Prostate Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stage IV Prostate Cancer Treatment
External-beam radiation therapy (EBRT) with or without hormonal therapy
EBRT may be used for attempted cure in (highly selected stage M0 patients).[41,42] Definitive radiation therapy should be delayed 4 to 6 weeks after TURP to reduce incidence of stricture.
Hormonal therapy should be considered in addition to EBRT.[35,44]
Evidence (radiation therapy with or without hormonal therapy):
- The Blue Cross and Blue Shield Association Technology Evaluation Center, an evidence-based practice center of the Agency for Healthcare Research and Quality (AHRQ), performed a systematic review of the available randomized clinical trial evidence comparing radiation therapy with radiation therapy and prolonged androgen suppression.[Level of evidence: 1iiA] Some patients with bulky T2b tumors were included in the studied groups.
- The meta-analysis found a difference in 5-year OS in favor of radiation therapy plus continued androgen suppression using an LH-RH agonist or orchiectomy compared with radiation therapy alone (HR, 0.63; 95% CI, 0.48–0.83).
- This reduction in overall mortality indicates that adjuvant androgen suppression should be initiated at the time of radiation therapy and continued for several years.
- The optimal duration of therapy and the issue of utility of neoadjuvant hormonal therapy have not been determined.
- The duration of neoadjuvant hormonal therapy has been tested in a randomized trial (TROG 96.01 [ACTRN12607000237482]) of 818 men with locally advanced (T2b, T2c, T3, and T4), nonmetastatic cancer treated with radiation therapy (i.e., 66 Gy in 2 Gy daily fractions to the prostate and seminal vesicles but not including regional nodes). In an open-label design, patients were randomly assigned to radiation therapy alone, 3 months of neoadjuvant androgen deprivation therapy (NADT) (goserelin 3.6 mg subcutaneously each month plus flutamide 250 mg by mouth 3 times per day) for 2 months prior to and during radiation, or 6 months of NADT for 5 months prior to and during radiation.[Level of evidence: 1iiA]
- After a median follow-up of 10.6 years, there were no statistically significant differences between the radiation alone group and the radiation plus 3 months of NADT group.
- However, the 6-month NADT arm showed better prostate cancer-specific mortality and overall mortality than radiation alone; 10-year all-cause mortality 29.2% versus 42.5%% (HR, 0.63; 95% CI, 0.48–0.83, P = .0008).
Palliative radiation therapy
A single fraction of 8 Gy has been shown to have similar benefits on bone pain relief and quality of life as multiple fractions (3 Gy × 10) as evidenced in the RTOG-9714 trial.; [Level of evidence: 1iiC] (Refer to the PDQ summary on Pain for more information.)
Palliative surgery with transurethral resection of the prostate (TURP)
Transurethral resection of the prostate may be useful in relieving urinary obstruction as part of palliative care in advanced prostate cancer.