Systemic Therapy in Men with Metastatic Castration-Resistant Prostate Cancer (CRPC) Guideline and Rapid Update

Systemic Therapy Update on ¹⁷⁷Lutetium-PSMA-617 For Metastatic Castration-Resistant Prostate Cancer Rapid Recommendation Update 

Published online September 29, 2023

Updated Recommendation 1.2.2. The panel recommends that either Ga-68 PSMA-11, F-18 piflufolastat, or F-18 flotufolastat be used as radiotracers to determine eligibility currently (Type: Informal consensus, benefits outweigh harms; Evidence quality: Low; Strength of recommendation: Weak). 

Practical information: The panel supports checking blood counts, renal, and hepatic function prior to each cycle of therapy. Radioprotection precautions must be taken in accordance with national and local regulations. The panel also supports multidisciplinary collaboration for the utilization of ¹⁷⁷Lu-PSMA-617 where and when possible.

Systemic Therapy Update on ¹⁷⁷Lutetium-PSMA-617 For Metastatic Castration-Resistant Prostate Cancer Rapid Recommendation Update (2022)

Published online August 15, 2022.

Updated Recommendations:

Updated Recommendation 1.1. The panel recommends the use of ¹⁷⁷Lu-PSMA-617 intravenously once every 6 weeks for 4-6 cycles as a treatment option in patients with PSMA PET/CT positive mCRPC who have progressed on one prior line of androgen receptor pathway inhibitor and at least one line of prior chemotherapy (Type: Evidence-based, benefits outweigh harms; Evidence quality: Moderate; Strength of recommendation: Strong). 

Updated Recommendation 1.2.1. The panel recommends that patients should be selected with PSMA PET (Type: Evidence-based; benefits outweigh harms; Evidence quality: Moderate; Strength of recommendation: Strong).  

​This rapid recommendation provides timely guidance on ¹⁷⁷Lu-PSMA-617.

2014 Guideline Abstract

Published online before print September 8, 2014

Basch E, Loblaw DA, Oliver TK, Carducci M, Chen RC, Frame JN, Garrels K, Hotte S, Kattan MW, Raghavan D, Saad F, Taplin ME, Walker-Dilks C, Williams J, Winquist E, Rumble RB, Dusetzina SB, Virgo K

Purpose

To provide treatment recommendations for men with metastatic castration-resistant prostate cancer (CRPC).

Methods

The American Society of Clinical Oncology and Cancer Care Ontario convened an Expert Panel to develop evidence-based recommendations informed by a systematic review of the literature.

Results

When added to androgen deprivation, therapies demonstrating improved survival, quality of life (QOL), and favorable benefit-harm balance include abiraterone acetate/prednisone, enzalutamide, or radium-223 (for men with predominantly bone metastases). Improved survival and QOL but moderate toxicity risk is associated with docetaxel/prednisone. For asymptomatic/minimally symptomatic men, improved survival with unclear QOL impact and low toxicity are associated with sipuleucel-T. For men who previously received docetaxel, improved survival, unclear QOL impact, and moderate to high toxicity risk are associated with cabazitaxel/prednisone. Modest QOL benefit without survival benefit and high toxicity risk are associated with mitoxantrone/prednisone after docetaxel. No benefits and excess toxicity are observed with bevacizumab, estramustine, or sunitinib.

Recommendations

Continue androgen deprivation (pharmaceutical or surgical) indefinitely. Abiraterone acetate/prednisone, enzalutamide, or radium-223 should be offered; docetaxel/prednisone should also be offered accompanied by discussion of toxicity risk. Sipuleucel-T may be offered to asymptomatic/minimally symptomatic men. For men who have progressed on docetaxel, cabazitaxel may be offered, accompanied by discussion of toxicity risk. Mitoxantrone may be offered, accompanied by discussion of limited clinical benefit and toxicity risk. Ketoconazole or antiandrogens (bicalutamide, flutamide, nilutamide) may be offered, accompanied by discussion of limited known clinical benefits. Bevacizumab, estramustine, or sunitinib should not be offered. There is insufficient evidence evaluating optimal sequences or combinations of therapies. Palliative care should be offered to all patients.

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