Guideline Recommendation for ADT Treatment in Prostate Cancer

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The NCCN guidelines provide essential framework for incorporating various androgen deprivation therapy (ADT) options into evidence-based prostate cancer treatment algorithms. These guidelines help clinicians navigate the complex landscape from unfavorable intermediate-risk disease through advanced metastatic cases, with ADT monotherapy becoming increasingly rare as combination therapies demonstrate superior outcomes. For metastatic castration-sensitive prostate cancer, guidelines now recommend combination therapy as standard of care, incorporating ADT with androgen receptor pathway inhibitors and/or chemotherapy.

Risk stratification using criteria from landmark trials like STAMPEDE and LATITUDE helps determine appropriate treatment intensity. High-risk or high-volume patients may benefit from triplet therapy combining ADT (such as relugolix), androgen receptor pathway inhibitors (ARPIs; like darolutamide or apalutamide), and chemotherapy (docetaxel). The simplicity of oral ADT facilitates this complex treatment initiation by eliminating the need for anti-androgen bridging therapy typically required with injectable GnRH agonists, streamlining the transition to combination therapy.

For lower-risk patients, doublet therapy combining ADT with ARPIs like enzalutamide, abiraterone, or apalutamide provides sufficient treatment intensity. The guidelines support the use of various ADT formulations, allowing clinicians to select the most appropriate option based on individual patient factors. The versatility of agents like abiraterone, which can be used across multiple disease states from locally advanced to castration-resistant disease, provides treatment continuity as patients progress through different stages of prostate cancer.