From the Guidelines
Castration-Resistant Prostate Cancer (CRPC) management guidelines are based on a shared decision-making approach, considering patient preferences, prior treatment exposures, and disease characteristics.
Key Principles
- Androgen Deprivation Therapy (ADT) with an LHRH agonist or antagonist should be continued to maintain castrate serum levels of testosterone (<50 ng/dL) in patients with CRPC 1.
- Monitoring with radiologic imaging, PSA tests, and clinical exams is essential for detecting progression 1.
- Therapy selection depends on prior exposure to docetaxel and novel hormone therapies, such as abiraterone, enzalutamide, darolutamide, or apalutamide 1.
Treatment Options
- Secondary hormone therapies, such as abiraterone, enzalutamide, darolutamide, or apalutamide, can be added to ADT in patients with nonmetastatic CRPC or metastatic CRPC (mCRPC) 1.
- Chemotherapy, immunotherapy, and targeted therapy are options for patients with mCRPC, considering patient preferences, prior treatment exposures, and disease characteristics 1.
- Radiopharmaceuticals can be used in patients with mCRPC, especially those with bone metastases 1.
Special Considerations
- Biomarker testing, such as microsatellite instability (MSI)/mismatch repair (MMR) testing and tumor mutation burden (TMB) testing, can inform treatment decisions and eligibility for clinical trials 1.
- Genetic counseling is recommended for patients with MSI-high (MSI-H) or deficient MMR (dMMR) tumors to assess for Lynch syndrome and consider germline and tumor testing for homologous recombination repair (HRR) genes 1.
From the Research
Guidelines for Management of Castration-Resistant Prostate Cancer (CRPC)
The management of CRPC involves a range of treatment options, including:
- Androgen-deprivation therapy (ADT) with luteinising hormone-releasing hormone (LHRH) agonists or antagonists 2
- Chemotherapy with docetaxel or cabazitaxel 3, 2
- Immunotherapy with sipuleucel-T 2, 4
- Targeted therapies such as abiraterone acetate and enzalutamide 3, 2, 5
- Bone-targeted therapies such as zoledronic acid and denosumab 2, 6
- Radionuclide therapy with radium-223 3, 2
Treatment Sequencing
The sequencing of these treatments depends on various factors, including the patient's overall health, disease severity, and previous treatments 3, 4. For example:
- Docetaxel-based chemotherapy is often used as a first-line treatment for metastatic CRPC 3
- Abiraterone acetate and enzalutamide are used in the pre-chemotherapy setting or as second-line treatments after docetaxel 3, 2
- Cabazitaxel is used as a second-line treatment after docetaxel 2
Clinical Practice Guidelines
Several clinical practice guidelines are available for the management of CRPC, including those from the American Urological Association (AUA), European Association of Urology (EAU), and National Comprehensive Cancer Network (NCCN) 4, 6. These guidelines provide recommendations for treatment selection, sequencing, and monitoring, and are based on the best available evidence from clinical trials.
Patient-Specific Factors
Patient-specific factors, such as comorbidities, preferences, and goals, should be taken into account when selecting treatments for CRPC 4, 5. For example: