Non-metastatic castration-resistant prostate cancer: the decisions you may face

Cancer page →Second-opinion finder →

3 treatment settings, 2 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.

Early / localised

High-risk nmCRPC (doubling time 10 months or less)

4 optionsCompare side by side →

Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.

Guideline

NCCN Guidelines: Prostate Cancer

The options, in plain words

ApalutamideApprovedSmall-molecule AR antagonist

An AR blocker approved for prostate cancer that has spread and for high-risk disease before it shows on scans.

EnzalutamideApprovedSmall-molecule AR antagonist

Enzalutamide is a second-generation androgen-receptor blocker that stops the receptor binding testosterone, entering the nucleus and switching on genes. It is approved at every stage of advanced prostate cancer, from rising PSA after surgery to castration-resistant disease, and fatigue, falls and memory problems are its main drawbacks.

DarolutamideApprovedSmall-molecule AR antagonist

Darolutamide is an AR blocker that barely enters the brain, so it causes fewer falls and cognitive side effects; it is approved with and without chemotherapy.

Androgen deprivation & AR pathway inhibitorsStandard of care

Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).

Prolonged disease control

Also referenced:Castration-resistant prostate cancer (CRPC)

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

Enzalutamide all recorded rates →

Seizure risk: caution with drugs that lower the seizure threshold.

Darolutamide all recorded rates →

Take with food (exposure roughly doubles).

Androgen deprivation & AR pathway inhibitors

Metabolic and bone toxicity; castration resistance inevitable in metastatic disease

Questions to ask about this decision

Between Apalutamide, Enzalutamide, Darolutamide and the other options, which do you recommend for me, and what about my case would make you choose differently?
Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
For my situation (high-risk nmcrpc (doubling time 10 months or less)), which of the standard options do you recommend and why?
Why: Guideline options include: Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.
Am I a candidate for Apalutamide, Enzalutamide, Darolutamide, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

Early / localised

Low-risk nmCRPC

2 options

Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.

Guideline

NCCN Guidelines: Prostate Cancer

The options, in plain words

Androgen deprivation & AR pathway inhibitorsStandard of care

Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).

Prolonged disease control

BicalutamideApprovedOral first-generation non-steroidal antiandrogen

The old antiandrogen pill used to block the testosterone flare from GnRH agonists and in combined androgen blockade; superseded by enzalutamide-class drugs.

Also referenced:PSA (prostate-specific antigen)

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

Androgen deprivation & AR pathway inhibitors

Metabolic and bone toxicity; castration resistance inevitable in metastatic disease

Questions to ask about this decision

Between Androgen deprivation & AR pathway inhibitors and Bicalutamide, which do you recommend for me, and what about my case would make you choose differently?
Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
For my situation (low-risk nmcrpc), which of the standard options do you recommend and why?
Why: Guideline options include: Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.
Am I a candidate for Bicalutamide, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

Screening, prevention and diagnosis

Staging

One path named

PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.

The path, in plain words

PSMA PETStandard of care

A prostate-cancer-specific PET scan that finds spread far earlier than CT or bone scan, and tells you whether a matched radioactive drug will work.

Detects recurrence at PSA <0.5 ng/mL
Theranostic gatekeeper

Also referenced:mCRPC and mHSPC (castration-resistant vs hormone-sensitive prostate cancer)

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

PSMA PET

PSMA-negative disease in ~10%
Uptake in ganglia, salivary glands

Questions to ask about this decision

Is PSMA PET the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
Why: A single standard does not mean a single choice; timing and trials are decisions too.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
For my situation (staging), which of the standard options do you recommend and why?
Why: Guideline options include: PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.

Add these to your appointment list, or take the full question set for this cancer.

How to read this page. Options and results come from OnCo records with their sources; the settings are the standard-of-care rows on the cancer page, and the lines of therapy are on the sequencing grid. Where a setting names one path, the choice is usually about timing, trials and where to be treated: see expert centres. OnCo is orientation, not medical advice.

Living with cancer·Standard of care

Non-metastatic castration-resistant prostate cancer: the decisions you may face

Cancer page →Second-opinion finder →

Early / localised

High-risk nmCRPC (doubling time 10 months or less)

4 optionsCompare side by side →

Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.

Guideline

NCCN Guidelines: Prostate Cancer

The options, in plain words

ApalutamideApprovedSmall-molecule AR antagonist

An AR blocker approved for prostate cancer that has spread and for high-risk disease before it shows on scans.

EnzalutamideApprovedSmall-molecule AR antagonist

DarolutamideApprovedSmall-molecule AR antagonist

Darolutamide is an AR blocker that barely enters the brain, so it causes fewer falls and cognitive side effects; it is approved with and without chemotherapy.

Androgen deprivation & AR pathway inhibitorsStandard of care

Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).

Prolonged disease control

Also referenced:Castration-resistant prostate cancer (CRPC)

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

Enzalutamide all recorded rates →

Seizure risk: caution with drugs that lower the seizure threshold.

Darolutamide all recorded rates →

Take with food (exposure roughly doubles).

Androgen deprivation & AR pathway inhibitors

Metabolic and bone toxicity; castration resistance inevitable in metastatic disease

Questions to ask about this decision

Between Apalutamide, Enzalutamide, Darolutamide and the other options, which do you recommend for me, and what about my case would make you choose differently?
Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
For my situation (high-risk nmcrpc (doubling time 10 months or less)), which of the standard options do you recommend and why?
Why: Guideline options include: Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.
Am I a candidate for Apalutamide, Enzalutamide, Darolutamide, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

Early / localised

Low-risk nmCRPC

2 options

Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.

Guideline

NCCN Guidelines: Prostate Cancer

The options, in plain words

Androgen deprivation & AR pathway inhibitorsStandard of care

Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).

Prolonged disease control

BicalutamideApprovedOral first-generation non-steroidal antiandrogen

The old antiandrogen pill used to block the testosterone flare from GnRH agonists and in combined androgen blockade; superseded by enzalutamide-class drugs.

Also referenced:PSA (prostate-specific antigen)

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

Androgen deprivation & AR pathway inhibitors

Metabolic and bone toxicity; castration resistance inevitable in metastatic disease

Questions to ask about this decision

Between Androgen deprivation & AR pathway inhibitors and Bicalutamide, which do you recommend for me, and what about my case would make you choose differently?
Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
For my situation (low-risk nmcrpc), which of the standard options do you recommend and why?
Why: Guideline options include: Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.
Am I a candidate for Bicalutamide, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

Screening, prevention and diagnosis

Staging

One path named

PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.

The path, in plain words

PSMA PETStandard of care

A prostate-cancer-specific PET scan that finds spread far earlier than CT or bone scan, and tells you whether a matched radioactive drug will work.

Detects recurrence at PSA <0.5 ng/mL
Theranostic gatekeeper

Also referenced:mCRPC and mHSPC (castration-resistant vs hormone-sensitive prostate cancer)

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

PSMA PET

PSMA-negative disease in ~10%
Uptake in ganglia, salivary glands

Questions to ask about this decision

Is PSMA PET the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
Why: A single standard does not mean a single choice; timing and trials are decisions too.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
For my situation (staging), which of the standard options do you recommend and why?
Why: Guideline options include: PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.

Add these to your appointment list, or take the full question set for this cancer.