Clinicians should assess men with mCRPC for extent of metastatic disease using conventional imaging at least annually or at intervals determined by lack of response to therapy. They should also offer patients germline testing and somatic tumor genetic testing “to identify DNA repair deficiency mutations and microsatellite instability status that may inform prognosis and counseling regarding family risk as well as potential targeted therapies.” Both of these recommendations are based on expert opinion.

The guideline strongly recommends that patients with newly diagnosed mCRPC be offered continued ADT with abiraterone plus prednisone or enzalutamide (grade A evidence) or docetaxel (grade B evidence).

The panel strongly recommends, based on grade B evidence, that clinicians offer radium-223 treatment to patients who have symptomatic bony metastases from mCRPC and without known visceral metastases.

Noting that optimal sequencing of agents in mCRPC remains an understudied area of research, the guideline panel gives a moderate recommendation, based on grade B evidence, to “consider prior treatment and consider recommending therapy with an alternative mechanism of action.”

The panel strongly recommends, based on grade B evidence, that men with mCRPC who received prior docetaxel chemotherapy and abiraterone plus prednisone or enzalutamide be offered cabazitaxel instead of an alternative androgen pathway directed therapy.

Bone Health

The also offered clinical principles with respect to bone health in men with advanced PCa. Clinicians should discuss the risk of osteoporosis associated with ADT and assess the risk of fragility fracture. They also should recommend preventative treatment for fractures and skeletal-related events (SREs), including supplemental calcium, vitamin D, smoking cessation, and weight-bearing exercise. For patients with a high fracture risk due to bone loss, clinicians should recommend preventative treatments with bisphosphates or denosumab.

In a moderate recommendation based on grade B evidence, the guideline advises clinicians to prescribe a bone-protective agent such as denosumab or zoledronic acid for men with bony metastases to prevent SREs.

“The treatment landscape of advanced prostate cancer has expanded rapidly over the past decade driven by our better understanding of the molecular underpinning of prostate cancer,” said Keyan Salari, MD, PhD, a urologic oncologist and surgeon at Massachusetts General Hospital in Boston. “The new guideline provides an important, unified resource for the medical community to help navigate this complex landscape.”

Notably, Dr Salari told Renal & Urology News, the guideline recommends germline genetic testing for all patients with metastatic hormone-sensitive or castration-resistant PCa as well as somatic tumor genetic testing in patients with mCRPC to identify DNA repair deficiency mutations and microsatellite instability status. “This new guideline reflects our growing appreciation of how the genetic makeup of a patient’s tumor can inform prognosis and treatment decisions and ultimately help us realize the potential of precision cancer medicine,” he said.

References

  1. Lowrance W, Breau R, Chou R, et al. Advanced prostate cancer: AUA/ASTRO/SUO guideline.
  2. American Urological Association. Leading organizations release new clinical guideline on advanced prostate cancer. American Urological Association [June 25, 2020 press release].

This article originally appeared on Renal and Urology News