Chemotherapy-Naïve Castration-Resistant Prostate Cancer

Men who develop castration-resistant prostate cancer (CRPC) despite castrate levels of testosterone should be maintained in a castrate state indefinitely.

Abiraterone acetate plus prednisone or enzalutamide should be offered for second-line hormonal treatment following first-line hormonal treatment failure for chemotherapy-naïve men who develop CRPC and have radiographic evidence of metastases (M1a/M1s CRPC) because these agents have been shown to significantly increase radiographic progession-free survival (rPFS) and overall survival (OS). (Evidence-based, Strong recommendation)

Palliative care should be offered to all chemotherapy-naïve men with M1 CRPC, particularly those exhibiting symptoms or decreased QOL.

For chemotherapy-naïve patients with M0 CRCP at high risk of developing metastases (rapid PSA doubling time or velocity), second-line hormonal therapies which lower PSA values or slow the rate of rise may be offered, preferably in a clinical trial setting where available, following a discussion with the patient about the limited scientific evidence, potential harms, benefits, cost, and patient preferences.

There are no data to support the use of second-line hormonal therapies for chemotherapy-naïve men with M0 CRPC who are at low risk of developing metastases (low-risk is defined as low PSA and slow PSA doubling time).