What is the typical chemotherapy regimen for prostate cancer?

Chemotherapy Regimens for Prostate Cancer

For patients with metastatic prostate cancer, docetaxel at 75 mg/m² every 3 weeks with prednisone 5 mg twice daily is the standard first-line chemotherapy regimen, with cabazitaxel as the recommended second-line option after docetaxel failure. 1, 2

Chemotherapy Indications in Prostate Cancer

Chemotherapy is primarily indicated in two clinical scenarios:

1. Metastatic Castration-Resistant Prostate Cancer (mCRPC):

   • First-line: Docetaxel 75 mg/m² IV every 3 weeks with prednisone 5 mg twice daily continuously 1, 2
   • Second-line (post-docetaxel): Cabazitaxel 1

2. Metastatic Hormone-Sensitive Prostate Cancer:

   • ADT plus docetaxel for patients fit enough for chemotherapy 1, 3

Treatment Algorithm Based on Disease Stage

For Metastatic Hormone-Sensitive Disease:

• First-line: Continuous ADT with docetaxel 75 mg/m² every 3 weeks for 6 cycles in chemotherapy-eligible patients 1, 3
• Regular exercise should be recommended to reduce fatigue and improve quality of life 1

For Castration-Resistant Prostate Cancer:

1. Asymptomatic/Mildly Symptomatic Patients:

   • Abiraterone or enzalutamide (preferred first) 1, 3
   • Sipuleucel-T is an option in select patients 1

2. Symptomatic Patients:

   • Docetaxel 75 mg/m² IV every 3 weeks with prednisone 5 mg twice daily 1, 2
   • For bone-predominant disease without visceral metastases: Consider Radium-223 1

3. Post-Docetaxel Options:

   • Cabazitaxel (more effective than mitoxantrone) 1, 4
   • Abiraterone, enzalutamide (if not used previously) 1
   • Radium-223 (for those without visceral metastases) 1

Chemotherapy Administration Details

For docetaxel administration in prostate cancer 2:

• Dose: 75 mg/m² IV infusion over 1 hour
• Schedule: Every 3 weeks
• Premedication: Oral dexamethasone 8 mg at 12 hours, 3 hours, and 1 hour before infusion
• Concurrent medication: Prednisone 5 mg orally twice daily continuously
• Monitoring: Complete blood count before each cycle; neutrophil count should be ≥1,500 cells/mm³
• Dose reduction: Reduce to 60 mg/m² if patient experiences febrile neutropenia, severe cutaneous reactions, or moderate neurosensory symptoms

Special Considerations

• Neuroendocrine features: Patients showing neuroendocrine changes should receive chemotherapy rather than hormonal therapy 1
• Sequencing matters: Evidence suggests better outcomes when docetaxel is used first-line rather than second-line after mitoxantrone 4
• Monitoring for toxicity: Second-line chemotherapy has limited efficacy and significant toxicity, with high rates of dose reduction, delay, or discontinuation 4
• Bone health: For patients with bone metastases at risk for skeletal-related events, denosumab or zoledronic acid should be considered 1

Common Pitfalls to Avoid

• Delaying chemotherapy: In metastatic hormone-sensitive disease, early addition of docetaxel to ADT improves survival 3, 5
• Inadequate premedication: Failure to administer dexamethasone premedication increases risk of hypersensitivity reactions and fluid retention 2
• Overlooking neuroendocrine differentiation: These patients respond better to chemotherapy than to hormonal therapy 1
• Continuing chemotherapy despite significant toxicity: Dose reductions or treatment discontinuation should be implemented for severe adverse events 2

The role of chemotherapy in prostate cancer has evolved significantly, with docetaxel now having established benefits in both hormone-sensitive and castration-resistant settings, improving overall survival and quality of life when used appropriately 5, 6.