The first 60 days: Non-metastatic castration-resistant prostate cancer

Below, week by week, is what OnCo's record of Non-metastatic castration-resistant prostate cancer says about the first two months: the order is typical, the timing is yours to ask about. Non-metastatic castration-resistant prostate cancer is a PSA that keeps rising on hormone therapy while scans still show nothing. Three androgen receptor blockers, apalutamide, enzalutamide and darolutamide, each delay metastasis by about two years and lengthen life, and darolutamide is the gentlest. Sections appear only where the record has something to say. Orientation, not medical advice.

Weeks 1 to 2

What happens now

Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.

Staging
PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.
PSMA PET mCRPC and mHSPC (castration-resistant vs hormone-sensitive prostate cancer)

Biomarkers your report may list

Castrate testosterone (below 50 ng/dL)PSA doubling time Conventional imaging negative PSMA PET (often positive)AR alterations and AR-V7 (research)

Ask which of these were tested and what the results were; see the report reader for what each value means.

Tests and imaging linked to this cancer

PSMA PET

Weeks 1 to 3

Who is on your team

These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.

A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.

Weeks 2 to 6

Decisions coming up

Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.

1.High-risk nmCRPC (doubling time 10 months or less)NCCN Guidelines: Prostate Cancer
Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.
Apalutamide Enzalutamide Darolutamide Androgen deprivation & AR pathway inhibitors Castration-resistant prostate cancer (CRPC)
2.Low-risk nmCRPC NCCN Guidelines: Prostate Cancer
Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.
Androgen deprivation & AR pathway inhibitors Bicalutamide PSA (prostate-specific antigen)

Every visit

Questions to ask at each visit

Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.

Newly diagnosed

What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
Which biomarkers have been tested on my tumour (for example Castrate testosterone, PSA doubling time, Conventional imaging negative, PSMA PET, AR alterations and AR-V7), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include High-risk nmCRPC, Low-risk nmCRPC, PSMA PET-positive, conventional imaging-negative castration-resistant disease.
Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.

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

For my situation (high-risk nmcrpc (doubling time 10 months or less)), which of the standard options do you recommend and why?Guideline options include: Continue androgen deprivation and add apalutamide (SPARTAN), enzalutamide (PROSPER) or darolutamide (ARAMIS); darolutamide preferred when falls or cognition are concerns.
Am I a candidate for Apalutamide, Enzalutamide, Darolutamide, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.

Low-risk nmCRPC

For my situation (low-risk nmcrpc), which of the standard options do you recommend and why?Guideline options include: Observation on androgen deprivation with PSA monitoring and imaging; first-generation antiandrogen or its withdrawal as older options.
Am I a candidate for Bicalutamide, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.

Staging

For my situation (staging), which of the standard options do you recommend and why?Guideline options include: PSMA PET locates disease in most men; conventional imaging still defines the setting the trials studied.

Any stage

Are there clinical trials I could join, for example of Darolutamide, PSMA PET, AR-V7 splice variant?Trials are how the next standard of care is set; asking early keeps options open.
Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
I read that “Whether PSMA PET-detected metastases should be treated locally or the man treated as metastatic”. How does that affect my plan?Open problems are where trials and second opinions matter most.
I read that “Cost and side effects of years of androgen receptor inhibition in men without symptoms”. How does that affect my plan?Open problems are where trials and second opinions matter most.

Weeks 3 to 8

Trials to ask about

Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.

A Study of Apalutamide (ARN-509) in Men With Non-Metastatic Castration-Resistant Prostate CancerPhase 3 · active · NCT01946204A Multicenter, Randomized, Double-Blind, Placebo-Controlled, Phase III Study of ARN-509 in Men With Non-Metastatic (M0) Castration-Resistant Prostate Cancer

From day one

Help that costs nothing

Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.

Any time

What to read next

Words this page and the cancer page use

mCRPC and mHSPC (castration-resistant vs hormone-sensitive prostate cancer): Prostate cancer starts out fed by testosterone (hormone-sensitive) and shrinks when it is removed.
Disease volume (CHAARTED high-volume versus low-volume) and LATITUDE risk: In newly metastatic hormone-sensitive prostate cancer the treatment plan starts with a count: four or more bone metastases with at least one outside the spine and pelvis, or any spread to liver or lung, is high-volume disease (CHAARTED), and high-volume men gain years from adding docetaxel to hormone therapy while low-volume men gain more from radiotherapy to the prostate.
PSA doubling time: How long the PSA takes to double, used to tell a slow rise from a fast one.
AR-V7 splice variant: A truncated form of the androgen receptor that is permanently switched on and ignores hormone-blocking pills.
Castration-resistant prostate cancer (CRPC): Prostate cancer that keeps growing even though testosterone has been reduced to castrate levels.
Prostate cancer drugs in England: what NICE recommends, and what it refuses: Having a licence is not the same as being funded.
What androgen deprivation costs: the side of hormone therapy the survival curves do not show: Hormone therapy for prostate cancer works by removing testosterone, which means hot flushes, loss of sexual desire and erections, tiredness, loss of muscle, weaker bones and a changed body.
Metastasis-free survival (MFS): The time from joining a trial until a scan first shows the cancer has spread, or the man dies, whichever comes first.
PSA kinetics: PSA doubling time and PSA density: How fast PSA is rising matters more than its level: a doubling time under ten months after surgery or radiotherapy, or under nine months in castration-resistant disease, marks the men whose cancer is moving quickly and who benefit from earlier hormone therapy or a PSMA scan, while PSA density (PSA divided by prostate volume) helps decide who needs a biopsy at all.
PSA (prostate-specific antigen): A blood protein made by the prostate; raised levels prompt further tests, and falling levels show treatment is working.

Every term links to the glossary.