What is the next step in treating my metastatic prostate cancer?

Treatment for Metastatic Prostate Cancer

For metastatic prostate cancer, androgen deprivation therapy (ADT) plus docetaxel is recommended as first-line treatment for patients who are fit enough for chemotherapy. 1

First-Line Treatment Options

• Continuous androgen deprivation therapy (ADT) is the cornerstone of treatment for metastatic hormone-naïve prostate cancer 1, 2
• ADT can be achieved through:
  • Surgical castration (bilateral orchiectomy) 2
  • Medical castration using LHRH agonists 2
  • LHRH antagonists for patients at high risk of immediate complications from metastases 1
• When starting an LHRH agonist, an antiandrogen should be given for the first 3-4 weeks to prevent testosterone flare 1, 2
• For patients fit enough for chemotherapy, ADT plus docetaxel is now recommended as first-line treatment rather than ADT alone 1, 3

Treatment for Hormone-Naïve Metastatic Disease

• Continuous ADT is preferred over intermittent ADT for metastatic hormone-naïve prostate cancer 1, 4
• The standard docetaxel regimen for metastatic prostate cancer is 75 mg/m² every 3 weeks with prednisone 5 mg orally twice daily administered continuously 3
• Regular exercise should be recommended to reduce fatigue and improve quality of life while on ADT 1
• Concomitant bone-targeting therapy with denosumab or bisphosphonates is not recommended for metastatic hormone-naïve prostate cancer 1

Treatment After Progression to Castration-Resistant Disease

If your disease progresses to castration-resistant prostate cancer (CRPC), several options are available:

• For asymptomatic/mildly symptomatic patients with chemotherapy-naïve metastatic CRPC:
  • Abiraterone or enzalutamide are recommended 1
• For symptomatic patients with metastatic CRPC:
  • Docetaxel chemotherapy is appropriate for patients with good performance status 1
• For patients who have failed docetaxel:
  • Several options are available including cabazitaxel, abiraterone, enzalutamide, or radium-223 (for bone-predominant disease without visceral metastases) 1

Monitoring and Side Effect Management

• Regular monitoring should include clinical assessment and PSA measurement 1
• Men on long-term ADT should be monitored for side effects including:
  • Osteoporosis (using bone densitometry) 1
  • Metabolic syndrome 1
• For patients with bone metastases from CRPC at high risk for skeletal-related events, denosumab or zoledronate can be considered 1
• MRI of the spine is recommended for patients with CRPC with vertebral metastases to detect subclinical cord compression 1

Important Considerations

• Docetaxel has significant potential side effects including neutropenia, hypersensitivity reactions, and fluid retention 3
• Liver function should be monitored before each cycle of docetaxel, as abnormal liver function increases the risk of severe toxicity 3
• The trend in treatment has shifted from ADT alone to combination therapies with novel hormonal agents or chemotherapy, which have shown improved survival outcomes 5
• Recent data suggests that triplet therapy (ADT + docetaxel + abiraterone/darolutamide) may provide additional survival benefits in high-volume metastatic disease 5

Based on the most recent evidence, your next step should be to start ADT plus docetaxel if you are fit enough for chemotherapy, or ADT alone if chemotherapy is not appropriate for your situation.