Latest Cancer TreatmentsDr. Mohammadreza Dabiri
Dr. Mohammadreza Dabiriفارسی

Treating prostate cancer that has spread: why a hormone injection alone is not enough

The story of hormone therapy, the new anti-hormone tablets, docetaxel chemotherapy and targeted radiation treatment, and the question to ask from day one

Updated: 28 October 20262 min read13 references
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Key points

  • In prostate cancer that has spread, a hormone injection alone is not enough. The European guideline says another drug should be added from the start [1].
  • Adding a new anti-hormone tablet (abiraterone, enzalutamide, apalutamide or darolutamide) cut the risk of death by about a third [5, 8, 9, 10].
  • Even so, in many countries most patients still receive only a hormone injection [13].
  • In high-volume disease, docetaxel chemotherapy has also lengthened life [3].

The story: from one injection to combination treatment

Prostate cancer cells grow on male hormone (testosterone). That is why for decades the main treatment for prostate cancer that had spread was lowering this hormone: with injections (such as leuprorelin) or surgery. This treatment works, but after a while the cancer cells find a way to grow without the hormone [1].

From 2015, several large studies showed that if another treatment is added to the injection right from the start, patients live much longer. First docetaxel chemotherapy: when the disease was in many places, it added more than a year of life [2, 3]. Then abiraterone tablets: in high-risk patients, they added more than a year of life [4, 5], and in a large UK study they also reduced deaths [6]. Then enzalutamide and apalutamide, which both cut the risk of death by about a third [7, 8, 9].

In patients whose cancer had spread at diagnosis, the triple combination (injection, docetaxel and a new tablet) lengthened life even further [10, 11].

53 vs 37 months
Median survival of high-risk patients with abiraterone added
[5]
A third
Reduction in the risk of death with the new anti-hormone tablets added
[8, 9, 10]

Why does this matter?

A review of 29 studies from different countries showed that in every region of the world most patients with prostate cancer that has spread still receive only a hormone injection, and combinations are used least of all in Asia [13]. This means many men miss out on treatment that adds years to their lives.

The question to ask from day one

If your prostate cancer has spread to the bones or elsewhere and you have been prescribed only a hormone injection, ask: "Should abiraterone or enzalutamide tablets (or a similar drug), or docetaxel chemotherapy, be started with it?" [1]. This decision is best made in the first few weeks.

Today's options

Injection + anti-hormone tablet

For most patients: abiraterone (with prednisone), enzalutamide or apalutamide [5, 8, 9].

Injection + docetaxel + tablet

In high-volume disease and patients fit enough for chemotherapy [10, 11].

Targeted radiation treatment

Lutetium-PSMA is used in more advanced disease, and at an earlier stage it also controlled the disease longer; its effect on survival is not yet clear [12] (news of this study).

When should I call my doctor?

New or worsening back pain with weakness or numbness in the legs, or trouble controlling your bladder and bowels, is an emergency (pressure on the spinal cord) (cancer emergencies). With abiraterone, have your blood pressure and potassium checked regularly [5].

Frequently asked questions

Do these tablets have a lot of side effects?

In most studies, serious side effects were close to those of the group without the tablet; each tablet has its own particular side effects (for example high blood pressure with abiraterone, skin rash with apalutamide) [5, 9].

How long do I need to take the tablet?

Usually for as long as the disease is controlled and side effects are tolerable; it continues together with the hormone injection [1].

Do I need chemotherapy?

The greatest benefit of docetaxel has been in high-volume disease; in low-volume disease no survival benefit was seen [3]. Your doctor decides based on the volume of disease and your physical fitness.

For physicians

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For physicians

ESMO 2026: ADT alone is not enough in mHSPC; intensify with an ARPI or triplet therapy [1]. CHAARTED: median OS 57.6 versus 47.2 months; in high volume 51.2 versus 34.4 (HR 0.63), no benefit in low volume [3]. LATITUDE: median OS 53.3 versus 36.5 months (HR 0.66) [5]. STAMPEDE (abiraterone): HR for death 0.63 [6]. ARCHES: HR for death 0.66 [8]. TITAN: HR for death 0.67 [9]. ARASENS: darolutamide + ADT + docetaxel, HR for death 0.68 [10]. PEACE-1: abiraterone + ADT + docetaxel, HR for overall survival 0.82 [11]. PSMAddition: better rPFS, immature OS [12]. Real world: ADT monotherapy predominates in every region [13]. Doses: ADT + abiraterone · ADT + enzalutamide · triplet therapy.

Scientific evidence

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Scientific evidence

8 items
Clinical trial · Phase 3

Chemohormonal Therapy in Metastatic Hormone-Sensitive Prostate Cancer: Long-Term Survival Analysis of the Randomized Phase III E3805 CHAARTED Trial

J Clin Oncol · 2018
57.6 vs 47.2 monthsMedian overall survival (all patients)
Summary
Clinical trial · Phase 3

Abiraterone acetate plus prednisone in patients with newly diagnosed high-risk metastatic castration-sensitive prostate cancer (LATITUDE): final overall survival analysis of a randomised, double-blind, phase 3 trial

Lancet Oncol · 2019
53.3 vs 36.5 monthsMedian overall survival
Summary
Clinical trial · Phase 3

Improved Survival With Enzalutamide in Patients With Metastatic Hormone-Sensitive Prostate Cancer

J Clin Oncol · 2022
34% reduction in the risk of deathOverall survival
Summary
Clinical trial · Phase 3

Apalutamide for Metastatic, Castration-Sensitive Prostate Cancer

N Engl J Med · 2019
68.2% vs 47.5%Radiographic progression-free survival at 24 months
Summary
Clinical trial · Phase 3

Darolutamide and Survival in Metastatic, Hormone-Sensitive Prostate Cancer

N Engl J Med · 2022
32.5%Overall survival (reduction in risk of death)
Summary
Clinical trial · Phase 3

Abiraterone plus prednisone added to androgen deprivation therapy and docetaxel in de novo metastatic castration-sensitive prostate cancer (PEACE-1): a multicentre, open-label, randomised, phase 3 study with a 2 × 2 factorial design

Lancet · 2022
HR 0.54Radiographic progression-free survival — overall population
Summary
Clinical trial · Phase 3

[177Lu]Lu-PSMA-617 in patients with PSMA-positive metastatic androgen pathway modulator-naive/sensitive prostate cancer (PSMAddition): a phase 3 randomised, controlled trial

Lancet · 2026
HR 0.72Radiographic progression-free survival
Summary
Clinical trial

Abiraterone for Prostate Cancer Not Previously Treated with Hormone Therapy

N Engl J Med · 2017
184 in the combination group vs 262 in the ADT-alone groupNumber of deaths
Summary

Read more

Related cancer types

Prostate cancer

References

13 references
Show all references, 12 with a study cardClose the reference list

Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.

  1. 1
    Advanced and metastatic prostate cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-upFizazi K, Attard G, Azad AA, Baciarello G, Beltran H, Bjartell A, et al · Ann Oncol · 2026;37:590-607
    Study cardDOIPubMed Back to text: 1 2 3 4 5
  2. 2
    Chemohormonal Therapy in Metastatic Hormone-Sensitive Prostate CancerSweeney CJ, Chen YH, Carducci M, Liu G, Jarrard DF, Eisenberger M, et al · N Engl J Med · 2015;373:737-746
    Study cardDOIPubMed Back to text
  3. 3
    Chemohormonal Therapy in Metastatic Hormone-Sensitive Prostate Cancer: Long-Term Survival Analysis of the Randomized Phase III E3805 CHAARTED TrialKyriakopoulos CE, Chen YH, Carducci MA, Liu G, Jarrard DF, Hahn NM, et al · J Clin Oncol · 2018;36:1080-1087
    Study cardDOIPubMed Back to text: 1 2 3 4
  4. 4
    Abiraterone plus Prednisone in Metastatic, Castration-Sensitive Prostate CancerFizazi K, Tran N, Fein L, et al · N Engl J Med · 2017;377:352-360
    Study cardDOIPubMed Back to text
  5. 5
    Abiraterone acetate plus prednisone in patients with newly diagnosed high-risk metastatic castration-sensitive prostate cancer (LATITUDE): final overall survival analysis of a randomised, double-blind, phase 3 trialFizazi K, Tran N, Fein L, Matsubara N, Rodriguez-Antolin A, Alekseev BY, et al · Lancet Oncol · 2019;20:686-700
    Study cardDOIPubMed Back to text: 1 2 3 4 5 6 7
  6. 6
    Abiraterone for Prostate Cancer Not Previously Treated with Hormone TherapyJames ND, de Bono JS, Spears MR, et al · N Engl J Med · 2017;377:338-351
    Study cardDOIPubMed Back to text: 1 2
  7. 7
    ARCHES: A Randomized, Phase III Study of Androgen Deprivation Therapy With Enzalutamide or Placebo in Men With Metastatic Hormone-Sensitive Prostate CancerArmstrong AJ, Szmulewitz RZ, Petrylak DP, et al · J Clin Oncol · 2019;37:2974-2986
    Study cardDOIPubMed Back to text
  8. 8
    Improved Survival With Enzalutamide in Patients With Metastatic Hormone-Sensitive Prostate CancerArmstrong AJ, Azad AA, Iguchi T, Szmulewitz RZ, Petrylak DP, Holzbeierlein J, et al · J Clin Oncol · 2022;40:1616-1622
    Study cardDOIPubMed Back to text: 1 2 3 4 5
  9. 9
    Apalutamide for Metastatic, Castration-Sensitive Prostate CancerChi KN, Agarwal N, Bjartell A, Chung BH, Pereira de Santana Gomes AJ, Given R, et al · N Engl J Med · 2019;381:13-24
    Study cardDOIPubMed Back to text: 1 2 3 4 5 6
  10. 10
    Darolutamide and Survival in Metastatic, Hormone-Sensitive Prostate CancerSmith MR, Hussain M, Saad F, Fizazi K, Sternberg CN, Crawford ED, et al · N Engl J Med · 2022;386:1132-1142
    Study cardDOIPubMed Back to text: 1 2 3 4 5
  11. 11
    Abiraterone plus prednisone added to androgen deprivation therapy and docetaxel in de novo metastatic castration-sensitive prostate cancer (PEACE-1): a multicentre, open-label, randomised, phase 3 study with a 2 × 2 factorial designFizazi K, Foulon S, Carles J, et al · Lancet · 2022;399:1695-1707
    Study cardDOIPubMed Back to text: 1 2 3
  12. 12
    [177Lu]Lu-PSMA-617 in patients with PSMA-positive metastatic androgen pathway modulator-naive/sensitive prostate cancer (PSMAddition): a phase 3, randomised, controlled trialTagawa ST, Sartor O, Piulats JM, Saad F, Fizazi K, Reid A, et al · Lancet · 2026;408:793-807
    Study cardDOIPubMed Back to text: 1 2
  13. 13
    Real-world use of androgen-deprivation therapy intensification for metastatic hormone-sensitive prostate cancer: a systematic reviewRaval AD, Lunacsek O, Korn MJ, et al · BJU Int · 2025;135:408-421
    DOIPubMed Back to text: 1 2 3

This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.

Printed from the website; the full and up-to-date version: https://drdabiri.com/en/articles/metastatic-prostate-cancer-treatment/

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