CUA 2018: Development of a Management Algorithm for Prostate Cancer Patients with a Biochemical Recurrence after Radical Therapy

Halifax, Nova Scotia ( Biochemical recurrence, defined as a PSA recurrence without radiographic evidence of disease following definitive primary therapy for prostate cancer, is a growing clinical entity – and one identified by the Genitourinary Research Consortium (GURC) Best Practice Working Group as a priority to “develop a monitoring and treatment algorithm to support the optimal management of patients with non-metastatic prostate cancer.” As more of the systemic therapies previously limited to patients with metastatic disease or castration-resistance are working their way into the castration-sensitive non-metastatic setting, the authors of this multi-institutional Canadian group offer a management algorithm for these patients.
This is a Canadian national working group of uro-oncologists, radiation oncologists, and medical oncologists. They engaged in a series of best practice consensus discussions to examine the clinical trial evidence (literature review) and identify additional practice recommendations (expert opinion) that could be incorporated into an algorithm for the monitoring and treatment of patients with prostate cancer with a biochemical recurrence post-radical local therapy. It should be noted that it was done with the support of Janssen Inc., a pharmaceutical company. 

Based on multiple consensus meetings, the group integrated evidence from RCTs and key retrospective studies, which was supplemented by expert consensus opinion in areas where evidence was lacking. 

They did also consult 7 key guidelines statements:
UroToday CUA 2018 Development of a Management Algorithm 1

This led to the development of an algorithm (Fig. 1) that provides practice guidance on the definition of biochemical failure, when to refer for local salvage options, recommended prostate-specific antigen (PSA) thresholds for use of intermittent and continuous androgen-deprivation therapy (ADT), and the use of PSA doubling time to guide frequency of laboratory and imaging investigations once patients have developed castrate-resistant prostate cancer
UroToday CUA 2018 Development of a Management Algorithm 2

By no means is this the only method of management, but it is recommended based on expert review. It does take the clinician from initial biochemical recurrence all the way through the management of non-metastatic castration-resistant prostate cancer (cM0 CRPC). However, it should be noted, it does limit management to what is currently available and approved by Health Canada. 

Novel therapies with strong RCT support (use of enzalutamide or apalutamide in M0 CRPC or abiraterone for metastatic hormone-sensitive prostate cancer) without approval are not included in the algorithm. 

Presented by: Shayegan, Bobby, MD, Associate Professor and Head, McMaster University, Hamilton, Canada
Co-Authors: Brita Danielson1, Scott Morgan2, Fred Saad3, Robert Hamilton4, Shawn Malone2, Anousheh Zardan5, Laura Park-Wyllie5, Bobby Shayegan6
Author Information
1. Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada; 
2. The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; 
3. Centre Hospitalier de l’Université de Montréal, University of Montreal, Montreal, QC, Canada; 
4. Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
5. Medical Affairs, Janssen Inc., Toronto, ON, Canada
6. Juravinski Cancer Centre & St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada

Written By: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto   Twitter: @tchandra_uromd at the 73rd Canadian Urological Association Annual Meeting - June 23 - 26, 2018 - Halifax, Nova Scotia

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