Introduction: Review of CRPC Guideline Updates

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There are several clinical practice guidelines in circulation for the treatment of men with castration-resistant prostate cancer (CRPC), with the most widely used in the United States being from AUA, NCCN, and ASCO. These guidelines are continually evolving, mirroring the ever-changing world of advanced prostate cancer treatment.

Initially released in 2003, the AUA Guidelines were updated in 2014 to integrate data and findings from nearly 40 new research articles, explains Christopher P. Evans, MD, FACS. To illustrate treatment approaches, the AUA Guidelines employ 6 index case scenarios for patients with castration-resistant prostate cancer. Each of these scenarios assesses 3 factors to differentiate each patient: non-metastatic or metastatic disease; pre-chemotherapy or post chemotherapy; and performance status.

The guideline stratifies the 6 index patients to recommended therapies, based on currently available evidence. These guidelines continue to be updated, notes Evans, to integrate updated abiraterone survival data and findings from the randomized phase III PREVAIL trial in which enzalutamide demonstrated significant survival benefit compared with placebo.

The NCCN Guidelines are frequently updated, and serve as a reference for reimbursement, states Celestia S. Higano, MD, FACP. The 2015 NCCN Guideline for metastatic prostate cancer has shifted from dividing patients with metastatic disease into symptomatic, asymptomatic, and minimally symptomatic to classifying them based on presence or absence of visceral disease. The resulting approach is that patients are taken care of earlier in the algorithm regardless of symptomatology.

Those patients with good performance status who are minimally symptomatic or asymptomatic are offered sipuleucel-T, and then divided based on visceral versus non-visceral disease. This, Higano notes, is the big change in the guidelines for NCCN between this year and previous years. While this leads to the loss of the arbitrary designation of whether the patient was pre-docetaxel or post docetaxel, Higano still considers exposure to docetaxel when determining treatment.

In September 2014, ASCO and Cancer Care Ontario updated their treatment guideline for men with mCRPC. This was the first update specific to systemic therapy since 2007, and included data on the six treatments approved in the past 5 years. These guidelines recommend indefinite use of androgen therapy, a discussion on toxicity for chemotherapy, and the use of sipuleucel-T for asymptomatic or minimally symptomatic men.