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Prostate Cancer Treatment (PDQ®)

Health Professional Version

Recurrent Prostate Cancer Treatment


In recurrent prostate cancer, the selection of further treatment depends on many factors, including:

  • Previous treatment.
  • Site of recurrence.
  • Coexistent illnesses.
  • Individual patient considerations.

Definitive radiation therapy can be given to patients with disease that fails only locally following prostatectomy.[1-4] An occasional patient can be salvaged with prostatectomy after a local recurrence following definitive radiation therapy;[5] however, only about 10% of patients treated initially with radiation therapy will have local relapse only. In these patients, prolonged disease control is often possible with hormonal therapy, with median cancer-specific survival of 6 years after local failure.[6]

Cryosurgical ablation of recurrence following radiation therapy is associated frequently with a high complication rate. This technique is still undergoing clinical evaluation.[7]

Hormonal therapy is used to manage most relapsing patients with disseminated disease who initially received locoregional therapy with surgery or radiation therapy. (Refer to the Standard Treatment Options for Stage IV Prostate Cancer section of this summary for more information.)

It is not clear whether additional treatments given on the basis of rising prostate-specific antigen (PSA) in asymptomatic men with prostate cancer increase overall survival (OS). Biochemical evidence of failure on the basis of elevated or rising PSA alone, therefore, may not be sufficient to alter treatment, and using surrogate endpoints for clinical decision-making is, therefore, controversial.

PSA is often used to monitor patients after initial therapy with curative intent, and elevated or rising PSA is a common trigger for additional therapy even in asymptomatic men. After radical prostatectomy, detectable PSA levels identify patients at elevated risk of local treatment failure or metastatic disease;[8] however, a substantial proportion of patients with elevated or rising PSA levels after initial therapy with curative intent may remain clinically free of symptoms for extended periods of time.[9]

  1. For example, in a retrospective analysis of nearly 2,000 men who had undergone radical prostatectomy with curative intent and who were followed for a mean of 5.3 years. 315 men (15%) demonstrated an abnormal PSA of 0.2 ng/ml or higher, which is evidence of biochemical recurrence.[10]
    • Of these 315 men, 103 men (34%) developed clinical evidence of recurrence.
    • The median time to development of clinical metastasis after biochemical recurrence was 8 years.
    • After the men developed metastatic disease, the median time to death was an additional 5 years.

Likewise, after radiation therapy with curative intent, persistently elevated or rising PSA may be a prognostic factor for clinical disease recurrence. However, reported case series have used a variety of definitions of PSA failure. Criteria have been developed by the American Society for Therapeutic Radiology and Oncology Consensus Panel.[11,12] The implication of the various definitions of PSA failure for OS is not known, and as in the surgical series, many biochemical relapses (rising PSA alone) may not be clinically manifested in patients treated with radiation therapy.[13,14]

Hormonal Therapy for Recurring Disease

Intermittent versus continuous androgen suppression therapy

The majority of men who are treated for recurrence after initial local therapy are asymptomatic, and the recurrence is detected by a rising PSA. It is possible that intermittent androgen deprivation therapy (IAD) can be used as an alternative to continuous androgen deprivation (CAD) therapy (ADT) in an attempt to improve quality of life and decrease the amount of time during which the patient experiences the side effects of hormonal therapy, without decreasing the survival rate.

  1. This important clinical question was addressed in a noninferiority-designed, randomized, controlled trial with 1,386 men who had rising PSA levels (>3 ng/ml, with serum testosterone >5 nmol/L) more than 1 year after primary or salvage radiation therapy for localized prostate cancer.[15][Levels of evidence: 1iiA, 1iiB, 1iiC]
    • The ADT arm consisted of 8-month treatment cycles with a luteinizing hormone-releasing hormone (LH-RH) agonist (combined with a nonsteroidal antiandrogen for at least the first 4 weeks) that was reinstituted if the PSA level exceeded 10 ng/ml. The study was powered to detect (with 95% confidence) an 8% lower OS rate in the IAD group compared with the CAD group at 7 years.
    • After a median follow-up of 6.9 years (maximum follow-up 11.2 years), OS in the two groups was nearly identical, and the study was stopped (median survival 8.8 vs. 9.1 years; hazard ratio [HR]death of 1.02; 95% confidence interval [CI], 0.86–1.21). This fulfilled the prospective criterion of noninferiority.
    • In a retrospective analysis, prostate cancer-specific mortality was also similar in the two arms (HR, 1.18; 95% CI, 0.90–1.55; P = 0.24). In addition, IAD was statistically significantly better than CAD in several quality-of-life domains, such as hot flashes, desire for sexual activity, and urinary symptoms. Patients on the IAD study arm received a median of 15.4 months of treatment versus 43.9 months on the CAD arm.
    • The study does not address the unanswered question about whether the initiation of any ADT for an elevated PSA after initial local therapy extends survival compared with delay until clinically symptomatic progression. Of note, 59% of all deaths were unrelated to prostate cancer, and only 14% of all patients died of prostate cancer.
  2. A systematic evidence review and meta-analysis identified nine randomized controlled trials of varying quality, published up to September 2012, that addressed the issue of the addition of chemotherapy.[16]
    • More than 5,000 men with increasing PSA after local treatment or with locally advanced or metastatic prostate cancer were randomly assigned to receive IAD therapy versus CAD therapy if they met the criteria of a satisfactory decline in serum PSA on initial androgen therapy (generally to <4 mg/ml).
    • Among 4,101 men for whom OS data were available (four studies), there was no statistically significant difference for IAD versus CAD (HR, 1.02; 95% CI, .93–1.11).[16][Level of evidence: 1iiA] There was also no statistically significant difference in the three studies (2,596 men) reporting time to progression (HR, 0.96; 95% CI, 0.76–1.20).[16][Level of evidence: 1iiDii]
    • Some trials reported better sexual function and general well-being with IAD compared with CAD, but overall quality of life was similar.
    • On the basis of drug price lists in the Red Book pharmacy reference, the authors estimated that a median saving of $5,685 per patient per year in drug cost would be achieved with IAD compared with a cost of $11,710 per patient per year with CAD.
  3. In another study, 852 men with locally advanced or metastatic prostate cancer were enrolled and received ADT (ADT included administration of the LH-RH-agonist–goserelin acetate 3.6 mg subcutaneously every 28 days) for 24 weeks (with cyproterone acetate 100 mg given orally twice daily for the initial 12.5 days).[17] The 554 patients whose initial PSA decreased to less than 10 ng/ml or by more than 50%, if initial PSA was greater than 20 ng/ml, were randomly assigned to either an open-label strategy of intermittent ADT (IAD therapy included stopping ADT, with intermittent reinstitution whenever the PSA rose above 20 ng/ml or above the initial baseline value) or CAD therapy (CAD therapy included administration of a continuous LH-RH agonist or a bilateral orchiectomy).
    1. After a median follow-up of 65 months, outcomes in the IAD versus CAD study groups were:
      • Median time to death: 45.2 versus 45.7 months.
      • Median time to death from prostate cancer: 45.2 versus 44.3 months.
      • Median time-to-treatment failure: 29.9 versus 30.5 months.
    2. None of these differences were statistically significant.[17][Level of evidence: 1iiA]

Hormonal approaches

As noted above, studies have shown that chemotherapy with docetaxel or cabazitaxel and immunotherapy with sipuleucel-T can prolong OS in patients with hormone-resistant metastatic prostate cancer. Nevertheless, hormonal therapy has also been shown to improve survival even in men who have progressed after other forms of hormonal therapy as well as chemotherapy. Some forms of hormonal therapy are effective in the management of metastatic hormone–refractory prostate cancer.

Evidence (hormonal approaches):

  1. Abiraterone acetate is an inhibitor of androgen biosynthesis that works by blocking cytochrome P450c17 (CYP17). Abiraterone has mineralocorticoid effects, producing an increased incidence of fluid retention and edema, hypokalemia, hypertension, and cardiac dysfunction. In addition, abiraterone is associated with hepatotoxicity.[18] However, compared with other therapies, abiraterone toxicities are mild. In a double-blinded placebo-controlled trial, 1,088 men with progressing hormone refractory disease (serum testosterone <50 ng per deciliter on prior antiandrogen therapy), no prior chemotherapy, and Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 to 1 were given prednisone (5 mg orally twice per day).[19] The coprimary endpoints were radiologic progression-free survival (PFS) and OS. Four sequential analyses were planned.
    • At the second interim analysis, after a median follow-up of 22.2 months, the study was stopped and unblinded on the basis of aggregate efficacy and safety as assessed by the data monitoring committee. At that point, the radiologic PFS had reached the prespecified stopping boundary in favor of abiraterone: median PFS 16.5 versus 8.3 months (HR, 0.53; 95% CI, 0.45–0.62; P < .001).
    • The OS difference did not cross the prespecified stopping boundary of P ≤.001, but there was a trend in favor of abiraterone: median OS was not reached versus 27.2 months (HR, 0.75; 95% CI, 0.61–.93; P = .01).
    • Median time to health-related quality-of-life deterioration was long in the abiraterone study arm, as assessed by the Functional Assessment of Cancer Therapy-Prostate Version 4 (FACT-P) total score (12.7 months vs. 8.3 months; HR, 0.78; 95% CI, 0.66-0.92; P = .003) and by the prostate–cancer-specific subscale (11.1 months vs. 5.8 months; HR, 0.70; 95% CI, 0.60–0.83; P < .0001).[20][Level of evidence: 1iC]
    • In addition, patients in the abiraterone study group had statistically significant longer median times to opiate use for pain, initiation of cytotoxic chemotherapy, decline in PS, and PSA progression.[19,20][Levels of evidence: 1iC; 1iDiii]
  2. Enzalutamide, an androgen-receptor signaling inhibitor, has been shown to increase OS and quality of life in men with metastatic prostate cancer that has progressed despite ADT. In the PREVAIL study, 1,717 asymptomatic or mildly symptomatic men with recurrent metastatic prostate cancer despite ADT were randomly assigned to receive enzalutamide (160 mg orally per day) versus placebo.[21][Level of evidence: 1iiA]
    • After a median follow-up of 22 months, the study was stopped because of an OS benefit in the enzalutamide study arm (HR, 0.72; 95% CI, 0.6–0.84; P < .001). The proportion of men who had died was 28% versus 35%, and the median OS was 32.4 versus 30.2 months.
    • Median time until decline in global quality of life, measured by the Functional Assessment of Cancer Therapy-Prostate (FACT-P) score, was 11.3 versus 5.6 months in the enzalutamide and placebo groups (P < .001).[21][Level of evidence: 1iiC]
    • Grade 3 or worse adverse events were more common in the enzalutamide group (43% vs. 37%), primarily because of differences in hypertension, fatigue, and falls. Because patients receiving enzalutamide were on assigned therapy for an average of 1 year longer than those on placebo, the duration of response was longer in patients receiving enzalutamide, and this difference may have contributed to the increase in adverse events.
  3. Enzalutamide has also been shown to increase survival in patients with progressive prostate cancer who received prior ADT as well as docetaxel. In a double-blind, placebo-controlled trial, 1,129 men were randomly assigned in a 2:1 ratio to receive enzalutamide (160 mg orally per day) versus placebo.[22][Levels of evidence; 1iA, 1iC]
    • After a median follow-up of 14.4 months, the study was stopped at the single-planned interim analysis because improved OS, the primary endpoint, was found in the enzalutamide study group (median OS, 18.4 months; 95% CI, 17.3 to not yet reached vs. 13.6 months; 95% CI, 11.3–15.8; HRdeath of 0.63; 95% CI, 0.53–0.75; P < .001). In addition, quality of life, measured by the FACT-P questionnaire, was superior in the enzalutamide arm.
    • A seizure was reported in five of the 800 men in the enzalutamide study group versus none in the placebo group; however, the relationship to enzalutamide is not clear. Of the reported seizures, two patients had brain metastases, one patient had just received intravenous lidocaine, and one seizure was not witnessed.
  4. Men with metastatic prostate cancer who had biochemical or clinical progression after treatment with docetaxel (N = 1,195) were randomly assigned in a 2:1 ratio to receive either abiraterone acetate (1,000 mg) (n = 797) or placebo (n = 398) orally once a day (COU-AA-301 [NCT00638690]). Both groups received prednisone (5 mg) orally twice a day.[23][Level of evidence; 1iA]
    • After a median follow-up of 12.8 months, the trial was stopped when an interim analysis showed an OS advantage in the abiraterone group. The final report of the trial was published after a median follow-up of 20.2 months.
    • Median OS was 15.8 months in the abiraterone group versus 11.2 months in the placebo group (HRdeath of 0.74; 95% CI, 0.64–0.86; P < .0001).

Because there are no head-to-head comparisons, there are no trials to help decide which of these agents should be used first or in what sequence.

Even among patients with metastatic hormone-refractory prostate cancer, some heterogeneity is found in prognosis and in retained hormone sensitivity. In such patients who have symptomatic bone disease, several factors are associated with worsened prognosis: poor performance status, elevated alkaline phosphatase, abnormal serum creatinine, and short (<1 year) previous response to hormonal therapy.[24] The absolute level of PSA at the initiation of therapy in relapsed or hormone-refractory patients has not been shown to be of prognostic significance.[25]

Some patients whose disease has progressed on combined androgen blockade can respond to a variety of second-line hormonal therapies. Aminoglutethimide, hydrocortisone, flutamide withdrawal, progesterone, ketoconazole, and combinations of these therapies have produced PSA responses in 14% to 60% of patients treated and have also produced clinical responses of 0% to 25% when assessed. The duration of these PSA responses has been in the range of 2 to 4 months.[26] Survival rates are similar whether ketoconazole plus hydrocortisone is initiated at the same time as antiandrogen (e.g., flutamide, bicalutamide, or nilutamide) withdrawal or when PSA has risen after an initial trial of antiandrogen withdrawal as seen in the CLB-9583 trial, for example.[27][Level of evidence: 1iiA] Data on whether PSA changes while on chemotherapy are predictive of survival are conflicting.[25,28]

Patients treated with either luteinizing-hormone agonists or estrogens as primary therapy are generally maintained with castrate levels of testosterone. One study from ECOG showed that a superior survival resulted when patients were maintained on primary androgen deprivation;[8] however, another study from SWOG (formerly the Southwest Oncology Group) did not show an advantage to continued androgen blockade.[29]

Prevention of bone metastases

Painful bone metastases can be a major problem for patients with prostate cancer. Many strategies have been studied for palliation, including:[30-34]

  • External-beam radiation therapy (EBRT).
  • Bone-seeking radionuclides (strontium chloride Sr 89).
  • Denosumab (a monoclonal antibody that inhibits osteoclast function).
  • Pain medication.
  • Corticosteroids.
  • Bisphosphonates.

(Refer to the PDQ summary on Pain for more information.)

Evidence (palliation for bone metastases using radiation therapy):

  1. EBRT for palliation of bone pain can be very useful. 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) was seen in the RTOG-9714 trial, for example.[35,36][Level of evidence: 1iiC]

Evidence (palliation for bone metastases using strontium chloride):

The use of radioisotopes such as strontium chloride Sr 89 has been shown to be effective as palliative treatment of some patients with osteoblastic metastases. As a single agent, strontium chloride Sr 89 has been reported to decrease bone pain in 80% of patients treated.[37]

  1. A multicenter randomized trial of a single intravenous dose of strontium chloride Sr 89 (150 MBq: 4 mCi) versus palliative EBRT was done in men with painful bone metastases from prostate cancer despite hormone treatment.[38][Level of evidence: 1iiA]; [39]
    • Similar subjective pain response rates were shown in both groups: 34.7% for strontium chloride Sr 89 versus 33.3% for EBRT alone.
    • OS was better in the EBRT group than in the strontium chloride Sr 89 group (P = .046; median survival 11.0 months vs. 7.2 months).
    • No statistically significant differences in time-to-subjective progression or in PFS were seen.
    • When used as an adjunct to EBRT, strontium chloride Sr 89 was shown to slow disease progression and to reduce analgesic requirements, compared with EBRT alone.

Evidence (palliation or prevention of bone metastases using denosumab):

  1. A placebo-controlled randomized trial (NCT00321620) compared denosumab with zoledronic acid for the prevention of skeletal events (pathologic fractures, spinal cord compression, or the need for palliative bone radiation or surgery) in men with hormonal therapy-resistant prostate cancer with at least one bone metastasis.[30]
    • The trial reported that denosumab was more effective than zoledronic acid; median time to first on-study skeletal event was 20.7 versus 17.1 months (HR, 0.82; 95% CI, 0.71–0.95).
    • Serious adverse events were reported in 63% of denosumab patients versus 60% in patients on zoledronic acid. The cumulative incidence of osteonecrosis of the jaw was low in both study arms (2% in the denosumab arm vs. 1% in the zoledronic acid arm). There was grade 3 to 4 toxicity. There was no difference in survival. The incidence of hypocalcemia was higher in the denosumab arm (13% vs. 6%).[40]
  2. A randomized placebo-controlled trial included 1,432 men with castration-resistant prostate cancer with no evidence of any metastases who were given denosumab (120 mg administered subcutaneously every 4 weeks) to prevent the first evidence of bone metastasis (whether symptomatic or not).[40][Level of Evidence: 1iDiii]
    • After a median follow-up of 20 months, median bone metastasis-free survival was 29.5 versus 25.2 months in the denosumab versus placebo arms (HR, 0.85; 95% CI, 0.73–0.98; P = .028).
    • Symptomatic bone metastases were reported in 69 (10%) denosumab patients versus 96 (13%) placebo patients (HR, 0.67; 95% CI, 0.49–0.92; P = .01).
    • There were no differences in OS between the two groups.
    • Osteonecrosis occurred in 33 (5%) of men on the denosumab arm versus none on the placebo arm. Hypocalcemia occurred in 12 (2%) versus 2 (<1%) men, and urinary retention in 54 (8%) of men on denosumab versus 31 (4%) of men on placebo.

Treatment Options for Recurrent Prostate Cancer

Treatment options for recurrent prostate cancer include the following:

Chemotherapy for hormone-resistant prostate cancer

Evidence (chemotherapy for hormone-resistant prostate cancer):

  1. A randomized trial showed improved pain control in patients with hormone-resistant prostate cancer treated with mitoxantrone plus prednisone compared with those treated with prednisone alone.[41] Differences in OS or measured global quality of life between the two treatments were not statistically significant.
  2. In a randomized trial involving patients with hormone-refractory prostate cancer, docetaxel (75 mg/m2 every 3 weeks) and docetaxel (30 mg weekly for 5 out of every 6 weeks) were compared with mitoxantrone (12 mg/m2 every 3 weeks). All patients received oral prednisone (5 mg twice per day). Patients in the docetaxel arms also received high-dose dexamethasone pretreatment for each docetaxel administration (8 mg given at 12 hours, 3 hours, and 1 hour prior to the 3-week regimen; 8 mg given at 1 hour prior to the 5 out-of-every-6 weeks' regimen).[42]
    • OS at 3 years was statistically significantly better in the 3-weekly docetaxel arm (18.6%) than in the mitoxantrone arm (13.5%, HRdeath of 0.79; 95% CI, 0.67–0.93).
    • However, the OS rate for the 5 out-of-every-6 weeks' docetaxel regimen was 16.8%, which was not statistically significantly better than mitoxantrone.
    • Quality of life was also superior in the docetaxel arms compared with mitoxantrone (P = .009).[43][Levels of evidence: 1iiA, 1iiC]
  3. In another randomized trial involving patients with hormone-refractory prostate cancer, a 3-week regimen of estramustine (280 mg orally 3 times a day for days 1 to 5, plus daily warfarin and 325 mg aspirin to prevent vascular thrombosis), and docetaxel (60 mg/m2 intravenously [IV] on day 2, preceded by dexamethasone [20 mg times 3 starting the night before]) was compared with mitoxantrone (12 mg/m2 IV every 3 weeks) plus prednisone (5 mg daily).[44][Level of evidence: 1iiA]
    • After a median follow-up of 32 months, median OS was 17.5 months in the estramustine/docetaxel arm versus 15.6 months in the mitoxantrone arm (P = .02; HRdeath of 0.80; 95% CI, 0.67–0.97).
    • Global quality of life and pain palliation measures were similar in the two treatment arms.[45][Level of evidence: 1iiC]
  4. A 2-weekly regimen of docetaxel has been compared with a 3-weekly regimen. OS appeared to be better in the 2-week regimen, and hematologic toxicity was less.[46][Level of evidence: 1iiA]
    • In the trial, 361 men with metastatic hormone-resistant prostate cancer were randomly assigned to receive docetaxel either in a 2-weekly regimen (50 mg/m2 IV) or a 3-weekly regimen (75 mg/m2 IV) until progression. All patients were also to receive prednisolone (10 mg by mouth daily) and dexamethasone (7.5–8.0 mg daily), starting the day before and continuing for 1 to 2 days after each docetaxel dose. Fifteen randomly assigned patients (4.2%) were thought to be ineligible in retrospect or withdrew consent, and they were dropped from the analysis.
    • With a median follow-up of 18 months, there was a small difference in time-to-treatment failure, the primary endpoint of the study (5.6 months [95% CI, 5.0–6.2] vs. 4.9 months [95% CI, 4.5–5.4]; P = .014). However, there was a larger difference in median OS, a secondary endpoint, in favor of the 2-week regimen (19.5 months [95% CI, 15.9–23.1] vs. 17.0 months [95% CI, 15.0 –19.1]; P = .02).
    • There was a lower rate of grade 3 to 4 neutropenia with the 2-week regimen (36% vs. 53%; P < .0001) and a lower rate of febrile neutropenia (4% vs. 14%; P = .001).
  5. In patients with hormone-resistant prostate cancer whose disease progressed during or after treatment with docetaxel, cabazitaxel was shown to improve survival compared with mitoxantrone in a randomized trial (NCT00417079).[47] In this trial, 755 such men were treated with daily oral prednisone (10 mg) and randomly assigned to receive either cabazitaxel (25 mg/m2 IV) or mitoxantrone (12 mg/m2 IV) every 3 weeks.[47][Level of evidence; 1iiA]
    • Median OS was 15.1 months in the cabazitaxel arm and 12.7 months in the mitoxantrone study arm (HRdeath of 0.70; 95% CI, 0.59–0.83; P < .0001).

Other chemotherapy regimens reported to produce subjective improvement in symptoms and reduction in PSA level include the following:[48][Level of evidence: 3iiiDiii]; [49]

  • Paclitaxel.
  • Estramustine/etoposide.
  • Estramustine/vinblastine.
  • Estramustine/paclitaxel.

A study suggests that patients whose tumors exhibit neuroendocrine differentiation are more responsive to chemotherapy.[50]


Sipuleucel-T, an active cellular immunotherapy, has been shown to increase OS in patients with hormone-refractory metastatic prostate cancer. Sipuleucel-T consists of autologous peripheral blood mononuclear cells that have been exposed ex vivo to a recombinant fusion protein (PA2024) composed of prostatic acid phosphatase fused to granulocyte-macrophage colony-stimulating factor.

Side effects are generally consistent with cytokine release and include chills, fever, headache, myalgia, sweating, and influenza-like symptoms, usually within the first 24 hours of infusion. No increase in autoimmune disorders or secondary malignancies has been noted.[51]

Evidence (immunotherapy):

  1. In the largest trial (Immunotherapy for Prostate Adenocarcinoma Treatment: IMPACT trial [NCT00065442]), 512 patients with hormone-refractory metastatic disease were randomly assigned in a 2:1 ratio to receive sipuleucel-T (n = 341) versus placebo (n =171) intravenously by 60-minute infusion every 2 weeks for a total of 3 doses.[52] Patients with visceral metastases, pathologic bone fractures, or Eastern Cooperative Oncology Group (ECOG) performance status worse than 0–1 were excluded from the study. At documented disease progression, patients in the placebo group could receive, at the physician’s discretion, infusions manufactured with the same specifications as sipuleucel-T but using cells that had been cryopreserved at the time that the placebo was prepared (63.7% of the placebo patients received these transfusions). Time-to-disease progression and time to development of disease-related pain were the initial primary endpoints, but the primary endpoint was changed prior to study unblinding based upon survival differences in two prior trials of similar design (described below).[52][Level of evidence: 1iA]
    • After a median follow-up of 34.1 months, the overall mortality was 61.6% in the sipuleucel-T group versus 70.8% in the placebo group (HRdeath of 0.78; 95% CI, 0.61–0.98; P = .03). However, the improved survival was not accompanied by measurable antitumor effects.
    • There was no difference between the study groups in rate of disease progression. In 2011, the estimated price of sipuleucel-T was $93,000 for a 1-month course of therapy. This translates into an estimated cost of about $276,000 per year of life saved.[53]
  2. The same investigators performed two prior smaller trials (NCT00005947) of nearly identical design to the IMPACT trial.[54,55]
    • The combined results of the two smaller trials, involving a total of 225 patients randomly assigned in a 2:1 ratio of sipuleucel-T to placebo were similar to those in the IMPACT trial. The HRdeath was 0.67 (95% CI, 0.49–0.91), but the time-to-progression rates were not statistically significantly different.

Low-dose prednisone may palliate symptoms in some patients.[56]

Evidence (low-dose prednisone for palliation):

  1. A randomized comparison of prednisone (5 mg 4 times per day) with flutamide (250 mg 3 times per day) was conducted in patients with disease progression after androgen ablative therapy (castration or luteinizing hormone-releasing hormone agonist).[57]
    • Prednisone and flutamide produced similar overall survival, symptomatic response, PSA response, and time to progression; however, there were statistically significant differences in pain, nausea and vomiting, and diarrhea in patients who received prednisone. (Refer to the PDQ summaries on Pain and Nausea and Vomiting; refer to the PDQ summary on Gastrointestinal Complications for information on diarrhea.)

Ongoing clinical trials continue to explore the value of chemotherapy for these patients.[9-12,41,48-50]

Radiopharmaceutical Therapy

Alpha Emitter Radiation

Radium-223 emits alpha particles (i.e., two protons and two neutrons bound together, identical to a helium nucleus) with a half- life of 11.4 days. It is administered intravenously and selectively taken up by newly formed bone stroma. The high-energy alpha particles have a short range of <100 mcM. Radium-223 improved OS in patients with prostate cancer metastatic to bone.

Evidence (alpha emitter radiation):

  1. In a placebo-controlled trial, 921 men with symptomatic castration-resistant prostate cancer, two or more bone metastases, and no known visceral metastases, were randomly assigned in a 2:1 ratio to receive radium-223 at a dose of 50kBq per kg body weight every 4 weeks for six injections versus placebo. All study participants had already received docetaxel, were not healthy enough to receive it, or declined it.[58,59]
    • Median OS was 14.9 months in the radium-223 study group versus 11.3 months in the placebo groups (HRmortality, 0.70; 95% CI, 0.58–0.83; P < .001).[58][Level of evidence: 1iA]
    • The rates of symptomatic skeletal events (33% vs. 38%) and spinal cord compression (4% vs. 7%) were also statistically significantly improved.
    • Prospectively measured quality of life was also better in the radium-223 study group (25% vs. 16% had a ≥10 point improvement on a scale of 0 to 156; P = .02).[58][Level of evidence: 1iC]
    • With administration of radium-223 at a dose of 50kBq per kg of body weight every 4 weeks for six injections, the side effects were similar to those of a placebo.

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent prostate cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.


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  4. Freeman JA, Lieskovsky G, Cook DW, et al.: Radical retropubic prostatectomy and postoperative adjuvant radiation for pathological stage C (PcN0) prostate cancer from 1976 to 1989: intermediate findings. J Urol 149 (5): 1029-34, 1993. [PUBMED Abstract]
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  9. Debruyne FJ, Murray R, Fradet Y, et al.: Liarozole--a novel treatment approach for advanced prostate cancer: results of a large randomized trial versus cyproterone acetate. Liarozole Study Group. Urology 52 (1): 72-81, 1998. [PUBMED Abstract]
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  • Updated: April 23, 2015