SAN DIEGO, CA USA (UroToday.com) - Michael Cookson, MD, Vice Chair and Professor of Urologic Surgery at Vanderbilt, presented the first AUA guideline for the management of castration-resistant prostate cancer, a lethal form of the disease.
The historical median survival for men with mCRPC is less than 2 years, but we are “beginning to impact on this and extend survival. Over the last few decades, we have greatly increased the treatment options available for castration resistant PCa,” said Dr. Cookson. Since the FDA approval of docetaxel in 2004, 4 additional agents with survival benefit have been FDA approved based on RCTs. The new AUA guidelines highlight 6 different index patients to illustrate management principles, and include a comprehensive literature review of 303 studies from 1996 to February 2013. The guideline statements are rated based on the strength of evidence (A, B, or C) and divided into standards, recommendations, or options (as is standard for all AUA guidelines).
“Index patients” are divided based on the extent of disease (presence/absence of metastatic disease), presence of symptoms, functional status, and prior receipt of docetaxel chemotherapy.
For an asymptomatic patient with non-metastatic CRPC, clinicians should recommend observation with continued ADT (Recommendation, Grade C). First generation anti-androgens or androgen synthesis inhibitors may be offered to select patients who are unwilling to accept observation (Option, Grade C). Systemic chemotherapy or immunotherapy should not be offered outside the context of a clinical trial (Recommendation, Grade C).
For asymptomatic or minimally symptomatic mCRPC without prior docetaxel therapy (index patient 2), clinicians should offer abiraterone and prednisone, docetaxel, or sipuleucel-T to patients with good performance status (Standard; Grade A (abiraterone)/B (docetaxel)/B (sipuleucel-T). Since no direct studies compare the agents, the least toxic and easy to administer regimen should be used. For patients with symptomatic mCRPC and good PS (index patient 3), docetaxel should be offered (Standard; Grade B). Abiraterone and prednisone may be offered as an alternative (Recommendation, Grade C). Similar patients with poor PS can be offered the same regimens (Option, Grade C). Clinicians should not offer treatment with either estramustine or sipuleucel-T (Recommendation, Grade C).
For patients with symptomatic mCRPC, good PS, and prior docetaxel chemotherapy, clinicians should offer abiraterone and prednisone, cabazitaxel, or enzalutamide (Standard; Grade A (abiraterone)/B(cabazitaxel)/A(enzalutamide). In patients who received abiraterone and prednisone prior to docetaxel, cabazitaxel or enzalutamide should be offered. Retreatment with docetaxel can be offered to patients who were benefitting at the time of discontinuation (due to reversible side effects) (Option, Grade C). Finally, in similar patients with poor PS (index patient 6), palliative care should be offered (Expert opinion).
That authors then noted that all patients with mCRPC should be offered preventative treatment (supplemental calcium and vitamin D) for fractures and skeletal related-events (Recommendation, Grade C). Either denosumab or zoledronic acid may be used when selecting a preventative treatment for SRE’s in patients with bone metastases (Option, Grade C).
Presented by Michael S. Cookson, MD, MMHC at the American Urological Association (AUA) Annual Meeting - May 4 - 8, 2013 - San Diego Convention Center - San Diego, California USA
Reported for UroToday.com by Jeffrey J. Tomaszewski, MD