Novel Guidelines for Treating Advanced Prostate Cancer

Novel Guidelines for Treating Advanced Prostate Cancer

For managing patients with advanced prostate cancer, novel recommendations for clinicians have been released.

To aid physicians to manage advanced prostate cancer (PCa), a novel guideline has been issued by the joint effort of three major medical organizations, the ASTRO (American Society for Radiation Oncology), AUA (American Urological Association), and SUO (Society of Urologic Oncology). It provides guidance for early evaluation, management, counseling, treatments, and diagnostic workups for patients with PCa.

It offers guidance for males having biochemical recurrence without metastatic disease after exhaustion of local treatment alternatives, bone health, nmCRPC (nonmetastatic castration-resistant prostate cancer), mHSPC (metastatic hormone-sensitive prostate cancer), and mCRPC (metastatic castration-resistant prostate cancer).

In the previous years, PCa care has been expeditiously evolving due to alterations in PSA (Prostate-specific antigen) screening standards and the approval of novel classes of treatment options for various prostate cancer states. The novel guideline encompasses clinical recommendations based on this novel evidence. It also aims to further support the patient and the medical community as they navigate through various disease states.

Continued ADT (androgen deprivation therapy) in combination with either androgen pathway directed therapy (comprises abiraterone plus apalutamide, prednisone, and enzalutamide) or docetaxel chemotherapy should be administered to mHSPC patients. In these patients, the first-generation antiandrogens (such as flutamide or bicalutamide) in combination with LHRH (luteinizing hormone-releasing hormone) agonists should be avoided, except to impede testosterone flare (based on grade A evidence).

Males with newly diagnosed mHSPC should be examined whether they are witnessing symptoms from the metastatic disease at the time of their presentation. This will aid direct discussions of prognosis and further supervision of disease (a moderate recommendation based on grade B evidence).
In newly diagnosed mHSPC men, clinicians should examine the extent of metastatic disease utilizing conventional imaging. After initiating ADT, a baseline and serial PSA estimations at 3- to 6-month intervals should be procured. Periodic conventional imaging should be considered (based on clinical principles). Regardless of family history and age, males with mHSPC should be offered genetic counseling and germline testing (based on expert opinion).

Serial PSA measurements every 3 to 6 months should be procured by clinicians and a PSADT (PSA doubling time) starting from the onset of castration resistance should be calculated for men with nmCRPC (based on clinical principle). Utilizing conventional imaging at 6 to 12 months interval, patients should be assessed for the development of metastatic disease (based on expert opinion).

Patients at elevated risk of progressing to metastatic disease, defined as patients with a PSADT of 10 months or less should be given apalutamide, enzalutamide, or darolutamide with continued ADT (based on grade A evidence). Utilizing conventional imaging (at least annually or at intervals) evaluated by a lack of response to therapy, mCRPC males should be examined for the extent of metastatic disease.

Continued ADT with abiraterone plus prednisone or enzalutamide (grade A evidence) or docetaxel (grade B evidence) should be administered to patients with newly diagnosed mCRPC. For patients who have symptomatic bony metastases from mCRPC and without known visceral metastases, clinicians should offer radium-223 treatment (based on grade B evidence).

Prior treatment and recommending therapy with an alternate mechanism of action should be considered since optimal sequencing of agents in mCRPC remains an unexplored research area (a moderate recommendation based on grade B evidence). Cabazitaxel (instead of an alternative androgen pathway directed therapy) should be given to mCRPC males receiving prior docetaxel chemotherapy and abiraterone plus prednisone or enzalutamide (a strong recommendation based on grade B evidence).

Osteoporosis risk linked with ADT should be taken into consideration and the risk of fragility fracture should be examined in men with advanced PCa. Preventative treatment measures for fractures and SREs (skeletal-related events) such as vitamin D, supplemental calcium, weight-bearing exercise, and smoking cessation should be advised. Clinicians should advocate preventative treatments with agents such as denosumab or bisphosphates for patients having a high fracture risk due to bone loss.

For men with bony metastases, clinicians should prescribe denosumab or zoledronic acid (bone-protective agent) to prevent SREs ( a moderate recommendation based on grade B evidence). In all patients with metastatic hormone-sensitive or castration-resistant PCa, germline genetic testing should be carried out.

In patients with mCRPC, somatic tumor genetic testing should be carried out. This helps to recognize microsatellite instability status and DNA repair deficiency mutations (based on expert opinion). Thus, the genetic makeup of a patient’s tumor can guide prognosis and treatment decisions. This ultimately helps to realize the potential of precision cancer medicine.



Link: [Last accessed on: 10 October, 2020]

Original title of the article

New Guideline Issued for Managing Advanced Prostate Cancer


Jody A. Charnow
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