Algorithm for Second-line Hormonal CRPC Treatment
Key Points
➤ 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).
Low Risk for Developing Metastases
• Second-line hormonal therapies are not recommended
for chemotherapy-naïve men thought to be at low risk of
developing metastases (low-risk is defined as those with a
low PSA and slow PSA doubling time).
• A PSA evaluation every 4–6 months should be performed
for men who develop CRPC and have no readiographic
evidence of metastases (M0 CRPC) and a slow PSA
doubling time or velocity. If PSA levels are rising, consider
also checking serum testosterone levels.
No radiographic
evidence of
metastases (M0
CRPC)
Patient is being considered for
Second-line Hormonal Therapies
