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Noncastrate Advanced, Recurrent or Metastatic Prostate Cancer Initial Management

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Treatment Intermittent Androgen Deprivation Recommendation 4.1 ➤ Intermittent therapy may be offered to men with high-risk biochemically recurrent non-metastatic prostate cancer after RP and/or RT based on evidence in meta-analyses of the non-inferiority of intermittent androgen deprivation therapy (IADT) when compared to continuous androgen deprivation therapy (CADT) with respect to overall survival. This is further supported by evidence from four meta-analyses testing superiority. Low-risk biochemical recurrence after radical prostatectomy is defined as a PSA doubling time >1 year and pathologic Gleason score <8. Low-risk biochemical recurrence after radiotherapy is defined as an interval to biochemical recurrence >18 months and clinical Gleason score <8. High-risk biochemical recurrence after radical prostatectomy is defined as a PSA doubling time <1 year or a pathologic Gleason score of 8–10. High-risk biochemical recurrence after radiotherapy is defined as an interval to biochemical recurrence <18 months or a clinical Gleason score of 8–10. Active surveillance may be offered to men with low-risk biochemically recurrent non-metastatic prostate cancer (Strong recommendation; EB-B-H). Qualifying Statements for IADT • Although men with noncastrate de novo metastatic prostate cancer were included in the studies reviewed for this clinical question, alternative standard of care therapies with proven survival benefits now exist, as outlined in Recommendation 1 to include ADT plus docetaxel, ADT plus abiraterone, ADT plus enzalutamide or ADT plus apalutamide. Similar support for these existing standards of care does not universally exist for men with LVD or those who develop M1 disease after prior local therapy, and further research is needed. No specific additional recommendation with respect to the use of IADT in the noncastrate metastatic prostate cancer population was possible at this time because IADT has not been studied in combination with additional cytotoxic or hormonal agents in this population. • Patients considering IADT should be made aware of the potential benefits of IADT associated with the off-treatment intervals, such as reduced treatment side effects, quality-of-life benefits and lower cost. As patients on IADT require close follow-up, they must be motivated to adhere to frequent doctor visits for monitoring, even during off-treatment periods.

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