Castration-Resistant Prostate Cancer: AUA Guideline
AUA Guideline: In April 2015, AUA released guidelines Castration-Resistant Prostate Cancer.
The major recommendations are as follows:
Index Patient 1
Asymptomatic Non-Metastatic Castration-Resistant Prostate Cancer (CRPC)
Index Patient 2
Asymptomatic or Minimally Symptomatic, Metastatic CRPC (mCRPC) Without Prior Docetaxel Chemotherapy
Index Patient 3
Symptomatic, mCRPC with Good Performance Status and No Prior Docetaxel Chemotherapy
Index Patient 4
Symptomatic, mCRPC With Poor Performance Status and No Prior Docetaxel Chemotherapy
Index Patient 5
Symptomatic, mCRPC With Good Performance Status and Prior Docetaxel Chemotherapy
Index Patient 6
Symptomatic, mCRPC With Poor Performance Status and Prior Docetaxel Chemotherapy
Guideline Statements on Bone Health (Not Specific to Any One Index Patient)
Article Source: AUANET
The major recommendations are as follows:
Index Patient 1
Asymptomatic Non-Metastatic Castration-Resistant Prostate Cancer (CRPC)
- Clinicians should recommend observation with continued androgen deprivation to patients with non-metastatic CRPC. (Recommendation; Evidence Level Grade C)
- Clinicians may offer treatment with first-generation anti-androgens (flutamide, bicalutamide, and nilutamide) or first-generation androgen synthesis inhibitors (ketoconazole + steroid) to select patients with non-metastatic CRPC who are unwilling to accept observation. (Option; Evidence Level Grade C)
- Clinicians should not offer systemic chemotherapy or immunotherapy to patients with non-metastatic CRPC outside the context of a clinical trial. (Recommendation; Evidence Level Grade C)
Index Patient 2
Asymptomatic or Minimally Symptomatic, Metastatic CRPC (mCRPC) Without Prior Docetaxel Chemotherapy
- Clinicians should offer abiraterone + prednisone, enzalutamide, docetaxel, or sipuleucel-T to patients with asymptomatic or minimally symptomatic mCRPC with good performance status and no prior docetaxel chemotherapy. (Standard; Evidence Level Grade A [abiraterone + prednisone and enzalutamide]/ B [docetaxel and sipuleucel-T])
- Clinicians may offer first-generation anti-androgen therapy, ketoconazole + steroid or observation to patients with asymptomatic or minimally symptomatic mCRPC with good performance status and no prior docetaxel chemotherapy who do not want or cannot have one of the standard therapies. (Option; Evidence Level Grade C)
Index Patient 3
Symptomatic, mCRPC with Good Performance Status and No Prior Docetaxel Chemotherapy
- Clinicians should offer abiraterone + prednisone, enzalutamide or docetaxel to patients with symptomatic, mCRPC with good performance status and no prior docetaxel chemotherapy. (Standard; Evidence Level Grade A [abiraterone + prednisone and enzalutamide]/ B [docetaxel])
- Clinicians may offer ketoconazole + steroid, mitoxantrone or radionuclide therapy to patients with symptomatic, mCRPC with good performance status and no prior docetaxel chemotherapy who do not want or cannot have one of the standard therapies. (Option; Evidence Level Grade C [ketoconazole]/ B [mitoxantrone]/ C [radionuclide therapy])
- Clinicians should offer radium-223 to patients with symptoms from bony metastases from mCRPC with good performance status and no prior docetaxel chemotherapy and without known visceral disease. (Standard; Evidence Level Grade B)
- Clinicians should not offer treatment with either estramustine or sipuleucel-T to patients with symptomatic, mCRPC with good performance status and no prior docetaxel chemotherapy. (Recommendation; Evidence Level Grade C)
Index Patient 4
Symptomatic, mCRPC With Poor Performance Status and No Prior Docetaxel Chemotherapy
- Clinicians may offer treatment with abiraterone + prednisone or enzalutamide to patients with symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy. (Option; Evidence Level Grade C)
- Clinicians may offer treatment with ketoconazole + steroid or radionuclide therapy to patients with symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy who are unable or unwilling to receive abiraterone + prednisone or enzalutamide. (Option; Evidence Level Grade C)
- Clinicians may offer docetaxel or mitoxantrone chemotherapy to patients with symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy in select cases, specifically when the performance status is directly related to the cancer. (Expert Opinion)
- Clinicians may offer radium-223 to patients with symptoms from bony metastases from mCRPC with poor performance status and no prior docetaxel chemotherapy and without known visceral disease in select cases, specifically when the performance status is directly related to symptoms related to bone metastases. (Expert Opinion)
- Clinicians should not offer sipuleucel-T to patients with symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy. (Recommendation; Evidence Level Grade C)
Index Patient 5
Symptomatic, mCRPC With Good Performance Status and Prior Docetaxel Chemotherapy
- Clinicians should offer treatment with abiraterone + prednisone, cabazitaxel or enzalutamide to patients with mCRPC with good performance status who received prior docetaxel chemotherapy. If the patient received abiraterone + prednisone prior to docetaxel chemotherapy, they should be offered cabazitaxel or enzalutamide. (Standard; Evidence Level Grade A [abiraterone]/ B [cabazitaxel]/ A [enzalutamide])
- Clinicians may offer ketoconazole + steroid to patients with mCRPC with good performance status who received prior docetaxel if abiraterone + prednisone, cabazitaxel or enzalutamide is unavailable. (Option; Evidence Level Grade C)
- Clinicians may offer retreatment with docetaxel to patients with mCRPC with good performance status who were benefiting at the time of discontinuation (due to reversible side effects) of docetaxel chemotherapy. (Option; Evidence Level Grade C)
- Clinicians should offer radium-223 to patients with symptoms from bony metastases from mCRPC with good performance status who received prior docetaxel chemotherapy and without known visceral disease. (Standard; Evidence Level Grade B)
Index Patient 6
Symptomatic, mCRPC With Poor Performance Status and Prior Docetaxel Chemotherapy
- Clinicians should offer palliative care to patients with mCRPC with poor performance status who received prior docetaxel chemotherapy. Alternatively, for selected patients, clinicians may offer treatment with abiraterone + prednisone, enzalutamide, ketoconazole + steroid or radionuclide therapy. (Expert Opinion)
- Clinicians should not offer systemic chemotherapy or immunotherapy to patients with mCRPC with poor performance status who received prior docetaxel chemotherapy. (Expert Opinion)
Guideline Statements on Bone Health (Not Specific to Any One Index Patient)
- Clinicians should offer preventative treatment (e.g., supplemental calcium, vitamin D) for fractures and skeletal-related events to CRPC patients. (Recommendation; Evidence Level Grade C)
- Clinicians may choose either denosumab or zoledronic acid when selecting a preventative treatment for skeletal related events for mCRPC patients with bony metastases. (Option; Evidence Level Grade C)
Article Source: AUANET
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