What are the AUA guidelines on the treatment of metastatic and advanced castration-resistant prostate cancer?

Updated: Dec 29, 2020
  • Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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Answer

Answer

American Urological Association guidelines for the management of CRPC describe six index-patient scenarios for which recommendations could be formulated. [54]

Index patient no. 1: Asymptomatic non-metastatic CRPC

Recommendations are as follows:

  • Observation with continued ADT

  • First-generation antiandrogens (flutamide, bicalutamide, and nilutamide) or first-generation androgen-synthesis inhibitors (ketoconazole plus steroid) to patients unwilling to accept observation.

  • Systemic chemotherapy or immunotherapy should not be offered to patients with non-metastatic CRPC outside the context of a clinical trial

Index patient no. 2: Asymptomatic or minimally-symptomatic, metastatic CRPC with good performance status and without prior docetaxel chemotherapy

Recommendations are as follows:

  • Abiraterone plus prednisone, enzalutamide, docetaxel, or sipuleucel-T

  • First-generation antiandrogen therapy or ketoconazole plus steroid or observation to patients who do not want or cannot have one of the standard therapies

Index patient no. 3: Symptomatic, metastatic CRPC with good performance status and no prior docetaxel chemotherapy

Recommendations are as follows:

  • Docetaxel

  • Abiraterone plus prednisone, enzalutamide, or docetaxel

  • Ketoconazole plus steroid, mitoxantrone, or radionuclide therapy for patients who do not want or cannot have one of the standard therapies

  • Radium-223 to patients with symptoms from bony metastases and without known visceral disease

  • Treatment with either estramustine or sipuleucel-T should not be offered

Index patient no. 4: Symptomatic, metastatic CRPC with poor performance status and no prior docetaxel chemotherapy

Recommendations are as follows:

  • Abiraterone plus prednisone or enzalutamide

  • Ketoconazole plus steroid or radionuclide therapy to patients who are unable or unwilling to receive abiraterone plus prednisone

  • Docetaxel or mitoxantrone chemotherapy in select cases, specifically when performance status is directly related to the cancer

  • Radium-223 to patients with symptoms from bony metastases and without known visceral disease in select cases, specifically when the performance status is directly related to symptoms related to bone metastases.

  • Treatment with sipuleucel-T should not be offered

Index patient no. 5: Symptomatic, metastatic CRPC with good performance status and prior docetaxel chemotherapy

Recommendations are as follows:

  • Abiraterone plus prednisone, cabazitaxel, or enzalutamide

  • If the patient received abiraterone plus prednisone prior to docetaxel chemotherapy, offer cabazitaxel or enzalutamide

  • Ketoconazole plus steroid if abiraterone plus prednisone, cabazitaxel, or enzalutamide is unavailable

  • Re-treatment with docetaxel for patients who were benefiting from but discontinued treatment with docetaxel because of reversible adverse effects

  • Radium-223 to patients with symptoms from bony metastases and without known visceral disease

Index patient no. 6: Symptomatic, metastatic CRPC with poor performance status and prior docetaxel chemotherapy

Recommendations are as follows:

  • Palliative care

  • For selected patients, offer treatment with abiraterone plus prednisone, enzalutamide, ketoconazole plus steroid, or radionuclide therapy

  • Systemic chemotherapy or immunotherapy should not be offered

Bone health recommendations

Because the skeletal system is the most common site for prostate cancer metastasis, the guideline also makes recommendations regarding bone health not specific to any index patient group:

  • Offer preventive treatment (eg, supplemental calcium, vitamin D) for fractures

  • Choose either denosumab or zoledronic acid as preventive treatment for skeletal-related events


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