be a treatment option for patients whose prostate cancer is considered low- to intermediate-risk and is confined to the prostate. Cryotherapy Cryotherapy, also called cryoablation or cryosurgery, freezes prostate tissue, causing cancer cells to die. This type of treatment is sometimes used as an alternative to surgical removal of the prostate or if the cancer has come back after radiation therapy. Cryotherapy is an option for those with localized or locally advanced prostate cancer.

Systemic Therapies

Systemic therapies refers to any type of treatment that targets or travels through the entire body. These include chemotherapy, hormone therapy, immunotherapy, targeted therapy, and radiopharmaceuticals. Hormone Therapy Hormone therapy is also called androgen deprivation therapy (ADT), hormone deprivation therapy, or hormone suppression therapy. Prostate cancer is fueled by male hormones called androgens. The primary male androgen is testosterone. Hormone therapy stops or slows the body’s ability to make testosterone, aiming to stop tumor growth and/or shrink the tumor. Several types of hormone therapy exist, but it is important to know that hormone therapy alone does not cure prostate cancer. Hormone therapy is especially important for those with advanced disease, whose cancer has returned (recurrence) after surgery or radiation, or whose cancer is considered high-risk for metastasis (spread). It can also be used in combination with other treatments or to shrink a tumor to make other treatments more effective. The main types of hormone therapies are: LHRH Agonists – Luteinizing hormone-releasing hormone (LHRH) is a key hormone released into the body before the body produces testosterone. LHRH agonists block the release of LHRH, causing testosterone levels to drop gradually, usually over a month’s time. LHRH Antagonists – These block the pituitary gland from making hormones, causing the testicles to stop making testosterone, resulting in an immediate drop in testosterone levels. Anti-Androgens – These keep testosterone from binding to androgen receptors, which may keep prostate cancer cells from growing. Inhibitors and Blockers – These inhibit the synthesis of the androgen and block androgen receptors to slow the production of testosterone. Orchiectomy – This is surgery to remove one or both testicles, thereby drastically reducing the body’s ability to produce testosterone.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE An exciting advancement in hormone therapy is a recently approved oral ADT option. While many forms of ADT are given by injection, oral ADT may provide patients with more flexibility in scheduling appointments and perhaps even reduced side effects. Ask your doctor which option is best for you. Chemotherapy Chemotherapy is a type of prostate cancer treatment that is used to kill cancer cells throughout the body. They are given intravenously (through the veins) or orally (as a pill), depending on the drug. Because chemotherapy also attacks other cells in the body, this treatment can cause significant side effects. Chemotherapy may be used when a patient’s prostate cancer has metastasized (spread) and is often given in combination with ADT or after hormone therapy stops working. I mmunotherapy Immunotherapy, also called biologic therapy, treats the whole body by attempting to activate a person’s immune system so that it will recognize and destroy prostate cancer cells. It uses materials either made by the body or in a lab to improve, target, or restore immune function. Different types of immunotherapies include vaccines, monoclonal antibodies, and non-specific immunotherapy. Radiopharmaceuticals Radiopharmaceuticals are medications that deliver radiation, typically given through a vein to men with metastatic prostate cancer that has spread widely to the bone. Targeted Therapy Targeted therapy uses drugs that are designed to find and attack cancer cells. The goal is to interfere with the specific molecules that drive the growth of the tumor. A targeted therapy approach is a form of personalized cancer treatment, also known as precision medicine, and is often associated with fewer side effects than other treatments. Targeted therapies may be used by themselves or in combination with other therapies. PARP Inhibitors – A type of targeted therapy that affects how DNA is repaired in cancer cells. They target certain gene mutations (such as BRCA1 and BRCA2) and therefore are only used in patients who are known to have these mutations found through genetic testing. Several oral PARP inhibitor medications are approved by the FDA for treatment of certain types of advanced prostate cancer. Previously, PARP inhibitors were approved to treat certain breast, ovarian, and pancreatic cancers. PSMA Targeted Therapies – The FDA has approved treatments for PSMA-positive prostate cancer. Learn more about PSMA and PSMA targeted therapies in the next section of this guide.

Clinical Trials

A clinical trial is a research study investigating experimental treatment to see if it is safe to use and effective in fighting a disease. Learn more about clinical trials later in this guide. A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate-Specific Membrane Antigen (PSMA) PSMA is a protein found on the surface of normal prostate cells, but it is found in higher amounts on prostate cancer cells. It is present in more than 80% of prostate cancer cells in men with prostate cancer. PSMA has been the subject of extensive and promising research over the last several decades. It is now used as a target for imaging to diagnose metastatic or recurrent prostate cancer, and it is also being explored as a target for medications that can treat prostate cancer. This dual purpose is why some refer to PSMA as a “theranostic” - a combination of the terms “therapeutics” and “diagnostics”. How is PSMA Targeted for Detecting Prostate Cancer? A PSMA PET (positron emission tomography) scan is an imaging procedure used to help detect prostate cancer cells within the body. For this procedure, a radioactive agent is injected into the bloodstream prior to the PET scan. The agent then attaches to the PSMA protein on the prostate cancer cells. Once there, it glows in the PET images that are taken to indicate where prostate cancer cells that have traveled outside the prostate may be. This procedure allows prostate cancer cells to be found that may not have been picked up on traditional scans like CT scans and bone scans. Multiple PSMA PET imaging agents are now approved by the FDA for use in patients whose prostate cancer has recurred or spread. How is PSMA Targeted for Treating Prostate Cancer? Targeting PSMA proteins on a prostate cancer cell enables treatments to be focused on the cancer cell itself, rather than on normal healthy cells in the body, allowing a precision medicine approach to treatment. PSMA targeted therapies will likely be made available to patients who have PSMA protein detected on their cancer cells using a PSMA PET scan. The FDA has approved a drug for the treatment of PSMA-positive mHRPC, and other forms of treatment that target PSMA are being developed. Questions For Your Doctor Is the PSMA PET scan right for me? Do you offer PSMA PET scans? Are they covered by my health insurance? Is exposure to the radioactive agent in a PSMA PET safe? Is PSMA targeted therapy a treatment option for me? What are the side effects of PSMA targeted therapy? Learn more at zerocancer.org/targeted-therapy.

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Clinical Trials After consulting with your doctor, you may consider enrolling in a clinical trial to gain access to potential new treatments or techniques that are still in the investigational stage. A clinical trial is a research study investigating experimental treatment to see if it is safe to use and effective in fighting a disease. All treatments used today for prostate cancer are available because of past clinical trials and thanks to past clinical trial participants. Many times people do not participate in a clinical trial because they did not know they were eligible or that one was available, so be sure to ask your doctor when making your treatment decisions. Participating in a clinical trial is a way to gain access to promising new drugs that are yet to be approved by the FDA. Hundreds of research projects are currently ongoing and investigating the potential of new drugs and new combinations of drugs. Historically, people of color are underrepresented in clinical trials. Diversity in clinical trial participation is critical to understanding the safety and efficacy of treatment options. When clinical trials lack diversity and participants are of the same age, race, and ethnicity, data from that clinical trial will fail to help researchers learn how different people may respond differently to the same medication.

CLINICAL TRIALS BY THE NUMBERS

10–15

6–7

80%

35+

the average number of years for a drug to be developed and get on the market for patients

the average number of years drugs are studied in clinical trials

of clinical trials fail because they don’t recruit enough patients

number of drugs approved by the FDA for prostate cancer

Additional information about clinical trials, as well as a free clinical trial matching service, can be found at zerocancer.org/clinicaltrials.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Managing Treatment Side Effects There are many side effects of prostate cancer treatment. Just as prostate cancer varies from patient to patient, so will the side effects experienced. Your healthcare team will work hard to ensure you experience minimal side effects as a result of treatment. Side effects related to prostate cancer treatments vary by the type of treatment you receive. Some common side effects of treatment are urinary incontinence (the inability to control your bladder) and erectile dysfunction (the inability to achieve a full erection). Other side effects can include fatigue, depression, and infertility. It is important to talk to your doctor and your partner about all potential side effects before choosing treatment, as these potential changes can impact your self-esteem and personal relationships. Once you determine your treatment, work with your doctor on a plan to manage any side effects you experience. Learn more at zerocancer.org/side-effects.

TREATMENT

WHAT IT DOES

POSSIBLE SIDE EFFECTS

Surgery

Removes the cancerous tissues and the prostate

Urinary incontinence, erectile dysfunction (ED), and infertility

Hormone Therapy

Minimizes presence of androgens which fuel prostate cancer growth

ED, hot flashes, mood changes, loss of libido, depression, cardiovascular events, and bone loss

Radiation

Slows prostate cancer cell growth by targeting cells externally or by injection

ED, increased urinary urgency and frequency, diarrhea, rectal bleeding, and discomfort during urination and bowel movement

Immunotherapy

Changes the body’s immune system to kill cancer cells

Fever, chills, fatigue, and joint or body ache

Targeted Therapy

Targets a particular protein or genetic mutation in the tumor

Nausea, fatigue, anemia, vomiting, diarrhea, decreased appetite, headache

Bone-Related Treatments

Inhibits bone loss and fractures and relieves pain from prostate cancer in the bone

Low grade fever, tingling around mouth or hand cramps from low calcium, dental pains

Chemotherapy

Targets cancer cells that grow quickly including cancer cells metastasized to the bone

Hair loss, fragile bones, nausea, and nervous system disorders like confusion, depression, or headaches

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Your Healthcare Team To receive the best care possible, seek care from a multidisciplinary team. A multidisciplinary team is a group of healthcare professionals from different specialties who work together to suggest a treatment plan for you based on your diagnosis, personal health, and preferences. This approach helps ensure you have the best health outcome and highest quality of life. Keep in mind that you have a choice in who manages your care. This is about finding the right treatment team to work with to make the right decisions for you and with you. Learn more at zerocancer.org/healthcare-team. A multidisciplinary team may include:

Urologist A urologist is a physician specializing in diseases of the male reproductive organs and male and female urinary tract. Some urologists have oncology training. Many urologists are also involved in certain aspects of other forms of therapy including radiation therapy, hormone therapy, treatment of advanced disease, clinical trials, and active surveillance. All urologists are surgeons as well, and many perform prostate cancer surgery.

Radiation Oncologist A radiation oncologist is a highly trained physician specializing in the treatment of prostate cancer using the various types of radiation approved to treat the disease.

Medical Oncologist A medical oncologist is a physician who specializes in the non-surgical treatment of cancer with medicines such as chemotherapy, hormonal therapy, immunotherapy, and other drugs.

Primary Care Physician A primary care physician (PCP) is often an internist or family medicine physician who treats common illnesses and oversees general care.

Oncology Social Worker Oncology social workers are trained to work with cancer patients and their families. It is important to understand your emotional well-being and get the support you need mentally, as well as physically. An oncology social worker provides individual counseling, access to support groups, and referrals to related services for men with prostate cancer. A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Physical Therapist A physical therapist can help deal with the physical changes caused by cancer treatment. Before and after surgery or radiation therapy, working with a physical therapist to strengthen the pelvic floor can help to manage or prevent side effects such as urinary incontinence.

Nutritionist A nutritionist provides information and guidance about good nutrition. This can help a patient combat cancer-related or treatment-related weight loss or gain by recommending foods that provide adequate calories, vitamins, and protein. In addition, a nutritionist provides helpful tips and recipes customized to fit your specific dietary needs.

Nurse, Patient, or Financial Navigator A navigator is an expert in understanding the details of cancer treatment and will support, inform, guide, and answer questions for you through all stages of treatment and beyond. As advocates for patients and their families, they provide support and enhance the quality of care you receive. If a patient navigator is not made available to you, ZERO can help with our ZERO360 patient support program. Visit zerocancer.org/zero360 for more information.

Genetic Counselor A genetic counselor is a healthcare professional who will collect your personal and family health history and use this information to help determine the likelihood of having a genetic condition. The genetic counselor can help you decide whether or not genetic testing might be right for you or your family members, and can help explain genetic testing results.

Sexual Health Professional A sexual health professional specializes in helping patients and their partners manage erectile dysfunction, low testosterone, hormone therapy, and incontinence related to prostate cancer treatment and side effects.

Mental Health Professional A prostate cancer diagnosis can be overwhelming. Consider whether or not speaking with a mental health professional might be helpful to you.

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Getting a Second Opinion Seeking a second opinion following a prostate cancer diagnosis is very common and doing so can make you feel more confident in the treatment decision that you make. It’s OK to get a second opinion at any point during your care.

Why Get a Second Opinion? To understand all available treatment options and have peace of mind with your treatment decision To get the opinion of another prostate cancer expert To confirm a diagnosis or treatment plan To hear information about your cancer explained in a different way To share the opinion of more than one healthcare expert with your insurance company

How to Ask About a Second Opinion Some people find it hard to tell their doctors that they’d like a second opinion. Your doctor shouldn’t discourage you from getting a second opinion. If you are unsure of how to begin, here are a few ways to start the conversation: “I’m thinking of getting a second opinion. Can you recommend someone?” “Before we start treatment, I’d like to get a second opinion. Will you help me with that?” “If you had my type of cancer, who would you see for a second opinion?” “I think that I’d like to talk with another doctor to be sure I have all my bases covered.”

The Process Before you start looking for a second opinion, contact your insurance company to find out what your policy covers. In some cases, you may have to get a second opinion from another doctor who is part of your health plan before the plan will pay for your treatment. It’s important to be able to give the new doctor the exact details of your diagnosis and proposed treatment. Make sure you have the following information handy and always keep copies for yourself: A copy of your pathology report from any biopsy or surgery If you had surgery, a copy of your operative report If you were in the hospital, a copy of your discharge summary A summary of your doctor’s current treatment plan or the plan that has been given to you as an option Since some drugs can have long-term side effects, a list of all your drugs, drug doses, and when you take/took them

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE You can ask your current doctor’s office for copies of your records. If you have had treatment or tests in a hospital or clinic, you may need to contact their medical records department to find out how to get these records. Sometimes you can request your records through an online patient portal if your doctor’s office, treatment center, or hospital has one.

Making Sense of the Second Opinion If the second opinion differs from the first, you may find the following tips helpful: Talk to the second doctor about the opinion of the first Make an appointment with your first doctor to talk about the second opinion Ask both doctors to explain how they arrived at their treatment plan Ask what research studies or professional guidelines they consulted Ask if it is possible for the two doctors to review your case together Do your own research on the latest treatment guidelines. Two good sources are the National Comprehensive Cancer Network (NCCN) Treatment Guidelines (nccn.org) and the National Cancer Institute’s (NCI) PDQ® Cancer Treatment Summaries (cancer.gov). Both are available in versions for health professionals (which use medical language and terminology) and patients (which use everyday language).

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Living with Prostate Cancer Monitoring for Recurrence Completing your prostate cancer treatment can bring relief. When caught early, your initial treatment may mean you are considered free of disease. Most men will live cancer-free for years, and some even for the rest of their lives. But you may also feel worried or fearful that your cancer may return. Up to 40% of men will experience a recurrence, so it is important to understand your risk. Cancer recurrence is the return of cancer after a period when no cancer cells could be detected in the body. Your doctor will recommend how often and when your PSA screening should be scheduled to continue monitoring your health. When PSA levels in the blood rise after prostate cancer treatment, this is known as biochemical recurrence. This can occur even if the patient has no symptoms. If this happens, the doctor will order additional tests and make recommendations for how to manage your disease.

Survivorship Survivorship focuses on the overall health and wellbeing of cancer patients. This includes monitoring for recurrence and providing follow-up care for the long-term physical and emotional side effects. This may include monitoring for secondary cancers and interventions to improve quality of life. Ask your healthcare team if they have a survivorship care plan for you. Learn more at zerocancer.org/survivorship.

SURVIVORSHIP CARE PLAN • Every cancer survivor should have one after primary treatment. • Is a comprehensive care summary. • Should include a record of treatments and follow-up plan. • Is a roadmap to life after prostate cancer treatment.

Nutrition and Exercise For many, the diagnosis and treatment of cancer leads people to improve their diet and exercise behaviors. Maintaining a healthy diet and exercise regimen can help you prepare for and recover after cancer treatment. It may also help to prevent prostate cancer from coming back. Some treatment such as ADT can result in weight gain and bone loss. Depression and fatigue, which are common lingering effects of prostate cancer, can make it hard for even the most motivated person to exercise or eat healthy foods. Take small steps to take care of yourself and make a conscious choice to live a healthier life. Nutrition to Fight Prostate Cancer Although there is no diet to prevent or cure prostate cancer, you can make healthy choices that will help you fight your disease. Watching your weight may reduce your risk of dying from prostate cancer. A PATIENT EDUCATION SERIES | ZEROCANCER.ORG

NEWLY DIAGNOSED PROSTATE CANCER GUIDE Recent studies have indicated that the risk of dying from prostate cancer is more than double in obese men when compared to men of normal weight at the time of diagnosis. Nutrition During Cancer Treatment Maintain a healthy weight. For many men, this means avoiding weight loss by getting enough calories on a daily basis. For men who are overweight and are obese, this may mean losing some weight. If you are trying to lose weight, it should be moderate, meaning only about a pound a week. Get essential nutrients the body needs, such as protein, carbohydrates, fiber, vitamins, minerals, and water. Not only will your body function better, you will feel better. Nutrition After Cancer Proper nutrition and a prostate-healthy diet can help survivors live longer, receive more enjoyment out of life, and feel more empowered about their choices. Eating a healthy diet may help you regain strength after prostate cancer treatment. In addition, recent research suggests that making healthy food choices after active treatment may lower your risk of recurrence and help you live longer. Exercise to Fight Prostate Cancer Physical activity and exercise are crucial factors for both fighting prostate cancer and preventing recurrence. In addition, it can be important for managing your weight, maintaining muscle and bone strength, improving mental health, and helping with potential side effects of prostate cancer treatment. Walking, gardening, climbing the stairs, playing soccer, or dancing are all good examples of being active. For greater health benefits, physical activity should be of moderate or vigorous intensity that makes you breathe harder and your heart beat faster, such as running, bicycling, or swimming. Benefits of Regular Exercise During and After Cancer Treatment The side effects of prostate cancer treatment can impact your quality of life. Exercise can help: Reduce anxiety, depression, and fatigue Improve self-esteem Increase feelings of optimism Improve heart health Maintain a healthy weight Boost muscle strength and endurance

Mental Health It is normal to experience a wide range of emotions if you or a loved one has been diagnosed with prostate cancer. Emotional reactions can include feelings of vulnerability, sadness, loneliness, and fear of recurrence or death. Many of these emotions fade over time, but some may develop into clinical depression, intense anxiety, or panic. Talk to your healthcare team if you are feeling depressed or emotionally distressed. Many prostate cancer survivors find valuable information and perspective from others who have “been there.” ZERO offers several peer support options, including support groups and a one-to-one MENtor program. ZERO360 can also provide emotional and psychosocial support service referrals.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Terms to Know With so many things to comprehend at once, we often hear that newly diagnosed men are struggling to understand all the new vocabulary that comes with prostate cancer. To help, we compiled a list of the most common terms used in discussions about prostate cancer.

The Basics Biochemical Recurrence Biochemical recurrence is a rise of prostate-specific antigen (PSA) levels in the blood of a prostate cancer patient after initial treatment, such as surgery or radiation. Biochemical recurrence may occur in patients who do not have symptoms. It may mean that the cancer has come back. Lobe The sections of the prostate. There are five lobes of the prostate, one anterior lobe, one posterior lobe, one median lobe, and two lateral lobes. Lymph Node The lymph node is a rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Lymph nodes filter lymph (lymphatic fluid) and store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called the lymph gland. Metastasis Metastasis is the spread of cancer from one part of the body to another. This happens through the lymph system or through the bloodstream. A tumor formed by cells that have spread is called a “metastatic tumor” or a “metastasis.” The metastatic tumor contains cells that are like those in the original (primary) tumor. The plural form of metastasis is metastases (meh-TAS-tuh-SEEZ). Primary Cancer Primary cancer refers to the place in the body where the cancer started. If a primary prostate cancer spreads to other parts of the body, it has metastasized. For example, a brain tumor from prostate cancer is still prostate cancer and not brain cancer. It is a metastasis of prostate cancer. Prostate-Specific Antigen (PSA) PSA is a substance in the blood that is made by the prostate gland. It can be used to detect unusual activity in the prostate.

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Diagnostic Tests Lymph Node Biopsy Lymph nodes are small bean-shaped parts of the immune system. A lymph node biopsy may be done if the doctor thinks the cancer might have spread from the prostate to nearby lymph nodes. Prostate Biopsy For a biopsy (by-op-see), the doctor takes out a small piece of tissue where the cancer seems to be. This tissue is checked for cancer cells. A core needle biopsy is often used to find prostate cancer. Prostate-Specific Antigen (PSA) Blood Test The PSA is a blood test that is done to see what your PSA level is and how it changes over time. Changes in PSA can be used to detect prostate cancer. Transrectal Ultrasound (TRUS) For this test, a small wand is put into your rectum. It gives off sound waves and picks up the echoes as they bounce off the prostate gland. The echoes are made into a picture on a computer screen.

Treatment Adjuvant Adjuvant is a treatment given after the primary treatment to increase the chances of a cure and usually involves chemotherapy or radiation. Neoadjuvant Neoajuvant is a treatment given before the primary treatment and usually involves chemotherapy or radiation.

Symptoms/Side Effects Erectile Dysfunction Erectile Dysfunction (ED), also known as impotence, is the inability to have an erection, a common side effect of prostate cancer treatment. Incontinence Incontinence is lack of voluntary control over urination or bowel movements. Neuropathy Neuropathy is a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body. It usually begins in the hands or feet and may worsen over time. It is a common side effect from platinum-based chemotherapy drugs.

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NEWLY DIAGNOSED WORKSHEET INFORMATION ABOUT YOUR PROSTATE CANCER Use this worksheet to keep track of basic information about your prostate cancer diagnosis as you need in order to make your decisions about your care. Date of diagnosis ________________________ PSA level at diagnosis ________________________ Gleason score __________________________________ Grade Group _________________________ Risk Group:

Very Low/Low

Intermediate Favorable

Intermediate Unfavorable

High Very High Number of biopsy samples taken ________________________________________________________ Number of biopsy samples containing cancer _____________________________________________ Stage at diagnosis (I-IV) _________________________________________________________________ Nodal involvement? My cancer is:

Yes

Localized (only in the prostate) Locally advanced (spread to just outside the prostate)

Advanced or Metastatic (spread to other organs or parts of the body) Location of metastasis (spread) _____________________________________ Date _____________________

Follow-up Tests

Results

CT Scan

____________________________________________________

_____________________

MRI

____________________________________________________

_____________________

PET or PET/CT Scan ______________________________________________________

_____________________

Other tests

____________________________________________________

PHYSICIANS Prostate cancer diagnosed by: Name: ______________________________________ Contact information: ______________________ Other doctors or healthcare providers seen: Name: ______________________________________ Contact information: ______________________ Name: ______________________________________ Contact information: ______________________ Other important numbers: ________________________________________________________________

LEARN MORE We encourage you to use this information in conversations with your healthcare team about prostate cancer and related topics. For more information about prostate cancer and ZERO Prostate Cancer, visit our website zerocancer.org/learn. ZERO Prostate Cancer provides this information as a service. It is not intended to take the place of medical professionals or the recommendations of your healthcare team. Consult your healthcare team if you have questions about your specific care. © 2024 ZERO® Prostate Cancer

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QUESTIONS FOR YOUR DOCTOR: NewlyNEWLY Diagnosed DIAGNOSED PROSTATE CANCER GUIDE

These questions are to help someone who has just been diagnosed with prostate cancer begin to make a plan with their healthcare team. Consider using a notebook to record test results, treatments, and upcoming appointments to feel more organized. Having all important information together may help reduce some of the stress of a prostate cancer diagnosis.

QUESTIONS FOR YOUR DOCTOR Diagnosis What exactly is my diagnosis? What is the stage and Gleason score? How aggressive is the cancer? What is my risk group? What other tests will be done? Should I consider talking to a genetic counselor or getting genetic testing? Treatment What are all of my treatment options? What is the goal of treatment? What treatment do you recommend based on my stage and risk group? Why do you recommend this particular treatment? Am I eligible for a clinical trial? What are the potential side effects of the treatments we discussed? How can these side effects be managed? What will my treatment schedule be? Living with Prostate Cancer Are my siblings, children, and grandchildren at higher risk? Where can I get more information about prostate cancer and treatment options? What steps can I take to be active and healthy during and after treatment? Do you have resources or services for my spouse or partner? How can I find support and resources to help pay for my cancer treatment?

Consider using a notebook at your appointments and taking someone with you if you can.

CONSIDER A SECOND OPINION?

Many people seek second opinions to explore all options. Seeking a second opinion is common and doing so can make you feel more confident in the treatment decision that you make.

Finding out that you or a loved one has prostate cancer can be scary. Prostate cancer is usually a slow growing disease. You have time to gather information about your diagnosis and make an informed decision about your next steps. Many resources and services are available and ZERO is here to help you along the way.

LEARN MORE We encourage you to use this information in conversations with your healthcare team about prostate cancer and related topics. For more information about prostate cancer and ZERO Prostate Cancer, visit our website zerocancer.org/learn. ZERO Prostate Cancer provides this information as a service. It is not intended to take the place of medical professionals or the recommendations of your healthcare team. Consult your healthcare team if you have questions about your specific care. © 2024 ZERO® Prostate Cancer

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QUESTIONS FOR YOUR DOCTOR: Advanced Prostate Cancer NEWLY DIAGNOSED PROSTATE CANCER GUIDE

These questions are to help someone living with advanced prostate cancer make a plan with their healthcare team to best manage the disease. Prostate cancer that spreads outside the prostate to other parts of the body is called metastatic prostate cancer (also called stage IV or advanced prostate cancer). Although metastatic prostate cancer cannot be cured, it can be treated and managed. Today, men are living longer with metastatic prostate cancer.

QUESTIONS FOR YOUR DOCTOR What does it mean that the cancer has metastisized? Where is the cancer (metastases) in my body? What ongoing tests can I expect to monitor the disease? Are there any risks with these tests? Can you help me talk to a genetic counselor or get genetic testing? What are all my treatment options? Which treatment(s) do you recommend and why? Consider using a What are the benefits of the treatment(s) you recommend? notebook at your What are the risks and potential side effects of the treatment(s) you recommend? appointments and taking someone with How long do I have to make my decision? you if you can. What do you suggest if the current treatment stops working? Am I eligible for a clinical trial? Living with Advanced Prostate Cancer Are my siblings, children, and grandchildren at higher risk? How can you help me maintain a good quality of life? What support services are available for me and my family? How can I find support and resources to help pay for my treatment? If You Have Metastases in the Bone What treatments are available to manage the cancer and the pain in my bones? What are the side effects of these treatments? How many visits will these treatments require?

CONSIDER A SECOND OPINION?

Many people seek second opinions to explore all options. Seeking a second opinion is common and doing so can make you feel more confident in the treatment decision that you make.

Finding out that you or a loved one has advanced prostate cancer can be scary. Many resources and services are available and ZERO is here to help you along the way.

LEARN MORE We encourage you to use this information in conversations with your healthcare team about prostate cancer and related topics. For more information about prostate cancer and ZERO Prostate Cancer, visit our website zerocancer.org/learn. ZERO Prostate Cancer provides this information as a service. It is not intended to take the place of medical professionals or the recommendations of your healthcare team. Consult your healthcare team if you have questions about your specific care. © 2024 ZERO® Prostate Cancer

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NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Prostate Cancer Support Programs

ZERO offers resources for all those impacted by prostate cancer. ZERO360: Comprehensive Patient Support 1-844-244-1309 (Toll-Free) zerocancer.org/zero360 ZERO360 is a free, comprehensive patient support service that helps patients navigate insurance, find resources to help pay for treatment and living expenses, connect with emotional support services, and ensure access to care. ZERO’s experienced case managers are ready to help patients and their families through their personal prostate cancer journeys.

“ I was alone in my doctor’s office when I first heard the words, ‘You have prostate cancer.’ I felt scared and confused. My life as I knew it was about to change. Contacting ZERO was the best thing I ever did; it changed my life! Each day spent with prostate cancer is a fight. I’m grateful to you for helping make sure a ZERO360 case manager was there to assist me every step of the way.”

Us TOO Support Groups zerocancer.org/supportgroups A variety of peer-led virtual and in-person groups are available offering emotional support, resources, and education to empower those impacted by prostate cancer to make informed decisions on testing, treatment, and management of side effects.

MENtor zerocancer.org/mentor A one-to-one peer support network where trained, volunteer MENtors have a wealth of insights to share based on their experiences.

Online Support Services ZERO Connect (facebook.com/groups/zeroconnect) is a Facebook-based support group for participants to share stories, ask questions, and connect. An invite-only Facebook group also exists for Black men/caregivers (email healthequity@zerocancer.org for information). The Inspire Online Support Community (zero.inspire.com) connects patients and loved ones to enhance the quality of life for all those affected by prostate cancer.

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PROSTATE CANCER FAMILY TREE NEWLY DIAGNOSED PROSTATE CANCER GUIDE

Family history is a risk factor for prostate cancer. Having one close relative with a prostate cancer diagnosis may double your risk of getting the disease. It is also important to know about a family history of breast, ovarian, or pancreatic cancers. Gene mutations found in those cancers have been identified in prostate cancer and linked to more aggressive disease. Start a dialogue with your family to protect your health and the health of those you love. Grandfather

Grandmother

Grandfather

Grandmother

Uncle(s)/Aunt(s)

Father

Mother

Uncle(s)/Aunt(s)

Sibling(s)

YOU Children

FAMILY TREE TIPS: For each blood relative, make note of any prostate, breast, ovarian, and pancreatic cancers

Update with information annually, such as at Thanksgiving or family reunions

Include age at initial diagnosis

Share with YOUR doctor(s)

Share this information with family members

In addition to your doctor, a genetic counselor can discuss your family risk, the pros and cons of genetic testing, help explain the results, and help determine next steps

Ask family members to share this family health history with their doctor

LEARN MORE We encourage you to use this information in conversations with your healthcare team about prostate cancer and related topics. For more information about prostate cancer and ZERO Prostate Cancer, visit our website zerocancer.org/learn. ZERO Prostate Cancer provides this information as a service. It is not intended to take the place of medical professionals or the recommendations of your healthcare team. Consult your healthcare team if you have questions about your specific care. © 2024 ZERO® Prostate Cancer

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NCCN GUIDELINES FOR PATIENTS

2024

Early-Stage Prostate Cancer

NATIONAL COMPREHENSIVE CANCER NETWORK

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FOUNDATION Guiding Treatment. Changing Lives.

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Early-Stage Prostate Cancer

About the NCCN Guidelines for Patients®

Did you know that top cancer centers across the United States work together to improve cancer care? This alliance of leading cancer centers is called the National Comprehensive Cancer Network® (NCCN®). Cancer care is always changing. NCCN develops evidence-based cancer care recommendations used by health care providers worldwide. These frequently updated recommendations are the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). The NCCN Guidelines for Patients plainly explain these expert recommendations for people with cancer and caregivers.

These NCCN Guidelines for Patients are based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Prostate Cancer, Version 4.2024 — May 17, 2024.

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NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

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Early-Stage Prostate Cancer

Contents 4

Prostate cancer basics

Tests for prostate cancer

Assessing your risk

Prostate cancer treatments

Initial treatment for your risk group

PSA persistence and recurrence

Making treatment decisions

Words to know

NCCN Contributors

NCCN Cancer Centers

Index

© 2024 National Comprehensive Cancer Network, Inc. All rights reserved. NCCN Guidelines for Patients and illustrations herein may not be reproduced in any form for any purpose without the express written permission of NCCN. No one, including doctors or patients, may use the NCCN Guidelines for Patients for any commercial purpose and may not claim, represent, or imply that the NCCN Guidelines for Patients that have been modified in any manner are derived from, based on, related to, or arise out of the NCCN Guidelines for Patients. The NCCN Guidelines are a work in progress that may be redefined as often as new significant data become available. NCCN makes no warranties of any kind whatsoever regarding its content, use, or application and disclaims any responsibility for its application or use in any way.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

NCCN Foundation seeks to support the millions of patients and their families affected by a cancer diagnosis by funding and distributing NCCN Guidelines for Patients. NCCN Foundation is also committed to advancing cancer treatment by funding the nation’s promising doctors at the center of innovation in cancer research. For more details and the full library of patient and caregiver resources, visit NCCN.org/patients. National Comprehensive Cancer Network (NCCN) and NCCN Foundation 3025 Chemical Road, Suite 100, Plymouth Meeting, PA 19462 USA

Prostate cancer basics 5

What is prostate cancer?

What are the symptoms of prostate cancer?

What causes prostate cancer?

What is early-stage prostate cancer?

Can prostate cancer be cured?

Key points

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

1 Prostate cancer basics » What is prostate cancer?

The prostate is a gland located

area of your body between your hip bones. The prostate is about the size of a ping-pong ball and is an important part of the male reproductive system. Besides the prostate, the male reproductive system includes the penis, seminal vesicles, and testicles.

deep inside the pelvis. Everyone with a prostate has a chance of getting prostate cancer. It’s usually not fatal, particularly

Cancer is what happens when something goes wrong with the natural cell process causing some cells to grow out of control.

early-stage prostate cancer. This chapter gives an overview of this common cancer.

Cancer cells don’t behave like normal cells. Cancer cells develop genetic changes (mutations) that allow them to multiply and make many more cancer cells. The cancer cells crowd out and overpower normal cells. This can end up harming the body.

What is prostate cancer? Prostate cancer is a disease where cells in the prostate gland grow out of control.

Cancer cells survive much longer than normal cells do. They can replace many normal cells and cause organs to stop working well. Cancer cells can also spread outside the prostate to other areas of the body.

The prostate is a gland located just below the bladder in the pelvis, deep inside the

The prostate gland is an important part of the male reproductive system. It’s located in the pelvis just below the bladder and is about the size of a ping-pong ball.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

1 Prostate cancer basics » What are the symptoms of prostate cancer?

What are the symptoms of prostate cancer?

Prostate cancer is the second most common cancer in American males, after skin cancer.

A symptom is a feeling or problem that can indicate a disease or condition. Prostate cancer often grows slowly and shows no symptoms for a long time.

However, prostate cancer has one of the highest survival rates of any cancer when found early.

But you don’t have to have symptoms to have prostate cancer. In fact, most patients who are diagnosed with early prostate cancer have no symptoms. Symptoms are more common for those with advanced prostate cancer. Symptoms, if they occur, can include:

Blood in the urine or semen

Burning or pain while urinating

Unexplained weight loss

Bone, hip, or back pain

BPH is much more common than prostate cancer. It’s difficult to tell the difference between the two conditions based on symptoms alone. Be sure to tell your health care providers if you have any of these symptoms:

It’s important to know that prostate cancer has many of the same symptoms as a condition called enlarged prostate (also called benign prostatic hyperplasia, or BPH). An enlarged prostate can push against the bladder and compress the urethra, which slows the flow of urine and can cause a feeling that you haven’t fully emptied your bladder.

Urinating frequently, especially at night

Weak or intermittent urine stream

Trouble urinating or straining to urinate

Trouble holding in urine

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Feeling like your bladder hasn’t fully emptied Dull pain in your groin or pelvis Erectile dysfunction (difficulty getting an erection) or painful ejaculation

1 Prostate cancer basics » What are the symptoms of prostate cancer?

Where does the prostate fit in? The prostate is located deep inside the lower body. It makes semen and is important for sexual reproduction. Prostate: A gland in the male reproductive system. A gland is an organ that makes fluids or chemicals the body needs. The prostate gland makes a protein (prostate-specific antigen, or PSA) that nourishes and helps transmit semen. The prostate also contains muscles that help propel semen through the urethra during ejaculation. Semen: A fluid made up of liquids from the prostate and the seminal vesicles as well as sperm from the testicles. During ejaculation, semen is released from the body through the urethra and out through the penis. Urethra: A tube that carries urine from the bladder and out of the body. The prostate wraps around the urethra just beneath the bladder. Seminal vesicles: Two glands that make another part of the fluid that becomes semen. The seminal vesicles are located above the prostate and behind the bladder. Bladder: An organ that holds urine.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

1 Prostate cancer basics » What causes prostate cancer?

What causes prostate cancer?

Genetic factors When cancer “runs in the family,” genetic testing can be done to find specific genetic changes (mutations) known to be linked with prostate cancer or other cancers. For instance, having an inherited genetic change in the BRCA2 gene increases the risk of getting prostate cancer. But genetic abnormalities that aren’t inherited can occur, too.

Many people who develop prostate cancer wonder where it came from and how they got it. Cancer researchers don’t know exactly what causes prostate cells to grow out of control (become cancerous). The fact is, everyone with a prostate has a risk of getting prostate cancer.

Race

But several factors are linked to a higher risk of prostate cancer. These are called risk factors. A risk factor is anything that increases your chance of getting cancer. Risk factors don’t necessarily cause prostate cancer, but people with prostate cancer usually have one or more of these risk factors:

In the United States, Black males are more likely than white males to develop prostate cancer. Prostate cancer in Black males is also more likely to occur at an earlier age and be more aggressive and more advanced when diagnosed. Black males are also twice as likely to die from prostate cancer compared with white males.

Age The biggest risk factor for prostate cancer is age. Prostate cancer is diagnosed most often in those aged 65 years and above. Your chances of getting prostate cancer increase as you become older.

Prostate cancer is diagnosed less often in Hispanic and Asian males than in white and Black males. Several things may contribute to these differences, such as barriers to accessing health care (including early detection screening), biological and genetic factors, and other causes. Specialists are researching each of these areas.

Family history Your family health history is information about the diseases and health conditions in your family. A family history reflects a pattern of certain diseases among family members. Having a close family member with prostate cancer (a sibling or parent) increases the chance of getting it yourself.

In light of these issues, Black males may want to talk with their health care providers about getting screening tests earlier than what’s recommended for other males.

Those with a family history of certain other cancers (breast, ovarian, colon, pancreatic, and other cancers) may also be at a higher risk for prostate cancer. NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

1 Prostate cancer basics » What is early-stage prostate cancer?

What is early-stage prostate cancer?

What does aggressive mean?

Prostate cancer can be grouped into earlystage cancer or advanced-stage cancer.

When health care professionals describe cancer as aggressive, they mean the cancer is likely to grow or spread more rapidly than average.

Early stage Early-stage prostate cancer has not spread beyond the prostate. The cancer usually grows slowly and stays in the prostate. Cancer that is contained entirely within the prostate is called localized prostate cancer.

Aggressive is also used to describe therapy that’s stronger or more intense than other treatment options.

This book is all about early-stage (localized) prostate cancer.

Advanced stage Diet and lifestyle

Advanced stage means that cancer cells have spread outside the prostate to other areas in the body. This spreading is called metastasis or metastatic cancer. Metastatic prostate cancer has spread to the lymph nodes, bones, liver, lungs, and other organs.

No one particular diet has been found to prevent prostate cancer or to cause prostate cancer. However, eating food that’s high in fat, such as meat and dairy products, has been linked with an increased risk of prostate cancer.

Advanced-stage prostate cancer can be separated into two types:

Eating more fruits and vegetables may reduce this risk. Exercise and losing weight may also decrease the aggressiveness of prostate cancer and the likelihood of dying from it. On the other hand, smoking and obesity increase the risks of developing and dying from prostate cancer.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Cancer that grows from the prostate gland to nearby lymph nodes, but no farther, is called regional prostate cancer. (It’s also called locally advanced prostate cancer. This book will call it regional prostate cancer to avoid confusion between localized and locally advanced.) Cancer that spreads outside the prostate to other parts of the body is called metastatic prostate cancer.

1 Prostate cancer basics » What is early-stage prostate cancer?

Early vs. advanced prostate cancer Early-stage prostate cancer has not visibly spread beyond the prostate gland. It usually grows slowly and stays within the prostate. This is also called localized prostate cancer.

Advanced-stage prostate cancer has grown outside the prostate and may have spread to other areas in the body such as lymph nodes (bottom left), bones, or organs like the liver or lungs (bottom right). This is also called metastatic prostate cancer.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

1 Prostate cancer basics » Can prostate cancer be cured?

Can prostate cancer be cured?

Advanced-stage prostate cancer has spread to other areas of the pelvis (regional prostate cancer) or the body (metastatic prostate cancer), and it's usually a life-long disease. But treatment can slow down its growth, reduce symptoms, and prolong your life.

Early-stage prostate cancer is highly treatable and often curable. The earlier that prostate cancer is diagnosed and treated, the more likely that a patient will live without cancer. Most people with early-stage disease live without cancer for many years, usually the rest of their lives.

Treatments for advanced-stage prostate cancer include hormone therapy, chemotherapy, radiation therapy, surgery, and other therapies.

Scientists have learned a great deal about prostate cancer in recent years. As a result, today’s detection methods and treatments work better than those in the past. Also, many patients with prostate cancer have more treatment choices now than they had before.

Early detection and treatment can greatly reduce the chances of getting advanced-stage prostate cancer. Many people with advancedstage prostate cancer continue to live their lives with the cancer and, in the end, may die from something else.

Treatments for early-stage prostate cancer include surgery, radiation therapy, and hormone therapy, among others. However, some people with prostate cancer don’t need to be treated right away. Many patients with early-stage prostate cancer can have their cancer managed with active surveillance.

Something to remember: When found early, prostate cancer has one of the highest survival rates of any cancer.

During active surveillance, you’ll have regular tests to keep an eye on your cancer. But you won’t have treatment unless the cancer grows or changes in a way that requires treatment. The goal of active surveillance is to avoid the potential side effects of treatment, with the option for treatment in the future if you need it. Some patients on active surveillance may never have to be treated.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

1 Prostate cancer basics » Key points

“

Key points

Prostate cancer develops when cells in the prostate gland grow out of control.

Be your own advocate. Talk to someone who has gone through the same thing as you. Ask a lot of questions, even the ones you are afraid to ask. You have to protect yourself and ensure you make the best decisions for you, and get the best care for your particular situation.”

Age is the biggest risk factor for prostate cancer. As you age, your chances of developing prostate cancer increase. Everyone with a prostate is at risk for prostate cancer. Not everyone with prostate cancer has symptoms. For most people, prostate cancer usually grows slowly and stays within the prostate. Early-stage prostate cancer hasn’t spread outside the prostate gland. Advanced-stage prostate cancer has spread outside the prostate to other areas in the body. This spread is called metastasis. Not everyone diagnosed with prostate cancer needs treatment.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Tests for prostate cancer 14

About testing

Common prostate tests

General health tests

Diagnostic tests

What’s next?

Key points

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » About testing

About testing

If you haven’t yet been diagnosed, testing is necessary to find out

if you have prostate cancer and whether it’s early-stage or advanced-stage cancer. Testing also helps your providers plan the right treatment.

This chapter will help you know what tests you may have and what to expect during testing. When you go for testing, bring someone with you to listen, ask questions, and write down the answers. Testing begins with prostate cancer screening tests, followed by tests of your general health, and then diagnostic tests, if needed. Not every person with prostate cancer will receive every test listed here.

When you go for testing, bring someone with you to listen, ask questions, and write down the answers.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » Common prostate tests

Common prostate tests

If there’s something wrong with the prostate— like prostate cancer—the prostate may make more PSA. While most PSA goes into semen, a little bit ends up in the bloodstream, too. An unusually high amount of PSA in the blood may be a sign of prostate cancer. Likewise, an increase in PSA after treatment may indicate that the treatment is losing effectiveness.

Common prostate cancer tests are used to detect the possibility of prostate cancer in someone who’s undiagnosed. They’re also used to check and monitor prostate cancer in patients who have been diagnosed. Two common tests that look for prostate cancer are the prostate-specific antigen (PSA) test and digital rectal exam.

However, age and other factors—such as an enlarged prostate or a urinary tract infection— can also cause high levels of PSA. This means that a PSA test by itself can’t provide a diagnosis of prostate cancer. That’s why a PSA test is often paired with imaging or a digital rectal exam, or both, to decide whether you need a biopsy.

PSA test This is a blood test that measures the amount of PSA in your bloodstream. PSA is a protein made inside the prostate gland. Its job is to help semen transport sperm. All prostate cells, both normal cells and cancer cells, make PSA.

PSA level (also called total PSA) is measured in nanograms of PSA per milliliter (ng/mL) of blood.

PSA testing Prostate-specific antigen (PSA) is a protein made inside the prostate gland. If there’s something wrong with the prostate, the prostate may make more PSA. An unusually high amount of PSA in the blood may be a sign of prostate cancer. But a high PSA level doesn’t automatically mean you have prostate cancer. Rather, it’s a warning sign that you may need further testing.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » Common prostate tests

Digital rectal exam Don’t be fooled by the name—no high-tech electronics are used in a digital rectal exam. For this test, the word “digital” means “finger.” The doctor will insert a finger into your rectum to feel your prostate for any signs of cancer. The doctor will wear gloves and use a lubricant to make it easier.

Don’t fear the digital rectal exam A digital rectal exam is the simplest and most direct way to check the size and texture of your prostate. Although it can be uncomfortable, it’s over in less than a minute.

A digital rectal exam (also called a prostate exam) may be an awkward and unpleasant form of testing. But it’s the simplest and most direct way to check the size and texture of your prostate. An irregular or hardened part of the prostate could be a sign of a tumor. Not all parts of the prostate can be felt during a digital rectal exam, though. So it’s usually paired with a PSA test and other factors— your age, race, family history, and more—to determine whether you need further testing.

Digital rectal exam A digital rectal exam is a procedure in which your doctor inserts a finger into your rectum to feel your prostate. An irregular or hardened part of the prostate could be a sign of a tumor. Not all parts of the prostate can be felt during this exam, though. So other tests, like PSA level and imaging, are used to get a more complete picture of your prostate health.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » General health tests

General health tests

Symptoms and quality of life Your doctor or another member of your care team will ask you a series of questions about what symptoms you may have (such as peeing frequently, difficulty peeing or pooping, or sexual problems). You’ll also be asked how these symptoms affect your quality of life.

Health history Your care team needs to have all your health information. They’ll ask you about any health problems and treatments you’ve had in your life. Be prepared to talk about any illness or injury you’ve had and when it happened. Also tell your doctor about any symptoms you have.

Quality of life refers to your overall satisfaction with your well-being and your ability to participate in regular activities. It’s important to answer all these questions honestly and completely so your care team has a full and up-to-date assessment of how you’re doing.

Bring a list of old and new medicines and any over-the-counter medicines, herbals, or supplements you take. Some of these (such as saw palmetto or St. John’s wort) can cause changes in your PSA level, so your doctor needs to know if you’re taking them.

Blood and urine tests For a blood test, a needle is inserted into a vein in your arm to remove a sample of blood. The sample is examined in a lab where cells, proteins, and other components in the blood are tested for signs of disease or other conditions.

Family history Some cancers and other diseases can run in families. Your care team will ask about the health history of family members who are blood relatives. This information is called a family history.

If you have a higher PSA level, you may have additional blood or urine testing. These tests, sometimes referred to as biomarker tests, can be used in addition to PSA to help decide whether further testing is needed. Such blood tests include 4Kscore, PHI, and IsoPSA, among others. Some of the urine tests include ExoDx, miR Sentinel, MPS, PCA3, and SelectMDx.

It’s important to ask members from both sides of your family about all cancers, not just prostate cancer. Ask family members about other health issues like heart disease and diabetes, at what age they were diagnosed, and if anyone died from cancer. Share this information and any changes to your family history with your care team.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » Diagnostic tests

Diagnostic tests

expert in reading imaging tests. The radiologist will send the results to your doctor. This information helps your doctor plan the next steps of your care. Your doctor will discuss the results with you. Be sure to ask any questions you may have.

If the PSA test, digital rectal exam, blood or urine tests, or other factors (like family history, race, or age) suggest you may have prostate cancer, you’ll be offered diagnostic testing. Talk with your doctor about whether a biopsy or imaging should be the next test you take.

Imaging may not be needed for early-stage prostate cancer. If your PSA, digital rectal exam, and prostate biopsy results indicate that your risk is low for the cancer to metastasize (spread beyond the prostate), then you may not need imaging tests at this time.

Imaging tests An imaging test takes pictures (images) of the insides of your body. The images can reveal cancer, including its size, location, and other features such as the size of the prostate itself. The images may show where the cancer started (primary tumor) and whether the cancer has spread (metastasized). Imaging is also used after cancer treatment to see how well it worked and to check if the cancer comes back.

Your team may recommend one or more of the following imaging tests to look for cancer growth: MRI scan A magnetic resonance imaging (MRI) scan uses radio waves and powerful magnets to take pictures of the inside of the body. An MRI can provide a detailed view of the cancer within the prostate. It’s also used to see if cancer has spread to nearby lymph nodes or to the bones in your pelvis.

Imaging can come before, during, or after a biopsy.

Before – Imaging is sometimes ordered beforehand to find out if a biopsy is truly necessary.

MRI may be used before a biopsy to target areas suspicious for cancer. Or it may be used after diagnosis to figure out whether the cancer has advanced outside the prostate or into the lymph nodes. It can help to plan treatment or to decide whether active surveillance is appropriate. MRI can also be used after treatment to check if the cancer has come back (recurrence).

During – Imaging is used during a biopsy to guide the removal of tissue samples. After – Imaging may come after a biopsy to see the size and location of the cancer, which helps to plan treatment.

Imaging methods for detecting prostate cancer include MRI, CT, PET, ultrasound, bone scan, or a combination of these.

An MRI scanner is a large machine with a tunnel in the middle. An MRI machine makes a lot of noise but you can wear headphones or earplugs and listen to music.

After your scan, your images will be studied by a radiologist. A radiologist is a doctor who’s an NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » Diagnostic tests

You may also be given a contrast agent (sometimes called contrast dye) before the scan. Contrast is used to make blood vessels, organs, and other tissues stand out more clearly in the images. The contrast agent is injected into the bloodstream and flushed out in urine.

CT scan If MRI is unavailable or not recommended for you, you might have a computed tomography (CT or CAT) scan instead. A CT scan takes many x-rays of your body from different angles. A computer combines all the x-ray pictures to make a single detailed image.

An appointment for an MRI scan can take about 1 to 2 hours, including 30 to 60 minutes of actual scanning time. You’ll need to remain as motionless as possible during each scan. You may be positioned with pillows or bolsters to help you keep still.

PET scan A positron emission tomography (PET) scan highlights cells in your body that may be cancerous. A PET scan is used after you’ve been diagnosed to determine the extent of your cancer or to see if it has metastasized. PET imaging can also show how well treatment is working.

Because an MRI uses magnets, don’t bring any metal objects (such as jewelry, cell phone, wristwatch, belts with metal buckles) into the imaging room.

A PET scan requires injecting a radioactive substance called a tracer into your bloodstream. It takes about an hour for the tracer to circulate throughout your body. The tracer targets your cancer cells, which show up as bright spots on the scan. Afterward, the radiotracer is passed out of your body in your urine.

PET imaging A positron emission tomography (PET) scan highlights cells in your body that may be cancerous. A PET scan is used after you’ve been diagnosed to determine the extent of your cancer or to see if it has metastasized. PET imaging can also show how well treatment is working. An irregular or hardened part of the prostate could be a sign of a tumor. Not all parts of the prostate can be felt during this exam, though. So other tests, like PSA level and imaging, are used to get a more complete picture of your prostate health.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » Diagnostic tests

Like an MRI and CT, a PET scanner is a large machine with a tunnel in the middle. A PET appointment can take 1 to 2 hours, including about 30 minutes of actual scanning time.

It’s also used to monitor prostate cancer that may return after treatment (recurrence). So, someone with early-stage prostate cancer may not need PSMA/PET imaging when first diagnosed. Your team will discuss whether a PSMA/PET scan could be helpful for your specific cancer.

Because PET uses a different imaging method, it’s often combined with other types of imaging, such as CT or MRI, to provide an even more detailed image. These combined methods are called PET/CT or PET/MRI scans.

Bone scan A bone scan can detect whether cancer has spread to your bones. A bone scan may be used if you have bone pain, have a high risk for bone metastases, or have changes in certain test results. Bone scans may also be used to monitor treatment.

PSMA/PET PSMA/PET imaging is a special kind of PET imaging that locates a protein called prostatespecific membrane antigen (PSMA) on the surface of prostate cancer cells. Prostate cancer cells make a lot of PSMA, so doctors developed tracers that target this specific protein.

A bone scan uses a radioactive tracer to make pictures of the inside of bones. Before the pictures are taken, the tracer is injected into your bloodstream. It can take a few hours for the tracer to enter your bones.

PSMA/PET is especially useful for detecting cancer that has spread to nearby lymph nodes or has metastasized to farther areas.

PET/CT scan of prostate cancer This image combines PET and CT scans to show a cross-section of a patient’s pelvis. The greenish circle identifies cancer in the prostate, while the intense red dot indicates cancer that has spread to a pelvic lymph node.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » Diagnostic tests

A special camera will take pictures of the tracer in your bones. Areas of bone damage absorb more tracer than healthy bone. These areas show up as bright spots in the pictures. Bone damage can be caused by cancer, cancer treatment, or other health problems.

You and your doctors will decide when, or if, you need a biopsy. A biopsy procedure is usually performed by a urologist. A urologist is a doctor who’s an expert in treating diseases of the urinary system and the male reproductive organs. For this procedure, you’ll lie on your side with your knees curled up or you’ll lie on your back with your legs raised. You’ll be given anesthesia to numb the pain or to put you to sleep. The urologist will insert a lubricated probe into your rectum. The probe provides a visual image of the prostate.

Biopsy Although a high PSA level and an abnormal digital rectal exam are signs of possible prostate cancer, the only way to confirm cancer is to have a biopsy. A biopsy is a procedure in which a sample of cells or tissue is removed from your body and tested for cancer.

The urologist will then insert a hollow needle into the prostate gland using the video display to guide it. The needle will be inserted either through the rectum or through the perineum (the skin between the anus and scrotum). When the urologist removes the needle, it will pull out a small sample of prostate tissue called a core. A core sample is only 1 to 2

A biopsy is an invasive test, which means that it goes into (invades) your body. All invasive tests have some risk. The risks for a prostate biopsy include infection, bleeding, and pain. Doctors use invasive tests only when needed.

Biopsy of the prostate A biopsy removes a sample of tissue that is tested for cancer. This is a transperineal biopsy, in which a needle is inserted through the perineum and into the prostate. An ultrasound probe, which goes into the rectum, helps the doctor guide the needle into the prostate. MRI scans of your prostate may be combined with the ultrasound image to provide a highly accurate picture of the cancer.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

2 Tests for prostate cancer » Diagnostic tests

Genetic tests

millimiters wide and about 12 to 20 millimeters long—about the width of a toothpick and the length of a raisin. The urologist will typically take 12 or more core samples from different parts of the prostate. Checking different areas provides a more complete evaluation of cancer throughout the gland.

A genetic test is used to find abnormal changes in your genes. Genes are small segments of DNA inside every cell. Genes provide the instructions to tell the cell how to make proteins, which carry out a lot of important functions in the body.

After the biopsy samples are removed, they’ll be sent to a lab for testing. At the lab, a specialist called a pathologist will examine the samples under a microscope and test them for cancer. The pathologist will find out how many of the core samples contain cancer and will also measure the percentage of cancer in each core. With this information, the pathologist can estimate the amount of cancer in the prostate. Also, by knowing where each core sample was taken, the pathologist can tell if the cancer is concentrated in a certain section of the prostate.

Once in a while, a gene will have or develop an abnormal change (mutation). A mutation is when something is different in your genes than in most other people’s genes. Sometimes an abnormal change can cause a gene to make the wrong type of protein or make no protein at all. This abnormality could affect the cell, which may in turn cause a disease such as cancer. Mutations can be passed down in families, in which case they occur in every cell in your body. Or mutations can occur spontaneously in just some of your cells. In other words, they may be present before you’re born (called an inherited or germline mutation) or occur on their own later in life (called an acquired or somatic mutation).

The pathologist will put these results into a report. Ask your doctor to review the pathology report with you. It’s common to have more than one biopsy if you’re on active surveillance. You’ll have one biopsy to determine your diagnosis and another biopsy within a year (called a confirmatory biopsy) to see if any changes have happened over time.

The two basic types of genetic tests used for prostate cancer care are germline testing and molecular biomarker testing: Germline testing Sometimes, mutations in genes inherited from your parents can increase the risk of different cancers. You can pass these genes on to your children. Other family members might also carry these mutations. If you have a family history of cancer, your doctor might suggest genetic germline testing to find out if you have an inherited cancer risk.

Having a biopsy may cause complications. A complication is an unwanted and unplanned result from a procedure. Complications may include infection, bleeding from the rectum, or blood in the urine, stool, or semen. These usually go away after a few days or, with semen, after a few weeks. However, it’s important to know that a biopsy doesn’t cause prostate cancer to spread or worsen. NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

The goal of this type of genetic testing is to look for germline (inherited) mutations that 22

2 Tests for prostate cancer » Diagnostic tests

occur in every cell in your body. Genetic germline testing is done using a sample of your blood, urine, or saliva.

For prostate cancer, germline testing looks for characteristic changes in these genes: BRCA1, BRCA2, ATM, CHEK2, MLH1, MSH2, MSH6, PALB2, PMS2, and others. Some mutations can put you at risk for more than one type of cancer. Germline mutations in genes like BRCA1 or BRCA2 are also related to breast cancer, ovarian cancer, pancreatic cancer, and skin cancer (melanoma). Germline mutations in MSH2, MSH6, MLH1, and PMS2 are related to colorectal and uterine cancers in addition to prostate cancer.

Having any other type of cancer

The main reason to have a molecular biomarker test is to help assess whether you have lower risk or higher risk prostate cancer. If you have lower risk cancer, you may be able to avoid or delay treatment such as surgery or radiation therapy, which means you’d also avoid or delay any treatment-related complications and side effects. At the same time, a molecular biomarker test can flag those who have higher risk prostate cancer, which may give them a head start on treatment.

Family members or relatives who have or had prostate cancer, breast cancer, ovarian cancer, intestinal cancer, and certain other cancers

Molecular biomarker testing is discussed further in Chapter 3.

Family history of mutations in certain genes including BRCA1, BRCA2, ATM, CHEK2, and others

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Ashkenazi Jewish ancestry

Molecular biomarker testing In biomarker testing, a sample from your biopsy is tested to look at its molecular components. This information helps figure out how likely your cancer could spread to other parts of the body. Biomarker testing can be considered for those with localized, regional, or metastatic prostate cancer. Biomarker testing is sometimes called genomic testing, tumor profiling, or molecular tumor testing.

Germline testing is recommended for those with prostate cancer and any of the following:

Talk to your medical providers and/or a genetic counselor about your family history of cancer.

If a germline mutation is suspected based on your family’s or your own health history, you should ask about testing. Your doctor can talk to you about testing or refer you to a genetic counselor. A genetic counselor is an expert who has special training in genetic diseases. A genetic counselor can help you decide whether you would like to undergo germline testing and help you interpret the results of these tests.

High-risk, very-high-risk, regional, or metastatic prostate cancer regardless of family history

2 Tests for prostate cancer » What’s next? » Key points

What’s next?

Key points

After you’ve had all these tests to find out if you have prostate cancer, your care team will put together all your test results to figure out whether your prostate cancer is lower risk or higher risk.

Once your level of risk has been identified, your team will assess whether you need treatment and, if so, what your treatment plan will be.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

An unusually high amount of PSA in the bloodstream may be a sign of prostate cancer. A digital rectal exam is the simplest way to check the size and texture of your prostate. A biopsy is used to confirm (diagnose) prostate cancer. It’s a procedure that removes samples of cells or tissue to find cancer. Imaging tests may be used to see if the cancer has spread beyond the prostate. Imaging may not be needed for earlystage prostate cancer. A genetic test is used to find abnormal changes (mutations) in your genes. To find out if you have an inherited risk for cancer, you can talk to your doctor about germline testing or ask to be referred to a genetic counselor. A biopsy sample of your tumor might be tested to look at its molecular components (biomarker testing).

Assessing your risk 26

Risk groups

Life expectancy

Nomograms

Molecular biomarker tests

What’s next?

Key points

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

3 Assessing your risk » Risk groups

It’s important to know the risk of

To assess risk, your care providers use these tools: risk groups, life expectancy, nomograms, and molecular biomarker tests. Although you may not receive all of them, let’s look at each of these assessment tools in turn:

your cancer getting worse. Your care team will look at several key characteristics to assess your risk. This chapter explains each of these characteristics.

Risk groups Your care team will look at the clinical characteristics of your cancer, such as your prostate-specific antigen (PSA) level, biopsy results, and other test results. From this information, your providers can classify your disease into one of five different risk groups, from very low risk to very high risk.

After being told you have cancer, your next thought may be, “How soon can I start treatment to get rid of it?” The fact is, a lot of patients with early-stage prostate cancer don’t need treatment right away. Many never need treatment. Figuring out whether someone needs treatment and which treatment to use requires an assessment of their risks. A risk assessment is a process for identifying potential problems and then considering what would happen if those problems occurred.

Why do you need to know your risk group? Because your risk group is the basis for your prognosis. A prognosis predicts the likely course and outcome of a disease. Your prognosis guides your treatment options. For example, patients with lower risk generally get minimal treatment or no treatment at all. Patients with higher risk usually get more aggressive treatment.

In the case of early-stage prostate cancer, a risk assessment considers how likely the cancer is to remain within the prostate or to spread to outside the prostate. A risk assessment also considers whether the cancer may come back after treatment (recurrence) and, if so, whether it can be controlled with a different type of treatment.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Test results and calculations—PSA level, Grade Group, tumor stage, and biopsy results —are put together to determine your risk group.

3 Assessing your risk » Risk groups

“

PSA level A simple blood test will tell you how much prostate-specific antigen (PSA) is in your bloodstream. A high PSA level may indicate a risk for prostate cancer. However, high PSA levels can vary by age, race, and other factors:

Now more than ever, those living with cancer are living better, longer lives thanks to the power of research and advancements in treatment.”

Age – PSA level tends to increase with age. For people in their 40s, a PSA level above 2.5 ng/mL is very suspicious for disease. For those in their 60s, 4.5 ng/mL or higher is suspicious. A PSA level of 10 ng/mL or higher is a danger sign at any age. Race – Normal PSA levels tend to be higher in Black males than in white males—about 1 point higher on average among males of the same age. Researchers don’t know the reason for this difference, but they’re investigating it.

PSA level doesn’t tell the whole story, though. There are other ways that PSA can be interpreted, such as PSA density. PSA density If you have a larger prostate, you’re also likely to have a higher PSA level. But that doesn’t mean you have a greater risk for prostate cancer. To adjust for this, care providers calculate PSA density.

Enlarged prostate – The larger the prostate, the more PSA it can make. Other health issues besides cancer can also cause an enlarged prostate. Sex and exercise – PSA may increase after ejaculation or vigorous exercise. Your doctor may recommend avoiding sex and exercise for 2 or 3 days before a PSA test. This short break allows PSA to return to its usual level.

PSA density is the amount of PSA compared to the size of the prostate. PSA density is calculated by dividing the PSA level by the prostate size. The size of the prostate is measured by transrectal ultrasound or MRI scan. A higher PSA density (above 0.15 ng/ mL², for example) indicates a greater likelihood of cancer. PSA density also accounts for those with small and very small prostates, who could have prostate cancer even with low PSAs.

Drugs and supplements – Some medicines, herbals, and supplements can also affect PSA level. Biopsy – PSA level rises temporarily after a biopsy of the prostate.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

3 Assessing your risk » Risk groups

Grade Group

Gleason patterns range from 1 to 5. However, patterns 1 and 2 are so rarely found that they are no longer used. So the lowest (most normal) pattern number is 3.

If cancer cells are found in your biopsy samples, further testing can identify your cancer risk. Results from these tests may indicate that the cancer will grow and spread quickly, for example. Or the results may suggest that the cancer will grow very slowly and not spread outside of the prostate at all. This information helps plan the best treatment for your type of cancer.

Gleason score If prostate tumors contained only one pattern of cancer cells, estimating risk would be much easier. But prostate biopsies often contain more than one pattern of cells. To account for this, the two most common Gleason patterns found in the biopsy sample are combined into a single Gleason score. The pattern of cancer cells that takes up the largest area in the sample is assigned the first number. The pattern that accounts for the secondlargest area is given the second number.

By looking at your biopsy samples, the pathologist will identify certain cancer cell patterns (called Gleason patterns), which are used to calculate your Gleason score, which translates to your Grade Group, which estimates your risk. Gleason patterns

Add these two numbers together and you get a Gleason score. For example:

 Gleason score



pattern 3 + pattern 4 = Gleason score of 7

Grade Group



A Gleason score represents how much your biopsy sample looks like normal prostate tissue. It also estimates how aggressive your prostate cancer is—how quickly it might grow and whether it will spread. A higher Gleason score means the cancer is more likely to grow and spread quickly than a cancer with a lower Gleason score.

Risk

This can be confusing at first (Gleason patterns? Gleason score? Grade Group?) but it’s not all that complicated in the end. Read on. Gleason patterns After studying your biopsy sample under a microscope, the pathologist will assign a number based on the “pattern” of cancer cells (Gleason pattern) in the sample. A cancer cell pattern that looks more like normal and healthy cells is given a lower number. A cell pattern that looks more abnormal is assigned a higher number.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Gleason scores range from 6 to 10, where 6 is the lowest score. A Gleason score of 7 is intermediate-grade, and 8 to 10 is high-grade. This can be confusing because 6 seems like it would be a medium score, not a low score. So to make Gleason scores simpler to use, they can be organized into Grade Groups.

3 Assessing your risk » Risk groups

Grade Groups A Grade Group is a way to interpret a Gleason score. There are five Grade Groups, numbered 1 to 5. The higher the Grade Group, the more aggressive the cancer. So cancer with a Gleason score of 6 is assigned as Grade Group 1 to show that it is the lowest score. Likewise, cancer with a Gleason score of 9 or 10 becomes Grade Group 5, the highest score.

7. The difference is the cancer in Grade Group 3 is more serious. Why? Because the first number of the Gleason score in Grade Group 3 (4+3) is higher than the first number in Grade Group 2 (3+4). Remember, the first number is given to the cancer pattern that makes up the largest area of the biopsy sample. Grade Group 1 indicates low risk. Grade Groups 2 and 3 correspond to intermediate risk. Grade Groups 4 and 5 predict high risk and very high risk. See Guide 1.

Importantly, the Grade Group system also takes into account that Grade Group 2 and Grade Group 3 both have a Gleason score of

Guide 1 How to find your risk from your Gleason score Gleason patterns

Gleason score

Grade Group

3+3

3+4

4+3

4+4 3+5 5+3

4+5 5+4 5+5

9 or 10

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Prognosis Low-grade cancer is less aggressive and is likely to grow and spread very slowly. If the cancer is small, many years may pass before it becomes a problem. Low-grade cancer may never need treatment. Intermediate-grade cancer is moderately aggressive and likely to grow and spread at a modest pace. If the cancer is small, several years may pass before it becomes a problem. To prevent problems, treatment may be needed.

High-grade cancer is very aggressive and likely to grow and spread quickly. If the cancer is small, a few years may pass before the cancer becomes a life-threatening problem. To prevent problems, treatment is needed now.

3 Assessing your risk » Risk groups

Tumor stage

A letter may also be included after the tumor stage (T2a, for example) to give more information based on the digital rectal exam or an examination of prostate tissue. The letter stands for the extent of cancer and/or its location in the prostate. See Guide 2.

The next characteristic that contributes to your overall risk group is the tumor stage. Staging is a way to describe the severity of the cancer in your body and how far it has spread. Knowing your stage is important for predicting the course of your disease and for making a treatment plan.

Cancer staging is often done twice. The first time is before any treatment. The second time is during or after treatment to see how well the treatment has worked.

The tumor, node, metastasis (TNM) system is used to stage prostate cancer. In this system, the letters T, N, and M stand for different areas of cancer growth:

Biopsy results Results from your core needle biopsy also help to determine your overall risk group. One finding is the number of core samples that contain cancer (for example, 5 out of 12 in each core). Using this information, the pathologist can estimate the amount of cancer in the entire prostate. Biopsy results can also show whether the cancer is concentrated in a certain section (or sections) of the prostate.

T (tumor) – Describes the size of the main (primary) tumor and if it has grown outside the prostate N (node) – Identifies whether cancer has spread to lymph nodes M (metastasis) – Indicates if cancer has spread to distant parts of the body (metastasized)

What’s your risk group? Based on the results of these tests and calculations—PSA level, Grade Group, tumor stage, and biopsy results—you’ll be placed into an initial risk group. See Guide 3.

Your providers will assign a number to each letter, based on test results. For example, the number after T ranges from 0 through 4 based on the tumor’s size and growth. The higher the number, the larger the tumor or the more the cancer has spread.

Your risk group helps determine which treatment options may be best for you. Using these tests together to create risk groups is more reliable than using any test by itself to choose treatment options.

The T, N, and M scores are combined to assign a stage to the cancer. Let’s say your prostate cancer is given a TNM score of T2, N0, M0. This score means that the tumor is big enough to be felt during a digital rectal exam (T2). But the numbers after N and M are zeros because early-stage cancer hasn’t spread outside the prostate gland to lymph nodes (N0) or to distant parts of the body (M0). NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

But risk groups aren’t the only risk assessment tool. There’s also life expectancy, nomograms, and molecular biomarker tests.

3 Assessing your risk » Life expectancy

Life expectancy

means life expectancy can be applied to a certain population or age range, but it’s not as easy to make a precise estimate of the lifespan of an individual person.

Life expectancy is the average lifespan of a person. It’s measured in years. An estimate of your life expectancy is a key factor in deciding which tests and treatments you’ll need.

So why estimate your life expectancy? Sometimes, patients in certain risk groups should wait until symptoms appear before having tests or starting treatment. There may be no benefit to having additional tests or

It’s important to know that life expectancy— when used for cancer care—is an estimate based on large numbers of people. That

Guide 2 Tumor details for T stage T1 – The tumor can’t be felt by a digital rectal exam, but a biopsy found cancer cells. T1a – The tumor is found unexpectedly during another procedure. Only a small part (5 percent [5%] or less) of the removed tissue is cancer. T1b – The tumor is found unexpectedly during another procedure. More than a small part (more than 5 percent [5%]) of the removed tissue is cancer. T1c – A high PSA level called for a biopsy of the prostate. T2 – The tumor can be felt by a digital rectal exam. It hasn’t spread outside the prostate. T2a – Cancer is found in half or less than half of one side of the prostate. T2b – Cancer is found in more than half of one side of the prostate, but it isn’t in both sides. T2c – Cancer has grown into both sides of the prostate. T3 – The tumor has spread outside the prostate to nearby tissues, but no farther. T3a – Cancer has grown outside the prostate, but not into the seminal vesicle(s). T3b – Cancer has grown outside the prostate and into the seminal vesicle(s). T4 – The tumor has spread outside the prostate to nearby tissues and also to other areas such as the bladder, rectum, pelvic wall, and/or pelvic muscles. NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

3 Assessing your risk » Life expectancy

Guide 3 Characteristics that make up your risk group Risk group

PSA level

Grade Group

Tumor stage

Biopsy results

Must have all of these characteristics: Very Low Risk

Less than 10 ng/mL*

T1c

Cancer found in 1 or 2 biopsy cores with no more than half of each core showing cancer

Must have all of these characteristics: Low Risk

Favorable Intermediate Risk

Unfavorable Intermediate Risk

Less than 10 ng/mL

T1 to T2a

Cancer found in more than 3 biopsy cores, but fewer than half of all cores show cancer

Must have all of these characteristics: 10 to 20 ng/mL

T2b or T2c

1 or 2

Cancer found in fewer than half of all biopsy cores

Must have at least one of these characteristics: 10 to 20 ng/mL

T2b or T2c

Cancer found in more than half of all biopsy cores

Only one of these characteristics needed: High Risk

More than 20 ng/mL

4 or 5

T3a

More than half of all biopsy cores show cancer, but fewer than 4 cores are Grade Group 4 or 5

Must have at least one of these characteristics: Very High Risk

More than 20 ng/mL

T3b to T4

5**

More than 4 biopsy cores are Grade Group 4 or 5

* With PSA density less than 0.15 ** In the cancer cells that take up the largest area in the biopsy sample NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

3 Assessing your risk » Nomograms » Molecular biomarker tests

Molecular biomarker tests

undergoing treatment if you don’t have any symptoms or if you have other more lifethreatening health conditions.

A biomarker is something found in your body that can be measured to assess your health. One type of cancer biomarker is a molecule released by a tumor.

If you don’t have any symptoms, are expected to live 10 years or less, and have very-low-risk, low-risk, or intermediate-risk prostate cancer, then observation is usually recommended. This is different than active surveillance, which usually involves routine imaging and biopsies.

Molecular biomarker tests use samples of your blood or your prostate or lymph node tissue removed during a biopsy. Results from these and other tests may help choose a treatment plan that’s right for you.

We’ll talk more about life expectancy and how it impacts treatment options in Chapter 5.

Importantly, molecular biomarker tests can help identify patients with lower risk prostate cancer who don’t need treatment right away. These patients can be spared aggressive treatment along with its complications and side effects.

Nomograms A nomogram predicts your prognosis, which is the likely course your cancer will take. A nomogram uses math to compare you and your prostate cancer to hundreds or thousands of other patients who have been treated for prostate cancer.

A molecular biomarker test is also known as a molecular tumor test, genomic test, somatic test, or tumor profiling. A few of the more common molecular tests for prostate cancer are named Decipher, Genomic Prostate Score, and Prolaris.

To use a nomogram, your doctor will input information about you and the characteristics of your cancer—your age, PSA level, Gleason score, or other details—and the nomogram will calculate the likelihood of a certain outcome (such as the cancer spreading).

If your doctor or genetic counselor recommends molecular testing, it would be in addition to standard measures such as PSA, Gleason score, Grade Group, and imaging. If you have any questions about why you’re having a test or what it means, ask your care team.

Risk groups and nomograms both provide information that is specific to you, but nomograms can give somewhat more accurate estimates of cancer risk. Both are used, along with other risk assessment tools, to plan treatment.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

3 Assessing your risk » What’s next? » Key points

What’s next?

Key points

This chapter explained how your care providers figure out your risk for your prostate cancer to grow and spread. Your risk level determines which treatment options are available to you. In many cases, early-stage cancer grows very slowly and may not spread (metastasize) to other parts of the body. So you may not need treatment right away.

Still, it’s important to know about all the types of therapies available, if and when you do need treatment. The next chapter describes each of the treatment options for early prostate cancer. After that chapter, you’ll read about which treatments may be best for you depending on your level of risk.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

A risk assessment identifies potential problems and then considers what would happen if those problems occurred. A risk assessment for early-stage prostate cancer takes into account your risk group, life expectancy, nomogram results, and possibly molecular biomarker profile. Patients with lower risk generally get minimal or no treatment. Patients with higher risk usually get more aggressive treatment. Cancer staging describes how much cancer is in the body and where it is located. Life expectancy is an estimate of the number of years you will likely live. It’s based on large numbers of people and is not an exact prediction. But it can help choose the best treatment for you. A nomogram predicts the course your cancer will likely take (prognosis). An important feature of molecular tumor (biomarker) testing is that it can identify lower risk prostate cancer that doesn’t need treatment right away.

Prostate cancer treatments 36

Active surveillance

Observation

Surgery

Radiation therapy

Hormone therapy

Cryotherapy

High-intensity focused ultrasound

Clinical trials

Supportive care

Key points

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » Active surveillance

There’s more than one treatment

PSA once or twice a year

for prostate cancer. This chapter

Digital rectal exam once a year

describes all the treatment

MRI every 1 to 2 years

options. Talk with your care team

Prostate biopsy every 2 to 5 years

about which treatment might be

You won’t receive any cancer treatment during active surveillance. But treatment will begin if your cancer grows or spreads.

best for you.

Why wait to be treated? Mainly because surgery and other forms of treatment have side effects. If you can delay treatment without harm—or avoid it altogether—then you can also delay or entirely avoid the side effects of treatment.

Prostate cancer is usually a slow-growing disease. It’s also a complex disease with many treatment options. Common treatments for early-stage prostate cancer include surgery and radiation therapy, which are sometimes combined with hormone therapy.

In general, active surveillance is the preferred strategy for patients with lower-risk prostate cancer and a longer life expectancy (10 years or more).

Then again, your treatment plan may include no direct therapy but instead involve active surveillance or observation.

To see if you’re a good candidate for active surveillance, you may need a confirmatory MRI with or without a confirmatory prostate biopsy. These confirmatory tests are usually performed within a year of your diagnosis to see if any changes have happened during that time.

Active surveillance Active surveillance is a plan that closely watches your condition, with treatment at the ready if needed. Because a small tumor can grow very slowly, it’s possible to wait to treat prostate cancer until the tumor grows larger. During this time, you’ll have tests and biopsies on a regular basis to look for changes in tumor growth.

Other factors to consider for active surveillance:

Although your care team may ask you to have tests more or less frequently, regular testing during active surveillance may follow a schedule like this:

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Your life expectancy

Your overall health

Features or unique qualities of your tumor

Possible side effects of treatment

Your wishes about treatment

4 Prostate cancer treatments » Observation » Surgery

A big question about active surveillance: When do you know to switch from surveillance to treatment? There are a number of factors, but the most common one is that a patient’s Grade Group in a recent biopsy has increased compared to a previous biopsy.

active surveillance involves frequent testing to see whether the cancer is progressing in order to treat it before it can get worse.

Surgery

Other reasons for starting treatment may include an increase in the size of the tumor or a rise in PSA level.

Surgery is a procedure to remove cancer from the body. The tumor is removed along with some normal-looking prostate tissue around its edge called the surgical margin.

Observation

Observation involves monitoring your prostate cancer and watching for symptoms. (You may hear it called watch-and-wait or watchful waiting.) If symptoms develop, treatment is often focused on palliative care or symptom relief instead of trying to cure the cancer.

A negative margin is when no cancer cells are found around the edge of the tissue that the surgeon removes.

A negative margin is the better result because it means that all the tumor in that area has likely been removed. On the other hand, a positive margin doesn’t always mean that you’ll have a recurrence.

Palliative care treats the symptoms of cancer and the side effects of cancer treatment. This allows patients to maintain a good quality of life without the burden of unnecessary treatment.

Surgery can be used as the main (primary) treatment. Or surgery may be only one part of your treatment plan. The type of surgery you receive depends on the size and location of the tumor. It also depends on whether cancer is found in any surrounding organs or tissues.

Observation often applies to older or frail patients with intermediate-risk prostate cancer and shorter life expectancies (5 to 10 years). It’s also recommended for patients with lower risk prostate cancer and short life expectancy (5 years or less). These patients commonly have one or more other illnesses or diseases that are more severe than their prostate cancer.

Radical prostatectomy Prostatectomy means removing the prostate gland through surgery. A radical prostatectomy removes not only the entire prostate but also the surrounding tissue, seminal vesicles, and sometimes the nearby lymph nodes. So it can be a highly effective way of curing prostate cancer.

Observation is different from active surveillance. Observation is a less aggressive way to monitor prostate cancer. It doesn’t require regular biopsies—just a visit for a physical once or twice a year. By comparison, NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

A positive margin is when cancer cells are found along the edge of the tissue that the surgeon removes.

4 Prostate cancer treatments » Surgery

Shared decision-making Some people with cancer want their doctors and treatment team to just tell them which treatment to have. Doctors, nurses, and other providers are the experts, right? While it’s true that your treatment team has lots of experience and knowledge, you’re also an expert— you’re the expert on you. It’s a good idea for your team to share the responsibility of your treatment with you. And it’s a good idea for you to fully participate in making decisions about your care. Here’s what your treatment team should share with you: •

An explanation of the likely benefits and potential harms of each treatment option.

•

The likelihood of cure, recurrence, progression, and possible mortality with each treatment option.

•

The side effects of each treatment option along with its impact on quality of life, including sexual, urinary, and bowel function.

And here’s what you should share with your treatment team: •

Your preferences and feelings about treatment, side effects, risks, and quality of life. These should be key parts of your treatment plan.

If the provider who’s leading your treatment team doesn’t have a talk with you about shared decision-making, feel free to speak up and ask about it.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » Surgery

Side effects of surgery

Radical prostatectomy is often used when:

Radical prostatectomy frequently causes two side effects:

The tumor is found only in the prostate. The tumor can be removed completely with surgery.

Urinary incontinence. After a radical prostatectomy, most people temporarily lose the ability to control when they pee. This is called urinary incontinence and it can be a major problem.

You have a life expectancy of 10 years or more. You have no other serious health conditions.

Right after the procedure, a catheter will be inserted into your urethra to allow you to empty your bladder and for your urethra to heal. The catheter will stay in place for 1 to 2 weeks after surgery. You’ll be shown how to care for it while at home. If the catheter is removed too early, you may lose control of your bladder or be unable to urinate due to scar tissue.

A radical prostatectomy is complex and requires a great deal of skill. Surgeons who are experienced in this type of surgery often have better results. There are two surgical methods for radical prostatectomy:

Open surgery removes the prostate through a single cut or incision. The incision is long enough to let your doctor directly view and access the tumor to remove it.

After the catheter is removed, you may need to use absorbent pads or incontinence underwear for several weeks or months. You can also do exercises that strengthen the pelvic floor muscle. (If you haven’t had prostate surgery yet, consider starting pelvic floor exercises beforehand to help to reduce urinary incontinence afterward.) In addition, certain prescription medications can reduce the need to pee so often.

Minimally invasive surgery uses several small incisions or holes instead of one larger cut. The surgeon inserts small tools through each incision to perform the surgery. In most centers, the surgeon uses a robot to guide the tools more precisely.

Most patients gradually recover most of the control of their bladder within a year, though many continue to use pads for minor leaks. If incontinence continues to be a major problem, you can have a surgical procedure to control urination.

Minimally invasive surgery has become more common than open surgery. Patients who receive minimally invasive surgery may have shorter hospital stays, less blood loss, fewer surgical complications, or faster recovery time. The major side effects from minimally invasive radical prostatectomy—incontinence and erectile dysfunction—occur about as often as they do with open surgery. NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » Surgery

Erectile dysfunction. Erectile dysfunction means having difficulty or being unable to have an erection of the penis. It’s a common problem after prostate surgery, but it often— although not always—improves over time.

prostatectomy, but damage to the nerves during surgery is sometimes unavoidable. Removing your prostate and seminal vesicles will cause you to have dry orgasms. This means there will be no semen, which would prevent you from having children. You may want to look into sperm banking before the surgery if you’re thinking of having children.

There’s a higher risk for erectile dysfunction if:

You are older You have erectile problems before surgery

It may take several months to 2 years to restore the erectile function you had before the prostatectomy. However, you may never regain the same erectile function or sex drive you once had. Treatment options for erectile dysfunction include pills (like Viagra and Cialis), injections of medication into the penis, vacuum constriction devices (“penis pump”), and surgical implants that produce an erection.

Your cavernous nerves are damaged or removed during surgery

The cavernous nerves control the ability to have erections. These nerves run alongside the prostate. Surgeons do their best to avoid these nerves when performing a

Open vs. minimally invasive prostatectomy A prostatectomy is an operation that removes the whole prostate. Open surgery removes the prostate through a single cut or incision. Minimally invasive surgery uses several small incisions or holes instead of one larger cut.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » Radiation therapy

EBRT

It’s also common to have psychological as well as relationship problems with erectile dysfunction. It’s a leading cause of depression in patients with prostate cancer. This happens often and is nothing to be ashamed of.

External beam radiation therapy (EBRT) uses a large machine outside the body that aims radiation at cancer inside the body. The radiation is focused directly on the cancer (and on surrounding areas where the cancer could spread), while trying to avoid healthy tissue. This technique delivers higher doses of radiation more safely than radiation therapy in the past.

Ask your doctor or someone else on your care team about therapy or counseling if you’re having problems due to erectile dysfunction or symptoms of depression. While it may be uncomfortable to talk about these problems, keep in mind that these side effects are common and help is readily available.

You won’t become radioactive and you can’t pass radiation to loved ones with this treatment.

Radiation therapy

Two forms of EBRT are used for treating prostate cancer. Photon radiation therapy delivers high-energy x-rays to destroy cancer cells and stop them from spreading. It’s used in the majority of treatments because it’s available at more centers. Proton beam radiation therapy uses streams of electrically charged particles called protons to precisely target cancer cells. Both are very good at treating prostate cancer and have similar risks of side effects.

Radiation therapy uses high-energy radiation, like x-rays or gamma rays, to kill cancer cells and shrink tumors. Radiation therapy is given in regular doses over a certain period of time. Radiation can be used instead of surgery to treat cancer. Sometimes, radiation therapy is given after surgery to help prevent your cancer from coming back. Also, if your PSA begins to rise after surgery, radiation therapy might be recommended to try to kill any cancer cells that could have been left behind. One advantage of radiation therapy is that it’s less invasive than surgery.

Both forms of EBRT require careful planning. A week to several weeks before you start therapy, you’ll have a radiation simulation. You won’t receive any actual treatment during the simulation. You’ll lie on the treatment table and get into the best position for receiving the radiation.

There are two main types of radiation treatment for prostate cancer: radiation from outside the body (external beam radiation therapy) and radiation from inside the body (brachytherapy).

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Because you’ll need to remain motionless during the treatment, you may be fitted with positioning devices to help you keep still. You’ll also have imaging to map the location of the tumor inside your body. This allows your treatment team to calculate the right amount of radiation delivered at the precise spot. 41

4 Prostate cancer treatments » Radiation therapy

During the treatment itself, the machine may rotate around the treatment table to deliver radiation from several different angles. You won’t be able to feel the radiation when it’s delivered. A treatment session may take up to an hour, but the actual radiation time will take only a few minutes. Treatments are usually given every day for several days or weeks.

Brachytherapy may be used alone or combined with EBRT, hormone therapy, or both. Patients with high-risk cancers aren’t usually considered for brachytherapy alone. You might hear it called brachy (said “braykey”) for short.

Brachytherapy

High dose-rate brachytherapy involves a procedure where 10 to 20 very narrow tubes are inserted through the perineum and into your prostate. Thin wires with radioactive tips slide through the tubes and are held within the prostate for several minutes. During this time, the tips deliver a high dose of radiation to the prostate. The wires are then retracted and the needles are removed, leaving no radioactive material behind.

Brachytherapy is an internal form of radiation therapy. In this treatment, radiation is delivered inside the body by placing a radioactive object into or next to the tumor. This can be invasive and is often done as a surgical procedure.

Low dose-rate brachytherapy is delivered by dozens of tiny metal “seeds” that are permanently implanted in your prostate. The seeds gradually release a continuous low dose of radiation over months.

Some treatments require specialized radiation planning and delivery techniques. In certain cases, stereotactic body radiation therapy (SBRT) may be used. SBRT uses precise image-guided targeting to deliver higher doses of radiation in a fewer number of days.

External beam radiation therapy External beam radiation therapy (EBRT) uses a machine that precisely aims radiation at cancer inside the body. The radiation beam focuses on the cancer while avoiding healthy tissue. This allows for safer delivery of higher doses of radiation, sometimes with fewer treatments.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » Hormone therapy

Side effects of radiation therapy

Erectile dysfunction. Radiation therapy can damage the nerves that control erections. Erectile dysfunction doesn’t happen right away after radiation. It usually occurs gradually, starting and then worsening between 1 to 3 years after radiation treatment. (For more, see “Erectile dysfunction” in the earlier section Side effects of surgery, page 40.) Having hormone therapy in addition to radiation therapy can make this side effect more likely.

Side effects that occur during or after treatment, called acute side effects, are more common but often temporary. Side effects that occur months to years later, called late side effects, are less common. Some of the common side effects of radiation therapy are urinary and bowel problems, erectile dysfunction, and fatigue.

Fatigue. Feeling very tired for a few weeks to months after radiation treatment is also common. However, regular physical activity and exercise can help relieve fatigue.

Urinary and bowel problems. Urinary problems include having to go more often, having to go suddenly, a burning sensation when you go, and sometimes blood in the urine. Bowel problems can include diarrhea, pooping frequently, being unable to hold it in and, rarely, bleeding from the rectum. Urinary and bowel problems usually lessen or go away after several weeks for most people but can last longer for others.

Hormone therapy Hormone therapy is rarely used by itself for the treatment of early-stage prostate cancer. When hormone therapy is used (generally for

Brachytherapy radiation Low dose-rate brachytherapy uses tiny radioactive metal “seeds” that are implanted into your prostate. Each seed is about the size of a grain of rice. They’ll stay in your prostate permanently and provide a low dose of radiation continuously for several months. This treatment strategy spares nearby healthy tissue from unnecessary radiation.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » Hormone therapy

patients with higher risk), it’s usually given with radiation therapy, which increases radiation’s effectiveness. Hormone therapy may be given before, during, or after radiation therapy.

Hormone therapies for prostate cancer include luteinizing hormone-releasing hormone (LHRH) agonists and LHRH antagonists, both of which cause the testicles to stop making testosterone. Most LHRH agonists and LHRH antagonists are injections. These may be given monthly or 2, 3, or 4 times a year. Antiandrogens, corticosteroids, and androgen synthesis inhibitors are available as pills and taken 1 to 3 times a day, depending on the medication. See Guide 4.

Hormone therapy is treatment that adds, blocks, or removes hormones. A hormone is a natural chemical made by a gland in the body. Its job is to activate cells or organs. Male hormones are called androgens. The main androgen is testosterone. Most of the testosterone in the body is made by the testicles. Testosterone helps produce sperm, among other functions. But testosterone also helps prostate cancer grow. A type of hormone therapy called androgen deprivation therapy (ADT) can stop your body from making testosterone or block cancer cells from using testosterone. This can shrink the tumor or slow tumor growth for a while.

Side effects of hormone therapy Hormone therapy has significant side effects. Many factors affect your risk for side effects including your age, your health before treatment, how long or often you have treatment, and other things. In general, the longer you’re on hormone therapy, the greater your risk of thinning and weakening of your bones (osteoporosis), bone fractures, weight gain, loss of muscle mass, diabetes, and heart disease. You may need an x-ray scan (DEXA scan) to check your bone density before starting hormone therapy.

You might hear the term “castration” used when describing prostate cancer or its treatment. This term describes a drastic reduction of testosterone. Castration can be a short-term reversible treatment using drugs or it can be permanent surgical removal of one or both testicles (orchiectomy). Though orchiectomy is a surgical procedure, it’s still considered hormone therapy because it removes the primary source of testosterone: the testicles. Unlike drug hormone therapy, orchiectomy can’t be reversed.

Other side effects of hormone therapy include tiredness (fatigue), mood changes, weight gain, and growth and tenderness of your breasts. Hormone therapy increases the risk for diabetes and cardiovascular disease. If you already have either of these conditions, hormone therapy can cause them to get worse. Hormone therapy may increase the risk of death from heart issues, particularly in Black patients.

Surgical removal of the testicles is much less common today because drug therapy is often just as effective at blocking testosterone. Orchiectomy is now used only for advanced metastatic prostate cancer.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » Cryotherapy

In addition, the sexual side effects of hormone therapy are a significant cause of stress. Hormone therapy may lower your desire for sex, cause erectile dysfunction, and reduce the size of the penis and testicles. Erectile dysfunction medicines (such as Viagra and Cialis) aren’t usually effective for those on hormone therapy, but other injected medicines may be helpful. These drugs don’t restore the loss of sexual desire caused by lower androgen levels.

medicine as well as with physical activity. Exercise and eating a healthy diet can also help with fatigue, mood, and weight gain.

It may take a year or more to regain your testosterone level and sex drive. Many patients never fully regain the same levels of testosterone and libido that they had before hormone therapy.

Cryotherapy

Loss of sex drive, erectile dysfunction, and other sexual side effects usually go away after you stop hormone therapy. In the meantime, consider talking to your partner and/or a therapist to help you deal with any problems you’re having.

Cryotherapy, also known as cryosurgery or cryoablation, destroys cancer cells by freezing them.

Talk to your care team about how to manage the side effects of hormone therapy. They have ways to lessen or soothe most of these problems. Bones can be strengthened with

For this treatment, long hollow needles are inserted through the perineum (the area between the scrotum and anus) and into the prostate. Freezing cold gas is sent through the

Guide 4 Hormone therapy drugs for early-stage prostate cancer LHRH agonists

Eligard (leuprolide), Lupron Depot (leuprolide), Trelstar (triptorelin), Zoladex (goserelin)

LHRH antagonists

Firmagon (degarelix), Orgovyx (relugolix)

Anti-androgens

Casodex (bicalutamide), Eulexin (flutamide), Nilandron (nilutamide)

Corticosteroids*

methylprednisolone, prednisone

Androgen synthesis inhibitors*

Zytiga (abiraterone)

* Only for patients with very-high-risk prostate cancer NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » High-intensity focused ultrasound » Clinical trials

Clinical trials

needles to destroy cancer tissue or the entire prostate. Cryotherapy affects only the prostate, leaving the surrounding area unharmed. You’ll be given anesthesia to relieve any pain during the procedure.

Therapy may also be given as part of a clinical trial. A clinical trial is a type of medical research study. After being developed and tested in a laboratory, potential new ways of fighting cancer need to be studied in people. If found to be safe and effective in a clinical trial, a drug, device, or treatment approach may be approved by the U.S. Food and Drug Administration (FDA).

Cryotherapy is not a standard treatment for newly diagnosed prostate cancer. It’s mainly used as a secondary therapy for people with early prostate cancer whose cancer returns after radiation treatment. Side effects of cryotherapy can include pain, erectile dysfunction, and urinary incontinence.

Everyone with cancer should carefully consider all of the treatment options available for their cancer type, including standard treatments and clinical trials.

High-intensity focused ultrasound

Talk to your doctor about whether a clinical trial may make sense for you.

Like cryotherapy, high-intensity focused ultrasound isn’t a standard treatment for newly diagnosed prostate cancer. It’s mainly used for early prostate cancer that returns after radiation treatment.

Phases Most cancer clinical trials focus on treatment. Treatment trials are done in phases.

High-intensity focused ultrasound, or HIFU, destroys prostate tissue with heat generated by high-energy ultrasound waves. For this procedure, an ultrasound probe is inserted into the rectum. The probe focuses high-frequency sound energy on the prostate, leaving the surrounding tissue unaffected. The energy converts into high heat, which vaporizes one portion of tissue at a time until the entire tumor is destroyed.

Side effects of HIFU are usually temporary and include having to pee urgently or more often, or having a weak or slower urine stream. Urinary incontinence and erectile dysfunction are also possible.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Phase 1 trials study the dose, safety, and side effects of an investigational drug or treatment approach. They also look for early signs that the drug or approach is helpful. Phase 2 trials study how well the drug or approach works against a specific type of cancer. Phase 3 trials test the drug or approach against a standard treatment. If the results are good, it may be approved by the FDA. Phase 4 trials study the long-term safety and benefit of an FDA-approved treatment.

4 Prostate cancer treatments » Clinical trials

Who can enroll? Every clinical trial has rules for joining, called eligibility criteria. The rules may be about age, cancer type and stage, treatment history, or general health. These requirements ensure that participants are alike in certain ways in order to compare how their disease responds to a specific treatment.

“

Without clinical trials, our treatment wouldn’t change. It would always remain the same. Some people refer to clinical trials as receiving tomorrow’s best treatment today.”

Informed consent Clinical trials are managed by a group of experts called a research team. The research team will review the study with you in detail, including its purpose and the risks and benefits of joining. All of this information is also provided in an informed consent form. This is an agreement that confirms you’ve been fully told about your part in the trial. Read the form carefully and ask questions before signing it. Take time to discuss it with family, friends, or others you trust. Keep in mind that you can leave and seek treatment outside of the clinical trial at any time.

Frequently asked questions There are many myths and misconceptions surrounding clinical trials. The possible benefits and risks are not well understood by many with cancer. Will I get a placebo? Placebos (inactive versions of real medicines) are almost never used alone in cancer clinical trials. It is common to receive either a placebo with a standard treatment or a new drug with a standard treatment. You will be informed, verbally and in writing, if a placebo is part of a clinical trial before you enroll.

Start the conversation Don’t wait for your doctor to bring up clinical trials. Start the conversation and learn about all of your treatment options. If you find a study that you may be eligible for, ask your treatment team if you meet the requirements. If you have already started standard treatment, you may not be eligible for certain clinical trials. Try not to be discouraged if you cannot join. New clinical trials are always becoming available.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Are clinical trials free? There’s no fee to enroll in a clinical trial. The study sponsor pays for research-related costs, including the study drug. You may, however, have costs indirectly related to the trial, such as the cost of transportation or childcare due to extra appointments. During the trial, you will continue to receive standard cancer care. This care is billed to—and often covered by—your insurance. You are responsible for copays and any costs for this care that are not covered by your insurance.

4 Prostate cancer treatments » Supportive care

Supportive care Supportive care aims to improve your quality of life. Supportive care (sometimes called palliative care) is health care that relieves the symptoms caused by cancer and the side effects caused by its treatment.

Finding a clinical trial

Supportive care addresses many needs: relieving symptoms, preventing or lessening treatment side effects, advising about nutrition and diet, and providing emotional or spiritual support, financial aid, or family counseling. Supportive care can also help with making treatment decisions.

In the United States NCCN Cancer Centers NCCN.org/cancercenters The National Cancer Institute (NCI) cancer.gov/about-cancer/treatment/ clinical-trials/search

Supportive care is important at any stage of cancer, not just at the end of life. In fact, people who start supportive care when they begin treatment tend to have improved outcomes and better quality of life.

Worldwide The U.S. National Library of Medicine (NLM) clinicaltrials.gov

Supportive care involves the whole person, not just their cancer. If you’re having a problem that’s interfering with your treatment or affecting your quality of life, ask what supportive care resources may be available to help you.

Need help finding a clinical trial? NCI’s Cancer Information Service (CIS) 1.800.4.CANCER (1.800.422.6237) cancer.gov/contact

Support groups Many people diagnosed with cancer find support groups to be helpful. Support groups often include people at different stages of treatment. Some people may be newly diagnosed, while others may be finished with treatment. If your hospital or community doesn’t have support groups for people with prostate cancer, check out the websites listed on page 80 of this book.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

4 Prostate cancer treatments » Key points

Key points

Active surveillance is the preferred strategy for most patients with lowerrisk prostate cancer and a longer life expectancy. Surgery removes the tumor along with some normal-looking tissue around its edge called a surgical margin. The goal of surgery is to leave no cancer cells in the surgical margin.

“

When you are deciding on your treatment options, remember that even though some decisions need to be made fast, don’t rush. Think through your options and get second, or even third opinions. Have people you can trust to talk through your options so you feel comfortable in your decisions.”

A radical prostatectomy removes the whole prostate, the surrounding tissue, the seminal vesicles, and sometimes the nearby lymph nodes in the pelvis. Radiation can kill cancer cells and stop new cancer cells from being made. Hormone therapy treats prostate cancer by stopping testosterone from being made or by blocking cancer cells from using testosterone. It’s sometimes used in combination with radiation therapy for early-stage prostate cancer. Castration describes a drastic reduction of testosterone. This can be done surgically or with drugs. Supportive care is important at any stage of cancer, not just at the end of life.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Initial treatment for your risk group 51

Very low risk

Low risk

Intermediate risk

Favorable intermediate risk

Unfavorable intermediate risk

High risk or very high risk

After treatment

Key points

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » Very low risk

Very low risk

You’ve had a lot of tests to assess your risk for prostate cancer. You

Patients included in the very-low-risk group have all of the following traits:

and your care team will now use your risk assessment to decide your initial treatment options.

Has your doctor or care team told you which risk group you’re in?

Stage T1c tumor

Grade Group 1

PSA less than 10 ng/mL

If you know your risk group, look for it in the following pages to learn about your initial therapy options.

Cancer in 1 to 2 biopsy cores with no more than half of each core showing cancer PSA density less than 0.15 ng/mL

NCCN experts are concerned about overtreatment of early-stage prostate cancer. One result of overtreatment is that the treatment might cause more problems than the disease itself. For many patients, especially those with lower risk prostate cancer, active surveillance or observation can be better options than direct treatment. Treatment options, based on life expectancy, are described next. Also see Guide 5.

Guide 5 Very-low-risk group: Initial therapy options Life expectancy

Initial therapy

10 years or more

Active surveillance

Less than 10 years

Observation

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » Very low risk

Life expectancy: 10 years or more

Life expectancy: Less than 10 years

If you have very-low-risk prostate cancer and your life expectancy is 10 years or more, options include:

If you have very-low-risk prostate cancer and your life expectancy is less than 10 years, observation is often recommended.

Active surveillance Active surveillance is the preferred option if you have slow-growing prostate cancer and your life expectancy is 10 years or more. Tests during active surveillance include prostatespecific antigen (PSA), digital rectal exam, MRI scan, and biopsies. These tests are done on a regular basis so that treatment can be started when and if needed. See Guide 6.

Observation This option is for those who have other more serious health problems and whose prostate cancer isn’t causing any symptoms. Observation involves occasional PSA tests and watching for symptoms, which can be treated with palliative therapy.

To see if you’re a good candidate for active surveillance, you may need a confirmatory MRI (if you haven’t received an MRI already) with or without a confirmatory prostate biopsy. All patients should have a confirmatory prostate biopsy 1 to 2 years after their initial biopsy.

Guide 6 Tests during active surveillance Test

Frequency

PSA test

Once or twice a year, or as needed

Digital rectal exam

Once a year, or as needed

Repeat MRI

Every 1 to 2 years, or as needed

Repeat prostate biopsy

Every 2 to 5 years, or as needed

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » Low risk

Low risk

Radiation therapy If you’ll likely live more than 10 years, you may decide you want treatment now instead of active surveillance. Low-risk cancers can be treated with radiation therapy, either external beam radiation therapy (EBRT) or brachytherapy.

The low-risk group includes patients who have all of the following traits:

Stage T1 to T2a tumor

Grade Group 1

PSA of less than 10 ng/mL

Prostate surgery Prostate surgery (radical prostatectomy) removes the whole prostate. It's not a common treatment option for people with low-risk prostate cancer.

Cancer found in more than 3 biopsy cores, but fewer than half of all cores show cancer

Treatment options are based on life expectancy. The initial treatment options for low-risk disease are described next and shown in Guide 7 on the next page.

In certain cases when prostate surgery is chosen for a patient with low-risk prostate cancer, the pathologist will look for signs of disease called adverse (or high-risk) features. See Guide 8 on the next page. If your prostate cancer has adverse features after prostate surgery, then you’ll be monitored or perhaps have additional treatment to prevent the cancer from returning. If test results don’t show adverse features, then you can be monitored for cancer recurrence.

Life expectancy: 10 years or more If you have low-risk prostate cancer and your life expectancy is 10 years or more, initial treatment options are: Active surveillance Active surveillance is the preferred option if you have slow-growing disease and you have a longer life expectancy. See Guide 6.

Life expectancy: Less than 10 years If you have low-risk prostate cancer and your life expectancy is less than 10 years, observation is often recommended.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Observation Observation is for those who have other more serious health problems and whose prostate cancer isn’t causing any symptoms. Observation involves occasional PSA tests and watching for symptoms, which can be treated with palliative therapy.

5 Initial treatment for your risk group » Low risk

Guide 7 Low-risk group: Initial therapy options Life expectancy

Initial therapy

Additional therapy

Active surveillance (preferred)

10 years or more

Radiation therapy (EBRT or brachytherapy)

Prostate surgery

Less than 10 years

Monitoring for cancer recurrence If needed,* additional treatment may include EBRT and/or hormone therapy

Observation

* See Guide 8 for adverse features

Guide 8 Adverse features

If tests show you have any of these high-risk features after prostate surgery, you may need additional therapy:

• Cancer in the normal-looking tissue removed with the tumor (surgical margin) • Cancer outside the layer surrounding the prostate • Cancer in the seminal vesicle(s) • Cancer in the lymph nodes • A detectable level of PSA

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » Intermediate risk » Favorable intermediate risk

Intermediate risk

Favorable intermediate risk

The intermediate-risk group is for those who don't have high-risk or very-high-risk group features but do have one or more of the following intermediate risk factors:

The favorable intermediate-risk subgroup is for those who have all of the following traits:

1 intermediate risk factor Grade Group 1 or 2

Stage T2b or T2c tumor

Grade Group 2 or 3

PSA 10 to 20 ng/mL

Less than half of biopsy cores show cancer

Treatment options are based on life expectancy. See Guide 9 on the next page.

The intermediate-risk group is further divided into favorable and unfavorable subgroups. Treatment is based on whether your prostate cancer is favorable intermediate risk or unfavorable intermediate risk:

Life expectancy: 10 years or more If you have favorable intermediate-risk prostate cancer and your life expectancy is 10 years or more, there are three initial treatment options: Active surveillance Active surveillance consists of testing on a regular basis so that treatment can be started when needed. For favorable intermediate-risk disease, you should be watched closely for any changes. See Guide 6.

NCCN experts are concerned about overtreatment of early-stage prostate cancer. In certain cases, overtreatment may cause more problems than the cancer itself.

To see if you’re a good candidate for active surveillance, you may need a confirmatory MRI (if you haven’t received an MRI already) with or without a confirmatory prostate biopsy and/ or molecular biomarker testing. Patients in the favorable intermediate-risk group who have a low percentage of Gleason pattern 4 cancer, low tumor volume, low PSA density, and/or low genomic risk (according to a molecular tumor analysis) are particularly good candidates for active surveillance.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » Favorable intermediate risk

Radiation therapy Radiation therapy is a treatment option for some patients with favorable-intermediate risk. Radiation treatments include either EBRT or brachytherapy.

You might have additional treatment after prostate surgery to help prevent the cancer from returning. This is called adjuvant therapy. Adjuvant therapy options are based on whether high-risk (adverse) features are found as a result of prostate surgery. Having adverse features suggests that not all of the cancer was removed during surgery. See Guide 8.

Prostate surgery If you’re expected to live 10 years or more, surgically removing your prostate (radical prostatectomy) may be an option. Your pelvic lymph nodes may also be removed if there’s a small risk for cancer to spread to them. Your urologist will determine this risk using a nomogram. A surgical procedure called a pelvic lymph node dissection (PLND) is performed to remove the nodes and check them for cancer.

If test results don’t find high-risk features after prostate surgery, then you’ll be monitored for recurrence of cancer. Monitoring involves periodic PSA tests and sometimes digital rectal exams. If your PSA level rises during monitoring, you’ll have further tests to see if the cancer has returned.

Guide 9 Favorable intermediate-risk group: Initial therapy options Life expectancy

Initial therapy

Additional therapy

Active surveillance (preferred)

10 years or more

Radiation therapy Prostate surgery with or without pelvic lymph node dissection

5 to 10 years

Observation (preferred) Radiation therapy

* See Guide 8 for adverse features NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Monitoring for cancer recurrence If needed,* additional treatment may include EBRT and/or hormone therapy

5 Initial treatment for your risk group » Unfavorable intermediate risk

Unfavorable intermediate risk

Life expectancy: Between 5 and 10 years If you have favorable intermediate-risk prostate cancer and your life expectancy is between 5 and 10 years, there are two treatment options:

The unfavorable intermediate-risk subgroup is for those who have one or more of the following:

Observation Observation is the preferred option for those with a life expectancy of 5 to 10 years and whose prostate cancer isn’t causing symptoms. Observation involves occasional PSA tests and watching for symptoms, which can be treated with palliative therapy.

2 or more intermediate-risk factors

Grade Group 3

More than half of biopsy cores show cancer

Treatment options are based on life expectancy. Treatment options for patients with unfavorable intermediate-risk cancer are shown in Guide 10 on the next page.

Radiation therapy Radiation therapy is a treatment option for some with favorable-intermediate risk. Radiation treatments include either EBRT or brachytherapy.

Life expectancy: 10 years or more If you have unfavorable intermediate-risk prostate cancer and your life expectancy is 10 years or more, your initial treatment options include radical prostatectomy or radiation and hormone therapy. Prostate surgery Surgically removing your prostate (radical prostatectomy) may be an option. Your pelvic lymph nodes may also be removed if there’s a small risk for cancer to spread to them. Your urologist will determine this risk using a nomogram. A surgical procedure called a pelvic lymph node dissection (PLND) is performed to remove the nodes and check them for cancer.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » Unfavorable intermediate risk

You may receive additional treatment after surgery to help stop the cancer from returning. This is called adjuvant therapy. Adjuvant therapy will be started after you’ve healed from your prostate surgery. The choice of adjuvant therapy is based on whether your cancer has high-risk (adverse) features and/or lymph node metastasis. See Guide 8. Having adverse features suggests that not all the cancer was removed during prostate surgery.

monitoring, you’ll have further tests to see if the cancer has returned. Radiation and hormone therapy Radiation therapy plus hormone therapy is also an initial treatment option for those with unfavorable intermediate risk and life expectancy of 10 years or more. Radiation therapy can be EBRT or brachytherapy, along with 4 to 6 months of hormone therapy.

Guide 10 Unfavorable intermediate-risk group: Initial therapy options Life expectancy

10 years or more

Initial therapy

Additional therapy

Prostate surgery with or without pelvic lymph node dissection

Monitoring for cancer recurrence If needed,* additional treatment may include EBRT and/or hormone therapy

Radiation therapy and hormone therapy Observation 5 to 10 years

Radiation therapy (EBRT or brachytherapy) and hormone therapy

* See Guide 8 for adverse features NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » High risk or very high risk

High risk or very high risk

Life expectancy: Between 5 and 10 years

The high-risk group includes those who have only one of the following characteristics:

If you have unfavorable intermediate-risk prostate cancer and your life expectancy is 5 to 10 years, your treatment options include: Observation Because the cancer may progress too slowly to cause problems within 5 to 10 years, active surveillance is not recommended for patients in this risk group. Observation is the recommended option instead. Observation involves occasional PSA tests and watching for symptoms, which can be treated with palliative therapy.

Stage T3a tumor

Grade Group 4

Grade Group 5

PSA of more than 20 ng/mL

More than half of the biopsy cores show cancer, but fewer than 4 cores are Grade Group 4 or 5 The very-high-risk group includes those who have one or more of the following characteristics:

Radiation and hormone therapy Radiation therapy plus hormone therapy is also a treatment option for those in the unfavorable-intermediate risk group. Treatment includes EBRT or brachytherapy, plus 4 to 6 months of hormone therapy.

Stage T3b to T4 tumor

Primary Gleason pattern 5

2 or more high-risk factors

More than 4 biopsy cores that are Grade Group 4 or 5

Those who have high-risk or very-high-risk cancer and are expected to live 5 years or less should undergo bone imaging to see if the cancer has spread to any bones. Imaging of your abdomen and pelvis is also important to look for cancer in the lymph nodes and areas besides the prostate. Treatment is more aggressive for high-risk and very-high-risk prostate cancer. Treatment options are based on life expectancy and whether or not you have symptoms. See Guide 11 on the next page.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » High risk or very high risk

Life expectancy: More than 5 years or you have symptoms

before, during, and after radiation therapy for 18 months to 3 years.

If your life expectancy is more than 5 years or you have symptoms, there are several options for initial therapy:

Another radiation therapy option is EBRT, brachytherapy, and long-term hormone therapy (1 to 3 years). Combining EBRT and brachytherapy allows for more careful control of the radiation dose. When hormone therapy is added to this combination, patient outcomes tend to improve.

Radiation therapy Radiation therapy combined with longterm hormone therapy is an effective initial treatment for patients at high risk or very high risk. For this option, hormone therapy is given

Guide 11 High-risk and very-high-risk groups: Initial therapy options Life expectancy

Initial therapy

Additional therapy

Radiation therapy and hormone therapy

More than 5 years or you have symptoms

Radiation therapy, hormone therapy, and Zytiga (abiraterone) only for very-high-risk patients Prostate surgery with or without pelvic lymph node dissection Observation

5 years or less and you have no symptoms

Hormone therapy Radiation therapy (EBRT)

* See Guide 8 for adverse features NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Monitoring for cancer recurrence If needed,* additional treatment may include EBRT and/or hormone therapy

5 Initial treatment for your risk group » High risk or very high risk

“

There’s also a radiation treatment option just for patients with very-high-risk prostate cancer: Zytiga (abiraterone) can be combined with radiation therapy and 2 years of hormone therapy.

It’s OK to have bad days, but don’t let yourself stay there. A positive attitude goes a long way.”

Prostate surgery If you’re expected to live more than 5 years, a radical prostatectomy with the removal of your pelvic lymph nodes (pelvic lymph node dissection, or PLND) is an option for patients in the high-risk group and certain patients in the very-high-risk group. Your age and overall health will be factors in deciding if this is a good option for you.

If cancer has spread to your lymph nodes but there are no other adverse features, then monitoring is a reasonable option if your PSA level is undetectable. However, if your PSA level begins to rise during monitoring, you may need treatment for PSA recurrence. Hormone therapy (with or without EBRT) is also an option for additional therapy. You might start the hormone therapy right away with the option of adding radiation therapy later. See Chapter 7: Making treatment decisions.

You may receive additional treatment after prostate surgery to help prevent the cancer from returning. Treatment will be started after you’ve healed from the prostate surgery. Options for additional treatment after a prostatectomy are based on whether you have adverse (high-risk) features and/or cancer in the lymph nodes after prostate surgery. See

Guide 8.

If test results find no adverse features, no additional treatment is needed. Your cancer will be monitored. Monitoring involves periodic PSA tests and sometimes digital rectal exams. If your PSA level begins to rise during monitoring, you may need treatment for PSA recurrence. See Chapter 7. If test results find adverse features but no cancer in the lymph nodes after surgery, the preferred option is being monitored for cancer recurrence. EBRT (with or without hormone therapy) is also an additional treatment option. EBRT targets areas where the cancer cells have likely spread. Hormone therapy might be added to EBRT to improve outcomes. NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

5 Initial treatment for your risk group » After treatment

After treatment

Life expectancy: 5 years or less and no symptoms

After your initial treatment and your additional treatment, if needed, you’ll be monitored for any increase in PSA or cancer recurrence. Monitoring involves these follow-up tests:

There are three options for high-risk or veryhigh-risk prostate cancer when life expectancy is 5 years or less and you have no symptoms: Observation Observation is the option for most people in these higher-risk groups. Observation involves occasional PSA tests and watching for symptoms, which can be treated with palliative therapy. See Guide 11.

Hormone therapy If observation isn’t a good fit, hormone therapy is an option. Hormone therapy can be medical or surgical castration. Medical castration is treatment with drugs to drastically reduce male hormones. Surgical castration is the permanent surgical removal of one or both testicles (orchiectomy).

Digital rectal exam, if your doctor suspects cancer recurrence

If lymph node metastases are found while you’re on hormone therapy or under observation, or if your PSA (and digital rectal exam, if performed) indicates the cancer has returned, then you’ll have additional imaging and discussions of your options. Options may include ongoing monitoring or additional (or different) treatment. See Chapter 6: PSA persistence and recurrence.

Radiation therapy EBRT is an option because it’s been shown to be effective in patients with high-risk and veryhigh-risk prostate cancer. Supportive care In addition to these treatments, you may also receive supportive care (palliative care). Supportive care is for relieving the symptoms caused by cancer and the side effects caused by its treatment.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

PSA test every 6 to 12 months for 5 years, then once a year after that (For patients with a high risk of recurrence, PSA testing every 3 months may be better)

5 Initial treatment for your risk group » Key points

Key points

NCCN experts are concerned about overtreatment of early-stage prostate cancer. For many patients with lower risk prostate cancer, observation or active surveillance can be better options than direct treatment. All patients choosing active surveillance should have a confirmatory prostate biopsy 1 to 2 years after their initial biopsy. Adjuvant therapy is additional treatment after initial therapy that helps prevent cancer from returning. If there’s a risk that cancer has spread or will spread to lymph nodes within the pelvis, then a surgical procedure called a pelvic lymph node dissection (PLND) is performed to remove the lymph nodes and check them for cancer. After a radical prostatectomy, additional (adjuvant) treatment may help prevent the cancer from returning. The choice of adjuvant treatment is based on whether there are adverse (high-risk) features and/ or cancer in the lymph nodes after the surgery. Treatment is more aggressive for highrisk and very-high-risk cancer. For those who choose surgery, adjuvant treatment with radiation therapy is often needed. Sometimes long-term hormone therapy is also added to improve outcomes. If your PSA level begins to rise after initial treatment, you may need treatment for PSA recurrence.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

PSA persistence and recurrence 65

Testing for persistence or recurrence

Treatment for persistence or recurrence

What’s next?

Survivorship

Key points

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

6 PSA persistence and recurrence » Testing for persistence or recurrence

Testing for persistence or recurrence

Even after treatment with prostate surgery or radiation therapy, your PSA level may not go down low

Before deciding on any treatment, you’ll need some more tests to find out how aggressive the cancer may be. Imaging is used to find out whether cancer has returned in the pelvis or another area of the body.

enough. Or your PSA level may drop but, at some point, begin to rise again. These are usually signs that you’ll need further treatment.

If you had a radical prostatectomy, all the cells that make PSA should be gone, so your PSA level should be undetectable. If you had radiation therapy, your PSA level should fall steadily to near zero.

But in about 1 in 3 people with prostate cancer, their PSA level either doesn’t drop low enough (called PSA persistence) or it drops to near zero buts eventually starts to rise again (called PSA recurrence). PSA recurrence may not happen for several years after initial treatment.

PSA persistence and PSA recurrence may be signs that the cancer hasn’t fully gone away or that it has come back in other parts of the body. For these reasons, treatment for PSA persistence and PSA recurrence often includes both local and systemic (wholebody) therapies. The local therapy is usually radiation, while systemic therapy involves hormone treatment. Most of the treatment options listed in this chapter are for those with a life expectancy of more than 5 years. For those with a life expectancy of 5 years or less, observation and/or supportive care (palliative therapy) may be more reasonable options than undergoing treatment. NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

PSA doubling time – This test measures the time that the PSA level takes to double. If it doubles in a short amount of time (6 months or less, for example), it suggests that the cancer is growing quickly. Imaging – This often includes imaging the whole body. Biopsy – If your PSA is elevated or imaging shows possible cancer somewhere, you may need a biopsy of that area. A biopsy may be needed in the prostate after radiation, in the prostate bed after surgery, or somewhere else like the seminal vesicles, a lymph node, or a bone.

6 PSA persistence and recurrence » Treatment for persistence or recurrence

Treatment for persistence or recurrence

After radiation therapy If you have PSA recurrence and your initial treatment was radiation therapy, your next treatment depends on your latest test results:

If your life expectancy is more than 5 years, treatment for PSA persistence or PSA recurrence is based on whether your previous treatment was radical prostatectomy or radiation therapy. See Guide 12 on the next page.

No other cancer found If your PSA level is up but tests don’t find cancer in pelvic lymph nodes or anywhere else in the body, you may have another biopsy or simply be monitored with regular testing. If symptoms appear or treatment is needed, you may be given hormone therapy or a radical prostatectomy, if appropriate. Other, nonsurgical options include cryotherapy, highintensity focused ultrasound (HIFU), or more radiation therapy.

After prostate surgery If you have PSA persistence or PSA recurrence and your initial therapy was radical prostatectomy, your next treatment depends on your latest test results: No other cancer found If your PSA level is up but tests don’t find cancer in lymph nodes in the pelvis or anywhere else in the body, the preferred treatment is radiation therapy with or without hormone therapy. Monitoring is an option for certain patients.

Cancer in the pelvis If tests find cancer in lymph nodes in the pelvis, your options include monitoring or treatment with hormone therapy (with or without abiraterone). Other treatment options (given with or without hormone therapy) include radiation or dissection of pelvic lymph nodes.

Cancer in the pelvis If tests find cancer in lymph nodes in the pelvis, then you may be given radiation therapy, possibly combined with hormone therapy. Additional hormone therapy with abiraterone may also be included.

Cancer in another area of the body If tests find that cancer has spread to another area of the body, that means the cancer has metastasized and needs more advanced treatment. See the NCCN Guidelines for Patients: Advanced-Stage Prostate Cancer available at NCCN.org/patientguidelines and on the NCCN Patient Guides for Cancer app.

Cancer in another area of the body If tests find that cancer has spread to another area of the body, it means the cancer has metastasized and needs more advanced treatment. See the NCCN Guidelines for Patients: Advanced-Stage Prostate Cancer.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

6 PSA persistence and recurrence » Treatment for persistence or recurrence

Guide 12 Treatment for PSA persistence or PSA recurrence Initial therapy

Radical prostatectomy

Test results

Treatment options for persistence or recurrence

No other signs of cancer

• Radiation therapy with or without hormone therapy (preferred) • Monitoring

Cancer in pelvic lymph nodes

• Radiation therapy and hormone therapy with or without abiraterone

Cancer has spread to another area of the body (metastasized)

• Advanced treatment required

No other signs of cancer

• Biopsy • Monitoring • Hormone therapy • Radical prostatectomy • Cryotherapy • High-intensity focused ultrasound • More radiation therapy

Cancer in pelvic lymph nodes

• Biopsy • Monitoring • Hormone therapy with or without abiraterone • Radiation therapy of pelvic lymph nodes with or without hormone therapy • Dissection of pelvic lymph nodes with or without hormone therapy

Cancer has spread to another area of the body (metastasized)

• Advanced treatment required

Radiation therapy

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

6 PSA persistence and recurrence » What’s next? » Survivorship

What’s next?

Survivorship

After you’ve been treated for PSA persistence or PSA recurrence, you’ll continue to have tests and visits to treat your existing cancer or to watch out for cancer to return. Surveillance is a key part of your follow-up plan. Be sure to continue to go to follow-up visits and stay in touch with your treatment team.

Survivorship focuses on the health and wellbeing of a person with cancer, from diagnosis until the end of life. This includes the physical, mental, emotional, social, and financial effects that begin at diagnosis, continue through treatment, and arise afterward. Survivorship also includes concerns about follow-up care, late effects of treatment, cancer recurrence, and quality of life. Support from family members, friends, and caregivers is also an important part of survivorship.

If the cancer comes back again but doesn’t spread beyond the pelvis, you can continue to have treatment for persistence/recurrence. If the cancer comes back again but spreads to another area of the body, you’ll need more advanced treatment. See the NCCN Guidelines for Patients: Advanced-Stage Prostate Cancer. As always, you can ask to join a clinical trial.

Read more about survivorship in the NCCN Guidelines for Patients: Survivorship Care for Healthy Living and Survivorship Care for Cancer-Related Late and Long-Term Effects, available at NCCN.org/patientguidelines and on the NCCN Patient Guides for Cancer app.

It’s common to feel frustration, anger, regret, despair, and uncertainty—even all at the same time. Know that you can have prostate cancer and still enjoy living after diagnosis and treatment. Try to take as much pleasure in life as possible. Talk with family or friends. Join a support group to learn how other patients are dealing with their cancer. Or talk to your doctor or another member of your care team. They can point you to professionals who can help you deal with these feelings and guide you toward your next steps.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

6 PSA persistence and recurrence » Key points

Key points

After treatment for prostate cancer, some people have PSA persistence (PSA level doesn’t drop low enough) or PSA recurrence (PSA level drops buts starts to rise again).

We want your feedback!

PSA persistence and PSA recurrence may be signs that cancer hasn’t fully gone away or that it may come back in other parts of the body.

Our goal is to provide helpful and easy-to-understand information on cancer.

For those with PSA persistence or recurrence and a life expectancy of 5 years or less, observation may be a more reasonable option than undergoing treatment.

Take our survey to let us know what we got right and what we could do better. NCCN.org/patients/feedback

If tests find that cancer has spread to another area of the body, that means the cancer has metastasized and needs more advanced treatment. You can have prostate cancer and still enjoy life after diagnosis and treatment.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Making treatment decisions 71

It’s your choice

Questions to ask

Resources

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » It’s your choice » Questions to ask

It’s important to be comfortable with

Think about what you want from treatment. Discuss openly the risks and benefits of specific treatments and procedures. Weigh options and share concerns with your care team.

the cancer treatment you choose. This choice starts with having an open and honest conversation with your care team about the benefits

Second opinion

and risks of treatment.

It’s normal to want to start treatment as soon as possible. While cancer treatment shouldn’t be ignored, there is usually time to have another cancer care provider review your test results and suggest a treatment plan. This is called getting a second opinion, and it’s a normal part of cancer care. Even doctors get second opinions!

It’s your choice Treatment decisions are very personal. What is important to you may not be important to someone else. In shared decision-making, you and your providers share information, discuss the options, and agree on a treatment plan. Be clear about your goals for treatment and find out what to expect from treatment. It starts with an open and honest conversation between you and your team.

Seek out a prostate cancer specialist, if you can, because they have experience diagnosing and treating a lot of people with your type of cancer. Things you can do to prepare:

Some things that may play a role in your decision-making:

What you want and how that might differ from what others want Your religious and spiritual beliefs

Your feelings about certain treatments like surgery or hormone therapy

Check with your insurance company about its rules on second opinions. There may be out-of-pocket costs to see providers who are not part of your insurance plan. Make plans to have copies of all your records sent to the doctor you will see for your second opinion.

Your feelings about pain or side effects

Questions to ask

Cost of treatment, travel to treatment centers, and time away from school or work

Possible questions to ask your cancer care team are listed on the following pages. Feel free to use these or come up with your own. Have a notebook handy to jot down the answers to your questions.

Quality of life and length of life How active you are and the activities that are important to you

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » Questions to ask

Questions about cancer testing 1. What tests will I have? 2. Do the tests have any risks? 3. Will my insurance pay for all the tests you are recommending? 4. Do I need to do anything to prepare for testing? 5. Should I bring someone with me to the appointments? 6. Where do I go for testing, and how long will it take? 7. If any of the tests will hurt, what will you do to make me comfortable? 8. How soon will I know the results and who will explain them to me? 9. How can I get a copy of the pathology report and other test results? 10. What is the cancer stage? What does this stage mean in terms of survival?

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » Questions to ask

Questions about treatment options 1. What are my treatment options? 2. Is a clinical trial an option for me? 3. What will happen if I do nothing? 4. Are you suggesting options other than what NCCN recommends? If yes, why? 5. How do my age, sex, overall health, and other factors affect my options? 6. Does any option offer a cure or long-term cancer control? 7. What are the side effects of the treatments? 8. Will the treatment hurt? 9. How long do I have to decide about treatment, and is there a social worker or someone who can help me decide? 10. How do I get a second opinion?

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » Questions to ask

Questions about resources and support 1. Who can I talk to about help with housing, food, and other basic needs? 2. What assistance is available for transportation, childcare, and home care? 3. Who can tell me what my options for health insurance are and assist me with applying for insurance coverage? 4. How much will I have to pay for my treatment? What help is available to pay for medicines and other treatment? 5. Who can help me with my concerns about work or school? 6. How can I connect with others and build a support system? 7. Who can I talk to if I don’t feel safe at home, at work, or in my neighborhood?

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » Questions to ask

Questions about what to expect 1. Does this hospital or cancer center offer the best treatment for me? 2. Do I have a choice of when to begin treatment? 3. How long will treatment last? 4. Will my insurance cover the treatment you’re recommending? 5. Are there any programs to help pay for treatment? 6. What supportive care and services are available to me and my caregivers? 7. Who should I contact with questions or concerns if the office is closed? 8. How will you know if treatment is working? 9. What are the chances of the cancer worsening or returning? 10. What follow-up care is needed after treatment?

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » Questions to ask

Questions about side effects 1. What are the possible complications and side effects of treatment? 2. Which side effects are most common and how long do they usually last? 3. Which side effects are serious or life-threatening? 4. Are there any long-term or permanent side effects? 5. What symptoms should I report right away, and who should I contact? 6. Will treatment affect my ability to urinate? Or have an erection? 7. What can I do to prevent or relieve the side effects of treatment? 8. Do any medications worsen side effects? 9. Do any side effects lessen or worsen in severity over time? 10. Will you stop or change treatment if there are serious side effects?

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » Questions to ask

Questions about clinical trials 1. Do you recommend that I consider a clinical trial for treatment? 2. How do I find clinical trials that I can participate in? 3. What are the treatments used in the clinical trial? 4. Has the treatment been used for other types of cancer? 5. What are the risks and benefits of this treatment? 6. What side effects should I expect and how will they be managed? 7. How long will I be in the clinical trial? 8. Will I be able to get other treatment if this doesn’t work? 9. How will you know if the treatment is working? 10. Will the clinical trial cost me anything?

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » Questions to ask

Questions about your care team’s experience 1. Are you board certified? If yes, in what area? 2. What is your experience as well as your team’s experience with treating my type of prostate cancer? 3. How many patients like me (of the same age, race) have you treated? 4. Will you be consulting with experts to discuss my care? Whom will you consult? 5. Is my treatment or procedure a major part of your practice? How often have you done this treatment or procedure in the last year? 6. How many of your patients have had complications? What were the complications?

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Notes

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

7 Making treatment decisions » Resources

Resources

PCaAware National Prostate Cancer Awareness Foundation pcaaware.org

AnCan Foundation ancan.org

Prostate Conditions Education Council (PCEC) prostateconditions.org

Bag It bagitcancer.org

Prostate Health Education Network (PHEN) prostatehealthed.org

Cancare Cancare.org

Triage Cancer triagecancer.org

CancerCare cancercare.org

ZERO Prostate Cancer zerocancer.org

Cancer Hope Network cancerhopenetwork.org FORCE: Facing Our Risk of Cancer Empowered facingourrisk.org Imerman Angels imermanangels.org Malecare malecare.org National Alliance of State Prostate Cancer Coalitions (NASPCC) naspcc.org National Coalition for Cancer Survivorship canceradvocacy.org

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Words to know

Words to know active surveillance Frequent and ongoing testing to watch for changes in cancer status so treatment can be started if needed.

erectile dysfunction A lack of blood flow to the penis that limits getting or staying erect. external beam radiation therapy (EBRT) A treatment in which a machine outside the body aims radiation precisely at cancer inside the body.

androgen deprivation therapy (ADT) Hormone therapy that stops the body from making testosterone or blocks cancer cells from using testosterone. ADT can be given through drugs or surgery.

genetic abnormality An abnormal change in the cell’s instructions for making and controlling cells. Also called a mutation.

anti-androgen A drug that stops the action of the hormone testosterone.

Gleason score A rating of how much prostate cancer cells look like normal cells under the microscope.

biopsy A procedure that removes fluid or tissue samples to be tested for disease.

Grade Group Like a Gleason score, a Grade Group is a rating of how much prostate cancer cells look like normal cells under the microscope. Grade Groups are meant to be easier to use than Gleason scores.

brachytherapy A treatment with radiation from an object placed near or in the tumor. Also called internal radiation. castration Surgery that removes the testicles or drugs that suppress the function of the testicles to keep testosterone levels low or close to zero.

hormone therapy A cancer treatment that stops the making or action of hormones. Also called androgen deprivation therapy.

computed tomography (CT) An imaging test that uses x-rays from many angles to make a picture of the inside of the body.

life expectancy The number of years a person is likely to live based on statistics of other people in similar circumstances.

digital rectal exam An exam of the prostate by feeling it through the wall of the rectum.

luteinizing hormone-releasing hormone (LHRH) agonist A drug that acts in the brain to stop the testicles from making testosterone.

enlarged prostate An overgrowth of tissue in the prostate that isn't caused by cancer. Also sometimes called benign prostatic hyperplasia. NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Words to know

luteinizing hormone-releasing hormone (LHRH) antagonist A drug that acts in the brain to stop the testicles from making testosterone.

positron emission tomography (PET) A test that uses radioactive material to see the shape and function of body parts. prostate-specific antigen (PSA) A protein made by the prostate that helps semen transport sperm. PSA is measured in nanograms per milliliter of blood (ng/mL).

magnetic resonance imaging (MRI) A test that uses radio waves and powerful magnets to make pictures of the insides of the body.

PSA density The level of PSA—a prostate-made protein—in relation to the size of the prostate.

metastasis The spread of cancer from the site where it started to a new site.

PSA persistence When PSA level is still detectable after prostate cancer treatment.

nerve-sparing radical prostatectomy An operation that removes the prostate and one or neither cavernous nerve bundle.

PSA recurrence When PSA level drops after prostate cancer treatment but then rises again.

nomogram A mathematical tool that uses health information to predict an outcome.

radiation therapy Treatment that uses high-energy rays (radiation) to kill cancer cells.

observation A period of watching for cancer growth or occurrence while not receiving treatment.

radical prostatectomy An operation that removes the entire prostate as well as surrounding tissue, seminal vesicles, and sometimes lymph nodes.

orchiectomy An operation to reduce testosterone in the body by removing one or both testicles. palliative therapy Health care for the symptoms of cancer or the side effects of cancer treatment. Palliative therapy is an important part of supportive care.

recurrence The return of cancer after a disease-free period. risk factor Something that increases the chance of getting a disease.

pathologist A doctor who specializes in testing cells and tissue to find disease.

seminal vesicle One of two male glands that makes fluid used by sperm for energy.

pelvic lymph node dissection (PLND) An operation that removes lymph nodes between the hip bones.

staging The process of rating the extent of cancer in the body.

perineum The body region between the scrotum and anus.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Words to know

supportive care Health care other than curative treatment that supports the physical, emotional, social, and spiritual needs of patients, families, and caregivers.

share with us.

surgical margin The normal-looking tissue around a tumor that is removed during an operation. testosterone A hormone that helps male sexual organs to work.

Take our survey and help make the NCCN Guidelines for Patients better for everyone!

ultrasound A test that uses sound waves to take pictures of the inside of the body.

NCCN.org/patients/comments

urethra A tube that carries urine from the bladder to outside the body through the penis. It also expels semen. urinary incontinence A condition in which the release of urine can’t be controlled.

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

NCCN Contributors

NCCN Contributors This patient guide is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Prostate Cancer, Version 4.2024. It was adapted, reviewed, and published with help from the following people: Dorothy A. Shead, MS

Senior Director Patient Information Operations

John Murphy

Susan Kidney

Medical Writer

Senior Graphic Design Specialist

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Prostate Cancer, Version 4.2024 were developed by the following NCCN Panel Members: Edward M. Schaeffer, MD, PhD

Robert H. Lurie Comprehensive Cancer Center of Northwestern University

Sandy Srinivas, MD

Stanford Cancer Institute

Nabil Adra, MD, MSc

Indiana University Melvin and Bren Simon Comprehensive Cancer Center

Yi An, MD

Yale Cancer Center/Smilow Cancer Hospital

Shilpa Gupta, MD

Case Comprehensive Cancer Center/ University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

Thomas Guzzo, MD, MPH Abramson Cancer Center at The University of Pennsylvania

Joseph E. Ippolito, MD, PhD Siteman Cancer Center at BarnesJewish Hospital and Washington University School of Medicine

Tyler Robin, MD, PhD

University of Colorado Cancer Center

*Stan Rosenfeld

University of California San Francisco Patient Services Committee Chair

Ahmad Shabsigh, MD

The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

Daniel E. Spratt, MD

Mayo Clinic Comprehensive Cancer Center

Case Comprehensive Cancer Center/ University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

The University of Texas MD Anderson Cancer Center

Michael R. Kuettel, MD, MBA, PhD

Russell Szmulewitz, MD

Heather H. Cheng, MD, PhD

Joshua M. Lang, MD, MS

Rhonda Bitting, MD Duke Cancer Institute

Brian Chapin, MD

*R. Jeffrey Karnes, MD

Roswell Park Comprehensive Cancer Center

The UChicago Medicine Comprehensive Cancer Center

University of Wisconsin Carbone Cancer Center

Benjamin A. Teply, MD

Tamara Lotan, MD

Jonathan Tward, MD, PhD

UT Southwestern Simmons Comprehensive Cancer Center

Rana R. McKay, MD

Richard Valicenti, MD

Tanya Dorff, MD

Todd Morgan, MD

*Jessica Karen Wong, MD

Fred Hutchinson Cancer Center

*Anthony Victor D’Amico, MD, PhD

Dana-Farber/Brigham and Women’s Cancer Center | Mass General Cancer Center

*Neil Desai, MD, MHS

City of Hope National Cancer Center

James A. Eastham, MD

Memorial Sloan Kettering Cancer Center

Thomas A. Farrington, BSEE

Prostate Health Education Network (PHEN)

Xin Gao, MD

Dana-Farber/Brigham and Women’s Cancer Center | Mass General Cancer Center

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins UC San Diego Moores Cancer Center University of Michigan Rogel Cancer Center

Huntsman Cancer Institute at the University of Utah

UC Davis Comprehensive Cancer Center Fox Chase Cancer Center

Julio M. Pow-Sang, MD Moffitt Cancer Center

Robert Reiter, MD, MBA

NCCN

UCLA Jonsson Comprehensive Cancer Center

Deborah Freedman-Cass, PhD

Mack Roach, III, MD

Jenna Snedeker, MS, ASCP

UCSF Helen Diller Family Comprehensive Cancer Center

* Reviewed this patient guide. For disclosures, visit NCCN.org/disclosures. NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Fred & Pamela Buffett Cancer Center

Senior Manager, Guidelines Processes Associate Scientist/Medical Writer

NCCN Cancer Centers

NCCN Cancer Centers Abramson Cancer Center at the University of Pennsylvania

Memorial Sloan Kettering Cancer Center New York, New York 800.525.2225 • mskcc.org

Philadelphia, Pennsylvania 800.789.7366 • pennmedicine.org/cancer

Moffitt Cancer Center

Case Comprehensive Cancer Center/ University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

Tampa, Florida 888.663.3488 • moffitt.org

O’Neal Comprehensive Cancer Center at UAB

Cleveland, Ohio UH Seidman Cancer Center 800.641.2422 • uhhospitals.org/services/cancer-services CC Taussig Cancer Institute 866.223.8100 • my.clevelandclinic.org/departments/cancer Case CCC 216.844.8797 • case.edu/cancer

Birmingham, Alabama 800.822.0933 • uab.edu/onealcancercenter

Robert H. Lurie Comprehensive Cancer Center of Northwestern University Chicago, Illinois 866.587.4322 • cancer.northwestern.edu

City of Hope National Medical Center

Roswell Park Comprehensive Cancer Center

Duarte, California 800.826.4673 • cityofhope.org

Buffalo, New York 877.275.7724 • roswellpark.org

Dana-Farber/Brigham and Women’s Cancer Center | Mass General Cancer Center

Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

Boston, Massachusetts 877.442.3324 • youhaveus.org 617.726.5130 • massgeneral.org/cancer-center

St. Louis, Missouri 800.600.3606 • siteman.wustl.edu

St. Jude Children’s Research Hospital/ The University of Tennessee Health Science Center

Duke Cancer Institute

Durham, North Carolina 888.275.3853 • dukecancerinstitute.org

Memphis, Tennessee 866.278.5833 • stjude.org 901.448.5500 • uthsc.edu

Fox Chase Cancer Center Philadelphia, Pennsylvania 888.369.2427 • foxchase.org

Stanford Cancer Institute

Stanford, California 877.668.7535 • cancer.stanford.edu

Fred & Pamela Buffett Cancer Center Omaha, Nebraska 402.559.5600 • unmc.edu/cancercenter

The Ohio State University Comprehensive Cancer Center James Cancer Hospital and Solove Research Institute

Fred Hutchinson Cancer Center

Columbus, Ohio 800.293.5066 • cancer.osu.edu

Seattle, Washington 206.667.5000 • fredhutch.org

Huntsman Cancer Institute at the University of Utah

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Indiana University Melvin and Bren Simon Comprehensive Cancer Center

The UChicago Medicine Comprehensive Cancer Center

Baltimore, Maryland 410.955.8964 www.hopkinskimmelcancercenter.org

Salt Lake City, Utah 800.824.2073 • healthcare.utah.edu/huntsmancancerinstitute

Indianapolis, Indiana 888.600.4822 • www.cancer.iu.edu

Chicago, Illinois 773.702.1000 • uchicagomedicine.org/cancer

Mayo Clinic Comprehensive Cancer Center

The University of Texas MD Anderson Cancer Center Houston, Texas 844.269.5922 • mdanderson.org

Phoenix/Scottsdale, Arizona Jacksonville, Florida Rochester, Minnesota 480.301.8000 • Arizona 904.953.0853 • Florida 507.538.3270 • Minnesota mayoclinic.org/cancercenter

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

UC Davis Comprehensive Cancer Center Sacramento, California 916.734.5959 • 800.770.9261 health.ucdavis.edu/cancer

NCCN Cancer Centers

UC San Diego Moores Cancer Center La Jolla, California 858.822.6100 • cancer.ucsd.edu

UCLA Jonsson Comprehensive Cancer Center Los Angeles, California 310.825.5268 • uclahealth.org/cancer

UCSF Helen Diller Family Comprehensive Cancer Center San Francisco, California 800.689.8273 • cancer.ucsf.edu

Let us know what you think!

University of Colorado Cancer Center Aurora, Colorado 720.848.0300 • coloradocancercenter.org

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University of Michigan Rogel Cancer Center Ann Arbor, Michigan 800.865.1125 • rogelcancercenter.org

University of Wisconsin Carbone Cancer Center Madison, Wisconsin 608.265.1700 • uwhealth.org/cancer

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UT Southwestern Simmons Comprehensive Cancer Center

Dallas, Texas 214.648.3111 • utsouthwestern.edu/simmons

Vanderbilt-Ingram Cancer Center Nashville, Tennessee 877.936.8422 • vicc.org

Yale Cancer Center/Smilow Cancer Hospital New Haven, Connecticut 855.4.SMILOW • yalecancercenter.org

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

Index

Index active surveillance 11, 18, 22, 33, 36–37, 51–56, 59, 68

pelvic lymph node dissection (PLND) 56– 58, 60–61, 66–67

biomarker 17, 22–23, 26, 30, 33, 53, 55

persistence 65–68

biopsy 15, 18, 21–23, 26–30, 32–33, 36–37, 51–53, 55, 58, 60, 65–67

prostate–specific antigen (PSA) 7, 15, 52, 61–62, 65–66

bone scan 18, 20–21, 44, 59

prostate surgery (radical prostatectomy) 11, 23, 36–41, 53–54, 56–58, 60–61, 65–67

brachytherapy 41–43, 53–54, 56–60

PSA density 27, 32, 51, 55

castration (orchiectomy) 44, 62, 68

PSA doubling time 65

clinical trial 46–48, 68

recurrence 18, 20, 26, 37–38, 53–54, 56, 58, 60–62, 65–68

digital rectal exam 15–16, 30–31, 52 enlarged prostate (benign prostatic hyperplasia) 6, 15, 27

risk factor 8–9, 55, 57, 59 sexual side effects 17, 38, 40–41, 45

erectile dysfunction 6, 39, 40–41, 43, 45–46

staging 30–32

external beam radiation therapy (EBRT) 41–44, 53–54, 56–62

supportive care 48, 62, 65

genetic testing 22–23, 33

ultrasound imaging 18, 21, 27

Gleason score 28–29, 33

urinary incontinence 38–39, 43, 46

Grade Group 26, 28–30, 32–33, 37, 51, 53, 55, 57, 59 hormone therapy (androgen deprivation therapy, ADT) 11, 36, 42–45, 54, 56–62, 65–67, 71 life expectancy 26, 30–33, 36–37, 39, 51–60, 62, 65–66 metastasis 9–11, 18–20, 23, 30, 34, 44, 58, 62, 66–67 nomogram 26, 30, 33, 56–57 observation 33, 36–37, 51–54, 56–60, 62, 65

NCCN Guidelines for Patients® Early-Stage Prostate Cancer, 2024

NCCN GUIDELINES FOR PATIENTS

Early-Stage Prostate Cancer 2024 To support the NCCN Guidelines for Patients, visit NCCNFoundation.org/Donate

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ADVANCED PROSTATE CANCER ADVANCED PROSTATE CANCER TYPES Prostate cancer that has spread beyond the prostate to other parts of the body is considered advanced prostate cancer. Locally Advanced: Cancer has spread beyond the outer layer of the prostate into nearby tissues, such as nearby lymph glands or the seminal vesicles. Locally advanced prostate cancer is referred to as Stage III and is considered non-metastatic. Metastatic: Cancer has spread to other parts of the body, such as the bones, lymph nodes, lungs, or liver. This is also referred to as Stage IV prostate cancer. Castration-Sensitive Prostate Cancer (CSPC, also called Hormone-Sensitive Prostate Cancer): A form of prostate cancer that still responds to testosterone suppression therapy. CSPC can be referred to as non-metastatic, or nmCSPC, when there is no detectable metastases - spread of cancer - upon imaging. It can be referred to as mCSPC when it has advanced to metastatic stage. Castration-Resistant Prostate Cancer (CRPC): Cancer that keeps growing even when the amount of testosterone in the body is reduced to very low levels. CRPC can be referred to as non-metastatic, or nmCRPC when there is no detectable metastases upon imaging, and as mCRPC when it has advanced to metastatic stage. PROSTATE CANCER AND TREATMENT PROGRESSION Radiation Surgery

Hormone Therapy

Novel Antiandrogens Chemotherapy

Targeted Therapy Chemotherapy Immunotherapy

CLINICAL TRIALS Non-metastatic prostate cancer

Metastatic prostate cancer

Castration Sensitive (CSPC)

Castration Resistant (CRPC)

TREATMENTS FOR ADVANCED PROSTATE CANCER Patients with advanced prostate cancer may need a combination of treatments. Treatment decisions should be based on a patient’s specific diagnosis, values, and goals. Treatment options include: Hormone Therapy Hormone therapy is also called androgen deprivation therapy (ADT), hormone deprivation therapy, or hormone suppression therapy. Hormone therapy stops or slows the body’s ability to make testosterone, aiming to stop tumor growth and/or shrink the tumor. Immunotherapy Immunotherapy treats the whole body by activating the immune system to recognize and destroy prostate cancer cells. It uses materials to improve, target, or restore immune function. Different types of immunotherapies include vaccines, monoclonal antibodies, and others. Targeted Therapy Targeted therapy uses drugs that are designed to find and attack cancer cells. They shut down specific proteins in cancer cells that help the cells divide, grow, and spread. Different types of targeted therapies include PARP inhibitors, PSMA targeted therapy, radioligand therapy, and others. Chemotherapy Chemotherapy is used to kill cancer cells throughout the body. They are given through the veins or orally, depending on the drug. Because chemotherapy also attacks other cells in the body, it may cause significant side effects. ABOUT CLINICAL TRIALS A clinical trial is a research study investigating experimental treatment to see if it is safe to use and effective in fighting a disease. All treatments used today for prostate cancer are available because of past clinical trials. Visit zerocancer.org/clinicaltrials to learn more. A PATIENT EDUCATION SERIES Continued on reverse side

ADVANCED PROSTATE CANCER PROSTATE CANCER IS THE MOST COMMONLY DIAGNOSED CANCER IN MEN BESIDES SKIN CANCER AND THE SECOND LEADING CAUSE OF CANCER DEATH IN MEN IN THE U.S.

AMERICAN MEN

3.1+ MILLION

WILL BE DIAGNOSED WITH PROSTATE CANCER IN THEIR LIFETIME

MEN ARE LIVING WITH PROSTATE CANCER IN THE U.S.

PROSTATE CANCER IN THE BONES When prostate cancer spreads, it most often spreads to the bones. This can weaken the bones, cause pain, and increase the risk of fractures. Drugs approved by the FDA are available for the treatment of prostate cancer that has spread to the bones. Maintaining Bone Health Hormone therapy can weaken bones over time. Medicines and lifestyle changes may help prevent bone loss and improve bone density. Some ways to improve bone health are: Strive for a healthy diet Include weight-bearing exercises in your daily routine. Be sure to talk to your healthcare professional before starting a new exercise routine. Take calcium (600 mg twice daily) and vitamin D (400-500 IU twice daily) supplements to help slow bone loss LIVING WITH ADVANCED PROSTATE CANCER Living with advanced prostate cancer can lead to shifting lifestyle priorities and may cause anxiety. Reduce anxiety by: Talking about these fears with friends or loved ones Joining a prostate cancer support group Writing down thoughts in a journal Speaking with a counselor Treatment teams, patients, and families can work together to manage side effects from cancer and from its treatments.

Within 5 years of diagnosis, 10%–20% of men with prostate cancer globally will develop CRPC. Patients should work with their doctor to further understand advanced prostate cancer and what they can do to prepare. Visit www.zerocancer.org for more information. A PATIENT EDUCATION SERIES American Cancer Society. Cancer Facts & Figures 2023. Atlanta: American Cancer Society; 2023.

03/23

NCCN GUIDELINES FOR PATIENTS

2024

AdvancedStage Prostate Cancer

NATIONAL COMPREHENSIVE CANCER NETWORK

Presented with support from

Available online at

FOUNDATION NCCN.org/patientguidelines Guiding Treatment. Changing Lives.

Advanced-Stage Prostate Cancer

About the NCCN Guidelines for Patients®

These NCCN Guidelines for Patients are based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Prostate Cancer, Version 4.2024 — May 17, 2024.

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Advanced-Stage Prostate Cancer

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NATIONAL COMPREHENSIVE CANCER NETWORK

FOUNDATION Guiding Treatment. Changing Lives.

NCCN Guidelines for Patients are supported by funding from the NCCN Foundation® NCCN Foundation gratefully acknowledges the following supporters for helping to make available these NCCN Guidelines for Patients: Astellas, and Janssen Biotech, Inc. NCCN independently adapts, updates, and hosts the NCCN Guidelines for Patients. Our corporate supporters do not participate in the development of the NCCN Guidelines for Patients and are not responsible for the content and recommendations contained therein.

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NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

PatientGuidelines@ NCCN.org

Advanced-Stage Prostate Cancer

Contents 4

Prostate cancer basics

Tests for advanced prostate cancer

Prostate cancer treatments

Regional prostate cancer treatment options

Metastatic prostate cancer treatment options

Supportive care and other assistance

Making treatment decisions

Words to know

NCCN Contributors

NCCN Cancer Centers

Index

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate cancer basics 5

What is prostate cancer?

What are the symptoms of prostate cancer?

What causes prostate cancer?

What is advanced-stage prostate cancer?

Can prostate cancer be cured?

What’s the best treatment?

Key points

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 1 Prostate cancer cancer basics basics » What » What is prostate is prostate cancer? cancer? » What is prostate cancer?

The prostate is a gland located

reproductive system. Besides the prostate, the male reproductive system includes the penis, seminal vesicles, and testicles.

deep inside the pelvis. Everyone with a prostate has a chance

Prostate cancer is one of the most common types of cancer. Cancer is what happens when something goes wrong with the natural cell process, which causes some cells to grow out of control.

of getting prostate cancer. This chapter offers an overview of this common cancer.

Cancer cells don’t behave like normal cells. Cancer cells develop genetic changes (mutations) that allow them to multiply and make many more cancer cells. The cancer cells crowd out and overwhelm normal cells. This can end up harming the body.

What is prostate cancer? Prostate cancer is a disease where cells in the prostate gland grow out of control.

Cancer cells can survive much longer than normal cells do. They can replace many normal cells and cause organs to stop working well. Cancer cells can also spread outside the prostate to other areas of the body.

The prostate is a gland located just below the bladder in the pelvis, deep inside the area of your body between your hip bones. The prostate is an important part of the male

The prostate gland is an important part of the male reproductive system. It’s located in the pelvis just below the bladder and is typically about the size of a pingpong ball.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 1 Prostate cancer cancer basics basics » What » What are the are symptoms the symptoms of prostate of prostate cancer? cancer?

What are the symptoms of prostate cancer?

A symptom is a feeling or problem that can indicate a disease or condition. Prostate cancer often grows slowly and shows no symptoms for a long time. You don’t have to have symptoms to have prostate cancer.

Blood in the urine or semen

Burning or pain while urinating

Unexplained weight loss

Bone, hip, or back pain

Dull pain in your groin or pelvis Erectile dysfunction (difficulty getting an erection) or painful ejaculation

What causes prostate cancer?

Symptoms, if they occur, may include:

Feeling like your bladder hasn’t fully emptied

Age The biggest risk factor for prostate cancer is age. Prostate cancer is diagnosed most often in those aged 65 years and above. Your chances of getting prostate cancer increase as you become older.

Urinating frequently, especially at night

Weak or intermittent urine stream

Family history

Trouble urinating or straining to urinate

Trouble holding in urine

Your family health history is information about the diseases and health conditions in your family. A family history reflects a pattern of certain diseases among family members.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 1 Prostate cancer cancer basics basics » What » What causes causes prostate prostate cancer? cancer? » What causes prostate cancer?

Where does the prostate fit in? The prostate is a gland located in the pelvis—the area between your hips. The prostate is important for sexual reproduction. Prostate: A gland in the male reproductive system. A gland is an organ that makes fluids or chemicals the body needs. The prostate gland makes a fluid that nourishes and helps transmit sperm. The prostate also contains muscles that help propel semen through the urethra during ejaculation. Semen: A fluid made up of liquids from the prostate and the seminal vesicles as well as sperm from the testicles. During ejaculation, semen is released from the body through the urethra and out through the penis. Urethra: A tube that carries urine from the bladder and out of the body. The prostate surrounds the urethra just beneath the bladder. Seminal vesicles: Two glands that make and store another part of the fluid that becomes semen. The seminal vesicles are located above the prostate and behind the bladder. Bladder: An organ that holds urine.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 1 Prostate cancer cancer basics basics » What » What causes causes prostate prostate cancer? cancer? » What causes prostate cancer?

Having a close family member with prostate cancer (a sibling or parent) increases the chance of getting it yourself. Those with a family history of certain other cancers (breast, ovarian, colon, pancreatic, and other cancers) may also be at higher risk for prostate cancer.

What does aggressive mean? When health care professionals describe cancer as aggressive, they mean the cancer is likely to grow or spread more rapidly than average.

Genetic factors When cancer “runs in the family,” genetic testing can be done to find specific genetic changes (mutations) known to be linked with prostate cancer and other cancers. For instance, having an inherited genetic change in the BRCA2 gene increases the risk of getting prostate cancer.

Aggressive can also be used to describe therapy that may be stronger or more intense than other treatment options.

There are also genetic abnormalities that don’t run in families and aren’t inherited. Black males may want to talk with their health care providers about getting screening tests earlier and perhaps more often than what’s recommended for other males.

Race In the United States, Black males are more likely than white males to develop prostate cancer. Prostate cancer in Black males is also more likely to occur at an earlier age and be more aggressive and more advanced when diagnosed. Black males are also twice as likely to die from prostate cancer compared to white males.

Diet and lifestyle No one particular diet has been found to cause prostate cancer or to prevent it. However, eating food that’s high in fat, such as meat and dairy products, has been linked with an increased risk of prostate cancer. Smoking and obesity also increase the risks of developing and dying from prostate cancer.

Hispanic and Asian males are less likely than both white and Black males to be diagnosed with prostate cancer.

On the other hand, those who eat more fruits and vegetables have a lower risk of developing advanced prostate cancer. Exercise and maintaining a healthy weight may also decrease the aggressiveness of prostate cancer and the likelihood of dying from it.

Several things contribute to these differences, such as barriers to accessing health care (including early detection screening), as well as biological and genetic factors, and other causes. Researchers are trying to understand the reasons for these differences and what can be done to improve outcomes. NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 1 Prostate cancer cancer basics basics » What » What causes causes prostate prostate cancer? cancer? » What causes prostate cancer?

Early vs. advanced prostate cancer Early-stage prostate cancer has not visibly spread beyond the prostate. It usually grows slowly and stays in the prostate. This is also called localized prostate cancer.

Advanced-stage prostate cancer has grown outside the prostate and spread to other areas in the body such as distant lymph nodes (bottom left), bones, or organs like the liver or lungs (bottom right). This is also called metastatic prostate cancer.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 1 Prostate cancer cancer cancer basics basics basics »» What What » isWhat advanced-stage is advanced-stage is advanced-stage prostate prostate prostate cancer? cancer? cancer? » Can prostate cancer be cured?

What is advanced-stage prostate cancer?

Prostate cancer can be grouped into earlystage cancer or advanced-stage cancer.

How does prostate cancer spread? Cancer cells use the bloodstream like a highway to travel to distant areas in the body. Cancer cells can also spread through the lymphatic system. The lymphatic system is a network of organs and vessels that fights infections and circulates a clear fluid called lymph throughout the body.

A normal and important part of the lymphatic system are the lymph nodes. Lymph nodes are small, disease-fighting clusters that filter lymph fluid to remove germs. Lymph vessels and nodes are found everywhere in the body.

More information about early-stage prostate cancer can be found in the NCCN Guideline for Patients: Early-Stage Prostate Cancer at NCCN. org/patientguidelines and on the NCCN Patient Guides for Cancer app.

Some patients have advanced-stage prostate cancer when they’re first diagnosed. Others develop advanced-stage cancer after having treatment for early-stage cancer.

Advanced stage Advanced stage means that the cancer has spread beyond the prostate to other areas in the body. This spreading is called metastasis or metastatic cancer. Metastatic prostate cancer may spread to the lymph nodes, bones, liver, lungs, and other organs.

Can prostate cancer be cured? Advanced-stage prostate cancer is usually a life-long disease. But treatment can slow down its growth, reduce symptoms, and prolong life. Treatments for advancedstage prostate cancer include hormone therapy, chemotherapy, radiation therapy, immunotherapy, targeted therapy, radiopharmaceuticals, surgery, and other therapies.

This book is all about advanced-stage prostate cancer.

Cancer that grows from the prostate gland to nearby areas such as lymph nodes, but no farther, is called regional prostate cancer. (It’s also called locally advanced prostate cancer. This book will call it regional prostate cancer to avoid confusion between localized and locally advanced.)

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Cancer that spreads beyond the prostate to other parts of the body is called distant metastatic prostate cancer or simply metastatic prostate cancer.

It’s true that prostate cancer in the advanced stage can be fatal for some patients. But in the past few years, improved detection methods

Prostate 1 Prostate cancer cancer basics basics » What’s » What’s the best the best treatment? treatment? » Key points

and better treatments have been reducing the number of deaths from prostate cancer in patients of all races and ethnicities. Many people with advanced-stage prostate cancer continue to live with the cancer and, in the end, may die from something else.

Many new tests and treatments are now available for advanced prostate cancer. If possible, seek care or a second opinion from a medical center that specializes in prostate cancer.

What’s the best treatment?

Key points

The best treatment for prostate cancer is the treatment that’s right for you. Your team will work with you to figure out the therapies that have the best chance for fighting your particular cancer.

Importantly, your team should follow best practices. This book is based on the best practices for treating advanced-stage prostate cancer. Best practices come from the latest research and methods at top cancer centers. Your treatment team should personalize your care following the best practices.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate cancer develops when cells in the prostate gland grow out of control. Age is the leading risk factor for prostate cancer. As you age, your chances of developing prostate cancer increase. Having a close family member with prostate cancer means that you have a higher chance of getting it yourself. Everyone with a prostate is at risk for prostate cancer. Black people and people with certain inherited genetic mutations are at greater risk. Advanced-stage prostate cancer has spread outside the prostate to other areas in the body. This spreading is called metastasis. Advanced-stage prostate cancer is usually a life-long disease. Treatment can slow it down, reduce its symptoms, and help people live longer.

Tests for advanced prostate cancer 13

Common prostate tests

General health history

Diagnostic tests

Genetic tests

Tumor staging

What’s next?

Key points

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Common » Common prostate prostate teststests » Common prostate tests

If you haven’t yet been diagnosed

PSA test

with prostate cancer, you may

This is a blood test that measures the amount of prostate-specific antigen (PSA) in your bloodstream. PSA is a protein made inside the prostate gland. Its job is to help semen transport sperm. All prostate cells, both normal cells and cancer cells, make PSA.

need multiple tests and scans to find out if you have it and whether it has spread. These tests and scans will help your team make

the best plan to treat your prostate cancer.

Health care providers use a variety of tests to find prostate cancer and to determine how advanced the cancer is. Tests are used to plan treatment, check how well treatment is working, and monitor your health after treatment ends. This chapter describes what tests you might have and what to expect during testing. Not every person with prostate cancer will receive every test listed here.

When you go for testing, bring someone with you to listen, ask questions, and write down the answers.

PSA level (also called total PSA) is measured in nanograms of PSA per milliliter (ng/mL) of blood.

Common prostate tests

Digital rectal exam

A digital rectal exam (also called a prostate exam) may be an awkward and unpleasant form of testing. But it’s the simplest and most direct way to check the size and texture of your prostate.

Two common tests that look for prostate cancer are the PSA test and digital rectal exam.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

For this test, the doctor will insert a gloved finger into your rectum to feel your prostate for any signs of cancer. An irregular or hardened part of the prostate could be a sign of a tumor. 13

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » General » General health health history history » General health history

Not all parts of the prostate can be felt during a digital rectal exam, though. So it’s usually paired with a PSA test and other factors— your age, race, family history, and more—to determine whether you need further testing.

may feel for enlarged glands (lymph nodes) in your groin, underarms, and neck.

General health history Health history and physical exam

It’s important to ask members from both sides of the family about all cancers, not just prostate cancer. Ask family members if any relatives had cancer, at what age they were diagnosed, and if they died from it. Also ask family members about other health issues like heart disease, stroke, and diabetes. Share this information with your care team and update your team with any changes to your family history.

Your care team needs to have all your health information. They’ll ask you about any health problems and treatments you’ve had in your life. Be prepared to talk about any illness or injury you’ve had and when it happened. Also tell your team about any symptoms you have. Bring a list of your regular medications and any over-the-counter medicines, herbs, or supplements you take. Some of these (such as saw palmetto or St. John’s wort) can cause changes in your PSA level, so your care team needs to know if you’re taking them.

Symptoms and quality of life Your doctor or another member of your care team will ask you a series of questions about what symptoms you may have (such as peeing

A physical exam is a check of your body for any signs of disease. Your health care provider

Taking supplements? Bring a list of your medicines to your doctor’s office when you begin testing. It’s also important to tell your treatment team if you’re using any complementary medicines, especially supplements, vitamins, or herbs. Some of these can interfere with your cancer tests or treatment. This may reduce the effectiveness of treatment or cause more side effects.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Diagnostic » Diagnostic teststests » Diagnostic tests

frequently, difficulty peeing or pooping, or sexual problems). You’ll also be asked how these symptoms affect your quality of life.

Diagnosis vs. prognosis What’s the difference between your diagnosis and your prognosis? These two words sound alike but they’re very different.

Quality of life refers to your overall satisfaction with your well-being and your ability to participate in regular activities. It’s important to answer all these questions honestly and completely so your care team has full and upto-date information about how you’re doing.

Diagnosis is identifying an illness based on tests. Your diagnosis names what illness you have.

Diagnostic tests

Prognosis is the likely course and outcome of a disease. Your prognosis predicts how your illness will turn out.

Diagnostic tests are used to confirm you have cancer. They’re also used to find out if the cancer is localized or advanced. Diagnostic tests can help plan treatment after you’ve been diagnosed and can detect whether the cancer is still growing or spreading after treatment.

Imaging can come before, during, or after a biopsy. Imaging may also be used after cancer treatment to see how well it worked and to check if the cancer comes back.

Diagnostic tests include imaging scans, biopsies, and genetic tests.

Imaging tests

Imaging methods for prostate cancer include MRI, CT, PET, ultrasound, bone scan, or a combination of these.

An imaging test takes pictures (images) of the insides of your body. The images can reveal cancer, including its size, location, and other features such as the size of the prostate itself. The images may show where the cancer started (primary tumor) and whether the cancer has spread (metastasized).

MRI scan A magnetic resonance imaging (MRI) scan uses radio waves and powerful magnets to take pictures of the inside of the body. An MRI can be used to get a more detailed view of the cancer within the prostate. It’s also used to see if cancer has spread to nearby lymph nodes or to the bones in your pelvis.

After your scan, your images will be studied by a radiologist. A radiologist is a doctor who’s an expert in reading imaging tests. The radiologist will send the results to your care team. This information helps to plan the next steps of your care. Your team will discuss the results with you. Be sure to ask any questions you may have. NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

MRI scans can also help to plan treatment, and may be used after treatment to

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Diagnostic » Diagnostic teststests » Diagnostic tests

PET scan A positron emission tomography (PET) scan highlights cells in your body that may be cancerous. You may have a PET scan after you’ve been diagnosed to determine the extent of your cancer or to see if it has metastasized. PET imaging can also show how well treatment is working.

check whether the cancer has come back (recurrence). An appointment for an MRI scan can take 1 to 2 hours, including 30 to 60 minutes of actual scanning time. You’ll need to remain as motionless as possible during each scan. You may be positioned with pillows or bolsters to help you keep still.

Because an MRI uses magnets, you can’t bring any metal objects (such as jewelry, phones, wristwatches, or belts with metal buckles) into the imaging room. CT scan A computed tomography (CT or CAT) scan uses x-rays and computer technology to take pictures of the inside of the body. CT takes many x-rays of the same body part from different angles. The computer combines all the x-ray pictures to make a single detailed image. A CT scan is usually completed in less than 30 minutes.

A PET scan appointment can take 1 to 2 hours, including about 30 minutes of actual scanning time. Because PET uses a different imaging method, it’s often combined with other types of imaging, such as CT or MRI, to provide an even more

PET imaging A positron emission tomography (PET) scan highlights cells in your body that may be cancerous. A PET scan can determine the extent of your cancer or see if it has metastasized. PET imaging can also show how well treatment is working.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Diagnostic » Diagnostic teststests » Diagnostic tests

detailed image. This combined method is called a PET/CT or PET/MRI scan.

PSMA-PET PET scans use different types of tracers. The most common tracer in prostate cancer locates a protein called prostate-specific membrane antigen (PSMA) on the surface of prostate cancer cells. Prostate cancer cells can make a lot of PSMA, so doctors developed tracers that target this specific protein.

A special camera will take pictures of the tracer in your bones. Areas of bone damage absorb more tracer than healthy bone. These areas show up as bright spots in the scans. Ultrasound Ultrasound imaging is commonly used to help guide a biopsy of the prostate. This is called transrectal ultrasound (TRUS) imaging.

Not everyone with prostate cancer will need a PSMA-PET scan. It’s mostly used to monitor prostate cancer for recurrence. It’s also used to determine whether targeted therapy can treat certain cases of metastatic prostate cancer.

During a biopsy, an ultrasound probe is inserted into the rectum. The probe is about the size of a finger. The device uses highenergy sound waves to create a view of the prostate from inside the body. These images allow the surgeon to remove a small sample of the prostate without having to open up your abdomen.

Bone scan A bone scan can detect whether cancer has spread to your bones. A bone scan may be used if you have bone pain, have a high risk for bone metastasis, or have changes in certain test results. Bone scans may also be used to monitor treatment.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Diagnostic » Diagnostic teststests » Diagnostic tests

At some centers, your saved MRI images can be combined with real-time ultrasound to provide a more detailed view for a more precise biopsy. This is called MRI-TRUS fusion.

tests have some risk. The risks for a prostate biopsy include infection, bleeding, and pain. Doctors use invasive tests only when needed. You and your care team will decide when, or if, you need a biopsy.

Biopsy

A biopsy sample may be taken from the prostate, the metastasis (an area of cancer that has spread outside of the prostate), or sometimes both.

A biopsy is a procedure in which a sample of cells, fluid, or tissue is removed from your body and tested for cancer. It’s the main way to confirm whether you have cancer.

Biopsy of the prostate A prostate biopsy is usually performed by a urologist. A urologist is a doctor who’s an

A biopsy is an invasive test, which means that it goes into (invades) your body. All invasive

PSMA-PET scan of prostate cancer A CT scan for a patient treated for prostate cancer shows a crosssection of the body at the pelvis. The CT pinpoints a lymph node that appears normal (top image). But a PMSA-PET scan of the same lymph node highlights prostate cancer cells (arrow in bottom image). Images: University of Chicago Medicine

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Diagnostic » Diagnostic teststests » Diagnostic tests

expert in treating diseases of the urinary system and the male reproductive organs.

take 12 or more core samples from different parts of the prostate. Checking different areas provides a more complete evaluation of cancer throughout the gland.

For this procedure, you’ll lie on your side with your knees curled up or you’ll lie on your back with your legs raised. You’ll be given anesthesia to numb the pain or to make you fall asleep. The urologist will insert a lubricated probe into your rectum. The probe provides a visual image of the prostate.

After the biopsy samples are removed, a specialist called a pathologist will examine the samples under a microscope and test them for cancer cells. The pathologist will find out how many of the core samples contain cancer and will also measure the percentage of cancer in each core.

The urologist will then insert a hollow needle into the prostate gland using the video display to guide it. The needle is inserted either through the perineum (the skin between the anus and scrotum) or through the rectum.

With this information, the pathologist can estimate the amount of cancer in the prostate and how aggressive it may be. Also, by knowing where each core sample was taken, the pathologist can tell if the cancer is concentrated in a certain section of the prostate.

When the urologist removes the needle, it will pull out a small sample of prostate tissue called a core. A core sample is only about 1 to 2 millimeters wide and 12 to 20 millimeters long—about as wide as a toothpick and as long as a raisin. The urologist will usually

The pathologist will put these results into a report. Ask your doctor or another member of

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Genetic » Genetic teststests » Genetic tests

Genetic tests

your care team to review the pathology report with you.

A genetic test is used to find harmful changes in your genes. Genes are small segments of DNA inside every cell. Genes provide the instructions to tell the cell how to make proteins, which carry out a lot of important functions in the body.

Biopsy of the metastasis A biopsy of a metastasis can be taken from a lymph node, an internal organ, or a bone. This biopsy is performed in a similar way to a prostate biopsy—using a hollow needle to remove cores of tissue.

Once in a while, a gene will have or develop a change, called a mutation, that damages its function. As a result of this mutation, the gene isn’t able to make a normal protein so the protein can’t do its necessary job. This can affect the usual activities of the cell, which can lead to disease, such as cancer.

Sometimes, a blood sample is taken, also called a “liquid biopsy,” to look for cancer cells in the blood. Having a biopsy may cause complications. A complication is an unwanted and unplanned result from a procedure. Complications may include infection, bleeding from the rectum, or blood in the urine, stool, or semen. These usually go away after a few days or, with semen, after a few weeks. It’s also important to know that a biopsy won’t cause prostate cancer to spread or worsen.

Mutations can be passed down in families, in which case they occur in every cell in your body. Or mutations can occur spontaneously in just some of your cells. In other words, they may be in your body before you’re born (called a hereditary or germline mutation) or occur by

Biopsy of the metastasis Prostate cancer may metastasize to lymph nodes, bones, or internal organs. A biopsy of a metastasis (as seen here, taken from the liver) uses a hollow needle to remove a small core of tissue. The tissue is tested in a lab to look for cancer cells.

Removed liver tissue NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Genetic » Genetic teststests » Genetic tests

chance or environmental factors later in life (called an acquired or somatic mutation).

and other cancers in addition to prostate cancer.

The two basic types of genetic tests used for prostate cancer care are hereditary gene testing and tumor testing:

If an inherited cancer risk gene is suspected based on your family’s or your own health history, you should ask about genetic testing. Your health care provider can talk to you about testing or refer you to a genetic counselor. A genetic counselor is an expert who has special training in genetic diseases. A genetic counselor can help you decide whether you would like to undergo germline testing and also help you interpret the results of these tests.

Hereditary gene testing Sometimes, mutations in genes inherited from your parents can increase the risk of different cancers. You can pass these genes on to your children. Your siblings or other family members might also carry these mutations. If you have a family history of cancer, your health care provider might suggest genetic testing to find out if you have an inherited cancer risk. This is also called germline testing.

Inherited gene testing is recommended if you have prostate cancer and any of the following:

The goal of this type of genetic testing is to look for inherited (germline) mutations that occur in every cell in your body. Genetic germline testing is done using a sample of your blood, urine, or saliva.

For prostate cancer, this testing typically looks for characteristic changes in these genes: BRCA1, BRCA2, ATM, CHEK2, MLH1, MSH2, MSH6, PALB2, PMS2, and others.

Having a hereditary mutation doesn’t mean you’ll automatically get cancer. It means your chances for developing certain cancers is higher.

Family history of mutations in certain genes including BRCA1, BRCA2, ATM, CHEK2, and others Very-high-risk, high-risk, regional (cancer in a lymph node), or metastatic prostate cancer regardless of family history Ashkenazi Jewish ancestry

Talk to your medical providers and/or a genetic counselor about your family history of cancer.

Tumor testing

Some mutations can put you at risk for more than one type of cancer. Inherited mutations in genes like BRCA1 or BRCA2 are also related to breast cancer, ovarian cancer, pancreatic cancer, and skin cancer (melanoma). Inherited mutations in MSH2, MSH6, MLH1, and PMS2 are related to colorectal cancer, uterine cancer, NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Family members or relatives who have or had prostate cancer, breast cancer, ovarian cancer, intestinal cancer, and certain other cancers

Tumor testing (also called somatic testing, molecular tumor testing, or tumor profiling) requires a tissue sample from the tumor itself or from a metastasis in a lymph node, bone, liver, lung, or other affected area. Or it may come a sample of your blood, which contains the tumor’s DNA. 21

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » Tumor » Tumor staging staging » Tumor staging

In this type of testing, the sample is analyzed to look at its molecular components. Tumors often release molecules that can be used as clues for finding and learning about the cancer. This information helps figure out the likelihood that your cancer could spread to other parts of the body. It can also help predict whether the cancer could transform into a more aggressive type.

In this system, the letters T, N, and M stand for different areas of cancer growth:

Importantly, targeted therapies (PARP inhibitors, for example) can be used against cancers that have particular molecular tumor markers. So the testing looks for specific abnormalities in a number of genes involved in DNA repair, including BRCA1, BRCA2, ATM, PALB2, FANCA, and others.

Your provider will assign a number to each letter, based on your test results. The higher the number, the larger the tumor (T) or the more the cancer has spread (M). These scores are combined to assign a “stage” to the cancer.

Tumor staging

Staging is a way to describe how much cancer is in your body and how far it has spread. Knowing your stage is important for predicting the course of your disease and for making a treatment plan.

Tumors come in different shapes and sizes. So it’s not easy to compare one tumor to another. To solve this problem, cancer experts created the tumor, node, metastasis (TNM) system to describe any tumor. It’s based on the results of your imaging scans, biopsies, and blood tests.

Cancer staging is done when you’re first diagnosed. It may also be done after treatment to confirm that the stage hasn’t changed.

How to read a TNM score Let’s say your prostate cancer is given a TNM score of T4, N1, M1. This score means that the tumor has grown outside the prostate gland (T4) and has spread to nearby lymph nodes (N1) and to one or more distant parts of the body (M1). Why know your TNM score? For one, it lets you know the extent of your cancer. It also helps characterize your risk for the cancer to spread. Your level of risk helps indicate the most appropriate treatment for you.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests 2 Tests for advanced for advanced prostate prostate cancer cancer » What’s » What’s next? next? » Key points

Key points

Measurements and assessments not covered in this book include PSA density, Gleason score, Grade Group, and risk groups. To learn more about these, see the NCCN Guidelines for Patients: Early-Stage Prostate Cancer, which can be found at NCCN.org/ patientguidelines and on the NCCN Patient Guides for Cancer app.

What’s next?

After you’ve had all these tests to confirm you have prostate cancer, your care team will discuss your test results and will work with you to develop a plan for treatment.

The next chapter describes the different treatment options for advanced-stage prostate cancer. After that chapter, you’ll read about which of those treatments may be right for you and your particular type of cancer.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Tests are used to plan treatment and check how well treatment is working. An unusually high amount of PSA in the bloodstream may be a sign of prostate cancer. Imaging tests are used to see where the cancer has spread beyond the prostate. Imaging also shows the size and location of the cancer. A biopsy is a procedure that removes samples of cells or tissue, which are tested for cancer. A genetic test is used to find abnormal changes (mutations) in your genes. An inherited genetic mutation occurs in every cell in your body. A somatic mutation occurs all by itself and is only found in the cells of a tumor. To find out if you have an inherited risk for cancer, talk to your doctor about germline testing or ask to be referred to a genetic counselor.

Prostate cancer treatments 25

Hormone therapy

Non-hormone therapy

Clinical trials

Supportive care

What’s next?

Key points

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 3 Prostate cancer cancer treatments treatments » Hormone » Hormone therapy therapy » Hormone therapy

There’s more than one treatment

key word in ADT is “deprivation”—this therapy “deprives” (starves) the cancer of its main fuel: androgens. This can shrink the tumor or slow tumor growth for a while.

for advanced prostate cancer. This chapter describes the available treatment options and what you

You might hear the term “castration” used when describing prostate cancer or its treatment. This term describes a drastic reduction of testosterone. Castration can be done with hormone-lowering medication or by surgical removal of one or both testicles (orchiectomy). Though orchiectomy is a surgical procedure, it’s still considered hormone therapy because it removes the primary source of testosterone: the testicles. While drug hormone therapy can be reversed when the medication is stopped, orchiectomy is permanent and can’t be reversed.

might expect from them. Talk with your care team about which treatment could be best for you.

Prostate cancer is a complex disease with many treatment options. Treatments for advanced-stage prostate cancer include hormone therapy as well as non-hormone therapies like chemotherapy, immunotherapy, targeted therapy, and radiation therapy. Often, hormone therapy is combined with one or more other therapies. Combining therapies can be more effective than using either therapy alone.

Surgical removal of the testicles is much less common these days because systemic

Hormone therapy

What is ADT? Androgen deprivation therapy (ADT) brings testosterone down to a very low level. ADT treatments include:

Hormone therapy is a systemic (whole-body) treatment that adds, blocks, or removes hormones. A hormone is a natural chemical made by a gland in the body. Its job is to activate cells or organs. Male hormones are called androgens. The main androgen is testosterone. Most of the testosterone in the body is made by the testicles. Testosterone helps produce sperm, among other functions. But testosterone also helps prostate cancer grow. A type of hormone therapy called androgen deprivation therapy (ADT) can stop your body from making testosterone or block cancer cells from using testosterone. The NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

•

LHRH agonist (goserelin, leuprolide, or triptorelin)

•

LHRH agonist + anti-androgen (nilutamide, flutamide, or bicalutamide)

•

LHRH antagonist (degarelix or relugolix)

•

Surgical castration

Prostate 3 Prostate cancer cancer treatments treatments » Hormone » Hormone therapy therapy » Hormone therapy

hormone therapy is often just as effective at blocking testosterone.

LHRH antagonist that comes as a tablet taken once a day. Anti-androgens, corticosteroids, and androgen synthesis inhibitors are also available as pills and taken 1 to 3 times a day, depending on the medication. See Guide 1.

Hormone therapies for prostate cancer include luteinizing hormone-releasing hormone (LHRH) agonists and LHRH antagonists, both of which cause the testicles to stop making testosterone. You may have heard of leuprolide (Lupron), a commonly used LHRH agonist or degarelix (Firmagon), a commonly used LHRH antagonist. Most LHRH agonists and LHRH antagonists are injections. These may be given monthly, or 2, 3, or 4 times a year. The exception is relugolix (Orgovyx), an

Newer hormone therapies Hormone therapy has been the main treatment for advanced prostate cancer for several decades. Longstanding hormone therapies (such as bicalutamide, flutamide, and nilutamide) are sometimes still used for treating prostate cancer.

Guide 1 Hormone therapy drugs for prostate cancer Anti-androgens block receptors on prostate cancer cells from receiving testosterone.

apalutamide (Erleada), bicalutamide (Casodex), darolutamide (Nubeqa), enzalutamide (Xtandi), flutamide (Eulexin), nilutamide (Nilandron)

LHRH agonists prevent the release of luteinizing hormone-releasing hormone (LHRH), which causes the testicles to stop making testosterone.

goserelin (Zoladex), leuprolide (Lupron Depot, Eligard), triptorelin (Trelstar)

LHRH antagonists block or stop the pituitary gland (located in the brain) from making LHRH. This causes the testicles to stop making testosterone.

degarelix (Firmagon), relugolix (Orgovyx)

Androgen synthesis inhibitors block androgen production.

abiraterone (Zytiga, Yonsa), ketoconazole (Nizoral)

Corticosteroids (“steroids”) are synthetic hormones made in a lab that can stop the adrenal glands and other tissues from making testosterone.

dexamethasone, hydrocortisone, methylprednisolone, prednisone

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 3 Prostate cancer cancer treatments treatments » Hormone » Hormone therapy therapy » Hormone therapy

However, newer hormone therapies are better at delaying the spread of cancer and extending life. These newer drugs include abiraterone, apalutamide, darolutamide, and enzalutamide. You may hear your treatment team refer to these as novel, advanced, or next-generation hormone therapies.

worse. In Black patients, hormone therapy may increase the risk of death from heart issues.

Side effects of hormone therapy

LHRH agonists can cause a surge in testosterone for a few weeks before dropping to an undetectable level. This increase is called a testosterone flare. A testosterone flare can cause bone pain and urinary problems. But these symptoms will go away after the first few weeks of treatment. You might be given an anti-androgen medicine to prevent testosterone flare.

Ask your doctor about monitoring your blood pressure and cholesterol levels. Also, let your primary care physician know you’re being treated with ADT.

Hormone therapy can have significant side effects. These vary from person to person and from one type of hormone therapy to another. Many other factors affect your risk for side effects including your age, your health before treatment, how long or often you have treatment, and other things. The good news is that your treatment team can offer supportive care to lessen or reverse many of these effects.

The sexual side effects of hormone therapy can be a significant cause of stress. Hormone therapy may reduce your desire for sex and cause erectile dysfunction.

In general, the longer you’re on hormone therapy, the greater your risk for side effects. These can include tiredness (fatigue), hot flashes, mood changes, weight gain, changes in penis length and testicle size, tenderness and growth of your breasts, and loss of muscle mass.

Erectile dysfunction means having difficulty or being unable to have an erection of the penis. Erectile dysfunction medicines (such as Viagra and Cialis) aren’t as effective for those on hormone therapy. These drugs don’t restore the loss of sexual desire caused by lower androgen levels.

Thinning and weakening of your bones (osteoporosis) and bone fractures can also happen. When you start ADT, you may have a test to measure your bone density. If your bone density is low, your care team can recommend medications you can take to strengthen your bones.

However, some treatments that may improve erectile function include injections of medication into the penis, vacuum constriction devices (“penis pump”), or surgical implants that produce an erection. Your sex drive and your ability to have an erection may gradually return after stopping hormone therapy, though the process may take up to a year or more. Some patients never regain full ability to have an erection.

Hormone therapy also increases the risk for diabetes and cardiovascular disease. If you already have either of these conditions, hormone therapy can cause them to get NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 3 Prostate cancer cancer treatments treatments » Hormone » Hormone therapy therapy » Key points

Erectile dysfunction is a leading cause of depression in patients with prostate cancer. Ask your care team about therapy or counseling if you’re having problems due to erectile dysfunction or symptoms of depression. Help is available.

 TIP Regular exercise can lessen the symptoms and side effects of hormone therapy, including:

Talk to your care team about how to manage the side effects of hormone therapy. They have ways to lessen or soothe most of these problems. Bones can be strengthened with medicine as well as with physical activity. Exercise and eating a healthy diet can also help with fatigue, mood, and weight gain.

weight gain

•

fatigue

•

loss of bone and muscle mass

Physical activity can also improve your general health and make you feel better. Ask your care team to recommend an exercise program for you.

Hormone therapy resistance

It’s important to know that prostate cancer that’s resistant to hormone therapy is still treatable. So most people with hormoneresistant prostate cancer stay on ADT to keep their testosterone at a low level.

Hormone therapy can be very effective at shrinking or slowing the growth of your prostate cancer. But for people with metastatic prostate cancer, hormone therapy can lose this effect over time, even when their testosterone is at a very low level.

Other hormone-reducing drugs are also still used. These hormone therapies are often combined with non-hormone treatments like chemotherapy, targeted therapy, or immunotherapy to help get better results.

Why? Because the cancer eventually learns how to survive without using much testosterone, which makes it unaffected by hormone therapy. The cancer can “resist” the hormone therapy. This is called hormoneresistant prostate cancer (also called castration-resistant prostate cancer).

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

•

Prostate 3 Prostate cancer cancer treatments treatments » Non-hormone » Non-hormone therapy therapy » Non-hormone therapy

Non-hormone therapy

live longer as well as reduce their pain and other symptoms. Docetaxel is an option for some who are taking ADT for the first time. Docetaxel is also used to treat metastases after ADT fails to stop cancer growth.

Hormone therapy may be the first treatment recommended for advanced prostate cancer, but it’s not the only one. Other systemic treatments that don’t use hormones can also slow cancer growth, prevent cancer symptoms, and prolong life.

Cabazitaxel Cabazitaxel (Jevtana) is a chemotherapy option if docetaxel isn’t effective. Cabazitaxel can’t cure prostate cancer but it can help people live longer and improve pain and other symptoms.

If you’re given non-hormone therapy, you’ll likely also stay on ADT to make sure your testosterone remains at the lowest possible level. See Guide 2.

Carboplatin and cisplatin Carboplatin and cisplatin are chemotherapy drugs made from platinum. These are sometimes used for patients with very advanced or aggressive cancer. Usually, either carboplatin or cisplatin is combined with another chemotherapy medicine such as cabazitaxel or docetaxel.

Chemotherapy Chemotherapy is a systemic drug treatment that damages rapidly dividing cells throughout the body. Cancer cells divide and multiply rapidly, which makes them a good target for chemotherapy. But chemotherapy can harm healthy cells, too. That’s how it can cause side effects. Because chemotherapy can be a tough treatment to go through, it’s recommended only for those who are able to physically tolerate it. Despite the side effects, it can help people with metastatic prostate cancer live significantly longer.

Mitoxantrone Mitoxantrone (Novantrone) is used to relieve pain and decrease the need for pain medications. It’s an option if you aren’t able to tolerate other therapies.

Chemotherapy for prostate cancer is a liquid medicine given by intravenous infusion. This means that it’s slowly injected into a vein for up to an hour. It’s given every 3 weeks for a total of 6 to 10 times (cycles), along with a daily steroid.

The immune system is the body’s natural defense against infection and disease. Immunotherapy is a type of systemic therapy that boosts the ability of your immune system to find and destroy cancer cells. Immunotherapy is usually given alone for treating prostate cancer. Immunotherapy drugs include sipuleucel-T and pembrolizumab.

Immunotherapy

Docetaxel Docetaxel (Taxotere) is the chemotherapy medicine used most often to treat patients with advanced prostate cancer. Though docetaxel can’t cure prostate cancer, it can help people NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Sipuleucel-T Sipuleucel-T (Provenge) is intended for those with hormone-resistant metastatic prostate

Prostate 3 Prostate cancer cancer treatments treatments » Non-hormone » Non-hormone therapy therapy » Non-hormone therapy

Pembrolizumab Pembrolizumab (Keytruda) is a type of immunotherapy called an immune checkpoint inhibitor. For a small percentage of people whose prostate cancer is due to specific genetic mutations, pembrolizumab can restore the immune system’s ability to detect and destroy cancer cells.

cancer who have few or no symptoms. This drug is known as a “cancer vaccine.” First, immune cells are collected from your body and sent to a lab. The immune cells are then activated to identify and target prostate cancer cells. Lastly, the immune cells are injected back into your body where they attack cancer cells.

Guide 2 Non-hormone systemic therapies for advanced prostate cancer Type of therapy

Chemotherapies

Immunotherapies

Biomarker-targeted therapies

Radiopharmaceuticals

Bone-targeted therapies

Brand name

Generic name

Taxotere

docetaxel

Jevtana

cabazitaxel

Paraplatin

carboplatin

Platinol

cisplatin

Novantrone

mitoxantrone

Provenge

sipuleucel-T

Keytruda

pembrolizumab

Rubraca

rucaparib

Lynparza

olaparib (plus abiraterone)

Akeega

niraparib/abiraterone

Talzenna

talazoparib (plus enzalutamide)

Pluvicto

lutetium-177

Xofigo

radium-223

Prolia, Xgeva

denosumab

Zometa

zoledronic acid

Fosamax

alendronate

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Drug form

infusion into a vein

tablet

capsule infusion into a vein

injection tablet

Prostate 3 Prostate cancer cancer treatments treatments » Non-hormone » Non-hormone therapy therapy » Non-hormone therapy

Biomarker-targeted therapy

Lutetium-177 Lutetium-177 (Pluvicto) is a targeted radiopharmaceutical that looks for a particular protein (prostate-specific membrane antigen, PSMA) on the surface of prostate cancer cells anywhere in the body. When the drug finds PSMA, it attaches itself to the cancer cells and implants a small amount of its radioactive substance in them. The cancer cells absorb the radiation from the drug and die.

This treatment targets specific biomarkers that are found through molecular tumor testing. Biomarker-targeted therapies are useful only in patients whose prostate cancer is due to specific genetic mutations. This includes mutations in BRCA1, BRCA2, and other genes that repair damaged DNA. About 1 in 4 patients with metastatic hormone-resistant prostate cancer have this kind of genetic mutation.

Lutetium-177 is an intravenous infusion given once every 6 weeks for up to 6 doses. You’ll need a PSMA-PET scan to find out if this treatment may work for you.

Biomarker-targeted therapies (also known as PARP inhibitors) for advanced prostate cancer include rucaparib (Rubraca), olaparib (Lynparza), niraparib and abiraterone (Akeega), and talazoparib (Talzenna). Because genetic mutations differ between people, a treatment that helps one person may not help another.

Radium-223 Radium-223 (Xofigo) is used to treat prostate cancer that has metastasized in bone but hasn’t spread to other organs. Radium-223 collects in bones and gives off radiation that can kill prostate cancer cells there. It’s an injection given once a month for 6 months. You’ll need to have blood tests before each dose. A bone-targeting therapy, either denosumab or zoledronic acid, is often given with radium-223.

Radiopharmaceuticals A radiopharmaceutical is a medicine that contains a radioactive substance. This radioactive substance releases radiation to kill cancer cells. The radiation doesn’t travel far from cancer cells so nearby healthy tissue remains mostly unharmed.

Radium-223 is also used to reduce pain from bone metastases.

Radiopharmaceuticals are injected into a vein (intravenous injection). Because radiopharmaceuticals leave the body through the gut, common side effects are nausea, diarrhea, and vomiting.

Radiation therapy Radiation therapy uses high-energy rays, like x-rays or gamma rays, to kill cancer cells and shrink tumors. Radiation therapy is given in regular doses over a certain period of time.

Radiopharmaceutical drugs include lutetium-177 and radium-223:

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

External beam radiation therapy (EBRT) is the type of radiation used for prostate cancer. EBRT uses a machine that aims radiation precisely at cancer inside the body. The

Prostate 3 Prostate cancer cancer treatments treatments » Clinical » Clinical trialstrials » Clinical trials

Clinical trials

radiation beam focuses directly on the cancer while trying to avoid healthy tissue. This technique delivers higher doses of radiation more safely.

Therapy may also be given as part of a clinical trial.

For metastatic prostate cancer, radiation therapy is mainly used for treatment of prostate cancer that returns after initial treatment (recurrence). Radiation therapy is also used as palliative treatment to relieve the pain of bone metastases.

A clinical trial is a type of medical research study. Clinical trials are a key way to assess new treatment approaches. After being developed and tested in a laboratory, potential new ways of fighting cancer need to be studied in people. If found to be safe and effective in a clinical trial, a drug, device, or treatment approach may be approved by the FDA.

Radiation therapy (EBRT) is more commonly used along with hormone therapy as the initial treatment for patients who have early-stage or regional prostate cancer. EBRT treats the prostate as well as cancerous lymph nodes, while hormone therapy lowers testosterone to a minimal level to prevent the cancer from getting worse.

Everyone with cancer should carefully consider all the treatment options available for their cancer type, including standard treatments and clinical trials. Talk to your doctor about whether a clinical trial may make sense for you.

Some of the possible side effects of radiation therapy are urinary and bowel problems, erectile dysfunction, and fatigue.

Black males have a higher risk of developing and dying from prostate cancer. But many may not know about clinical trial opportunities. As a result, not as much is known about whether new treatments can work for Black males with prostate cancer. Everyone with cancer can ask for and should be given information about clinical trials. Knowing all the options means not missing out on clinical trial opportunities for promising new treatments.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Prostate 3 Prostate cancer cancer treatments treatments » Clinical » Clinical trialstrials » Clinical trials

Finding a clinical trial In the United States

Informed consent

NCCN Cancer Centers NCCN.org/cancercenters

Clinical trials are managed by a group of experts called a research team. The research team will review the study with you in detail, including its purpose and the risks and benefits of joining.

The National Cancer Institute (NCI) cancer.gov/about-cancer/treatment/ clinical-trials/search

All of this information is also provided in an informed consent form. This is an agreement that confirms you’ve been fully told about your part in the trial. Read the form carefully and ask questions before signing it. And discuss it with family, friends, or others you trust.

Worldwide The U.S. National Library of Medicine (NLM) clinicaltrials.gov

Keep in mind that clinical trials are voluntary and you can seek treatment outside of the clinical trial at any time.

Need help finding a clinical trial?

Start the conversation

NCI’s Cancer Information Service (CIS) 1.800.4.CANCER (1.800.422.6237) cancer.gov/contact

Don’t wait for your doctor to bring up clinical trials. Start the conversation and learn about all your treatment options. Ask if a clinical trial is available for your situation. If you find a study that you may be eligible for, ask your treatment team if you meet the requirements.

Frequently asked questions

If you have already started standard treatment, you may not be eligible for certain clinical trials. Try not to be discouraged if you cannot join. New clinical trials are always becoming available. NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

There are many myths and misconceptions surrounding clinical trials. The possible benefits and risks are not well understood by many with cancer.

Prostate 3 Prostate cancer cancer treatments treatments » Supportive » Supportive carecare » Supportive care

“

Supportive care

Without clinical trials, our treatment wouldn’t change. It would always remain the same. Some people refer to clinical trials as receiving tomorrow’s best treatment today.”

Supportive care (also called palliative care) treats cancer symptoms, the side effects of cancer treatment, and other related health issues. All patients with advanced cancer should be offered supportive care. Supportive care is important at any stage of cancer, not just at the end of life. In fact, people who start supportive care when they begin treatment tend to have better quality of life and potentially improved outcomes.

Bone-targeted therapy Supportive care may be especially useful for patients with bone metastases. Prostate cancer that metastasizes to bones can cause severe pain, fractures (breaks) in bones, bone loss (osteoporosis), and squeezing (compression) of the spinal cord.

Will I get a placebo? Placebos (inactive versions of real medicines) are almost never used alone in cancer clinical trials. It’s common to receive either a placebo with a standard treatment or a new drug with a standard treatment. You’ll be informed if a placebo is part of a clinical trial before you enroll.

Also, some treatments for prostate cancer, like hormone therapy, can cause osteoporosis and increase your risk of fractures.

If you’re at risk for osteoporosis, you may have a bone mineral density test. This is a special x-ray scan that measures how much calcium and other minerals are in your bones. Bone mineral density tests look for osteoporosis and help predict your risk for bone fractures.

Depending on the trial, you may continue to receive standard cancer care. The standard therapy is billed to—and often covered by— insurance. You’re responsible for copays and any costs for this care that aren’t covered by your insurance.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

You should have a follow-up bone mineral density test after 1 year of hormone therapy. You might also have blood tests to monitor kidney function and calcium levels.

Prostate 3 Prostate cancer cancer treatments treatments » Supportive » Supportive carecare » Supportive care

Shared decision-making Some people with cancer want their doctors and treatment team to just tell them which treatment to have. Doctors, nurses, and other providers are the experts, right? While it’s true that your treatment team has lots of experience and knowledge, you’re also an expert—you’re the expert on you. It’s a good idea for your team to share the responsibility of your treatment with you. And it’s a good idea for you to fully participate in making decisions about your care.

Here’s what your treatment team should share with you:

•

An explanation of the likely benefits and potential harms of each treatment option.

•

The likelihood of cure, recurrence, progression, and possible mortality with each treatment option.

•

And here’s what you should share with your treatment team:

The side effects of each treatment option along with their impact on quality of life, including sexual, urinary, and bowel function.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

•

Your preferences and feelings about treatment, side effects, risks, and quality of life. These should be key parts of your treatment plan.

•

If the provider who’s leading your treatment team doesn’t have a talk with you about shared decision-making, feel free to speak up and ask about it.

Prostate 3 Prostate cancer cancer treatments treatments » What’s » What’s next? next? » Key points

Key points

Medicines that target bones can help to relieve bone pain and reduce the risk of bone problems. Some medicines work by slowing or stopping bone breakdown, while others help increase bone thickness. Drugs include Prolia (denosumab), Xgeva (denosumab), Zometa (zoledronic acid), and Fosamax (alendronate).

For more information about supportive care, see Chapter 6.

What’s next?

This chapter described the available treatment options for advanced-stage prostate cancer, which includes both regional prostate cancer and metastatic prostate cancer.

If you’ve been diagnosed with regional prostate cancer, turn to the next chapter to read about the typical therapies included in your treatment plan.

If you’ve been diagnosed with metastatic prostate cancer, go to Chapter 5 to read about the common (and uncommon) treatment options for this advanced-stage cancer.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Testosterone helps prostate cancer grow. Hormone therapy treats prostate cancer by stopping testosterone from being made or by blocking cancer cells from using testosterone. Hormone therapy can eventually lose its effectiveness against prostate cancer. This becomes hormone-resistant prostate cancer. Hormone therapy is often combined with one or more other therapies, which can be more effective together at slowing or shrinking advanced prostate cancer. Other treatments used with hormone therapy for advanced prostate cancer include chemotherapy, immunotherapy, target therapy, radiopharmaceuticals, and radiation therapy. Hormone therapy can cause a number of possible side effects. But treatment and therapy are available. Supportive care relieves the symptoms caused by cancer and the side effects caused by its treatment. Everyone with advanced-stage prostate cancer should be offered supportive care.

Regional prostate cancer treatment options 38

About regional prostate cancer

Treatment

Follow-up after treatment

Treatment for persistence or recurrence

What’s next?

Key points

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Regional 4 Regional prostate prostate cancer cancer treatment treatment options options » About » About regional regional prostate prostate cancer cancer » Treatment

Regional prostate cancer has

Treatment options are also based on life expectancy and symptoms. The longer the life expectancy and the more symptoms, the more aggressive the treatment. See Guide 3.

grown outside the prostate gland to nearby areas like lymph nodes, but not any farther. It usually

Life expectancy Life expectancy is the average lifespan of a person. It’s measured in years. An estimate of your life expectancy may be a key factor in deciding which tests and treatments you’ll need.

requires both local and systemic (whole-body) treatment.

About regional prostate cancer

It’s important to know that life expectancy— when used for cancer care—is an estimate based on large numbers of people. That means life expectancy can be applied to a certain population or age range, but it’s not as easy to make a precise estimate of the lifespan of an individual person.

Regional prostate cancer is cancer that has spread from the prostate gland to neighboring tissue, such as nearby lymph nodes, the bladder, or the rectum. But it hasn’t spread any farther. (To read about prostate cancer that has spread to distant lymph nodes, bones, or organs, turn to Chapter 5.) Regional prostate cancer is also sometimes called locally advanced prostate cancer.

Life expectancy: More than 5 years or you have symptoms If your life expectancy is more than 5 years or you have symptoms, treatment usually includes:

Treatment

Radiation therapy External beam radiation therapy (EBRT along with long-term hormone therapy plus abiraterone (Zytiga) is the preferred initial treatment for patients who have regional prostate cancer and a longer life expectancy or symptoms. Preferred treatments are ones that have the most scientific evidence that they work well.

The key concern about prostate cancer that spreads just outside the prostate is that it could continue to spread farther (metastasize) to other areas of the body. As a result, treatment for regional prostate cancer is more aggressive than treatment for early-stage prostate cancer. Treatment takes aim at cancer in the prostate itself as well as cancer outside the prostate. So it often includes both local therapy (radiation therapy or prostate surgery) and systemic therapy (hormone therapy). NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

EBRT treats the prostate as well as cancerous lymph nodes, while long-term hormone therapy lowers testosterone to a minimal level to prevent the cancer from getting worse. Long-

Regional 4 Regional prostate prostate cancer cancer treatment treatment options options » Treatment » Treatment » Treatment

term hormone therapy is given before, during, and after EBRT for 2 to 3 years.

help patients live longer although it may also come with more side effects.

Hormone therapy Long-term hormone therapy consists of androgen deprivation therapy (ADT) plus abiraterone, an androgen inhibitor. If you’re taking abiraterone, you’ll also need to take a steroid to reduce abiraterone’s side effects.

Prostate surgery Prostatectomy means removing the prostate gland through surgery. A radical prostatectomy removes not only the entire prostate but also the surrounding tissue and seminal vesicles. A pelvic lymph node dissection (PLND) is an operation to remove the nearby lymph nodes.

Another option for initial treatment is radiation therapy plus long-term (2 to 3 years) ADT without the addition of abiraterone. This may be an option for those who can’t take abiraterone due to other health conditions.

A radical prostatectomy with PLND is a treatment option only in certain cases of regional prostate cancer. It’s used when:

ADT on its own is an option for patients with regional prostate cancer who have other significant or life-threatening health problems. Abiraterone can be added to ADT, which may

The tumor is found only in the prostate. The tumor can be removed completely with surgery.

Guide 3 Regional risk group: Initial therapy options Life expectancy

Treatment EBRT with ADT + abiraterone + steroid (preferred) EBRT with ADT

More than 5 years or you have symptoms

ADT with or without abiraterone Radical prostatectomy and dissection of pelvic lymph nodes

5 years or less and you have no symptoms

Observation ADT

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Additional treatment: • Monitoring (preferred) • EBRT with or without ADT • ADT with or without EBRT

Regional 4 Regional prostate prostate cancer cancer treatment treatment options options » Treatment » Treatment » Treatment

You have a life expectancy of 10 or more years.

Urinary incontinence (being unable to hold your urine) is usually temporary. Most patients gradually recover control of their bladder after a few months or so. Doing exercises to strengthen the pelvic floor can help. If incontinence continues to be a problem, another surgical procedure can be done to improve it.

You have no other serious health conditions.

A radical prostatectomy is complex and requires a great deal of skill. Surgeons who are experienced in this type of surgery often have better results.

Erectile dysfunction may slowly improve over several months to 2 years after the surgery. However, you may never regain the same erectile function you once had. Treatment options include pills (like Viagra and Cialis), injections of medication into the penis, vacuum constriction devices (“penis pump”), and surgical implants that produce an erection.

Even so, sometimes cavernous nerve bundles are damaged or removed during surgery. The cavernous nerves control the ability to have erections. These nerves run alongside the prostate. Surgeons do their best to avoid these nerves when performing a prostatectomy, but damage to the nerves during surgery is sometimes unavoidable. This damage can cause side effects.

Erectile dysfunction is a leading cause of depression in patients with prostate cancer. Ask your care team about therapy or counseling if you’re having any problems due to erectile dysfunction or any symptoms of depression. Help is available.

Possible side effects of radical prostatectomy can include urinary incontinence and erectile dysfunction.

About 1 in 8 people who are diagnosed with prostate cancer have prostate cancer that is regional.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Regional 4 Regional prostate prostate cancer cancer treatment treatment options options » Treatment » Treatment » Treatment

“

Additional therapy after prostate surgery Because the surgeon is able to see inside your body during prostate surgery, it often reveals more details about your disease. It could show that the cancer has spread to nearby lymph nodes. Or there may be other signs of cancer after the prostate is removed. In either case, you might have additional treatment at some point after the surgery.

I had a radical prostatectomy. Because my prostate cancer was very close to one nerve bundle, I chose to have it removed also. I wasn’t troubled by this because I learned that there are other ways of getting erections. I wanted to live to see my grandchildren grow up, and now they have!”

If there are signs of remaining cancer but no metastasis in lymph nodes, additional treatment involves EBRT with or without added hormone therapy. But additional treatment, like any treatment, comes with some risk of side effects. So instead of active therapy, your care team may suggest that you delay additional treatment but have regular testing until signs or symptoms (such as a rising PSA level) begin to occur. This is called monitoring.

Life expectancy: 5 years or less and you have no symptoms Treatment is less aggressive for people with regional prostate cancer whose life expectancy is 5 years or less and who have no symptoms:

If prostate surgery shows that the cancer has spread to the lymph nodes, monitoring may still be an option. If active therapy is recommended instead, the treatment involves ADT with or without EBRT.

Observation Observation is an option for patients with a life expectancy of 5 years or less. It’s for those with other serious health problems whose prostate cancer isn’t causing any symptoms. Observation involves occasional PSA tests and watching for symptoms, which can be treated with pain-relieving (palliative) therapy. ADT ADT on its own is an option for patients with regional disease, no symptoms, and a life expectancy of 5 years or less. It’s used to slow cancer and delay or reduce symptoms. ADT may include an LHRH agonist, an LHRH antagonist, or surgical removal of the testicles.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Regional Regional 4 Regional prostate prostate prostate cancer cancer treatment cancer treatment treatment optionsoptions »Follow-up options »after Follow-up »treatment Follow-up after »Treatment after treatment treatment forpersistenceorrecurrence

Follow-up after treatment

Treatment for persistence or recurrence

After initial treatment, you’ll have follow-up tests to find out how well your therapy worked. Periodic prostate-specific antigen (PSA) tests and occasional imaging scans can indicate whether the cancer is under control.

If you have PSA persistence or recurrence after your initial therapy, your life expectancy will guide what treatment you may have next.

More than 5 years

PSA is very low or undetectable

Before deciding on any treatment, you’ll need some more tests to find out how aggressive the cancer may be. Tests include PSA doubling time; imaging with CT, MRI, or whole-body PET scan; and possibly a biopsy. Results of these tests will indicate your next treatment.

If your PSA is very low after radiation therapy or undetectable after prostate surgery, you’ll be monitored for cancer recurrence. Monitoring involves PSA testing every 6 to 12 months for several years. Patients with a high risk of recurrence may have PSA testing more often, such as every 3 months. You’ll continue to be monitored on an ongoing basis or until signs or symptoms occur.

In addition, treatment for cancer persistence or recurrence is based on whether your initial treatment for regional prostate cancer was radiation therapy or prostate surgery. See

Guide 4.

PSA is elevated or rising

5 years or less

If your PSA doesn’t fall to an undetectable level after prostate surgery, you may still have cancer (persistence). Or, if your PSA drops after initial treatment but then later rises again, it probably means the cancer has come back (recurrence). In either case, further treatment is available.

If your life expectancy is 5 years or less, observation may be a better option than undergoing treatment. Observation involves checking up on your prostate cancer and watching for symptoms. If symptoms develop, treatment is often focused on easing or stopping them instead of trying to cure the cancer. This allows patients to maintain a good quality of life without the burden of unnecessary treatment.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Regional Regional 4 Regional prostate prostate prostate cancer cancer treatment cancer treatment options treatment »Treatment options options forpersistence » Treatment » Treatment orrecurrence for persistence for »Treatment persistence foror persistence recurrence or recurrence orrecurrence

Guide 4 Treatment for PSA persistence or recurrence Initial therapy

Radical prostatectomy

Imaging results

Treatment options

No other signs of cancer

• Radiation therapy with or without hormone therapy (preferred) • Monitoring

Cancer in pelvic lymph nodes

• Radiation therapy and hormone therapy, with or without abiraterone

Cancer has spread to another area of the body (metastasized)

• Advanced treatment required

No other signs of cancer or Cancer only in the prostate

• Biopsy • Monitoring • Hormone therapy • Radical prostatectomy • Cryotherapy • High-intensity focused ultrasound • More radiation therapy

Cancer in pelvic lymph nodes

Cancer has spread to another area of the body (metastasized)

• Advanced treatment required

Radiation therapy

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Regional 4 Regional prostate prostate cancer cancer treatment treatment options options » What’s » What’s next? next? » Key points

What’s next?

Key points

After you’ve been treated for regional prostate cancer, and perhaps PSA persistence or PSA recurrence, you’ll continue to have tests and visits to treat your existing cancer or to watch out for cancer to return.

Surveillance is a key part of your follow-up plan. Be sure to continue to go to follow-up visits, have your PSA tested regularly, and stay in touch with your treatment team.

If the cancer comes back again but doesn’t spread beyond the pelvis, you can continue to have treatment for persistence/recurrence. If the cancer comes back again but spreads to another area of the body, you’ll need more advanced treatment. See the next chapter for treatment options for metastatic prostate cancer.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Regional prostate cancer has spread from the prostate gland to neighboring tissue, but no farther. The main concern about regional prostate cancer is that it could continue to spread to other areas of the body. Treatment for regional prostate cancer often includes both local therapy and systemic therapy. The preferred initial treatment for regional prostate cancer in people with a longer life expectancy or symptoms is external beam radiation therapy (EBRT), long-term androgen deprivation therapy (ADT), and abiraterone. Treatment is less aggressive for people with regional prostate cancer whose life expectancy is 5 years or less and who have no symptoms. Prostate-specific antigen (PSA) persistence is when your PSA doesn’t fall to an undetectable level. This indicates the cancer hasn’t gone away. PSA recurrence is when your PSA level drops after initial treatment but rises again. This indicates the cancer has come back.

Metastatic prostate cancer treatment options 46

About metastatic prostate cancer

Main treatment

Hormone-sensitive treatment

Hormone-resistant treatment

What’s next?

Key points

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Metastatic 5 Metastatic prostate prostate cancer cancer treatment treatment options options » About » About metastatic metastatic prostate prostate cancer cancer

Main treatment

When prostate cancer spreads to other parts of the body, then

The main treatment for metastatic prostate cancer is hormone therapy, specifically androgen deprivation therapy (ADT).

systemic (whole-body) therapy is needed. This chapter explains the treatment options for distant

The aim of ADT is to reduce androgens (mostly testosterone) to a point where they don’t provide fuel for the cancer. This low point is called castration level, which is when there’s nearly zero testosterone in the bloodstream.

metastatic prostate cancer.

About metastatic prostate cancer

Patients whose metastatic prostate cancer is newly diagnosed will begin ADT to get their testosterone down to castration level. Patients with metastatic prostate cancer who are already being treated with ADT will continue the treatment to keep testosterone at a minimal level.

Metastatic prostate cancer is cancer that has spread (metastasized) outside the prostate and beyond the pelvis to other areas of the body. Areas where prostate cancer tends to spread are:

ADT comes in a few forms. These include drugs (an LHRH agonist with or without an anti-androgen, or an LHRH antagonist) or sometimes surgery (removal of the testicles).

Lymph nodes farther away from the prostate

Although ADT is the main therapy for advanced prostate cancer, it’s not usually given on its own any more. Adding one or two additional therapies to ADT may help you live longer and with fewer symptoms.

Bones in the spine, pelvis, or ribs Organs such as the liver, lungs, brain, or others

You may have metastatic cancer when you’re first diagnosed. Or your cancer may become metastatic after you’ve already had treatment for early-stage or regional prostate cancer.

Additional therapies include second hormone therapy, chemotherapy, immunotherapy, targeted therapy, and radiopharmaceuticals. You may hear this called doublet therapy (ADT + another therapy) or triplet therapy (ADT + two additional therapies).

Metastatic prostate cancer can be difficult to treat. However, a variety of therapies are available to target the cancer, stop or slow its progress, reduce symptoms, and prolong life.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Which additional therapy you’ll have depends on a number of considerations. The first consideration is whether ADT is still effective

Metastatic Metastatic 5 Metastatic prostate prostate prostate cancer cancer cancer treatment treatment treatment options options »Hormone-sensitive options » Hormone-sensitive » Hormone-sensitive treatment»Hormone-sensitive treatment treatment treatment

for you. To put it into medical terms, is your cancer hormone resistant or is it hormone sensitive?

That is, hormone therapy can still treat it. You may also hear it called by its former name, castration-naïve prostate cancer, which means that hormone therapy is a new (“naïve”) treatment for the cancer.

Hormone-resistant prostate cancer (also called castration-resistant prostate cancer) is cancer that learns how to grow without using testosterone as its fuel. As a result, hormone therapy is no longer as effective against it—most of the cancer becomes “resistant” to ADT.

If this describes your cancer, read the following section about treatment options for hormonesensitive prostate cancer.

Hormone-sensitive treatment

If you’ve had ADT but it’s no longer working well, go to page 49 to read about treatment options for hormone-resistant metastatic prostate cancer.

As its name implies, hormone-sensitive metastatic prostate cancer is treated mainly with hormone therapy. ADT is considered the first hormone therapy. But a second hormonereducing therapy is commonly added to ADT for treating advanced prostate cancer. It can prevent your cancer from growing and spreading farther. See Guide 5.

Hormone-sensitive prostate cancer (also called castration-sensitive prostate cancer) is not currently being treated with ADT or has never been treated with ADT. (This doesn’t include ADT given as short-term additional therapy, such as hormone therapy given during radiation therapy.) As a result, this cancer is “sensitive” to hormone therapy.

“When you are deciding on your treatment options, remember that even though some decisions need to be made fast, don’t rush. Think through your options and get second, or even third opinions. Have people you can trust to talk through your options so you feel comfortable in your decisions.”

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Preferred treatments

medicine (docetaxel) plus a hormone-reducing medicine (either abiraterone or darolutamide).

Preferred treatments are ones that have the most scientific evidence that they work well. Preferred treatment options for hormonesensitive prostate cancer include ADT plus a second hormone-reducing medicine. Medical research has shown that patients on ADT plus another hormone-reducing medicine tend to live longer than those on ADT alone. The preferred second hormone-reducing medicines are abiraterone, apalutamide, and enzalutamide. Your care team will talk to you about which medicine might work best for you.

This adds up to a lot of medicine. So triplet therapy is only recommended for people who have high-volume prostate cancer who also can physically tolerate chemotherapy while on hormone therapy, plus other treatment. High-volume prostate cancer means having multiple metastases in bones and/or at least one metastasis in an internal organ. (Prostate cancer that has spread to an internal organ is called a visceral metastasis.)

Other treatments

If you’re prescribed abiraterone, you’ll also be given a steroid medication. The steroid helps reduce the side effects of abiraterone.

Low-volume prostate cancer means having zero to a few metastases in bones and/or some metastases in distant lymph nodes, with no metastases in internal organs.

Other preferred treatments for hormonesensitive metastatic prostate cancer are triplet therapy options: ADT plus a chemotherapy

Guide 5 Treatment options for hormone-sensitive prostate cancer

Preferred options

Other options

ADT

abiraterone (Zytiga) + steroid

ADT

apalutamide (Erleada)

ADT

enzalutamide (Xtandi) abiraterone (Zytiga) + steroid

ADT + chemotherapy (docetaxel)

ADT

radiation therapy (EBRT)

ADT

radiation therapy (EBRT) + abiraterone

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

darolutamide (Nubeqa)

Metastatic Metastatic 5 Metastatic prostate prostate prostate cancer cancer cancer treatment treatment treatment options options »Hormone-resistant options » Hormone-resistant » Hormone-resistant treatment»Hormone-resistant treatment treatment treatment

Hormone-resistant treatment

For patients with low-volume hormonesensitive prostate cancer, ADT plus external beam radiation therapy (EBRT) to the metastases is recommended to help stop the cancer from spreading farther. In some cases, abiraterone (or docetaxel chemotherapy) is given in addition to ADT and EBRT for a stronger effect.

Hormone-resistant metastatic prostate cancer is cancer that keeps growing even when testosterone is at a very low level. How? Some cancer cells learn to survive without the usual supply of testosterone. Also, the cancer may get some androgens from the adrenal glands, which make a small amount of testosterone. Even the tumor itself can create androgens that help cancer cells grow. As these cells multiply, ADT gradually loses its effectiveness against the cancer.

ADT used by itself is usually not recommended for hormone-sensitive metastatic prostate cancer, except for patients who aren’t able to handle side effects or take other medicines.

Follow-up visits

ADT

After treatment, you’ll have follow-up tests on a regular basis to see how well the treatment is working and to check for any signs or symptoms that the cancer has returned.

To treat hormone-resistant metastatic prostate cancer, your testosterone needs to remain at castration level. So it’s still important to stay on ADT. Your care team may keep you on your same ADT treatment or might ask you to switch to a different medicine.

If follow-up tests find that treatment isn’t working and your hormone-sensitive prostate cancer is growing or spreading, then you may have developed hormone-resistant prostate cancer. This is discussed next.

Besides ADT, your care team will recommend additional treatment. See Guide 6 and Guide 7. Which treatment you’ll receive will depend on a few factors. These include:

Your previous treatment (if any)

Location of the metastasis in your body

Amount of metastatic disease

Symptoms

Potential side effects

Your preferences

In addition to ADT, treatments for hormoneresistant metastatic prostate cancer include second hormone therapy, chemotherapy, NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

immunotherapy, biomarker-targeted therapies, and radiopharmaceuticals—or a combination of these treatments.

If you were first diagnosed with early prostate cancer or hormone-sensitive prostate cancer, then you may have already had ADT and chemotherapy or next-generation hormone therapy. Having had either of these therapies will affect which treatment you’ll have next.

Second hormone therapy

Abiraterone (Zytiga)

Enzalutamide (Xtandi)

ADT plus chemotherapy can be the first treatment for metastatic prostate cancer or it can be given later if other treatments haven’t worked well. Chemotherapy can be given as a single drug (such as docetaxel) or as a pair (cabazitaxel and carboplatin) if the cancer is more aggressive. Docetaxel is the preferred chemotherapy. Other chemotherapy drugs may be used in certain cases. These include cabazitaxel, cisplatin, carboplatin, and mitoxantrone. You can also take a steroid (prednisone or dexamethasone) to reduce the side effects of chemotherapy.

Other second hormone therapy If the preferred second hormone therapies don’t slow down your cancer, there are other hormone-reducing options:

Adding one of the early-generation antiandrogens (nilutamide, flutamide, or bicalutamide) may be effective if newer hormone therapies aren’t an option due to cost or availability. Stopping an anti-androgen may also be effective. Sometimes stopping the drug has the opposite effect of lowering PSA levels in some patients.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Ketoconazole (Nizoral) is a pill that’s occasionally prescribed when second hormone therapy or chemotherapy can’t be used or isn’t available. It’s taken with a steroid (hydrocortisone) to reduce side effects such as nausea and vomiting.

Chemotherapy

ADT is the first hormone therapy used for treating metastatic prostate cancer. If prostate cancer becomes hormone resistant, then a second hormone therapy is commonly added. A second hormone therapy may be able to slow down your cancer or keep it from spreading farther. The preferred second therapy options include newer (nextgeneration) hormone therapies:

A corticosteroid (hydrocortisone, prednisone, or dexamethasone) can be a hormone-reducing therapy itself when used in addition to ADT.

Immunotherapy

Immunotherapy drugs boost the body’s own immune system to fight cancer. However, immunotherapy for prostate cancer is used only for certain patients. Immunotherapy drugs include:

Sipuleucel-T (Provenge) can be used for patients whose hormone-resistant metastatic prostate cancer is causing few or no symptoms. Such patients usually have less cancer and a stronger immune system, which allows this immunotherapy to be more effective. Sipuleucel-T is not recommended for those whose prostate cancer has spread to internal organs.

Pembrolizumab (Keytruda) is recommended only for patients whose hormone-resistant metastatic prostate cancer has grown or spread despite having chemotherapy and second hormone therapy. Patients’ test results will also show specific genetic changes (defects in DNA called mismatch repair deficiency and high microsatellite instability).

Targeted therapy Biomarker-targeted therapies are useful only in patients whose hormone-resistant metastatic prostate cancer is linked with specific genetic mutations. These drugs are called PARP inhibitors because they target PARP, which is a

Guide 6 Treatment options for hormone-resistant prostate cancer Type of therapy

Preferred options

Second hormone therapy

Chemotherapy

Other options

Second hormone therapy

Treatment ADT +

abiraterone (Zytiga) + steroid

Initial therapy

ADT +

enzalutamide (Xtandi)

Initial therapy

ADT +

docetaxel (Taxotere) + steroid

Initial therapy

ADT +

anti-androgen (start one or stop one)

Only if you’ve already had initial therapy

ADT + corticosteroid ADT +

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

When to use

ketoconazole (Nizoral) + hydrocortisone

Only if you’ve already had initial therapy Only if you’ve already had initial therapy

Guide 7 Treatment options for specific cases of hormone-resistant prostate cancer Specific case

Treatment

If you have few or no symptoms and prostate cancer hasn’t spread to other internal organs

ADT + sipuleucel-T (Provenge)

ADT + If you have a BRCA mutation and haven’t been treated for hormone-resistant prostate cancer

niraparib/abiraterone (Akeega) + prednisone

olaparib (Lynparza) + ADT + abiraterone (Zytiga) + steroid

If you have a BRCA mutation and were already treated with hormone therapy and chemotherapy

ADT + rucaparib (Rubraca)

If you have a DNA-repair gene mutation (BRCA or other) and haven’t received treatment for hormoneresistant prostate cancer

ADT +

If you have a DNA-repair gene mutation (BRCA or other) and were already treated with hormone therapy

ADT + olaparib (Lynparza)

If you have aggressive metastatic prostate cancer or more than one genetic mutation, and docetaxel isn’t a good option

cabazitaxel (Jevtana) + ADT + steroid, with or without carboplatin

If you need pain relief but can’t take other therapies

ADT +

If you have bone metastases that are causing symptoms but have no other metastases

ADT + radium-223 (Xofigo)

If your prostate cancer produces PSMA and you already received hormone therapy and chemotherapy

ADT + lutetium-177 (Pluvicto)

If you have certain genetic mutations (high microsatellite instability or high tumor mutational burden) and were already treated with hormone therapy and chemotherapy

ADT + pembrolizumab (Keytruda)

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

talazoparib (Talzenna) + enzalutamide (Xtandi)

mitoxantrone (Novantrone) + prednisone

Radiopharmaceuticals

protein that cells use to repair damaged DNA. Biomarker-targeted therapies include:

If your initial or other treatments haven’t worked well, your care team may suggest a radiopharmaceutical drug.

Olaparib (Lynparza) plus abiraterone and a steroid can be used for patients with a BRCA mutation before having second hormone therapy or chemotherapy. Olaparib may also be used for patients whose metastatic cancer has grown or spread after second hormone therapy (abiraterone or enzalutamide) and who have a mutation in a BRCA gene or other gene that repairs DNA.

Rucaparib (Rubraca) can be used for patients with a BRCA mutation whose cancer has already been treated with both second hormone therapy and chemotherapy (docetaxel or cabazitaxel).

Lutetium-177 (Pluvicto) isn’t used until after both a second hormone therapy and chemotherapy (docetaxel or cabazitaxel) have been given. First, you’ll have PSMAPET imaging to confirm the treatment could work. Radium-223 (Xofigo) can be used if prostate cancer has spread mainly to bones but not to internal organs. It should only be used in combination with ADT, not with second hormone therapy or chemotherapy.

Niraparib and abiraterone (Akeega) plus prednisone is a new targeted therapy for patients with a BRCA mutation. Patients should also be on an LHRH agonist, LHRH antagonist, or have had orchiectomy (surgical removal of the testicles).

Clinical trial

Talazoparib (Talzenna), taken with enzalutamide (Xtandi), is another new targeted therapy for patients with a mutation in a BRCA or other DNA-repair gene.

Supportive care

Participating in a clinical trial is often an option. You can try to join a clinical trial at any time. You don’t need to wait until you feel like you have no other options.

Supportive care for patients with bone metastases includes:

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Bone-targeted therapy – Denosumab or zoledronic acid to help prevent fractures Palliative radiation therapy – Direct radiation to painful bone tumors or tumors that interfere with bodily functions Other treatments – Calcium or vitamin D supplements to help prevent fractures

Metastatic 5 Metastatic prostate prostate cancer cancer treatment treatment options options » Hormone-resistant » Hormone-resistant treatment treatment » Key points

Follow-up visits

different therapy. Many patients with advanced prostate cancer eventually receive two, three, or more different therapies in the course of their treatment.

After treatment, you’ll have follow-up tests on a regular basis to see how well the treatment is working and if there are any side effects from treatment. Tests include:

If possible, consider all the treatment options. Talk with your team about what you want from treatment. You may ask for a second opinion before you start another therapy. You can explore any clinical trials that are available. And you always have the option to stop systemic therapy.

Physical exam with PSA test every 3 to 6 months or more often Imaging if cancer symptoms occur Imaging as needed to look for cancer growth or spread

You’ll continue to be offered supportive care.

No growth or spread If the cancer doesn’t grow or spread, your current treatment may be keeping your cancer in check. Your provider will continue to give you tests. If your situation remains stable, you’ll stay on your current treatment unless changes or symptoms begin to occur. Growth or spread If your cancer grows or spreads, your treatment team may suggest you retry a therapy you’ve had before or try a new and

Many patients with advanced prostate cancer eventually receive two, three, or more different therapies in the course of their treatment.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Metastatic 5 Metastatic prostate prostate cancer cancer treatment treatment options options » What’s » What’s next? next? » Key points

What’s next?

Key points

Surveillance is a key part of your follow-up plan. Be sure to continue to go to follow-up visits and stay in touch with your treatment team.

It’s common to feel frustration, anger, regret, despair, and uncertainty—even all at the same time. Know that you can have prostate cancer and still find happiness after diagnosis and treatment. Try to enjoy life as much as possible. Talk with family or friends. Join a support group to learn how other patients are dealing with their cancer. Or talk to your doctor or another member of your care team. They can point you to professionals who can help you deal with these feelings and guide you toward your next steps.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Metastatic prostate cancer has spread outside the prostate and beyond the pelvis to other areas of the body, such as distant lymph nodes, bones, or organs. The first treatment for advanced metastatic prostate cancer is usually ADT. Adding another therapy or two to ADT may help you live longer and with fewer symptoms. Hormone-sensitive prostate cancer is treated mainly with hormone therapy. Hormone-resistant prostate cancer has learned how to grow without using testosterone as its fuel. It’s treated with ADT and another type of therapy—often a newer hormone therapy or chemotherapy. Second hormone therapy is commonly added to ADT as a preferred treatment option for advanced prostate cancer. Prostate cancer and its treatment may cause you to feel frustration, anger, regret, despair, and uncertainty. Know that you can still find happiness after diagnosis and treatment.

Supportive care and other assistance 57

Supportive care

Financial concerns

Survivorship

Advance care planning

Key points

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Supportive 6 Supportive carecare andand other other assistance assistance » Supportive » Supportive carecare » Supportive care

Supportive care

Supportive care addresses the symptoms and side effects

Supportive care is for relieving the symptoms of cancer, the side effects of cancer therapies, and other health issues related to the cancer. Supportive care also helps with psychological, social, and spiritual issues.

of prostate cancer, as well as psychological, social, financial, and spiritual issues. Many resources are available to help

Supportive care is given at any stage of disease, not just at the end of life.

you feel better and answer your questions.

Supportive care involves the whole person, not just their cancer. Supportive care addresses many needs. It can help with making treatment decisions. It can also assist with coordinating care between health providers. Notably, supportive care can help prevent or treat physical and emotional symptoms. Supportive care can also help with financial support, advance care planning, and end-of-life concerns.

The main concern for most patients with cancer is to find treatment that works. Having cancer is about more than just treatment, though. Cancer care can be a rollercoaster that includes many additional physical and emotional challenges. It’s important to know that you can get support for these challenges.

It’s important to talk openly with your treatment team about supportive care. Some medical centers have patient navigators or other staff members who coordinate nonclinical supportive care. Ask questions and reach out if you need more information about supportive care.

“

Anxiety and depression

Report any unusual feelings of sadness, loss of interest in activities, anxiety, and sleep problems to your doctor. Many people experience these feelings, and they should not go untreated. ”

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Many people with prostate cancer experience symptoms of distress, such as anxiety and depression. You may feel anxious during testing, or you may experience depression during a hard part of treatment, or because your life is not the same as it was before cancer. Tell your treatment team if you’re experiencing these symptoms so that you can get help.

Supportive 6 Supportive carecare andand other other assistance assistance » Financial » Financial concerns concerns » Financial concerns

Help can include support groups, talk therapy, or medication. At your cancer center, patient navigators, social workers, and other experts can help. Some people also feel better by exercising, talking with loved ones, or relaxing.

Support groups

It’s important to ask for help

Many people diagnosed with cancer find support groups to be helpful. A support group provides the opportunity to talk with others who are going through, or have been through, similar experiences. Support groups often include people at different stages of treatment. Some people may be newly diagnosed, while others may be finished with treatment. If your hospital or community doesn’t have support groups for people with cancer, have a look at the online resources listed on page 72 of this book.

Depression, anxiety, fear, and distress are very common feelings for people with cancer. These feelings can make it harder to deal with cancer and cancer treatment. They can hold you back even when you want to move forward. Getting help when you’re feeling worried or hopeless is an important part of cancer care. If you’re feeling anxious or overwhelmed, ask your treatment team for help.

Financial concerns

More information about cancer and distress is available at NCCN.org/ patientguidelines and on the NCCN Patient Guides for Cancer app.

The financial cost of prostate cancer can be overwhelming. As a result, many people with prostate cancer and their loved ones struggle with the cost of treatment, as well as the stress of paying for it. To make things worse, you may miss work during treatment or become unemployed. Or you may have trouble paying for or getting medicines. Or you may have too little or no health insurance.

You can also talk to your treatment team about work, health insurance, or money problems. Your team can include information in your treatment plan to help you manage your finances and medical costs. If your doctors and care providers don’t talk about how to pay for treatment, it’s okay for you to ask them about it first.

If you struggle to pay for food, housing, treatment, follow-up care, and other expenses, or you have difficulty getting to appointments, talk with your care team’s social worker, patient navigator, and hospital financial services staff. They can help you find financial support and transportation options. NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Supportive 6 Supportive carecare andand other other assistance assistance » Survivorship » Survivorship » Advance care planning

Survivorship Survivorship focuses on the health and wellbeing of a person with cancer from diagnosis until the end of life. This includes the physical, mental, emotional, social, and financial effects of cancer that begin at diagnosis, continue through treatment, and arise afterward.

Consider quality of life Quality of life is a term used often in cancer care. It refers to a person’s overall enjoyment of life, including their sense of well-being and ability to participate in regular activities. For some people, aggressive cancer treatment may extend their life but reduce their quality of life. That’s one reason why quality of life should be an important consideration when making decisions about cancer treatment.

Survivorship also includes concerns about follow-up care, late effects of treatment, cancer recurrence, and quality of life. Support from family members, friends, and caregivers is also an important part of survivorship. Read more about survivorship in NCCN Guidelines for Patients: Survivorship Care for Healthy Living and Survivorship Care for Cancer-Related Late and Long-Term Effects, available at NCCN.org/patientguidelines and on the NCCN Patient Guides for Cancer app.

Advance care planning is for everyone, not just for those who are very sick. Advance care planning means deciding what care you would want if you become unable to make medical decisions for yourself. It’s about making sure that your wishes are understood and respected.

Advance care planning

The focus is on you receiving the best possible care at the end of your life. Patients with incurable cancer can set up an advance care plan early to help them feel less stressed and better able to cope with their condition.

When cancer is diagnosed at an advanced stage or keeps progressing despite all treatment efforts, it may be time to consider what lies ahead. Even when cancers are curable, talking about future scenarios should begin when starting treatment. This exploration of what’s important to you is called advance care planning.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

The advance care planning process starts with an open and honest discussion with your care team about your prognosis—what you may experience in the coming months—and the medications or therapies that may give

Supportive 6 Supportive carecare andand other other assistance assistance » Advance » Advance carecare planning planning » Advance care planning

you the best quality of life. Quality of life refers to a person’s overall enjoyment of life, including their sense of well-being and ability to participate in their usual activities. This discussion should include important people in your life such as your spouse or partner and family members or friends who are likely to be with you at the end.

advance directive when you’re too ill to make decisions about your care. Tell your care team and family about your advance directive and its contents. Give a copy of your advance directive to all your doctors. Make sure you give a copy to anyone you’ve authorized to make decisions on your behalf (health care proxy). If your family or loved ones disagree with your plan, speak to your care team. Sometimes they or other specialists can help you and your family navigate these difficult conversations.

Make your wishes clear. It’s important that everyone clearly understands the goals of your care and your personal wishes about what should—and should not—be done. You can decide if there is a point where you might want to stop cancer treatment. You can also decide what treatments you would want for symptom relief.

You can change your advance care plan at any time. Frequent conversations with your care team can help.

Once you’ve made these decisions, you’ll fill out a legal document that explains what you want to be done if you aren’t able to tell your care team yourself. This document is called an advance directive. Your health care providers are required to follow the instructions in an

End-of-life considerations End-of-life care provides medical, psychological, and spiritual support for people who are close to the end of life as well as the people who love them. The goal is comfort, not a cure. It may also be called comfort care

Many people diagnosed with cancer find support groups to be helpful. A support group provides the opportunity to talk with others who are going through, or have been through, similar experiences.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Supportive 6 Supportive carecare andand other other assistance assistance » Key » Key points points » Key points

Key points

or hospice. Note that hospice is a special kind of end-of-life care. Hospice refers specifically to an insurance benefit for people whose life expectancy is 6 months or less. Hospice supports those at the end of life by bringing in additional care providers and resources such as home care.

The goal of end-of-life care is to give people the best life possible with the time they have left. Care can be provided in your home, a hospice facility, or even in the hospital. A major goal is to keep you pain-free and make sure that you can leave this world comfortably and with dignity. Hospice doctors, nurses, social workers, and chaplains are experts in helping patients work through the spiritual and emotional challenges of coping with the end of life.

Providing support for family members is a key part of hospice care. Most programs offer counseling and support groups for family members, including support after the patient has died. This is referred to as bereavement. It can be very comforting to know that your loved ones will have that kind of support after you’re gone.

“

Supportive care is for relieving symptoms and side effects, and for other health issues related to cancer. Supportive care is given at any stage of disease, not just at the end of life. Supportive care is treatment that involves the whole person, not just their cancer. Many people with prostate cancer experience anxiety and depression. Help is available. A support group provides the opportunity to talk with others who’ve been through similar experiences. For help with financial support and transportation options, talk with your care team’s social worker, patient navigator, and hospital financial services staff. Advance care planning is done to ensure that your end-of-life wishes are understood and respected.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making treatment decisions 63

It’s your choice

Questions to ask

Resources

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » It’s» your It’s your choice choice » It’s your choice

It’s important to be comfortable

with the cancer treatment you

choose. This choice starts with having an open and honest

Quality of life and length of life How active you are and the activities that are important to you

Think about what you want from treatment. Discuss openly the risks and benefits of specific treatments and procedures. Weigh options and share concerns with your care team.

conversation with your care team about the benefits and risks of treatment.

Second opinion It’s normal to want to start treatment as soon as possible. While cancer treatment shouldn’t be ignored, there is usually time to have another cancer care provider review your test results and suggest a treatment plan. This is called getting a second opinion, and it’s a normal part of cancer care. Even doctors get second opinions!

It’s your choice Treatment decisions are very personal. What’s important to you may not be important to someone else. In shared decision-making, you and your care team share information, discuss the options, and agree on a treatment plan. Be clear about your goals for treatment and find out what to expect from treatment. It starts with an open and honest conversation between you and your team.

Seek out a prostate cancer specialist, if you can, because they have experience diagnosing and treating a lot of people with your type of cancer.

Some things that may play a role in your decision-making:

Things you can do to prepare:

What you want and how that might differ from what others want Your religious and spiritual beliefs Your feelings about certain treatments like hormone therapy or radiation

Your feelings about pain or side effects Cost of treatment, travel to treatment centers, and time away from school or work

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Check with your insurance company about its rules on second opinions. There may be out-of-pocket costs to see providers who are not part of your insurance plan. Make plans to have copies of all your records and imaging scans sent to the doctor you will see for your second opinion.

Making 7 Making treatment treatment decisions decisions » Questions » Questions to ask to ask » Questions to ask

Things to think about when making treatment decisions Be sure to weigh all your options. There are no "correct" answers. The right decision is the one that’s best for you. Consider: Your personal preferences

vs.

Your health care providers’ recommendations

Having definitive treatment

vs.

Keeping other treatment options open

Length of life

vs.

Quality of life

Traveling for treatment

vs.

Staying close to home and family

Having more treatment

vs.

Having more side effects

Having standard treatment now, which is covered by your health plan

vs.

Waiting for specialized treatment, which requires your health plan’s approval

Questions to ask Possible questions to ask your care providers are listed on the following pages. Feel free to use these or come up with your own. Have a notebook handy to jot down the answers to your questions.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » Questions » Questions to ask to ask » Questions to ask

Questions about cancer testing 1. What tests will I have? 2. Do the tests have any risks? 3. Will my health plan pay for all the tests you’re recommending? 4. Do I need to do anything to prepare for testing? 5. Should I bring someone with me to the appointments? 6. Where do I go for testing, and how long will it take? 7. If any of the tests will hurt, what will you do to make me comfortable? 8. How soon will I know the results and who will explain them to me? 9. How can I get a copy of the pathology report and other test results? 10. What is the cancer stage? What does this stage mean in terms of survival?

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » Questions » Questions to ask to ask » Questions to ask

Questions about treatment choices 1. What are my treatment options? 2. Are you suggesting options other than what NCCN recommends? If yes, why? 3. What will happen if I do nothing? 4. Does any option offer a cure or long-term cancer control? 5. How do my age, family history, overall health, and other factors affect my options? 6. Will the treatment hurt? 7. How long do I have to decide about treatment? Is there a social worker or someone who can help me decide? 8. Is a clinical trial an option for me? 9. How do I get a second opinion?

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » Questions » Questions to ask to ask » Questions to ask

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » Questions » Questions to ask to ask » Questions to ask

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » Questions » Questions to ask to ask » Questions to ask

Questions about your care team’s experience 1. Are you board certified? If yes, in what area? 2. What is your experience as well as your team’s experience with treating my type of prostate cancer? 3. How many patients like me (of the same age, race) have you treated? 4. Will you be consulting with experts to discuss my care? Who will you consult? 5. Is my treatment or procedure a major part of your practice? How often have you done this treatment or procedure in the last year? 6. How many of your patients have had complications? What were the complications?

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » Questions » Questions to ask to ask » Questions to ask

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » Questions » Questions to ask to ask » Questions to ask

Questions about resources and support 1. Who can I talk to about help with housing, food, and other basic needs? 2. What assistance is available for transportation, childcare, and home care? 3. Who can tell me what my options for health insurance are and assist me with applying for insurance coverage? 4. How much will I have to pay for my treatment? What help is available to pay for medicines and other treatment? 5. Who can help me with my concerns about missing work or school? 6. How can I connect with others and build a support system? 7. Who can I talk to if I don’t feel safe at home, at work, or in my neighborhood?

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Making 7 Making treatment treatment decisions decisions » Resources » Resources » Resources

Resources

PCaAware National Prostate Cancer Awareness Foundation pcaaware.org

AnCan Foundation ancan.org

Prostate Conditions Education Council (PCEC) prostateconditions.org

Cancare Cancare.org

Prostate Health Education Network (PHEN) prostatehealthed.org

CancerCare cancercare.org

Triage Cancer triagecancer.org

Cancer Hope Network cancerhopenetwork.org

ZERO Prostate Cancer zerocancer.org

FORCE: Facing Our Risk of Cancer Empowered facingourrisk.org Imerman Angels imermanangels.org Malecare malecare.org National Alliance of State Prostate Cancer Coalitions (NASPCC) naspcc.org National Coalition for Cancer Survivorship canceradvocacy.org

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Words to know

Words to know advanced-stage prostate cancer Prostate cancer that has spread beyond the prostate to other areas in the body. This includes regional and metastatic prostate cancer.

androgen deprivation therapy (ADT) Hormone therapy that stops the body from making testosterone or blocks cancer cells from using testosterone. ADT can be given through drugs or surgery.

genetic mutation A harmful change in the cell’s instructions, which damages its function and can lead to disease.

anti-androgen A drug that stops the action of the hormone testosterone.

hormone therapy A cancer treatment that stops the making or action of hormones. Also called androgen deprivation therapy.

biopsy A procedure that removes fluid or tissue samples to be tested for disease.

life expectancy The number of years a person is likely to live based on statistics of other people in similar circumstances.

castration Surgery that removes the testicles, or drugs that suppress the function of the testicles, to minimize testosterone levels.

luteinizing hormone-releasing hormone (LHRH) agonist A drug that acts in the brain to stop the testicles from making testosterone.

computed tomography (CT) An imaging test that uses x-rays from many angles to make a picture of the inside of the body. digital rectal exam An exam of the prostate by feeling it through the wall of the rectum.

luteinizing hormone-releasing hormone (LHRH) antagonist A drug that acts in the brain to stop the testicles from making testosterone.

early-stage prostate cancer Prostate cancer that stays within the prostate and usually grows slowly.

lymphatic system A network of organs and vessels that fights infections and transports a fluid called lymph.

enlarged prostate An overgrowth of tissue in the prostate that isn’t caused by cancer. Also called benign prostatic hyperplasia (BPH).

lymph nodes Small clusters found throughout the body that filter lymph fluid to remove germs.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Words to know

magnetic resonance imaging (MRI) A test that uses radio waves and powerful magnets to make pictures of the insides of the body.

prostate-specific membrane antigen (PSMA) A protein found on the surface of prostate cancer cells. PSMA is a biomarker of prostate cancer cells.

metastasis The spread of cancer from the site where it started to a new site in the body.

PSA persistence When PSA level is still detectable after prostate cancer treatment.

metastatic prostate cancer Cancer that spreads beyond the prostate to other parts of the body.

PSA recurrence When PSA level drops after prostate cancer treatment but then rises again.

observation A period of watching for cancer occurrence or growth while not receiving treatment.

radiation therapy Treatment that uses high-energy rays (radiation) to kill cancer cells and stop new cancer cells from being made.

orchiectomy An operation to reduce testosterone in the body by removing one or both testicles.

radical prostatectomy An operation that removes the entire prostate as well as surrounding tissue, seminal vesicles, and sometimes nearby lymph nodes.

palliative therapy Health care for the symptoms of cancer or the side effects of cancer treatment. Palliative therapy is an important part of supportive care.

recurrence The return of cancer after a disease-free period.

pathologist A doctor who specializes in testing cells and tissue to find disease.

regional prostate cancer Cancer that has grown from the prostate to neighboring areas, but no farther.

pelvic lymph node dissection (PLND) An operation that removes lymph nodes in the pelvis.

risk factor Something that increases the chance of getting a disease.

positron emission tomography (PET) An imaging test that uses radioactive material to see the shape and function of body parts.

seminal vesicles Glands that make and store part of the fluid that becomes semen.

prostate-specific antigen (PSA) A protein made by the prostate that helps semen transport sperm. PSA is measured in nanograms per milliliter of blood (ng/mL).

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

supportive care Health care other than curative treatment that supports the physical, emotional, social, and spiritual needs of patients, families, and caregivers.

NCCN Contributors

Senior Director, Patient Information Operations

John Murphy

Susan Kidney

Medical Writer

Senior Graphic Design Specialist

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Prostate Cancer, Version 4.2024 were developed by the following NCCN Panel Members: Edward M. Schaeffer, MD, PhD

Robert H. Lurie Comprehensive Cancer Center of Northwestern University

Sandy Srinivas, MD

Stanford Cancer Institute

Nabil Adra, MD, MSc

Indiana University Melvin and Bren Simon Comprehensive Cancer Center

Yi An, MD

Yale Cancer Center/Smilow Cancer Hospital

Shilpa Gupta, MD

Case Comprehensive Cancer Center/ University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

Thomas Guzzo, MD, MPH

Abramson Cancer Center at The University of Pennsylvania

Joseph E. Ippolito, MD, PhD Siteman Cancer Center at BarnesJewish Hospital and Washington University School of Medicine

Tyler Robin, MD, PhD

University of Colorado Cancer Center

Stan Rosenfeld

University of California San Francisco Patient Services Committee Chair Emeritus

Ahmad Shabsigh, MD

The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

Daniel Spratt, MD

Mayo Clinic Comprehensive Cancer Center

Case Comprehensive Cancer Center/ University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

The University of Texas MD Anderson Cancer Center

Michael R. Kuettel, MD, MBA, PhD

Russell Szmulewitz, MD

*Heather H. Cheng, MD, PhD

Joshua M. Lang, MD, MS

*Rhonda Bitting, MD Duke Cancer Institute

*Brian Chapin, MD

Fred Hutchinson Cancer Center

*R. Jeffrey Karnes, MD

Roswell Park Comprehensive Cancer Center

The UChicago Medicine Comprehensive Cancer Center

University of Wisconsin Carbone Cancer Center

*Benjamin A. Teply, MD

Dana-Farber/Brigham and Women’s Cancer Center | Mass General Cancer Center

Tamara Lotan, MD

Jonathan Tward, MD, PhD

Neil Desai, MD, MHS

*Rana R. McKay, MD

Richard Valicenti, MD

Todd Morgan, MD

*Jessica Karen Wong, MD

Anthony Victor D’Amico, MD, PhD

UT Southwestern Simmons Comprehensive Cancer Center

Tanya Dorff, MD

City of Hope National Cancer Center

James A. Eastham, MD

Memorial Sloan Kettering Cancer Center

Thomas A. Farrington

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins UC San Diego Moores Cancer Center University of Michigan Rogel Cancer Center

Julio M. Pow-Sang, MD Moffitt Cancer Center

Robert Reiter, MD, MBA

Prostate Health Education Network (PHEN)

UCLA Jonsson Comprehensive Cancer Center

Xin Gao, MD

Mack Roach, III, MD

Dana-Farber/Brigham and Women’s Cancer Center | Mass General Cancer Center

UCSF Helen Diller Family Comprehensive Cancer Center

* Reviewed this patient guide. For disclosures, visit NCCN.org/disclosures.

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Fred & Pamela Buffett Cancer Center Huntsman Cancer Institute at the University of Utah

UC Davis Comprehensive Cancer Center Fox Chase Cancer Center

NCCN Deborah Freedman-Cass, PhD

Senior Manager, Guidelines Processes

Jenna Snedeker, MS, ASCP Associate Scientist/Medical Writer

NCCN Cancer Centers

NCCN Cancer Centers Abramson Cancer Center at the University of Pennsylvania

Memorial Sloan Kettering Cancer Center New York, New York 800.525.2225 • mskcc.org

Philadelphia, Pennsylvania 800.789.7366 • pennmedicine.org/cancer

Moffitt Cancer Center

Case Comprehensive Cancer Center/ University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

Tampa, Florida 888.663.3488 • moffitt.org

O’Neal Comprehensive Cancer Center at UAB

Birmingham, Alabama 800.822.0933 • uab.edu/onealcancercenter

Robert H. Lurie Comprehensive Cancer Center of Northwestern University Chicago, Illinois 866.587.4322 • cancer.northwestern.edu

City of Hope National Medical Center

Roswell Park Comprehensive Cancer Center

Duarte, California 800.826.4673 • cityofhope.org

Buffalo, New York 877.275.7724 • roswellpark.org

Dana-Farber/Brigham and Women’s Cancer Center | Mass General Cancer Center

Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

Boston, Massachusetts 877.442.3324 • youhaveus.org 617.726.5130 • massgeneral.org/cancer-center

St. Louis, Missouri 800.600.3606 • siteman.wustl.edu

St. Jude Children’s Research Hospital/ The University of Tennessee Health Science Center

Duke Cancer Institute

Durham, North Carolina 888.275.3853 • dukecancerinstitute.org

Memphis, Tennessee 866.278.5833 • stjude.org 901.448.5500 • uthsc.edu

Fox Chase Cancer Center Philadelphia, Pennsylvania 888.369.2427 • foxchase.org

Stanford Cancer Institute

Stanford, California 877.668.7535 • cancer.stanford.edu

Fred & Pamela Buffett Cancer Center Omaha, Nebraska 402.559.5600 • unmc.edu/cancercenter

The Ohio State University Comprehensive Cancer Center James Cancer Hospital and Solove Research Institute Columbus, Ohio 800.293.5066 • cancer.osu.edu

Fred Hutchinson Cancer Center Seattle, Washington 206.667.5000 • fredhutch.org

Huntsman Cancer Institute at the University of Utah

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Indiana University Melvin and Bren Simon Comprehensive Cancer Center

The UChicago Medicine Comprehensive Cancer Center

Baltimore, Maryland 410.955.8964 www.hopkinskimmelcancercenter.org

Salt Lake City, Utah 800.824.2073 • healthcare.utah.edu/huntsmancancerinstitute

Indianapolis, Indiana 888.600.4822 • www.cancer.iu.edu

Chicago, Illinois 773.702.1000 • uchicagomedicine.org/cancer

Mayo Clinic Comprehensive Cancer Center

The University of Texas MD Anderson Cancer Center Houston, Texas 844.269.5922 • mdanderson.org

Phoenix/Scottsdale, Arizona Jacksonville, Florida Rochester, Minnesota 480.301.8000 • Arizona 904.953.0853 • Florida 507.538.3270 • Minnesota mayoclinic.org/cancercenter

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

UC Davis Comprehensive Cancer Center Sacramento, California 916.734.5959 • 800.770.9261 health.ucdavis.edu/cancer

NCCN Cancer Centers

UC San Diego Moores Cancer Center La Jolla, California 858.822.6100 • cancer.ucsd.edu

UCLA Jonsson Comprehensive Cancer Center Los Angeles, California 310.825.5268 • uclahealth.org/cancer

UCSF Helen Diller Family Comprehensive Cancer Center

We want your feedback!

San Francisco, California 800.689.8273 • cancer.ucsf.edu

University of Colorado Cancer Center

Our goal is to provide helpful and easy-to-understand information on cancer.

Aurora, Colorado 720.848.0300 • coloradocancercenter.org

University of Michigan Rogel Cancer Center Ann Arbor, Michigan 800.865.1125 • rogelcancercenter.org

Take our survey to let us know what we got right and what we could do better.

University of Wisconsin Carbone Cancer Center Madison, Wisconsin 608.265.1700 • uwhealth.org/cancer

UT Southwestern Simmons Comprehensive Cancer Center

NCCN.org/patients/feedback

Dallas, Texas 214.648.3111 • utsouthwestern.edu/simmons

Vanderbilt-Ingram Cancer Center Nashville, Tennessee 877.936.8422 • vicc.org

Yale Cancer Center/Smilow Cancer Hospital New Haven, Connecticut 855.4.SMILOW • yalecancercenter.org

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Notes

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

Index

Index androgen deprivation therapy (ADT) 25, 27–29, 39, 41, 44, 46–53, 55

regional prostate cancer 10, 21, 32, 36, 38–44, 46

biopsy 13, 15, 17–20, 42, 43

risk factors 6, 8

bone scan 15, 17

sexual side effects 15, 27–28, 32, 35, 40–41

chemotherapy 10, 25, 28–30, 46, 48–53

supportive care 34, 36, 53–54, 57–58

clinical trial 32–34, 53–54

targeted therapy 10, 17, 22, 25, 28, 30–31, 46, 50–53

digital rectal exam 13–14

tumor, node, metastasis (TNM) system 22

erectile dysfunction 27–28, 32, 40–41

tumor testing 21

genetic testing 15, 20–22

ultrasound imaging 15, 17–9

hormone-resistant prostate cancer 29, 31, 47, 49–54

urinary problems (incontinence) 6, 27, 32, 35, 40

hormone-sensitive prostate cancer 47–49, 50 hormone therapy 10, 25–29, 32, 34, 38–39, 41, 43, 46–53, 63 immunotherapy 10, 25, 28–30, 46, 50–51 inherited gene testing 21 life expectancy 38–42, 61 metastasis 10, 15–18, 20–22, 31, 34, 38, 41, 43, 46, 48–49 pelvic lymph node dissection (PLND) 39, 43 prostate surgery (radical prostatectomy) 38–43 PSA persistence 42–44 PSA recurrence 16–17, 32, 35, 37, 42–44, 59 radiation therapy 10, 25, 31–32, 38–39, 41–43, 47–49, 53, 63 radiopharmaceutical 10, 30, 31, 46, 50, 53

NCCN Guidelines for Patients® Advanced-Stage Prostate Cancer, 2024

NCCN GUIDELINES FOR PATIENTS

AdvancedStage Prostate Cancer 2024 To support the NCCN Guidelines for Patients, visit NCCNFoundation.org/Donate

3025 Chemical Road, Suite 100 Plymouth Meeting, PA 19462 215.690.0300

NCCN.org/patients – For Patients | NCCN.org – For Clinicians PAT-N-1783-0624

ZERO® – ADVANCED PROSTATE CANCER NEWS

WINTER 2023/2024

NEWS

ADVANCED PROSTATE CANCER

Our Mission

WINTER 2023/2024

Who We Are

ZERO is a 501(c)(3) philanthropic organization recognized with four out of four stars by Charity Navigator, accredited by the Better Business Bureau, with regional chapters across the country. We dedicate 85 cents of every dollar to programs for people with prostate cancer.

A MESSAGE FROM DR. ALICIA MORGANS Dear Friends,

Alicia Morgans

M.D., M.P.H. Dana-Farber Cancer Institute Chair – ZERO Medical Advisory Board

This past year was one of ups and downs as we learned of several advancements for people diagnosed with metastatic prostate cancer, but also that there is an increase in Black men being diagnosed with later stage prostate cancer. According to results published in the medical journal JAMA Network Open, survival rates for men with metastatic prostate cancer as a group has increased between 2008 and 2020, but minority men need further advocacy and dedicated care to achieve the same successes. We must continue to support advances for all to achieve true success for our community, and I appreciate your ongoing support as we strive to do this.

Findings were presented at the 2023 ASCO Annual Meeting that are meaningful for metastatic castration-resistant prostate cancer (mCRPC). Two of these focused on patients with HRR (homologous recombinant repair) gene alterations, including BRCA 1 and 2. These studies helped shine a light on outcomes for patients with HRR gene alterations as well as the emerging importance of combining androgen receptor signaling inhibitors in combination with PARP inhibitors for patients with BRCA mutations. These findings further remind us to make sure that all patients with metastatic prostate cancer undergo testing for both germline genetic mutations (what we inherit and share with family members) and somatic tumor mutations (next generation sequencing testing done on tumor tissue or circulating tumor DNA). This testing can inform families of what they need to do to understand potential risk for prostate, breast, ovarian and other cancers, and can identify potential treatment options for patients with prostate cancer to allow personalized treatment plans. ZERO has long been committed to advancing health equity and working to eliminate health disparities and we are continuing to understand more about why these disparities exist and what we can do to eliminate them. Findings presented in October at the American Society for Radiation Oncology (ASTRO) annual meeting showed that Black prostate cancer patients were six times more likely to receive genomic testing if they were seen by a precision medicine navigator. These navigators identify patients eligible for genomic testing and then ensure those tests are completed. Unfortunately these navigators are not part of the majority of patients’ healthcare plans. Historically, Black patients have much lower genomic and genetic testing rates than white patients – often because these tests are not discussed by their providers. Increased access to and use of these tests by Black patients is one way to reduce health disparities and improve outcomes for Black patients. Ongoing work with Black men is critical to ensuring success for all patients with prostate cancer. As we continue to work to ensure patients and their loved ones have the critical information they need to make informed decisions, we also continue to partner with multiple accredited continuing medical education (CME) providers to educate and support healthcare providers. One of these partnerships was an Expert Think Tank on Applying the Continued on next page

ZERO® – ADVANCED PROSTATE CANCER NEWS

WINTER 2023/2024

A MESSAGE FROM DR. ALICIA MORGANS (cont. from page 1) Latest Data to Individualize Treatment in Prostate Cancer. This activity included a treatment decision-making tool for providers and now features a treatment decision-making tool for patients who have advanced prostate cancer. Patients can input information about their prostate cancer diagnosis and will be provided with the opinions of five different prostate cancer experts on a recommended treatment path. I was happy to serve as one of the five clinicians providing recommendations for this project. Tools like these incorporate guideline based care into expert experience and opinion to give patients more information and insight into the management of their own care. In closing, I wanted to remind you of all of the support resources that ZERO offers. The ZERO360 patient helpline supported an average of 142 callers each month in 2023 and provides personalized case management, assisting with everything from insurance questions to psychosocial services. The MENtor program provides one-on-one support and you can sign up to become a MENtor for someone else, or be paired with a MENtor for yourself. The ZERO Us TOO Support Groups offer peer-to-peer networking opportunities for everyone impacted by prostate cancer. More than 15 new groups were added in the fall alone! Last, but certainly not least, please consider registering now for the annual ZERO Prostate Cancer Summit, coming up in-person February 25–27, 2024 and virtually March 12–14, 2024. Please make sure you are there to lend your voice and play a part in the change that we need to see for patients and their families. Learn more about all of these programs and events at ZERO’s newly designed website, www.zerocancer.org. Thank you for being a part of the ZERO family. I am wishing you and your family good health as we begin 2024. Dr. Alicia Morgans

2023 FDA APPROVALS IN PROSTATE CANCER Diagnostics – Radiopharmaceutical

In May the FDA approved flotufolastat F 18 injection (Posluma) for positron emission tomography (PET) of prostate-specific membrane antigen (PSMA)–positive lesions in men with prostate cancer with suspected metastasis who are eligible for initial definitive therapy or with suspected recurrence based on elevated PSA level. This adds to our arsenal of PSMA PET imaging agents for prostate cancer.

Hormone Therapy

In November, the FDA approved enzalutamide (Xtandi) for non-metastatic castration-sensitive prostate cancer (nmCSPC) patients with biochemical recurrence at high risk for metastasis.

PARP Inhibitors

In May the FDA approved olaparib (Lynparza) with abiraterone and prednisone (or prednisolone) for adult patients with deleterious or suspected deleterious BRCA-mutated mCRPC, as determined by an FDAapproved companion diagnostic test. In June the FDA approved talazoparib (Talzenna) with enzalutamide for homologous recombination repair (HRR) gene-mutated mCRPC. In August the FDA approved the fixed dose combination of niraparib and abiraterone acetate (Akeega), with prednisone, for adult patients with deleterious or suspected deleterious BRCA-mutated mCRPC, as determined by an FDA-approved test.

New Patient Treatment Decision Tool ZERO partnered with Clinical Care Options to develop a Treatment Decision-Making Tool for advanced prostate cancer patients. Enter information about your prostate cancer diagnosis and see treatment path recommendations from five prostate cancer specialists. Check the patient tool out today! 2

ZERO® – ADVANCED PROSTATE CANCER NEWS

WINTER 2023/2024

HOW TO CONNECT TO SUPPORT AND MENTAL WELLNESS

Hakim Asadi LMSW Beyond Living

Men with advanced prostate cancer often face unique challenges that can impact them and their loved ones, mentally, emotionally, and physically. Coping with the diagnosis, treatment, and potential side effects can take a toll on their overall well-being. Here are some insights and ways to look out for mental health challenges in men with advanced prostate cancer:

Acknowledge Your Feelings: It’s essential to recognize and accept your emotions. It’s natural to experience fear, anger, sadness, anxiety, and grief. It’s important to practice vulnerability, (acknowledge and address feelings) with yourself and those you love and trust. Ask Questions and Stay Informed: Understanding your condition and the treatments available can help reduce anxiety and fear. Ask your healthcare team questions and seek reliable information from reputable sources.

Mind-Body Techniques: Practices like meditation, yoga, and deep breathing can help reduce stress and improve mental well-being. Advance Care Planning: It may be helpful to have discussions with your healthcare provider and loved ones about your long-term care plan. Knowing your options can provide a sense of control and peace of mind. Stay Socially Engaged: Isolation can lead to feelings of loneliness and depression. Try to stay engaged in social activities or maintain connections with friends and family. Stay Positive and Stay Active: Engage in activities that bring you joy – a hobby, volunteering, or spending time with loved ones. A positive attitude can make a significant difference in your mental well-being. Regular Follow-up: Keep regular appointments with your healthcare team to monitor your condition and address any concerns promptly.

Seek Support and Other Support Strategies: Identify your support system, including family, friends, and support groups. Sharing your thoughts and feelings with others can be therapeutic. Prostate cancer support groups are available, both in-person and online. Professional Help: Consider speaking with a mental health professional, such as a therapist or counselor. They can provide strategies for managing stress, anxiety, and depression. Maintain a Healthy Lifestyle: Eating a balanced diet, staying physically active (within your doctor’s recommendations), and getting enough sleep can positively impact your mental health.

Remember, there’s no one-size-fits-all approach to managing mental health challenges while dealing with advanced prostate cancer. It’s important to identify and reflect on your needs to tailor your coping strategies to your specific needs.

MENTAL HEALTH AND WELLNESS RESOURCES For more information on coping with a prostate cancer diagnosis and for more resources, go to zerocancer.org/mentalhealth. See page 7 of this newsletter for a list of all of ZERO’s support programs. 3

ZERO® – ADVANCED PROSTATE CANCER NEWS

WINTER 2023/2024

DOES YOUR LOVED ONE HAVE ADVANCED PROSTATE CANCER? Words of Wisdom from Our Caregiver Support Group Members Kathie Houchens and Karen Bernatis, A Forum for Her support group leaders

Kathie Houchens

Karen Bernatis

Kathie and Karen co-facilitate multiple support groups for women whose partners have advanced/metastatic prostate cancer, as part of ZERO’s Us TOO support group network. They reached out to more than 20 support group participants to glean their wisdom to share. What would you have liked to have known sooner? “ I wish I had known at the beginning that survival times are a HUGE bell curve. Things change. New treatments are coming along and we now feel like we have possibilities again. After… being told at the outset that this is not curable, then last week his PSA was undetectable for the second month! The doctor said ‘You could live a long and healthy life.’ It puts our minds in a whole new place. One of hope!” “ As treatment options evolve, so do the combination of various treatments. Men are beginning to go through second cycles of new drugs like Pluvicto, increasing their longevity. Being told at the beginning that there is a vibrant pipeline of possibility would have eased the panic of a stage IV diagnosis.”

“ I wish I had known more about how my husband’s body would change and how that would affect him. The loss of muscle mass and fatigue was downplayed… I think doctors could do a better job of incorporating the mental healthcare aspect at the time of diagnosis. And include the partner or spouse as an equal. Both of us need emotional support. I was not adequately prepared for how to handle it all.” “ I wish someone would have helped me find a group of other prostate cancer co-survivors in the beginning. Wives and partners are overlooked, undervalued, and overwhelmed in a strange new world of medical terms. There is little to no information about support groups like ZERO’s Us TOO.” What has your experience been like in these caregiver support groups? “ I appreciate the “safe space” – this is the one group of people with whom I can freely say what I have to say. Also, to hear other women talk takes away my feelings of isolation. I am not alone!” “ We’ve built enough trust that we can share our innermost fears. We can laugh and cry with each other. I think it’s helped my husband, too, because we learn of other treatments, side effects, etc. from each other which helps us all.” 4

How do you practice self-care? “ I do a 10-min “over age 50 arms workout” on YouTube with an instructor who is always smiling and makes me feel good.” “ Yoga helps me stay grounded in my body and in this present moment. It is a time I set aside to relax and refresh my body, mind, and spirit.” “ I try to have a full body massage once a month. It is a luxury, but one I need right now.” “ I attend a guided meditation class. I also try to swim or exercise regularly. I see a therapist once a month and that helps, too, as this journey is hard and I want to have the tools to be able to handle things when times get tougher.” “ I nap when I feel like it. Some days the emotional energy drains me and I allow myself to rest.” To read more advice from these caregivers, see our caregiver blog series at https:// zerocancer.org/blog/forum-her-supportgroup-members-caregiving-self-care-andmore-part-1. For more on resources for caregivers, visit zerocancer.org/caregivers.

ZERO® – ADVANCED PROSTATE CANCER NEWS

WINTER 2023/2024

MY PROSTATE CANCER CLINICAL TRIAL JOURNEY My cancer journey started two weeks after my 65th birthday. In September 2019, I was diagnosed with aggressive metastatic prostate cancer. I had experienced back pain for 18 months but thought it Dan Peddie was from lifelong scoliosis. My primary care doctor – who never previously did PSA tests – ordered one, along with an MRI and CT scan. My PSA was over 1000. A confirming biopsy revealed Gleason of 4+3 = 7. A bone scan showed 80% of the body had cancer – from my knees to skull. Fortunately, the ADT plus abiraterone and prednisone therapy had immediate effect. By January, my cancer had reduced significantly – PSA was between 1 and 2. Bone pain was still the primary symptom. I had very nominal side effects from hormone therapy.

monoclonal antibody cirmtuzumab, in combination with chemo (docetaxel), in treating prostate cancer. I finished this combination phase in July. There were initial positive results of less cancer and no progression. My PSA went from 168 to 63. It has since risen to 134. While I’m on a maintenance plan – cirmtuzumab once a month – we are doing an updated PSMA scan to see why the PSA is rising aggressively now. I’ve known of the benefits of clinical trials through my consulting career with medical-based clients. Now I’ve experienced the great level of care in this clinical trial. It has been remarkable. I recommend a trial for its comprehensive approach to care. As well, even if I don’t gain benefits from the experimental drug combination, I hope to benefit future patients through participation in a trial. Someone did this for me awhile back, now I can return the favor myself.

The abiraterone, and a prior diagnosis of atrial fibrillation (Afib), contributed to a brain stem stroke in January 2020 that almost took me out. I lost my motor functions in my right leg and arm, which I recovered soon with therapy. My swallowing was impacted so I had a feeding tube for 15 weeks. I lost 40 pounds through the whole process. Abiraterone worked for 32 months until April 2022 when my PSA started to double. I was switched to enzalutamide. My PSA continued to double each month until September when I was switched to olaparib. A blood biopsy in August 2022 revealed I had a rare genetic mutation that about 5–7% of metastatic castration-resistant prostate cancer (mCRPC) patients have. After another treatment failure, my oncologist and I determined a clinical trial might be appropriate due to the obvious disease progression. I joined a trial at the University of California San Diego in February 2023. The trial is testing the effectiveness of the

So, after four years I’ve learned a lot about the science of prostate cancer but more about life. Like the Tim McGraw song says, “Live like you were dying”, I have changed my perceptions of what is important, have learned to focus on gratitude for who is in my life, and gained a new perspective on suffering specific to my faith. I believe cancer has changed me for the better.

CLINICAL TRIALS IN PROSTATE CANCER There are many clinical trials available for advanced prostate cancer patients. Oftentimes people do not participate in a clinical trial because they don’t know they are eligible or that one is available. Be sure to ask your doctor if a clinical trial may be right for you.

To learn more about clinical trials, find available trials, and see our list of questions for your doctor, please visit: https://zerocancer.org/clinical-trials. 5

ZERO® – ADVANCED PROSTATE CANCER NEWS

WINTER 2023/2024

BLACK MEN’S PROSTATE CANCER INITIATIVE ZERO is committed to eliminating disparities in prostate cancer and ending prostate cancer for all. We work to ensure that everyone has a fair and just opportunity to prevent, find, treat, and survive prostate cancer, regardless of race, the financial resources one has or has access to, or where one lives.

their communities with prostate cancer education, resources, and support. The BMPCI also serves as a vehicle to help introduce communities to ZERO and give ZERO the opportunity to prove itself as a trusted partner in the fight to end prostate cancer for all.

We unfortunately still see the most evident disparities in prostate cancer experienced by Black men. Black men are 1.7 times more likely to get prostate cancer, often with a more advanced stage of the disease and higher PSA number, and are 2.1 times more likely to die from prostate cancer when compared to their White counterparts.

Over the last year, the BMPCI has seen tremendous growth with the implementation of support groups, both virtually and in-person in Atlanta, that are specifically for Black men diagnosed with prostate cancer. There have also been numerous podcasts on many subjects critical to Black men and their communities. We are busy planning our next Health Equity Symposium in June 2024. We have hosted over 13 editions of our “Prostate Cancer in the Black Community” film series, which has reached nearly 1,000 people since its inception in late 2022. And finally, through our work with dedicated partners, we’ve seen 370+ men receive a PSA test and linked to ZERO resources as well as a medical home.

To address this disparity and work towards achieving true health equity, ZERO has continued its work through the Black Men’s Prostate Cancer Initiative (BMPCI). This initiative provides Black men, their families, and

We’re excited to continue our work and scale our efforts to more communities. For more information on the BMPCI and other updates, visit: https://zerocancer. org/black-men/prostate-cancer-initiative.

Kris Bennett

ZERO Director, Health Equity, Community Organizing and Engagement

VETERANS UPDATE A year ago, we launched our Veterans Advisory Board (VAB), composed of a highly motivated group of Veterans committed to helping find solutions for the issues Veterans with prostate cancer face. 1 in 5 Veterans are diagnosed with prostate cancer, making Veterans a group at highest risk for prostate cancer in the United States.

Ali Manson

Over the past year, the VAB advised ZERO on a complete revamp of the Veterans 101 pamphlet, helping to create a product that is unique to Veterans and helping readers understand their risk and unique options for care. VAB members have also been working hard to disseminate information about prostate cancer to other Veterans in their communities by visiting local Veteran health facilities and attending events.

ZERO Vice President, Government Relations and Advocacy

On the advocacy front, President Biden signed legislation in December of 2022 establishing a clinical pathway for prostate cancer within the Veterans Health Administration, the first step to ensuring that all Veterans have access to high-quality, evidence-based prostate cancer care when they need it, no matter where they live. ZERO has been working closely with the VA to ensure that implementation of that pathway is patient-centric and comprehensive, beginning with prostate cancer education and screening, and running through advanced disease treatment and survivorship. To help inform the process, ZERO facilitated two discussions between VA personnel and Veterans, exploring ways the VA can improve healthcare for Veterans with prostate cancer. We’ll continue to work with the VA and other partners and look forward to the enactment of the pathway at the end of the year. Go to zerocancer.org/veterans to learn more about ZERO’s efforts to help Veterans with prostate cancer. 6

ZERO® – ADVANCED PROSTATE CANCER NEWS

WINTER 2023/2024

PROSTATE CANCER SUPPORT PROGRAMS ZERO360: Comprehensive Patient Support zerocancer.org/zero360 ZERO360 helps patients navigate insurance, find financial aid resources, connect with support services, and secure access to care. To connect, call 1 (844) 244-1309. Us TOO Support Groups zerocancer.org/supportgroups Us TOO Support Groups offer in-person and virtual peer support, resources, and education to empower men to make informed decisions on testing, treatment, and management of side effects. Groups are also available for special interests, including: Veterans, Black Men, LGBTQIA+ Community, Caregivers, Spanish Language, Deaf Men, and others. Online Support Services ZERO Connect (facebook.com/groups/zeroconnect) is a Facebook-based support group for participants to share stories, ask questions, and connect. Invite-only Facebook groups also exist for Black Men (email info@zerocancer.org for information). The Inspire Online Support Community (zero.inspire.com) connects patients, families, friends, and caregivers. Peer Support MENtor is a peer support network at zerocancer.org/mentor for anyone who has received a prostate cancer diagnosis. ZERO’s trained, volunteer MENtors have a wealth of insights to share based on their experiences. Educational Resources zerocancer.org/learn ZERO offers a variety of educational events and resources for prostate cancer awareness, early detection, screening, treatment, and side effects.

DO YOU HAVE QUESTIONS ABOUT ADT? Check out our “Questions For Your Doctor: Hormone Therapy” guide to start the conversation with your healthcare provider.

FEBRUARY 25–27 Washington, D.C.

Visit zerocancer.org/summit 7

ZERO® – ADVANCED PROSTATE CANCER NEWS

WINTER 2023/2024

This publication is provided with support from:

ADVANCED PROSTATE CANCER

NEWS

515 King Street, Suite 310 Alexandria, VA 22314 Phone: 202-463-9455 info@zerocancer.org

515 King Street, Suite 310 Alexandria, VA 22314 30% post-consumer

Maine Health Care Advance Directive Form You may use this form now to tell your physician and others what medical care you want to receive if you become too sick in the future to tell them what you want. You may choose to fill out the whole form or any part of the form and then sign and date the form in Part 6. These are the parts:

Part 1

Fill this out if you want to choose someone to make all your health care decisions for you, either right away or if you become too sick to tell others what you want. This person is called your agent.

Part 2

Fill this out if: (1) you did not name an agent in Part 1 and now want to choose whether you want certain treatments or, (2) you did name an agent in Part 1 and want to tell your agent your wishes about certain treatments, knowing that your agent must follow your directions.

Part 3

Fill this out if you want to give the name of your primary physician, physician assistant or nurse practitioner.

Part 4

Fill this out if you want to make decisions about donating your organs, body or tissues after your death.

Part 5

Fill this out if you want: (1) to choose someone to make all funeral and burial decisions after your death, or (2) to tell your family any wishes you have about funeral and burial decisions.

Part 6

You must sign and date your Advance Directive form on this page. Have two witnesses sign the form at the same time you sign it. Tell others about your decisions and give copies to your physician, other health care providers, family and hospital.

Part 7

If you do not wish to be revived by ambulance crews should your heart or breathing stop, then you and your physician (or nurse practitioner or physician assistant) need to sign this Do Not Resuscitate (DNR) form. Page 1 of 17 Revised March 2023

Note You may change any part of this form except for Part 6 and Part 7. You may cross out any words, sentences, or paragraphs you do not want. You can also add your own words. If you make any changes to the form, it is best if you put your initials and the date next to each change so that everyone knows it was your decision to make the change. The form lets you choose different ways to handle your care by checking boxes or filling in blanks. You may initial each box and each blank you fill in to show that it was your decision to check the box or fill in the blank. Before filling out this form, we suggest that you talk with your lawyer, family members, physicians, and others close to you about your wishes. If you make changes or complete a new form, be sure to let everyone know.

My Name (please print)______________________________________________________ My Address _______________________________________________________________ My Birth date______________________________________________________________

This is a list of all the people who have copies of my signed health care advance directive: 1. ________________________________________________________________________ 2. ________________________________________________________________________ 3. ________________________________________________________________________ 4. ________________________________________________________________________ 5. ________________________________________________________________________ 6. ________________________________________________________________________ 7. ________________________________________________________________________ 8. ________________________________________________________________________ 9. ________________________________________________________________________ 10. ________________________________________________________________________

Page 2 of 17 Revised March 2023

Part 1 – Power of Attorney for Health Care Instructions: This part lets you choose another person to make health care decisions for you, either right away or when you are too sick to choose your own care. The person you choose is called your agent. You may also name a second and third choice to be your agent, if your first choice is not willing, reasonably available or able to make decisions for you. If you choose an agent on this form, but do not fill out any other parts of the form, your agent will be able to:  Make all health care decisions for you, including decisions regarding tests, surgery and medication;  Decide whether or not to have food or fluids given to you through tubes or fed into your veins through an IV;  Decide whether or not to use treatments or machines to keep you alive or to restart your heart or breathing;  Choose who will give you health care and where you will get it, such as hospitals, nursing homes, assisted living settings, home health, or hospice care; and  Make any health decision he or she believes would be consistent with your values or in your best interest, even if it is not listed in the form. Who can be your agent: You can name any adult you trust to be your agent, except your agent may not be the owner, operator or employee of a nursing home or residential long-term care facility where you are receiving care, unless that person is your relative. How your agent must make decisions: If your agent does not know what you want, the agent must make decisions consistent with your personal values, if known, or based on your best interests. In Part 2, you can decide what you want in advance. If you make choices in Part 2, your agent must make decisions based on those choices. Who can see your health care information: Once your agent has the right to make health care decisions for you, your agent can look at your medical records and consent to giving your medical information to others. The state and federal privacy laws let your agent see all of your health information so that he or she can make the right decision for you. The first part of your advance directive begins on the next page.

Page 3 of 17 Revised March 2023

YOUR ADVANCE DIRECTIVE BEGINS HERE Choosing an agent: Fill in your name and the name of the person you choose to be your agent to make health care decisions for you here: My name______________________________________________________________________________ My agent’s name________________________________________________________________________ Title or relationship to me_________________________________________________________________ My agent’s address______________________________________________________________________ My agent’s home phone (___)___________________ My agent’s work phone (___)__________________ If the agent I have named above is not willing, reasonably available or able to make decisions for me, I choose the following person to be my agent:

If the person I have named as Choice # 2 is not willing, reasonably available or able to make decisions for me, I choose the following person to be my agent:

Choice # 2 to be my agent

Choice # 3 to be my agent

Name____________________________________

Name_________________________________

Title or Relationship to me___________________

Title or Relationship to me________________

Address__________________________________

Address_______________________________

_________________________________________

______________________________________

Home Phone (___)__________________________

Home Phone (___)_______________________

Work Phone (___)__________________________

Work Phone (___)_______________________

You may change your mind later about who you want to be your agent. If you want to stop the agent you have named from making decisions for you, you must tell your primary physician or fill in these blanks: I do not want ________________________ to be my agent. _______________________________________ My signature Date you filled out and signed this section _________________________ Any time you cancel, replace or change this form you should give copies of the changed or new form to everyone who has a copy of your original form. Page 4 of 17 Revised March 2023

Your agent’s power: When your agent can start making decisions for you: (Check only one box: A or B) A. My agent can make decisions only when my primary physician or a judge decides that I am too sick to make my own health care decisions. OR B. My agent can start making health care decisions for me right away, but this does not mean I have given up the right to make my own decisions if I am still able and willing to make my own decisions. When my agent makes a health care decision for me, I will be told, if possible, about that decision before it is carried out unless I say I do not want to know. If I disagree with that decision and am still able to decide, I can make a different decision. As long as I am able, I can end my agent’s right to make decisions for me, change my agent or make my own decisions. If I want to end my agent’s right to make decisions for me, I must tell my primary physician or put my decision in writing and sign it with the date of my signature. Nominating a guardian: A guardian is a person chosen by a court to make decisions about your personal care. These decisions can include not only health care, but other decisions such as where you will live and how your personal needs will be met. If you wish, you may ask that a court assign your agent as your guardian, if appointment of a guardian should become necessary. Check the box below to nominate your agent to be your guardian, if a judge needs to appoint a guardian for you. I nominate my agent to be my guardian if a judge needs to appoint a guardian for me. If you want to nominate someone other than your agent to be your guardian, you may fill in the section below. If a judge needs to appoint a guardian for me, I nominate the person named below as my guardian: Name__________________________________________ Title or Relationship to me________________ Address______________________________________________________________________________ _____________________________________________________________________________________ Home Phone (___)_______________________ Work Phone (___)______________________________

Page 5 of 17 Revised March 2023

Part 2 – Special Instructions Instructions if you did not name an agent in Part 1: If you did not name an agent in Part 1, you should fill out this Part to state what you want for care if you become too sick to make your choices known. OR Instructions if you did name an agent in Part 1: If you named an agent in Part 1, you do not have to fill out this part of the form. If you want your agent to make all of your health care decisions, DO NOT fill out this part of the form. Your agent will make decisions in your best interests, including decisions to refuse treatment. However, you may fill out this part if you want to give special directions to your agent about your wishes, such as when you are near death, in a permanent coma or no longer able to make your own decisions. You may also cross out or add words. It is best if you put your initials and date next to any changes you make so everyone knows the changes were your decision. If you complete this part, your physician and others will follow these instructions and your agent cannot make a different decision. You may also write your wishes on another piece of paper, sign it, date it, and keep it with this form. Life-Sustaining Treatment Choices: You may check one of the two boxes below to show your choice about getting treatments that would keep you alive:

 Choice not to be kept alive

 Choice to be kept alive

I do not want treatment to keep me alive if my physician decides that either of the following is true;

I want to be kept alive as long as possible within the limits of generally accepted health care standards, even if my condition is terminal or I am in a persistent vegetative state.

(i) I have an illness that will not get better, cannot be cured, and will result in my death quite soon (sometimes referred to as a terminal condition), OR (ii) I am no longer aware (unconscious) and it is very likely that I will never be conscious again (sometimes referred to as a persistent vegetative state).

Page 6 of 17 Revised March 2023

Life-Sustaining Treatment Choices: You may also check one of the two boxes below to show your choice about treatment that would keep you alive if, in the future, you have late stage Alzheimer’s disease or other severe dementia. These choices will not limit the authority under state law for your agent, surrogate, guardian or physician to make treatment choices if you are unable to make your own decisions and are not in late stage Alzheimer’s disease or other severe dementia.

 Choice not to be kept alive

 Choice to be kept alive

If my physician and a second physician decide that I am in the late stage of Alzheimer’s disease* or other severe dementia, I do not want treatment to keep me alive.

I want treatment to keep me alive as long as possible within the limits of generally accepted health care standards, even if my physician and a second physician decide that I am in the late stage of Alzheimer’s disease or other severe dementia.

* Only a physician can determine that someone is in the late stage of Alzheimer’s disease. People in the late stages of Alzheimer’s disease generally have a number of the following characteristics: loss of the ability to respond to their environment; loss of the ability to speak; loss of the ability to control movement; loss of the capacity for recognizable speech, although words or phrases may occasionally be uttered; needing help with eating and toileting; general incontinence of urine; loss of the ability to walk without assistance, then the ability to sit without support, then the ability to smile, and the ability to hold their head up; reflexes become abnormal; muscles grow rigid; and swallowing is impaired. Tube Feeding: You may check one of the two boxes below to show your choice about tube feeding or having water and nutrition fed into your body through an IV or tube (artificial nutrition and hydration):

 Artificial nutrition and hydration should not  Artificial nutrition and hydration should be be given, or should be stopped, based on the other life-sustaining treatment choices I made about keeping me alive on Pages 6 and 7.

given regardless of my condition.

Page 7 of 17 Revised March 2023

Relief from Pain: You may check the box or fill in the blanks below to show your choice about relief of pain or discomfort.

 I want treatment for relief of pain or

These are my wishes about relief of pain or discomfort:

discomfort to be given at all times, even if it shortens the time until my death or makes me drowsy, unconscious or unable to do other things.

Other Directions: You may give more directions or add any other treatment choices in the space below:

Page 8 of 17 Revised March 2023

Part 3 — Primary Physician This section is optional. Fill out this part only if you wish to name your primary physician today. Name of my primary physician:__________________________________________________________ Address: _____________________________________________ Phone: ________________________ I want any agent I named in Part 1 to talk with this physician about my health care. If the physician I have named above is not willing, reasonably available or able to carry out my wishes, I want the agent I named in Part 1 to talk with the physician listed below: Name of physician: _____________________________________________________________ Address:_____________________________________________ Phone:___________________ If you want your agent or those making decisions for you to speak with a nurse practitioner or physician assistant before making a decision, you may complete the following section: Name of nurse practitioner or physician assistant: _____________________________________ Address: _____________________________________________ Phone:___________________

Page 9 of 17 Revised March 2023

Part 4 – Donation of Body, Organs or Tissues at Death This section is optional. Fill out this part only if you want to give directions about donating your body, organs or tissues after your death. 

I do NOT wish to donate any organs, tissues or parts. --------------------------------------------------------------------------------------------------------------------------------------I have checked below my choices about donating my body, organs or tissues after death. I have spoken with my family so that they will not object to my wishes after I die .

I give my body. OR 

I give any needed organs, tissues or parts. OR I give only the following organs, tissues, or parts: ____________________________________________________________________ ____________________________________________________________________ My gift is for the following purposes (you may check any number of boxes):

My gift is for transplant or therapy for another person, to be chosen based on generally accepted health care standards.

My gift is for research and education. My preference, if any, is to give my body, organs, or tissues to the following hospital, medical school, or physician: Name ________________________________________________________ Address _______________________________________________________ ________________________________________________________ Page 10 of 17 Revised March 2023

I understand that I may need to contact the hospital, medical school, or physician before I die in order for them to accept my body, organs or tissues after my death.

Page 11 of 17 Revised March 2023

Part 5 – Instructions About Funeral and Burial Arrangements This section is optional. Fill out this part only if you wish to give special instructions about your funeral or burial arrangements here. I hope that my family will follow my wishes after I die as noted below.

I choose _____________________________________________________________ to have custody and control of my body after my death with the right to decide everything about my funeral and burial. OR

I want my family to know these are my wishes about: burial, cremation, funeral, or memorial service. (Fill in) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ If you plan to die at home, talk with your physician and funeral director about your plans. When you die, your family or agent should call your physician and the funeral home you have chosen. The funeral home staff will pick up your body from your home.

Page 12 of 17 Revised March 2023

Part 6—Signing the Form If you have filled out any part of this form, you must sign and date the form on this page. You must also have two other adults sign as witnesses at the same time you sign the form. It is recommended that your agent not sign as a witness. You do not need to have a Notary Public sign your Advance Directive form to make it legal in Maine. However, if you travel or live part of the year out-of-state, it would be wise to have it signed by a Notary. Some states require this. You can find this service under Notary Public in the phone book. Most banks also have Notaries Public and will usually notarize papers for bank customers when asked. The Notary Acknowledgment may be done at any time after you sign this form. If you are in a hospital or residential healthcare facility, have an infectious disease and are confined to a room or ward where isolation precautions prevent the physical presence of individuals or documents necessary for filling out and signing this form, you may be able to complete the form using audiovisual technology. You can find details on that process at 18-C M.R.S. § 5-803-A, located at https://legislature.maine.gov/statutes/18-C/title18-Csec5-803A.html. Sign and date the form here: Sign your name: ______________________________Your Address: Print your name: _________________________ Date: First witness: Signature: ___________________________________Address: Print your name: ________________________ Date: __________________________________ Second witness: Signature: ___________________________________Address: Print your name: ________________________ Date: Notary Acknowledgment. Then personally appeared the above named __________________________________ , known to me or who presented satisfactory evidence of his/her identity, and acknowledged this Advance Directive as his/her free act and deed before me. Notary signature: __________________________________________________ Date: Printed name: ______________________ Notary Public State of:___________Commission Exp.: Make sure to tell people. Tell your family members, physicians and others close to you what you have decided. You should talk to the agent(s) you have chosen to make sure that they understand your wishes and are willing to carry them out. Give a copy of this form to your physician, to any place where you get health care, and to any agent(s) you have chosen in Part 1. Please be sure to list the people who have copies of this form on the front page. Page 13 of 17 Revised March 2023

Canceling or changing the form. Part 1: You may end your agent’s right to make decisions while you are still able to make those decisions by telling your primary physician or putting your decision in writing and attaching it to this form. If you want to name a new agent, you must put that instruction in writing and sign it in front of two witnesses who must also sign their names. Parts 2-7: You may cancel any other part of this form or change your instructions in the other parts of this form while you are still able to make those decisions. It is best to do so by (1) writing on this form, (2) writing on another piece of paper and attaching it to this form, or (3) completing a new form. Any of those written changes should be signed and dated by you.

Page 14 of 17 Revised March 2023

Part 7—Instructions to Emergency Medical Services

(ambulance crews) about what to do if your heart or breathing stops. This section is optional. If you do not want ambulance crews to revive you if your heart or breathing stops, you and your physician (or nurse practitioner or physician assistant) must both complete and sign this part. Instructions for Part 7: 

If I stop breathing or my heart stops, I do not want the Emergency Medical Services (ambulance crews) to try to revive me. My physician (or nurse practitioner or physician assistant) and I have discussed this and signed the special form on the next page. I understand that this decision will not prevent me from receiving other emergency care, or comfort care from health care workers before I die.



I understand that the form goes into effect when I have signed it AND it is signed by my physician (or nurse practitioner or physician assistant).



I understand that this directive will not be followed unless my family, caretaker or I give the signed form on the next page to Emergency Medical Services (ambulance crews), and that it is solely my responsibility to make sure they see it.



I understand that I should carry the signed form with me unless I wear health alert jewelry, such as MedicAlert, that also tells people that I do not want to be revived if my heart or breathing stops (Please call Maine Emergency Medical Services at 207-626-3860 to see if there are other Maine EMS approved health alert jewelry companies).



I understand that if any health care provider has any doubts about what I want, they will try to restart my heart or breathing.



I understand that I may revoke this directive at any time by destroying this form and removing any Maine EMS approved Do-Not-Resuscitate jewelry. I can also tell the ambulance crews that I have changed my mind.



I understand that should I change my mind, it is my responsibility to tell my physician (or nurse practitioner or physician assistant) and other people who have copies of the signed form.



If I want my agent to make this decision later, my agent should take the form available at: http://www.maine.gov/dps/ems to my physician (or nurse practitioner or physician assistant) when it is time to make the decision.

If you complete and sign this section, put the original in a safe place and be sure to give copies to ambulance crews, your family, your caregivers, and your physician.

Page 15 of 17 Revised March 2023

DO-NOT-RESUSCITATE (DNR) DIRECTIVE This section is optional. If you do not want ambulance crews to revive you if your heart or breathing stops, you and your physician (or nurse practitioner or physician assistant) must complete and sign this form. FOR PATIENT TO COMPLETE after consultation with his or her health care provider: In the event that my heart or breathing stops and I am unable to speak for myself, I, ___________________ (printed name)direct that no efforts be taken to restart my heart or breathing and that Emergency Medical Services (ambulance crews) if notified, honor my directive. I have come to this decision after considering my condition and prognosis and the potential risks, burdens and benefits of refusing efforts to restart my heart or breathing. I understand that I may change my mind at any time by destroying this form and removing any Maine EMS approved Do-Not-Resuscitate jewelry, such as MedicAlert. I will also tell my physician (or nurse practitioner or physician assistant) and other caregivers if I change my mind. I understand that this form is not valid until my physician (or nurse practitioner or physician assistant) and I have signed it. I understand that in a hospital, nursing home, hospice or home health setting, federal law requires that my physician must include a specific DNR order in my medical record or plan of care, even if we have both signed this form.

 No expiration date OR  Expires on _______________________________________ ____________________________________________________ Patient Signature

________________________ Date Signed

FOR PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER TO COMPLETE: By my signature I affirm that: (i) After meeting with this patient and discussing this decision, I am satisfied that the patient understands the potential risks, burdens and benefits of refusing resuscitative interventions in light of the patient’s medical condition; and (ii) I believe that the patient has made a voluntary informed decision about resuscitation and I agree to comply with that decision. I will tell any health care providers providing care under my authority to comply with this decision. ________________________________________ Signature and license level (MD, DO, PA or NP)

________________________________________ Date Signed

________________________________________ Printed Name

________________________________________ Telephone Number

Page 16 of 17 Revised March 2023

THIS FORM IS ENDORSED BY MAINE EMERGENCY MEDICAL SERVICES

Page 17 of 17 Revised March 2023

SUPPORT AND LOCAL RESOURCES DOWNEAST GROUP | A Maine Prostate Cancer Support Group

PELVIC FLOOR PHYSICAL THERAPY

Cadie Saucier, DPT Mainely Pelvic Physical Therapy 97 Beechland Rd., Ellsworth, ME 04605

207-949-0290

ADDITIONAL RESOURCES NCCN Guidelines for Patients

Beth C. Wright Cancer Resource Center

Early- and advanced-stage prostate cancer guides

Navigation, transportation, financial support, and resources

Partin Tables - Johns Hopkins

Dempsey Center

Prostate cancer risk assessment tools

Virtual exercise, support groups, counseling, and nutrition

ZERO Prostate Cancer / Us TOO

Cancer Care News

Support groups, education, and mailed resources

Books, equipment, financial assistance, and other resources

Maine Coalition to Fight Prostate Cancer

Prostate Cancer Foundation

One-2-One peer mentor program: 1-855-552-7200 ext. 801

Information including "What's My Stage?" and "The PSA Test"

RECOMMENDED BOOKS Prostate Cancer 20/20 by Andrew Siegel A Primer on Prostate Cancer by Stephen Strum Greg's Paper: My Trip Through the Medical Jungle After My Diagnosis of Prostate Cancer

Need help finding the right resource? Beth C. Wright Cancer Resource Center | bethwrightcancercenter.org

Educational resources do not replace advice from your medical care team.

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