Treatment of Metastatic Hormone-Sensitive Prostate Cancer
Treatment of metastatic prostate cancer is generally based on whether its growth can be slowed or stopped with hormone therapy. Recall that testosterone (an androgen hormone) is the “fuel” that makes prostate cancer cells grow. Initially, growth of recurrent or metastatic prostate cancer may stop or slow down in a low-testosterone environment. That’s why hormone therapy (also called androgen deprivation therapy or ADT) is a part of most treatment plans for advanced and metastatic prostate cancer. Prostate cancer that can be controlled by hormone therapy is called hormone-sensitive prostate cancer (HSPC).
Today, hormone therapy is almost always combined with other therapies. Learn more about hormone therapy.
What is Combination Therapy?
Clinical trials have shown that for patients with metastatic HSPC (mHSPC), adding an androgen receptor pathway inhibitor with or without docetaxel chemotherapy together with standard hormone therapy significantly extended the length of time before disease progression and improved survival. While hormone therapy alone might still be the best choice for a small number of select patients, it is now recommended that patients with mHSPC strongly consider combination therapy with hormone therapy.
Hormone therapy plus androgen receptor pathway inhibitor (ARPI): ARPIs (abiraterone, apalutamide, darolutamide, and enzalutamide) are newer types of medicines that block the androgen receptor or block the production of androgens. They can be used in combination with standard hormone therapy for patients with mHSPC. Multiple large randomized controlled clinical trials have shown that this combination approach lengthens patient survival–a 30% to 40% reduction in the risk of death.
Hormone therapy plus ARPI plus docetaxel: Adding docetaxel chemotherapy to hormone therapy + an ARPI can be an option for select patients. You may hear this referred to as “triplet” therapy. Consult your doctor as to whether this approach might be right for you.
Hormone therapy plus radiation therapy: For patients with a low volume of metastatic disease at diagnosis, who have not previously received hormone therapy, guidelines now recommend that external beam radiation therapy to the prostate be considered in addition to systemic medical therapy. This benefit was not seen among patients with a high disease burden at diagnosis.
Low Number of Metastases
Some patients have a low number of metastatic lesions seen on imaging, termed “oligometastatic” disease. The threshold is generally 5 or fewer metastatic tumors. Stereotactic body radiation therapy (SBRT), a short course of high-intensity radiation therapy, can be directed to the metastases, and has been shown to delay the time to hormone therapy.
Intermittent Hormone Therapy
Intermittent hormone therapy may allow select patients to stop hormone therapy for a period of time, then restart. Patients report that their quality of life improves as their testosterone levels increase. There may be a trade-off in terms of overall cancer outcome. The most common approach is to give LHRH agonists (such as leuprolide) intermittently, meaning that the drug is taken during “on” periods and skipped during “off” periods. It is not right for all patients, especially those who have a rising PSA shortly after stopping hormone therapy. If you are considering this approach, discuss the risks and benefits with your doctor.
What About Surgery?
Note that surgery (radical prostatectomy) is currently not recommended for treating metastatic prostate cancer, as it would likely not be curative (because the cancer has already spread) at the cost of possible side effects such as urinary incontinence and erectile dysfunction. However, if the cancer itself is causing significant local symptoms, such as difficulty urinating, surgical procedures such as a transurethral resection of the prostate (TURP) may be considered.
Learn more in the 4-part article series For Metastatic Prostate Cancer, More is More with renowned medical oncologist Neeraj Agarwal, M.D., of the University of Utah’s Huntsman Cancer Institute.
Part 1: The New Standard of Care
Part 2: Why Aren’t More Men Getting Combination Therapy?
Part 3: Roadblocks to Combination Therapy
Part 4: Paving the Way for Success with Combination Therapy
Last Reviewed: 3/2025
