Page 11 - Practical Approaches to Managing Castration-Resistant Prostate Cancer (CRPC)

nmCRPC Management Algorithm

Non-Metastatic Castration-Resistant Prostate Cancer (nmCRPC)
Testosterone ≤1.7 nmol/L, rising PSA (≥2 ng/mL) and
no metastases on CT(or MRI)/BS

Consider multidisciplinary consult a

Continue androgen deprivation
• Consider addition or change of first-generation androgen receptor antagonist

High-Risk Low-Risk (Non-High Risk)
PSADT ≤10 mo AND b
b
Life expectancy >5 y PSADT >10 mo
Apalutamide OR Enzalutamide c Observation OR
First-Generation Hormonal
Manipulation
Monitoring: On Apalutamide OR
Enzalutamide Monitoring
• PSA/Testosterone q 3 mo • PSA/Testosterone q 3-6 mo
• CT/BS based on response/ • CT/BS q 6-12 mo or for symptoms
progression (at least q 12 mo), or for symptoms (unless PSA >20 ng/mL, then image q 3-6 mo)
Monitoring: If Observation Only
(not receiving apalutamide or
enzalutamide
• PSA/Testosterone q 3 mo
• CT/BS q 3-6 mo or for symptoms

a. An individualized approach to treatment selection should take into consideration the pros and cons of therapy,
as well as patient characteristics and preference
b. PSA doubling time can be easily calculated using an online calculator (see Resources)
https://www.mskcc.org/nomograms/prostate/psa_doubling_time
c. Apalutamide and enzalutamide are indicated for use in patients with nmCRPC based on both showing a
statistically significant benefit in the primary endpoint of metastasis-free survival in phase 3 trials; overall
survival data are not yet mature
This algorithm does not address other aspects of care such as bone health
or cardiovascular health.

8 Practical Approaches to Managing CRPC