PSA: prostate-specific antigen; ADT: androgen deprivation therapy; PSMA: prostate-specific membrane antigen; GnRH: gonadotropin-releasing hormone; RT: radiation therapy; CRPC: castration-resistant prostate cancer.
* For most men, androgen deprivation therapy should be continued as additional systemic therapy options are utilized sequentially. Where cost is an issues, another option is to hold the GnRH agonist and monitor serum testosterone at two- to three- month intervals; treatment can be resumed when testosterone levels begin to rise.
¶ All men with bone metastases should receive therapy with an osteoclast inhibitor, and those with painful bone metastases should be referred for external beam RT.
Δ Examples of aggressive features include: morphologic or histologic evidence of small cell neuroendocrine differentiation, exclusively visceral metastases, predominant lytic bone disease, bulky lymphadenopathy, low PSA at initial presentation or at symptomatic progression, short interval to androgen-independent progression following initiation of hormone therapy. Refer to UpToDate topics on castration-resistant prostate cancer.
◊ Sipuleucel-T use should be restricted to asymptomatic or minimally symptomatic males with CRPC who have slowly progressing disease not requiring a rapid response. It is contraindicated in those receiving glucocorticoids or opioids for cancer related pain, and should only be used cautiously in those with liver metastases.
§ Only for patients with symptomatic bone metastases, no visceral metastases.
¥ For hormone therapy enzalutamide is preferred, if not used previously. Secondary hormone therapies include a first-generation antiandrogen (eg, bicalutamide) if not used initially, ketoconazole, glucocorticoids, estrogen, and progesterone.