This page describes treatments for men whose prostate cancer is no longer responding so well to their first type of hormone therapy. You might hear this stage of cancer called hormone refractory, hormone resistant, androgen independent, castration resistant, or castrate resistant prostate cancer (CRPC).

Treatments for this stage of prostate cancer are often called second-line treatments, as they are given when your first hormone therapy stops working so well.

Why is my first hormone therapy not working so well?

The first hormone therapy you have may keep your cancer under control for several months or years. But over time, the behaviour of your cancer cells may change and your cancer could start to grow again. This can happen even though the hormone therapy is still lowering your testosterone levels.

Although your prostate cancer is no longer responding so well to your first hormone therapy, it may respond well to other types of hormone therapy or a combination of treatments.

How will I know if my first hormone therapy is not working so well?

While you're having hormone therapy you will have regular prostate specific antigen (PSA) tests to check how well the hormone therapy is working.

A continuous rise in your PSA level may be the first sign that the hormone therapy is no longer working so well. If this happens, you might have more PSA tests to confirm this. Your doctor or nurse will also ask you about any symptoms you may have developed, such as urinary problems or bone pain. You may have scans, such as an MRI scan, a CT scan, or a bone scan. These will give your doctor a better idea of how the cancer is growing and which treatments might help.

Your doctor will talk to you about other possible treatment options if you need them. If your PSA level is only rising very slowly and you don't have any symptoms, you might not need to start a new treatment straight away. Your doctor will keep an eye on you with regular PSA tests and scans, as well as asking about your symptoms. They will talk to you about how often you should have these check-ups.

What further treatments are available?

The aim of treatment is to control your cancer and delay or manage any symptoms you might have. You will probably continue with your first type of hormone therapy – even though it's not working so well. This is because it will still help to keep the amount of testosterone in your body low.

Further treatment options may include:

Which treatments will I have?

When your cancer stops responding to your first hormone therapy, there is no best treatment or best order to have treatments inYou might have more than one treatment, while some treatments might not be suitable for you.

The treatments you have will depend on lots of things. When talking about possible treatments you and your doctor will consider:

  • where your cancer has spread to
  • if you have any symptoms
  • how long your cancer responded to your first hormone therapy for
  • your general health and any other health problems you have
  • the possible side effects of each treatment
  • what your doctor thinks will work best for you
  • your own thoughts and feelings – for example, how you feel about the possible side effects and how a treatment would fit in with your daily life.

Abiraterone or enzalutamide?

If you've already had a drug called abiraterone, another drug called enzalutamide probably won't be an option. And if you’ve already had enzalutamide, abiraterone probably won’t be an option. This is because early research suggests that each drug may only have a small effect in men who've already had the other.

However, if you get severe side effects from either abiraterone or enzalutamide, you may be able to try the other one, as long as you've used the first drug for less than three months.

Speak to your doctor about which drug, if any, is the best option for you. You can also talk things through with our Specialist Nurses.

Anti-androgens

Anti-androgens, such as bicalutamide (Casodex®), are a type of hormone therapy that stop testosterone from reaching the prostate cancer cells. They may be an option if you've already had hormone therapy with injections, implants or surgery (an orchidectomy), which will have lowered the amount of testosterone in your blood.

If you're having LHRH agonist injections, you will probably start taking anti-androgens alongside them. Some health professionals call this combined androgen blockade or dual androgen blockade. It may be slightly more effective than using an LHRH agonist on its own if your PSA level is rising, or if your cancer has spread to other parts of the body (advanced prostate cancer).

If you are already having injections and anti-androgen tablets and your PSA level is rising, your doctor may suggest that you stop taking the anti-androgen for a little while to see if your PSA level falls. You may hear this called a ‘withdrawal response’. Some men find that their PSA level falls for a few months, or sometimes longer.

The side effects of anti-androgens can be similar to the side effects of other types of hormone therapy and can include breast swelling and breast tenderness.

Read more about the side effects of hormone therapy.

Abiraterone

Abiraterone (Zytiga®) is a new type of hormone therapy for men with advanced prostate cancer that has stopped responding to other types of hormone therapyIt is taken as tablets and works by stopping the production of testosterone. It may help some men to live longer and can help control symptoms.

Abiraterone can be given either before or after chemotherapy, but it isn’t usually given to men who’ve already had enzalutamide.

Abiraterone can cause side effects. You'll need to take a steroid called prednisolone with abiraterone to lower the risk of side effects.

Read more about abiraterone.

Enzalutamide

Like abiraterone, enzalutamide (Xtandi®) is a new type of hormone therapy for men with advanced prostate cancer that has stopped responding to other types of hormone therapy. It is taken as tablets and works by stopping testosterone from reaching the prostate cancer cells. It may help some men to live longer and can help control symptoms of advanced prostate cancer.

Enzalutamide can be given either before or after chemotherapy. But it isn’t usually given to men who’ve already had abiraterone.

Read more about enzalutamide, including the possible side effects.

Chemotherapy

Chemotherapy uses anti-cancer drugs to kill cancer cells, wherever they are in the body. It can help some men to live longer, and improve and delay symptoms such as pain.

In the UK, docetaxel (Taxotere®) is the most common type of chemotherapy for men with advanced prostate cancer that is no longer responding so well to hormone therapy.

If you’ve already had docetaxel and your cancer has started to grow again, you might be offered a newer chemotherapy drug called cabazitaxel (Jevtana®).

You will be given steroid tablets, such as prednisolone or dexamethasone, to take with chemotherapy. This can help make the treatment more effective and reduce the side effects of chemotherapy.

Chemotherapy isn't suitable for everyone as the side effects can be difficult to deal with. Some men get a lot of side effects, while others only have a few. Your doctor will check your general health to make sure you're fit enough for chemotherapy.

Read more about chemotherapy.

Steroids

Steroids can stop the adrenal glands producing as much testosterone, so can help to control your cancer. They can also improve your appetite, give you more energy, and help with symptoms such as pain.

You might have steroids alone or in combination with other treatments, including chemotherapy and abiraterone. Common steroids include dexamethasone, prednisolone and hydrocortisone.

Steroids can cause side effects. But because they are given in a low dose to treat prostate cancer, most men don’t get many side effects. Before you start taking steroids, talk to your doctor or nurse about the possible side effects. They affect each man differently, and you might not get any of them.

Side effects can include:

  • indigestion and irritation of the stomach lining  take steroids after a meal and ask your doctor about medicines that could help
  • a bigger appetite – try to eat a healthy diet to keep your weight under control
  • having more energy and a more active mind, which could make you feel irritable or anxious or give you trouble sleeping – take steroids before 4pm and tell your doctor or nurse if this is a problem
  • water retention, which can cause swollen hands and feet
  • a slightly higher risk of getting infections – tell your GP if you have a high temperature or other signs of infection
  • bruising more easily
  • raised blood sugar levels – tell your doctor if you need to urinate (pee) more often or get very thirsty, as these can be signs of high blood sugar
  • weak bones – you might need to take medicines or calcium and vitamin D supplements.

Don’t suddenly stop taking steroids as this can make you ill.

You'll be given a steroid treatment card that says you're taking steroids. You should carry this with you at all times and show it to anyone treating you (such as a doctor, nurse or dentist). It’s important that they know you're taking steroids.

Radium-223

Radium-223 (Xofigo®) is a new treatment for men with prostate cancer that has spread to the bones and has stopped responding to hormone therapy. It is a type of internal radiotherapy called a radioisotope. Radium-223 helps some men to live longer. It can also delay some symptoms, such as bone fractures, and can help to reduce bone pain. It can be given either before or after chemotherapy.

Radium-223 is injected into a vein in your arm. You will normally have an injection every four weeks, for up to six injections. Each injection only takes a few minutes and you will be able to go home straight away after each one.

Radium-223 travels around the body in the blood and is drawn towards the parts of the bones that have been damaged by the cancer. It collects in these parts of the bones and kills the cancer cells, but doesn’t damage many healthy cells. This means that any side effects of radium-223 tend to be mild.

Read more about radium-223, including the possible side effects.

Oestrogens

Oestrogens are a type of hormone therapy that can be used to treat prostate cancer that's no longer responding to other types of hormone therapy. They aren't used very often and may not be suitable if you have other health problems. Oestrogen is a hormone that's naturally found in both men and women, but women usually produce more.

Oestrogens can be given as a tablet called diethylstilbestrol (Stilboestrol®) or through a patch that sticks to your skin like a plaster.

The side effects can be similar to the side effects of other types of hormone therapy.

Other treatments to manage symptoms

If your prostate cancer has spread to the bones or other parts of your body, you may get symptoms such as bone pain or urinary problems. There are treatments to help manage symptoms. These are sometimes called palliative treatments. They include:

Clinical trials and new treatments

A clinical trial is a type of medical research that aims to find new and improved ways of preventing, diagnosing, treating and managing illnesses. There are clinical trials looking at new treatments for prostate cancer and new ways of using existing treatments, as well as the best order to have treatments in. If you decide to take part in a clinical trial, you may be able to have a newer treatment that isn't yet widely available.

Read more about clinical trials or speak to your doctor or nurse.

Who will be involved in my treatment?

You may see different health professionals depending on the treatment you have. For example, if you have chemotherapy you may see an oncologist, a specialist chemotherapy nurse, or a pharmacist, who will check you're having the right medicines at the right doses.

You may be offered a referral to community services, such as district nurses and palliative care nurses who can help control symptoms. You might also have appointments more often than before to help manage symptoms or to give you your treatment.

How will I know how well my treatment is working?

During and after your treatment your doctor or nurse will check how well your treatment is working.

You may have regular PSA tests, and other tests such as MRI scans or CT scans. Your PSA levels alone aren't always enough to know if your treatment is working. So your doctor will use your PSA level and any other test results, along with information about how you're feeling, to check how well the treatment is working.

If you are feeling better this could be a sign that the treatment is working. If the treatment isn't controlling the cancer, then you and your doctor can discuss which treatment to try next.

One aim of your treatment will be to help manage any symptoms from your cancer, so that your daily life is as good as possible. But treatments can cause side effects. Let your doctor or nurse know how you are feeling and about any symptoms or side effects. If you have symptoms in between check-ups, tell your doctor or nurse as soon as possible.

References

Updated: August 2017 | Due for review: August 2019

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  • List of reviewers  

    The following people helped to review this information:

    • Vanessa Basketter, Urology Lead Nurse, University Hospital Southampton NHS Foundation Trust
    • Chris Parker, Consultant Clinical Oncologist, The Royal Marsden NHS Foundation Trust, Sutton
    • Deborah Victor, Uro-oncology Clinical Nurse Specialist, Royal Cornwall Hospitals NHS Trust
    • Linda Welsh, Prostate Specialist Radiographer and Clinical Research
      Radiographer, Torbay Hospital
    • Our Specialist Nurses
    • Our Volunteers.