Surveillance
nmCRPC
- Minimum staging: bone scan and CT C/A/P, +/- MRI prostate
- PSMA PET useful if patient eligible to localize disease
- Ensure PSA/testosterone on standing lab req
- Ensure testosterone castrate and document GnRH agonist/antagonist
- ALP is useful to follow for bone mets
- Prefer to avoid bicalutamide TAB
- Prefer to add ARAT (apalutamide/enzalutamide/daralutamide) if PSA doubling time < 10 months
- Subsequent frequency of imaging depends on PSA doubling time
- General guidelines:
- PSA doubling time > 12 months, reasonable to monitor with CT C/A/P and bone scan q 6 monthly
- PSA doubling time < 2 months, monitor with CT C/A/P q 2 months
- General guidelines:
- Castrate Testosterone
- Ideally < 0.7 but < 2.0 is acceptable
- If higher consider castrate resistance or medicine adherence
- Can switch to Degarelix monthly to see if we can get Testosterone lower, but often does not pan out.
- If no improvement, switch to Q3 monthly
- Confirm ADT
- Not always clear who is following
- Aim for home Lupron injections
MCSPC
- Minimum baseline staging: bone scan and CT C/A/P
- Ensure PSA/testosterone on standing lab req
- Ensure testosterone castrate and document GnRH agonist/antagonist
- ALP is useful to follow for bone mets (controversial)
- Prefer to avoid bicalutamide TAB
- Prefer to add ARAT (abiraterone-prednisone/apalutamide/enzalutamide) to ADT
- With current guidelines preference is abiraterone as this allows enza in the CRPC setting
- Consider docetaxel/ADT followed by abiraterone/pred/ADT for fit patients (PEACE-1)
- Repeat imaging with CT C/A/P and bone scan for efficacy after 4 cycles, then q 4-6 monthly, earlier if PSA rises (NCCN suggests q3-6 months)
- If 2 serial rises on peripheral antiandrogen (enza,apa,dara) – discontinue agent, may see a withdrawal response (rare)
- Abiraterone/pred may be continued as long as clinical benefit even if PSA is rising
MCRPC
- Ensure PSA/testosterone on standing lab req
- Ensure testosterone castrate and document GnRH agonist/antagonist
- Ensure hereditary testing offered
- BRCA 1/2 may be eligible for olaparib
- ALP is useful to follow for bone mets
- Minimum baseline staging: bone scan and CT C/A/P
- If presents with visceral mets, especially with low PSA consider visceral biopsy to r/o neuroendocrine dedifferentiation
- May treat with platinum/etop if does not respond to ARAT/conventional chemo
- Prefer ARAT (if eligible)
- Repeat imaging with CT C/A/P and bone scan for efficacy after 4 cycles, then may increase interval to q 6 monthly, earlier if PSA rises
- If discordant imaging showing progression with no PSA elevation consider neuroendocrine dedifferentiation
- If progresses on ARAT then prefer Radium 223 if eligible (LN<2cm and no visceral mets) prior to docetaxel
- Synergistic with denosumab – excellent option for SRE proph if eligible
- Ensure RO restages post cycle 3 Ra 223 for patients eligible for chemo
- If 2 serial rises on peripheral antiandrogen (enza,apa,dara) – discontinue agent, may see a withdrawal response (rare)
- Abiraterone/pred may be continued as long as clinical benefit even if PSA is rising
Dr. Michael Humphreys
Medication Common Side Effects
Abiraterone
- Peripheral Edema
- Decreased potassium
- Hypertension
- Hepatotoxicity
Enzalutamide
- Neuropsychiatric Events (Seizure 1- 20 months since started)
- Memory impairment
- Sudden decrease LOC
- QT Prolongation
- Increased BP
Apalutamide
- Increased Fracture Risk
- Hypothyroidism
- Abdominal Pain
- Diarrhea
- Fatigue
- Falls
- Rash
SRE
Denosumab
Eligibility Criteria
- Metastatic prostate cancer to bone
- Evidence of castration resistance (progressive disease despite testosterone less
than 1.7 nmol/L) - Denosumab is covered by BC Pharmacare Plan P (a “Palliative Drug Benefit”
application form must be submitted prior to initiation of treatment). As a supportive
care medication, denosumab is not covered by the BC Cancer Agency but may be
reimbursed by private insurance plans.
Dr. Michael Humphreys
In The Pipeline
- Watch this space
