Senior Director & Unit Head, Urology, Kidney Transplant, Uro-Oncology, Robotic Surgery, Max Hospital, Gurugram
Part 11 of 11 in Prostate Cancer: Diagnosis and Management
Managing Metastatic and Castration-Resistant Prostate Cancer
September 6, 2026
For patients whose prostate cancer can't be treated with surgery or radiotherapy, androgen deprivation therapy is the starting point: a form of medical castration that stops testosterone's effect on the body. Dr. Amit Goel explained that bilateral orchidectomy, surgical removal of both testicles, remains a valid and cost-effective alternative to ongoing hormone injections, particularly for patients who don't want the recurring cost of medication, and works about as well.
When the Disease Becomes Castration-Resistant
After a period on hormone therapy, PSA can start rising again, a condition called castration-resistant or hormone-resistant prostate cancer. At that point, Dr. Goel moves patients to stronger anti-androgens such as abiraterone or enzalutamide, and to chemotherapy where needed; he noted that immunotherapy has also entered the treatment picture for this group in recent years.
Managing Bone Metastasis
For patients with bone metastasis, particularly weight-bearing bones at risk of fracture, treatment adds painkillers, steroids, bone-strengthening injections and radiotherapy directed at the affected bone. Dr. Goel singled out lutetium-177 PSMA therapy as a treatment that has performed well even in frail, heavily comorbid patients with widespread, painful bone disease.
Follow-Up and the Realistic Chance of Recurrence
Asked directly by an attending doctor about survival chances and the possibility of recurrence after surgery, Dr. Goel was candid: surgery is offered specifically in patients where cure is the realistic goal, but every patient needs lifelong follow-up, with PSA testing every three to six months, because recurrence can and does happen. As he put it to the audience, the name cancer itself is a reminder that it can come back, which is exactly why regular follow-up is not optional.
This article is based on a Jivo Masterclass session conducted by Dr. Amit Goel, Director and Head of Unit, Renal Transplant, Uro-oncology, Urology and Robotic Surgery, Max Hospital, Gurugram, India. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
This guide is based on a live Jivo Masterclass: Dr. Amit Goel taught doctors across Africa on April 20, 2025.
FROM THE LIVE Q&A
Moderator
What is the management of metastatic prostate cancer?
Dr. Amit Goel
It depends on where the metastasis is. Bilateral orchidectomy is still a valid option for patients who don't want to spend money on ongoing hormone injections, and it works about as well as hormone therapy. For bone metastasis with pain or fracture risk, bone-strengthening injections and radiotherapy to the affected bone are added. Once the disease becomes castration-resistant, treatment moves to stronger anti-androgens such as abiraterone or enzalutamide, chemotherapy for visceral metastasis, and increasingly immunotherapy.
Frequently Asked Questions
What are the survival chances after surgical treatment for a patient with prostate adenocarcinoma, and is there a possibility of recurrence?▼
Surgery is offered specifically in patients where the goal is cure. But every patient needs lifelong follow-up, with PSA testing every three to six months, because recurrence can and does happen. Nobody can promise a patient that surgery guarantees no recurrence. That possibility is exactly what the word cancer is telling us.
What is the average cost of robotic surgery for prostate cancer?▼
Approximately 8,700 US dollars, which is the total cost of the robotic surgery.
What is the management of metastatic prostate cancer?▼
It depends on where the metastasis is. Bilateral orchidectomy is still a valid option for patients who don't want to spend money on ongoing hormone injections, and it works about as well as hormone therapy. For bone metastasis with pain or fracture risk, bone-strengthening injections and radiotherapy to the affected bone are added. Once the disease becomes castration-resistant, treatment moves to stronger anti-androgens such as abiraterone or enzalutamide, chemotherapy for visceral metastasis, and increasingly immunotherapy.
What happens when prostate cancer becomes castration-resistant?▼
PSA starts rising again despite androgen deprivation therapy. Treatment then escalates to stronger anti-androgens such as abiraterone or enzalutamide, chemotherapy, or, more recently, immunotherapy.
How often should patients be followed up after prostate cancer surgery?▼
Dr. Amit Goel recommends PSA testing every three to six months after surgery, since recurrence remains possible even after a successful operation.
In This Series: Prostate Cancer: Diagnosis and Management
- 1.Diagnosis and Management of Prostate Cancer
- 2.Prostate Cancer Risk Factors and Why Men of African Descent Face the Highest Risk
- 3.Recognizing Prostate Cancer: From Early Symptoms to Advanced and Metastatic Disease
- 4.How Prostate Cancer Is Diagnosed: PSA Testing and Digital Rectal Examination
- 5.Prostate Biopsy: TRUS-Guided and MRI Fusion Techniques
- 6.The Gleason Score: Grading Prostate Cancer and What It Means for Treatment
- 7.Staging Prostate Cancer: TNM Classification and PSMA PET Scans
- 8.Choosing a Treatment: Risk-Based Options From Active Surveillance to Surgery
- 9.Robotic, Laparoscopic and Open Radical Prostatectomy: Comparing the Evidence
- 10.The Retzius-Sparing Technique: Protecting Continence and Erectile Function After Surgery
- 11.Managing Metastatic and Castration-Resistant Prostate Cancer