Treatment
Patient is being considered for
Second-line Hormonal Therapies
Algorithm for Second-line Hormonal CRPC Treatment (cont'd)
High Risk for Developing Metastases
• For chemotherapy-naïve patients 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.
• Alternative treatment options include observation (with
maintenance of a castrate state) or participation in a clinical trial.
• Chemotherapy or immunotherapy is NOT recommended except
in a clinical trial.
• No evidence provides guidance about the optimal order of
second-line hormonal therapies for patients with M0 CRPC. The
panel was unable to come to consensus on sequencing.
Following a discussion about the limited evidence, potential harms, benefits, cost and
patient preferences with chemotherapy-naïve men after first-line treatment failure:
• 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 rPFS and
OS. (Evidence-based, Strong recommendation)
• Alternative treatment options include immunotherapy (sipuleucel-T) or chemotherapy
(docetaxel and prednisone) or radium-223.
• If none of the above therapies can be obtained or tolerated by the patient, other
antiandrogens, prednisone and letoconazole/hydrocortisone may also be offered
beause they provide modest clinical benefits in this population, but no survival benefits
have been established.
• Alternative treatment options include enrollment in a clinical trial and observation.
• No evidence provides guidance about the optimal order of second-line hormonal
therapies for patients with M1 CRPsC.
• Other second-line hormonal therapy options where results from Phase III trials are
pending should NOT be used.
• A PSA evaluation every 3 months is recommended for men who develop CRPC with a
rapid PSA doubling time, velocity or radiographic evidence of metastases (M1 CRPC).
• Palliative care should be offered to all chemotherapy-naïve men with M1 CRPC,
particularly those exhibiting symptoms of decreased quality of life.
Radiographic
evidence of
metastases
(M1a/M1s
CRPC)
No radiographic
evidence of
metastases
(M0 CRPC)
