AUA Guidelines for Castrate-Resistant Prostate Cancer

San Diego—To help clinicians treat patients with castrate-resistant prostate cancer, the AUA released guidelines at its annual meeting to decide what options are best for numerous sub-types of the disease. Michael S. Cookson, MD, vice chairman and professor of urologic surgery at the Vanderbilt University Medical Center, presented the information during a plenary session.

“Given the current state of healthcare, it is imperative for all who care for men with advanced prostate cancer to familiarize themselves with these guidelines,” Dr. Cookson said.

Among men in the United States, prostate cancer is the second leading cause of death. In 2013, more than 28,000 men will die from the disease. Dr. Cookson said the median survival for men with castrate-resistant prostate cancer was less than 2 years. Recent FDA approvals have led to improvements in survival based on the quantity and quality of life, according to Dr. Cookson, although disease is still incurable.

Dr. Cookson noted that in 2004, two studies demonstrated a survival benefit in patients taking docetaxel. Since then, 5 new agents have been approved for the disease and showed a survival benefit: cabazitaxel, sipuleucel-T, abiraterone acetate, enzalutamide, and radium Ra 223 dichloride.

Before publishing the guidelines, the AUA reviewed the published literature on the therapies from January 1996 through February 2013. The authors identified 5376 potential studies and included 303 that qualified for the final analysis.

For patients with asymptomatic non-metastatic castrate-resistant prostate cancer, the guidelines suggest clinicians observe the patients and continue with androgen deprivation. If patients are unwilling to accept observation, clinicians can offer a first-generation anti-androgen or a first-generation synthesis inhibitor but they should not offer systemic chemotherapy or immunotherapy.

For patients with asymptomatic or minimally symptomatic metastatic castrate-resistant prostate cancer who have not received docetaxel chemotherapy, clinicians are advised to offer abiraterone acetate plus prednisone, docetaxel, or sipuleucel-T. They can also offer first-generation, anti-androgen therapy or observation if patients cannot receive standard therapies.

For patients with symptomatic, metastatic castrate-resistant prostate cancer and a good performance status who have not received docetaxel chemotherapy, the guidelines recommend clinicians offer docetaxel. They can also prescribe abiraterone acetate plus prednisone, but they cannot offer estramustine or sipuleucel-T.

For patients with symptomatic, metastatic castrate-resistant prostate cancer with poor performance status who have not received docetaxel chemotherapy, clinicians can offer abiraterone acetate plus prednisone or ketoconazole plus a steroid or radionuclide therapy. They should not offer sipuleucel-T.

For patients with symptomatic, metastatic castrate-resistant prostate cancer with good performance status who received docetaxel chemotherapy, clinicians are advised to offer abiraterone acetate plus prednisone, cabazitaxel or enzalutamide. If patients received abiraterone acetate plus prednisone before taking docetaxel, they should be offered cabazitaxel or enzalutamide.

For patients with symptomatic, metastatic castrate-resistant prostate cancer with poor performance status who received docetaxel chemotherapy, clinicians should offer palliative care. For some of these patients, clinicians can offer abiraterone acetate plus prednisone, enzalutamide, ketoconazole plus a steroid, or radionuclide therapy.

All patients with fractures and skeletal-related events should be offered preventive treatments such us supplemental calcium or vitamin D, according to Dr. Cookson. He added that for patients with bony metastases and skeletal related events, clinicians could offer denosumab or zoledronic acid.