The short answer
Two questions organise metastatic prostate cancer: castration-sensitive or castration-resistant, and high volume or low volume. Both change which drug is added to hormone therapy.
Castration-sensitive means the cancer is still controlled by lowering testosterone; castration-resistant means it is growing despite that.
In the trial NCI describes, high volume meant spread to organs, or at least four bone lesions with at least one outside the spine and pelvis.
In that one trial, adding docetaxel to hormone therapy improved median survival in high-volume disease, 61.2 months against 34.4, with no difference seen in low-volume disease; later trials have shifted how docetaxel is used, so ask what the current thinking is.
Abiraterone, apalutamide, enzalutamide and darolutamide are the drugs NCI describes adding to standard hormone therapy.
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The full explanation.
Castration-sensitive or castration-resistant
This is the dividing line in metastatic prostate cancer, and every drug decision sits on one side of it.
Castration-sensitive means the cancer is still controlled by lowering testosterone. Castration-resistant means it is growing despite that.
Ask which one you are today. Ask what result would show that it had changed.
High volume or low volume changes the advice
NCI describes how one major trial split patients. High-volume disease meant spread to organs, or at least four bone lesions with at least one outside the spine and pelvis.
That distinction was not academic. In that trial, adding docetaxel to hormone therapy improved survival in the high-volume group: median survival 61.2 months with docetaxel added, against 34.4 months without it. No survival difference was seen in low-volume disease.
Do not read that as a rule that docetaxel only ever helps high-volume disease. It is one trial, from one moment, and the field has moved since. Ask what today's evidence says for your situation.
Hormone therapy is usually not given alone
For most people with metastatic disease, something is now added to standard hormone therapy rather than hormone therapy running on its own. NCI's summaries describe abiraterone, apalutamide, enzalutamide and darolutamide among the additions, with docetaxel as the chemotherapy option that may be added instead or as well.
Which of these applies depends on whether your cancer is still castration-sensitive or has become castration-resistant, whether it was metastatic from the start or came back after earlier treatment, how much disease there is, how well you are, and what you have already been given. Some people are offered two additions rather than one. Hormone therapy alone is still the right answer for some, usually where frailty or other illness makes more treatment a poor trade.
Ask what is being proposed alongside hormone therapy, and what evidence sits behind that choice for your situation.
Scans that find what a bone scan misses
NCI lists PSMA-based imaging among prostate cancer staging tests. Gallium Ga 68 gozetotide and fluorine F 18 piflufolastat PET-CT are both named.
That scan also matters later. NCI describes lutetium Lu 177 vipivotide tetraxetan, which binds to PSMA and delivers radiation to it directly.
Ask whether a PSMA scan would change what is known about where your cancer is.
Questions for the urology and oncology team
- Am I castration-sensitive or castration-resistant right now?
- Do I have high-volume disease by the definition used in the trials?
- Which drug goes with my hormone therapy, and why that one?
- Would adding docetaxel change my odds, given my volume of disease?
- Should I have germline and tumor testing for BRCA and related genes?
- Would a PSMA PET scan change the plan?
- What is being done to protect my bones?
Bones, pain and the tools for them
Bone metastases are the usual problem in prostate cancer. NCI lists several strategies for them.
They include external beam radiation, denosumab, bisphosphonates such as zoledronic acid, pain medicine and corticosteroids.
One distinction is worth pinning down when you ask. Denosumab and zoledronic acid are used at one strength and schedule to protect bone thinned by hormone therapy, and at a different, more intensive one to reduce fractures and other skeletal events in castration-resistant disease that has spread to bone. They are not the same treatment under one name. Ask which of the two your team means.
Radium Ra 223 is a separate option. It is taken up by newly forming bone, and NCI reports that it improved survival in men with cancer that had spread to bone. Quality of life was also better in that trial.
When to get help sooner
- Call 911 or go to an emergency department if you get new weakness or numbness in the legs, unsteady walking, or you lose control of your bladder or bowels. Back pain that is constant, worse at night, or worse when you cough or sneeze fits the same picture. Prostate cancer is the second commonest cause of spinal cord compression from cancer, and people who cannot walk for more than a couple of days before treatment do far worse. Go straight in too if you cannot pass urine at all. A temperature of 100.4°F (38°C) or higher in the weeks after a docetaxel dose is the same kind of emergency: the drug leaves your white cell count at its lowest around then, and CDC advises being seen immediately rather than waiting for the clinic to ring back.
- Call your care team the same day if bone pain starts suddenly after a small knock or a twist, and you cannot put weight on the limb. A weakened bone can crack.
- Call your care team within a day or two if bone pain is steadily worsening, or you are getting new pain in the spine, hips or ribs. Radiation, denosumab, bisphosphonates and radium Ra 223 are all on the list above, and they work better before a bone gives way.
Related pages
Further reading: Cancer Staging, Biomarker Testing, Palliative Care, and Clinical Trial vs Standard Treatment.
Where this comes from
- NCI PDQ - Prostate Cancer Treatment (Patient Version)
- NCI PDQ - Prostate Cancer Treatment (Health Professional Version)
- NCI - Prostate-Specific Antigen (PSA) Test
- StatPearls (NCBI) — Metastatic Spinal Cord Compression
- NCI — Infection and Neutropenia During Cancer Treatment
- CDC — Watch Out for Fever (Preventing Infections in Cancer Patients)
Words to know
Tap any term to see what it means.
Common questions
What does castration-resistant mean?
That the cancer is growing despite testosterone being lowered. It is the dividing line in metastatic prostate cancer, and every drug decision sits on one side of it. Ask which side you are on today and what result would show a change.
Would docetaxel help me?
Volume of disease is part of it. In the trial NCI describes, adding docetaxel to hormone therapy improved median survival in the high-volume group, 61.2 months against 34.4 months, with no difference seen in low-volume disease. That is one trial from a particular era, and it is not the last word: how docetaxel is used has been reworked since, and it is often now discussed as part of a three-drug plan. Your fitness, whether the disease was there from the start or came back later, and what you have already had all count.
What is being done about my bones?
NCI lists external beam radiation, denosumab, bisphosphonates such as zoledronic acid, pain medicine and corticosteroids. Radium Ra 223 is a separate option that improved survival, and quality of life, in men whose cancer had spread to bone.
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Sources last checked: 2026-08-13 what this meansLast updated: 2026-08-19Next planned review: 2027-07-30
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How this page was created
Cancer Explained does not originate medical claims. Every page restates guidance already published by the National Cancer Institute, the CDC, the USPSTF and the FDA, in plain language, with the source cited so you can check the original yourself. AI does the translating and organizing; automated checks test claims, citations, clarity and safety before anything publishes. We do not employ clinicians and do not intend to — our work is translation and navigation, not clinical judgment. Nothing here is personal medical advice, and no page can account for your particular situation.
Editorial status: Source checked — This page was written with AI assistance and checked line by line against the sources listed on it. That confirms the sources support what the page says. It is not a medical review, and it does not confirm the page is complete or right for your situation.
Human medical review: not completed. Pages here are not signed off by a clinician before they publish. That is not an oversight we are quietly working around: we restate published guidance and cite it, so the authority belongs to the source rather than to us, and every page names where its claims come from — you can verify us instead of trusting us. Where a volunteer clinician has reviewed a page, their name and credentials appear on it; where no name appears, no clinician has checked it. We are glad to have reviewers and are recruiting them, and we do not hold pages back waiting for one. Use this site to understand your situation and to ask better questions of the people treating you.
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