Treatment of Metastatic Castration-Resistant Prostate Cancer

September 8, 2014


To help doctors give their patients the best possible care, the American Society of Clinical Oncology (ASCO), along with Cancer Care Ontario, has developed recommendations on systemic, or full-body, treatments for men with metastatic castration-resistant prostate cancer. This guide for patients and caregivers is based on ASCO recommendations.

Key Messages:

  • Metastatic castration-resistant prostate cancer is when the cancer has spread to parts of the body other than the prostate, and it is able to grow and spread even though drugs or other treatments to lower the amount of male sex hormones are being used to manage the cancer.
  • When deciding on treatments for metastatic castration-resistant prostate cancer, it is important to weigh the possible benefits with the risks and costs.
  • There are several different treatment options available for this type of prostate cancer.
  • In addition to treatment for the cancer, relieving symptoms and side effects is an important part of cancer care and treatment.


Prostate cancer growth is often driven by male sex hormones called androgens, which include testosterone. Because of this, a common treatment option for prostate cancer is to lower the levels of androgens in a man’s body. Androgen levels can be lowered by surgically removing the testicles or with drugs that stop the testicles from making androgens or block how they affect the body. This type of treatment is called hormone therapy or androgen-deprivation therapy.

If the cancer spreads to other parts of the body beyond the prostate in a process called metastasis, hormone therapy is usually continued. Eventually, many men with metastatic prostate cancer develop castration-resistant disease. This means that the cancer is able to grow and continue to spread despite using hormone therapy. For men with this type of disease, additional treatment is needed to help control the growth of the cancer. These treatments may include chemotherapy, targeted therapy, and other types of treatments.

Recommendations for men with metastatic castration-resistant prostate cancer

ASCO recommends that men with metastatic castration-resistant prostate cancer continue hormone therapy to keep androgen levels in the body low, regardless of the other treatments used. Relieving side effects, also called symptom management or palliative care, is also an important part of cancer care and treatment.

The following treatments may be given in addition to continuing hormone therapy:

  • Abiraterone (Zytiga) and prednisone (multiple brand names)
  • Enzalutamide (Xtandi)
  • Radium-223 (Xofigo) for men with cancer that  has spread to the bone
  • Docetaxel (Docefrez, Taxotere) and prednisone
  • Sipuleucel-T (Provenge) for men who have few or no symptoms from the cancer
  • Cabazitaxel (Jevtana) and prednisone for men with prostate cancer that has worsened while receiving docetaxel

The following treatments could be options, as well. However, the research has not yet shown that they lengthen men’s lives:

  • Mitoxantrone (Novantrone) plus prednisone
  • Bicalutamide (Casodex), flutamide (Eulexin), nilutamide (Nilandron), which are all types of anti-androgens
  • Ketoconazole (Nizoral, Xolegel)
  • Low-dose corticosteroids

The following treatments are not recommended:

  • Bevacizumab (Avastin)
  • Estramustine (Emcyt)
  • Sunitinib (Sutent)

What This Means for Patients

A diagnosis of metastatic castration-resistant prostate cancer often means that treatments to slow, stop, or eliminate the cancer are no longer working by themselves. This diagnosis is stressful, and it may be difficult to discuss with your health care team. There are several promising treatments available, each of which affects a man’s life differently. Because of the variety of treatment options, men should talk with their doctor about the different treatment options for castration-resistant prostate cancer, including the overall goals of treatment, possible benefits, the risks, and the costs. Before considering additional treatments, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns.  

Questions to Ask the Doctor

Consider asking the following questions of your doctor:

  • What type of prostate cancer do I have? What does this mean?
  • What is my prognosis (chance of recovery)?
  • What clinical trials are open to me?
  • What treatment plan do you recommend? Why?
  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?
  • How well is this treatment likely to work? What are the risks?
  • How will we know the treatment is working?
  • How will my quality of life change over time?
  • What are the next steps if the cancer worsens or comes back?
  • What treatments are available to manage the symptoms of the cancer?
  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
  • Where can I find support for me and my family?
  • Whom should I call with questions or concerns?

Helpful Links

Read the entire clinical practice guideline published at a separate ASCO website.

Guide to Prostate Cancer

Hormone Therapy for Advanced Prostate Cancer

Advanced Cancer Care Planning

Navigating Challenges Video Series: Talking with Your Cancer Care Team, Making Decisions about Your Cancer Treatment, Managing the Cost of Your Cancer Care, and Finding Emotional Support after a Cancer Diagnosis