Castration-Resistant Prostate Cancer
Publication Date: December 1, 2018
Last Updated: March 14, 2022
Guideline Statements
Asymptomatic non-metastatic CRPC
1. Clinicians should offer apalutamide or enzalutamide with continued androgen deprivation to patients with non-metastatic CRPC at high risk for developing metastatic disease. (Standard, A)
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2. Clinicians may recommend observation with continued androgen deprivation to patients with non-metastatic CRPC at high risk for developing metastatic disease who do not want or cannot have one of the standard therapies. (Recommendation, C)
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3. Clinicians may offer treatment with a second-generation androgen synthesis inhibitor (i.e. abiraterone plus prednisone) to select patients with non-metastatic CRPC at high risk for developing metastatic disease who do not want or cannot have one of the standard therapies and are unwilling to accept observation. (Option, C)
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4. Clinicians should not offer systemic chemotherapy or immunotherapy to patients with non-metastatic CRPC outside the context of a clinical trial. (Recommendation, C)
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Asymptomatic or minimally-symptomatic, mCRPC without prior docetaxel chemotherapy
5. Clinicians should offer abiraterone plus prednisone, enzalutamide, docetaxel, or sipuleucel-T to patients with asymptomatic or minimally symptomatic mCRPC with good performance status and no prior docetaxel chemotherapy.
- abiraterone plus prednisone and enzalutamide
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- docetaxel and sipuleucel-T
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6. Clinicians may offer first- generation anti-androgen therapy, ketoconazole plus steroid or observation to patients with asymptomatic or minimally symptomatic mCRPC with good performance status and no prior docetaxel chemotherapy who do not want or cannot have one of the standard therapies. (Option, C)
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Symptomatic, mCRPC with good performance status and no prior docetaxel chemotherapy
7. Clinicians should offer abiraterone plus prednisone, enzalutamide or docetaxel to patients with symptomatic, mCRPC with good performance status and no prior docetaxel chemotherapy.
- abiraterone plus prednisone and enzalutamide
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- docetaxel
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8. Clinicians may offer ketoconazole plus steroid, mitoxantrone or radionuclide therapy to patients with symptomatic, mCRPC with good performance status and no prior docetaxel chemotherapy who do not want or cannot have one of the standard therapies.
- ketoconazole and radionuclide therapy
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- mitoxantrone
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9. Clinicians should offer radium-223 to patients with symptoms from bony metastases from mCRPC with good performance status and no prior docetaxel chemotherapy and without known visceral disease. (Standard, B)
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10. Clinicians should not offer treatment with either estramustine or sipuleucel-T to patients with symptomatic, mCRPC with good performance status and no prior docetaxel chemotherapy. (Recommendation, C)
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Symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy
11. Clinicians may offer treatment with abiraterone plus prednisone or enzalutamide to patients with symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy. (Option, C)
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12. Clinicians may offer treatment with ketoconazole plus steroid or radionuclide therapy to patients with symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy who are unable or unwilling to receive abiraterone plus prednisone or enzalutamide. (Option, C)
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13. Clinicians may offer docetaxel or mitoxantrone chemotherapy to patients with symptomatic mCRPC with poor performance status and no prior docetaxel chemotherapy in select cases, specifically when the performance status is directly related to the cancer. (Expert Opinion , )
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14. Clinicians may offer radium-223 to patients with symptoms from bony metastases from mCRPC with poor performance status and no prior docetaxel chemotherapy and without known visceral disease in select cases, specifically when the performance status is directly related to symptoms related to bone metastases. (Expert Opinion , )
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15. Clinicians should not offer sipuleucel-T to patients with symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy. (Recommendation, C)
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Symptomatic, mCRPC with good performance status and prior docetaxel chemotherapy
16. Clinicians should offer treatment with abiraterone plus prednisone, cabazitaxel or enzalutamide to patients with mCRPC with good performance status who received prior docetaxel chemotherapy. If the patient received abiraterone plus prednisone prior to docetaxel chemotherapy, they should be offered cabazitaxel or enzalutamide.
- abiraterone plus prednisone and enzalutamide
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- cabazitaxel
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17. Clinicians may offer ketoconazole plus steroid to patients with mCRPC with good performance status who received prior docetaxel if abiraterone plus prednisone, cabazitaxel or enzalutamide is unavailable. (Option, C)
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18. Clinicians may offer retreatment with docetaxel to patients with mCRPC with good performance status who were benefitting at the time of discontinuation (due to reversible side effects) of docetaxel chemotherapy. (Option, C)
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19. Clinicians should offer radium-223 to patients with symptoms from bony metastases from mCRPC with good performance status who received prior docetaxel chemotherapy and without known visceral disease. (Standard, B)
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Symptomatic, mCRPC with poor performance status and prior docetaxel chemotherapy
20. Clinicians should offer palliative care to patients with mCRPC with poor performance status who received prior docetaxel chemotherapy. Alternatively, for selected patients, clinicians may offer treatment with abiraterone plus prednisone, enzalutamide, ketoconazole plus steroid or radionuclide therapy. (Expert Opinion , )
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21. Clinicians should not offer systemic chemotherapy or immunotherapy to patients with mCRPC with poor performance status who received prior docetaxel chemotherapy. (Expert Opinion , )
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Bone Health
22. Clinicians should offer preventative treatment (e.g., supplemental calcium, vitamin D) for fractures and skeletal related events to CRPC patients. (Recommendation, C)
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23. Clinicians may choose either denosumab or zoledronic acid when selecting a preventative treatment for skeletal related events for mCRPC patients with bony metastases. (Option, C)
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Recommendation Grading
Overview
Title
Castration-Resistant Prostate Cancer
Authoring Organization
American Urological Association
Publication Month/Year
December 1, 2018
Last Updated Month/Year
January 29, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Adult, Older adult
Health Care Settings
Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Management, Treatment
Diseases/Conditions (MeSH)
D011471 - Prostatic Neoplasms, D064129 - Prostatic Neoplasms, Castration-Resistant
Keywords
castration-resistant prostate cancer (CRPC), prostatic cancer
Methodology
Number of Source Documents
79
Literature Search Start Date
January 1, 1996
Literature Search End Date
February 1, 2013