NEW ORLEANS, LA USA (UroToday.com) - William Lowrance highlighted the AUA CRPC guideline amendment to incorporate enzalutamide into the management algorithm. This amendment was as a result of the PREVAIL trial which showed that when enzalutamide is used in mCRPC patients without prior chemotherapy, it extends overall and radiographic progression-free survival. He explained the dramatic changes that have occurred since 2004 when docetaxel was demonstrated as an active agent in CRPC patients, followed by sipuleucel-T, enzalutamide, abiraterone, cabazitaxel, and radium-223. The guidelines place patients into one of 6 groups based on symptoms, prior treatments, presence of metastasis, and performance status. He then briefly reviewed the 6 index patient groups:
Index patient 1 (asymptomatic nonmetastatic CRPC): This patient has rising PSA while castrate and has no radiographically measurable disease. The guideline recommends observation with continued ADT, and combined androgen blockade is an option.
Index patient 2 (asymptomatic or minimally symptomatic with mCPRC and no prior chemotherapy): The guideline recommends offering abiraterone, enzalutamide, docetaxel, or sipuleucel-T if the patient has good performance status.
Index patient 3 (symptomatic mCRPC with no prior chemotherapy and good performance status): The guideline recommends offering abiraterone, enzalutamide, or docetaxel. Radium-223 can be offered only if bony metastases are symptomatic and no visceral metastases are present. Sipuleucel-T or estramustine are not to be given.
Index patient 4 (symptomatic mCRPC with no prior chemotherapy poor performance status): The guideline recommends offering abiraterone or enzalutamide. Sipuleucel-T or estramustine should not be offered.
Index patient 5 (symptomatic mCRPC who has had prior chemotherapy and has good performance status): The guideline recommends offering abiraterone, enzalutamide, cabazitaxel. Radium-223 can be offered only if bony metastases are symptomatic and no visceral metastases are present.
Index patient 6 (symptomatic mCRPC who has had prior chemotherapy and has poor performance status): The guideline recommends no systemic chemotherapy or immunotherapy. These patients should be offered palliative care. Select patients could be offered abiraterone or enzalutamide.
Regarding bone health, all patients should be given calcium supplementation and vitamin D. If bone metastases are present, denosumab or zolendronic acid can decrease SRE.
The complete guidelines and more details regarding the strength of recommendations can be found at: http://www.auanet.org/education/guidelines/castration-resistant-prostate-cancer.cfm .
Presented by William Lowrance, MD, MPH at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA
Huntsman Cancer Hospital, Salt Lake City, UT USA
Reported by Phillip Abbosh, MD, PhD, medical writer for UroToday.com